Cervicitis

Introduction & Australian Epidemiology

Cervicitis is inflammation of the uterine cervix, commonly caused by sexually transmitted infections (STIs) or non-infectious factors. In Australia, cervicitis represents a significant burden of disease among sexually active women, particularly those aged 15-29 years.

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Australian Context: Chlamydia trachomatis is the most common notifiable STI in Australia, with rates of 426 per 100,000 in 2022. Gonorrhoea rates are 176 per 100,000, with higher rates in remote and Aboriginal and Torres Strait Islander communities.

Key Epidemiological Features

Chlamydia prevalence: 3-5% in general population, 10-15% in high-risk groups
Gonorrhoea prevalence: 0.1-0.3% in general population, 2-5% in high-risk groups
Higher rates in Aboriginal and Torres Strait Islander women (3-4x national average)
Peak incidence in women aged 20-24 years
Regional variations with higher rates in Northern Territory, Western Australia, and Queensland

Uncomplicated

Mucopurulent Cervicitis

Local cervical inflammation without complications

Primary care management

Complicated

With Upper Tract Involvement

PID, endometritis, or systemic symptoms

Specialist referral consideration

Severe

Disseminated Infection

Bacteraemia, arthritis, or perihepatitis

Hospital admission required

Pathophysiology & Microbiology

Infectious Causes

Primary Pathogens

Chlamydia trachomatis (serovars D-K) - 40-50% of cases
Neisseria gonorrhoeae - 20-30% of cases
Mycoplasma genitalium - 10-20% of cases
Herpes simplex virus (HSV-1/2) - 5-10% of cases

Secondary Pathogens

Trichomonas vaginalis
Ureaplasma urealyticum
Bacterial vaginosis-associated organisms
Human papillomavirus (HPV)

Non-Infectious Causes

Mechanical trauma (douching, sexual activity)
Chemical irritants (spermicides, lubricants)
Hormonal changes (oestrogen deficiency)
Malignancy
Foreign bodies (retained tampons, IUDs)

⚠️

Australian Resistance Patterns: Increasing azithromycin resistance in M. genitalium (30-40%) and emerging ceftriaxone resistance in N. gonorrhoeae require surveillance and appropriate antimicrobial selection.

Pathophysiological Process

Initial Contact

Pathogen adherence to cervical epithelial cells, particularly at the squamocolumnar junction (transformation zone)

Invasion

Intracellular replication (Chlamydia) or extracellular multiplication with toxin production (Gonorrhoea)

Inflammation

Neutrophil infiltration, cytokine release (IL-1β, TNF-α), and mucopurulent discharge formation

Progression

Potential ascension to upper genital tract causing endometritis, salpingitis, or pelvic inflammatory disease

Clinical Presentation & Diagnostic Criteria

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Key Point: Up to 70% of chlamydial cervicitis and 50% of gonococcal cervicitis may be asymptomatic, emphasising the importance of screening in high-risk populations.

Clinical Symptoms

Common Symptoms

Mucopurulent vaginal discharge (60-80%)
Postcoital bleeding (40-60%)
Intermenstrual bleeding (30-50%)
Pelvic pain or pressure (20-40%)
Dysuria (15-30%)
Dyspareunia (10-25%)

Associated Symptoms

Lower abdominal pain
Urinary frequency/urgency
Vulvar irritation
Fever (if upper tract involvement)
Nausea/vomiting (severe cases)

Physical Examination Findings

External Examination

Vulvar erythema, discharge, or ulcerations. Check for inguinal lymphadenopathy.

Speculum Examination

Mucopurulent cervical discharge, cervical erythema, oedema, friability, or ectopy.

Bimanual Examination

Cervical motion tenderness, uterine tenderness, or adnexal masses/tenderness.

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Red Flags: Fever >38°C, severe pelvic pain, nausea/vomiting, or signs of peritoneal irritation suggest upper tract involvement requiring urgent evaluation.

Diagnostic Criteria

Clinical Criteria	Laboratory Criteria	Microbiological Criteria
• Mucopurulent discharge from cervix • Cervical friability/bleeding • Cervical erythema or oedema	• >30 WBC per hpf on wet mount • Gram stain >30 PMNs per hpf • Positive leucocyte esterase	• NAAT positive for C. trachomatis • NAAT positive for N. gonorrhoeae • Culture positive (if available)

Differential Diagnosis

Bacterial vaginosis
Vulvovaginal candidiasis
Trichomoniasis
Urinary tract infection
Cervical dysplasia/malignancy
Pelvic inflammatory disease
Endometriosis
Chemical/mechanical irritation

Investigations

Essential Investigations

Essential

NAAT for Chlamydia trachomatis and Neisseria gonorrhoeae

First-line test. Cervical swab preferred over urine. High sensitivity (>95%) and specificity (>99%). Medicare item 69491. Available in all Australian pathology laboratories.
Essential

Microscopy of cervical discharge

Wet mount and Gram stain. >30 PMNs per hpf suggests cervicitis. Available in most laboratories and some point-of-care settings.
Available

Mycoplasma genitalium NAAT

Consider if symptoms persist after standard treatment. Limited availability in Australia - available through specialist laboratories and some reference centres.
Available

HSV PCR

If vesicles or ulcers present. High sensitivity. Available in most Australian pathology laboratories. Medicare item 69380.

Additional Investigations

Available
Trichomonas NAAT or microscopy
If trichomoniasis suspected. NAAT preferred over microscopy (sensitivity 80%
References
01
Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137.

02
Oakeshott P, Kerry S, Aghaizu A, et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ. 2010;340:c1642.

03
Australian Government Department of Health. National Notifiable Diseases Surveillance System Annual Report 2022. Canberra: Commonwealth of Australia; 2023.

04
Hocking JS, Temple-Smith M, Guy R, et al. Population effectiveness of opportunistic chlamydia testing in primary care in Australia: a cross-sectional analysis. Lancet. 2018;392(10156):1413-1422.

05
Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th edition. Melbourne: RACGP; 2018.

06
Department of Health and Human Services. National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy 2014-2017. Canberra: Commonwealth of Australia; 2014.

07
Guy RJ, Ward JS, Smith KS, et al. The impact of sexually transmissible infection programs in remote Aboriginal communities in Australia: a systematic review. Sex Health. 2012;9(3):205-212.

08
Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship in Australian Health Care 2018. Sydney: ACSQHC; 2018.

09
Pharmaceutical Benefits Advisory Committee. Guidelines for preparing submissions to the Pharmaceutical Benefits Advisory Committee (version 5.0). Canberra: Department of Health; 2016.

10
Australasian Society for Infectious Diseases. Antibiotic Guidelines 16th Edition. Melbourne: ASID; 2019.

11
Geisler WM, Uniyal A, Lee JY, et al. Azithromycin versus doxycycline for urogenital Chlamydia trachomatis infection. N Engl J Med. 2015;373(26):2512-2521.

12
Lewis D, Newton DC, Guy RJ, et al. The prevalence of Chlamydia trachomatis infection in Australia: a systematic review and meta-analysis. Pathology. 2012;44(4):282-290.

13
Australian Institute of Health and Welfare. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples 2015. Cat. no. IHW 147. Canberra: AIHW; 2015.

14
Bowden FJ, Savage J, Tabrizi SN, et al. A national Chlamydia trachomatis surveillance programme for Australia? Modelling the potential benefits of a national programme in a country with a decentralised health-care system. Sex Transm Infect. 2008;84(6):486-491.

15
Australian Government Department of Health. Pharmaceutical Benefits Scheme Online. Canberra: Commonwealth of Australia; 2023. Available at: www.pbs.gov.au