Approach

History

The common presentations of cervicitis include:

Dysuria and associated vaginal discharge

  • Patients with simple cystitis typically present with dysuria, urinary frequency, foul-smelling urine, and/or suprapubic pain.

  • These patients should be assessed for vaginitis/cervicitis if dysuria is associated with a discharge because Trichomonas vaginalis can affect the neighbouring Skene glands and Chlamydia trachomatis can present as urethritis.

Pruritic vaginal discharge

  • This complaint can result from various vaginal (candida, T vaginalis, bacterial vaginosis) or cervical infections.

Dyspareunia

  • Painful intercourse can result from a host of pathological and benign processes, but sexually transmitted infection (STI) should be included in the differential.

Intermenstrual or postcoital bleeding

  • These patients should be assessed for STIs and cervical cancer.

Physical findings

In all patients with suspected cervicitis, a full pelvic examination should be performed. The examination findings that support a diagnosis of cervicitis include:

Vulva

  • Can be erythematous (more consistent with candidal vaginitis) secondary to inflammatory discharge draining from the vagina or cervix.

  • Normal-appearing vulva does not exclude cervicitis.

Vagina

  • Typically erythematous and tender on speculum examination, but this can also result from vaginal infection.

  • Mucopurulent discharge is more characteristic of Neisseria gonorrhoeae with a positive predictive value of 40%.

Cervix

  • Friable, inflammatory exudates from the cervical os.

  • Tender on digital examination or swab use.

  • Strawberry cervix appearance is consistent with T vaginalis infection.

  • Easily induced cervical bleeding is suggestive of chlamydial infection, with a positive predictive value of 40%.

Investigations

A wet mount microscopic evaluation of cervical discharge is indicated for all patients with vaginal discharge. The positive predictive value of leukorrhoea in indicating presence of an STI is higher for nonpregnant women (92%) than for pregnant women (60%). The negative predictive value of leukorrhoea is also high (92% to 99%).[19]

The cervical discharge specimen should also be sent for:

  • Thayer-Martin culture: a sensitive test for gonococcal infection

  • Nucleic acid amplification testing: this is the definitive test for detection of C trachomatis, N gonorrhoeae, M genitalium, or T vaginalis[20]

  • Gram stain: gold standard for diagnosis of bacterial vaginosis.[1]​​​

European guidelines recommend that all M genitalium-positive nucleic acid amplification tests should be followed up with an assay capable of detecting macrolide resistance mutations. Sensitivity of macrolide resistance assays varies significantly.[8]

Fast and reliable point of care tests are now available to detect T vaginalis. Results are available within 30 minutes for OSOM Trichomonas rapid test and in 45 minutes for AFFIRM VP III.

Type-specific herpes simplex virus (HSV) serological assays might be useful in the following scenarios: 1) recurrent genital symptoms or atypical symptoms with negative HSV cultures, 2) a clinical diagnosis of genital herpes (vesicular lesions or cervical erosions) without laboratory confirmation, or 3) a partner with genital herpes.[1]​​​

Bacterial vaginosis may be diagnosed by vaginal Gram stain (by use of Nugent score) or by presence of at least 3 of the 4 Amsel criteria: 1) adherent white vaginal discharge; 2) clue cells on microscopy (vaginal epithelial cells with distinctive stippled appearance as covered by bacteria); 3) vaginal pH >4.5; 4) 'whiff test' (release of fishy odour following addition of 10% potassium hydroxide solution).[21][22]

If the patient is at high risk (<25 years of age, multiple sexual partners, inconsistent condom use), then screening for other STIs is warranted. Furthermore, if any STI is diagnosed, a full panel of STI screening should be offered, including STIs that do not cause cervicitis such as HIV, hepatitis B and C, and syphilis. If within the screening interval, Papanicolaou test may be performed during this examination, although it is not useful in diagnosing specific STIs. Endocervical Gram staining was found to have low detection of N gonorrhoeae (only 50%), and is no longer included in the US Centers for Disease Control and Prevention guidelines.[1]​​​

Women who are pregnant represent an at-risk population. Sexually active women of reproductive age should have a pregnancy test.

To aid the delivery of STI testing services, the World Health Organization recommends self-collection of samples as an option to test for N gonorrhoeae and C trachomatis and, where appropriate, T pallidum and T vaginalis.[23]​ The UK National Health and Care Excellence also recommends remote self-sampling be offered as an alternative to clinic attendance to improve uptake and frequency of STI testing.[16]

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