History and exam

Key diagnostic factors

common

presence of risk factors

Risk factors include age 15 to 24 years, inconsistent condom use, multiple or new sexual relationships, previous sexually transmitted infections, bacterial vaginosis, sex worker, or absence of hydrogen peroxide-producing lactobacilli.

purulent vaginal or cervical discharge

Mucopurulent discharge is more characteristic of Neisseria gonorrhoeae or Mycoplasma genitalium. Vaginal discharge is present in up to 70% of patients infected with Trichomonas vaginalis, but its consistency varies from sparse and thin to copious and thick, with 10% to 30% having the classic frothy yellow discharge.[20]

intermenstrual/postcoital bleeding

Should be assessed for sexually transmitted infection and cervical cancer.

dysuria and urinary frequency

If symptoms of cystitis (dysuria and urinary frequency) are associated with a discharge, patients should be assessed for vaginitis/cervicitis because Trichomonas vaginalis can affect the neighboring Skene glands and Chlamydia trachomatis can present as urethritis.

easily induced cervical bleeding

Friable and tender cervix on digital examination or swab use suggests cervicitis.

Other diagnostic factors

uncommon

dyspareunia

Can result from a host of pathological and benign processes, but sexually transmitted infection should be excluded.

vulval and/or vaginal inflammation

May appear erythematous due to inflammatory discharge draining from the vagina or cervix.

Normal-appearing vulva does not exclude cervicitis.

strawberry cervix

Consistent with Trichomonas vaginalis infection.

[Figure caption and citation for the preceding image starts]: Strawberry cervix due to trichomoniasisMittal S, et al. Atlas of visual inspection of the cervix with acetic acid for screening, triage, and assessment for treatment: IARC CancerBase No. 16 [Internet]. Lyon, France: International Agency for Research on Cancer; used with permission [Citation ends].com.bmj.content.model.Caption@4d710218

Risk factors

strong

age 15 to 24 years

Age-specific rates of chlamydia and gonorrhoea are highest in women aged 20 to 24 followed by women aged 15 to 19 years.[4]​​[5]

inconsistent condom use

The failure of condoms to protect against STIs usually results from inconsistent or incorrect use.[1]​​

multiple sexual relationships

This includes patients with recent new sexual partners.[12]

previous STIs

Patients initially diagnosed with an STI are more likely to be diagnosed with another within a 12-month period.[13]

bacterial vaginosis (BV)

These organisms facilitate passage of bacteria through the endocervical canal, resulting in cervicitis, endometritis, and potentially salpingitis.[12][14]

sex worker

People who exchange sex for money or non-monetary items are at increased risk of STIs because they are more likely to engage in risky sexual behaviours (e.g., unprotected sex or sex with multiple partners).[1]​​[15]

absence of hydrogen peroxide-producing lactobacilli

Cervicitis is common in women with BV, with a prevalence of up to 15%.[12] A risk factor for BV-related cervicitis is the absence of hydrogen peroxide-producing lactobacilli, although this finding is less consistent with Neisseria gonorrhoeae or Chlamydia trachomatis infection.[12]

weak

infertility

Infertility patients, particularly those with tubal factor infertility, have a high incidence of prior infection with an STI resulting in undiagnosed pelvic inflammatory disease and subsequent subfertility.

education <12 years

Cervicitis is common in women with BV, with a prevalence of up to 15%.[12] In one study, <12 years of education was found to be a strong risk factor for BV-related cervicitis, although this finding has not been specifically linked to Neisseria gonorrhoeae or Chlamydia trachomatis infection.[12]

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