Reproductive · Infectious Disease
The facts most likely to be tested
The most common infectious causes of cervicitis are Chlamydia trachomatis and Neisseria gonorrhoeae.
Physical examination reveals mucopurulent cervical discharge and cervical motion tenderness or friability.
The gold standard for diagnosis is nucleic acid amplification testing (NAAT) of endocervical or vaginal swabs.
Empiric treatment for Chlamydia is doxycycline 100 mg twice daily for 7 days.
Empiric treatment for Neisseria gonorrhoeae is ceftriaxone 500 mg intramuscularly as a single dose.
Patients diagnosed with cervicitis must be screened for other sexually transmitted infections (STIs), including HIV and syphilis.
Sexual partners from the preceding 60 days must be notified, evaluated, and treated to prevent reinfection.
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A 22-year-old female presents to the clinic complaining of increased vaginal discharge and postcoital spotting for one week. On physical exam, she has mucopurulent cervical discharge and the cervix exhibits easy bleeding upon contact with a cotton swab. She reports having a new sexual partner within the last month and does not consistently use barrier contraception. She denies fever, abdominal pain, or dysuria.
What is the most appropriate empiric treatment for this patient?
Ceftriaxone 500 mg IM and Doxycycline 100 mg BID for 7 days
The patient presents with classic signs of cervicitis (mucopurulent discharge and cervical friability); empiric treatment must cover both Chlamydia and Gonorrhea due to the high likelihood of coinfection.
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Etiology / Epidemiology
Primarily caused by Chlamydia trachomatis and Neisseria gonorrhoeae in sexually active individuals.
Clinical Manifestations
Characterized by mucopurulent cervicitis and cervical motion tenderness (CMT).
Diagnosis
Nucleic acid amplification test (NAAT) is the gold standard for definitive diagnosis.
Treatment
Empiric therapy with ceftriaxone plus doxycycline; avoid sexual activity until treatment complete.
Prognosis
Untreated cases lead to pelvic inflammatory disease (PID) and potential infertility.
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Epidemiology & Etiology
Most common in young, sexually active patients with multiple partners or inconsistent barrier protection. While *C. trachomatis* and *N. gonorrhoeae* are primary, Mycoplasma genitalium is an emerging pathogen. Non-infectious causes include chemical irritation or mechanical trauma.
Pertinent Anatomy
The cervix acts as a physical barrier between the vagina and the sterile upper reproductive tract. Inflammation of the columnar epithelium of the endocervix leads to the characteristic discharge and friability.
Pathophysiology
Pathogens invade the endocervical columnar epithelium, triggering a robust inflammatory response. This results in the recruitment of neutrophils, leading to mucopurulent discharge. Chronic inflammation can cause cervical friability, where the cervix bleeds easily upon contact.
Clinical Manifestations
Patients often present with postcoital bleeding, intermenstrual bleeding, or dyspareunia. Physical exam reveals mucopurulent discharge and cervical friability (bleeding on swab). Red flags include fever or severe pelvic pain, suggesting progression to pelvic inflammatory disease.
Diagnosis
The Nucleic acid amplification test (NAAT) is the gold standard for identifying *Chlamydia* and *Gonorrhea*. A wet mount may show >10 white blood cells per high-power field in the endocervical mucus. Always perform a pregnancy test to rule out ectopic gestation.
Treatment
Empiric treatment is mandatory if high risk. Use ceftriaxone (500mg IM) for gonorrhea and doxycycline (100mg BID x 7 days) for chlamydia. Doxycycline is teratogenic; use azithromycin in pregnancy. Partners must be treated to prevent reinfection.
Prognosis
Prompt treatment prevents pelvic inflammatory disease (PID), chronic pelvic pain, and tubal factor infertility. Patients should be screened for other STIs including HIV and syphilis.
Differential Diagnosis
Vaginitis: presence of malodorous discharge without cervical friability
PID: presence of adnexal tenderness and systemic symptoms
Cervical cancer: persistent postcoital bleeding with visible lesion
Ectropion: normal physiological finding of columnar epithelium on ectocervix
Endometritis: uterine tenderness rather than cervical tenderness