[STDs] Atlas of Mucopurulent Cervicitis

Mucopurulent Cervicitis, Atlas of Mucopurulent Cervicitis, EPIDEMIOLOGY, LABORATORY EVALUATION, DIAGNOSIS, Treatment

Mucopurulent Cervicitis 

Mucopurulent cervicitis (MPC) is characterized by inflammation of the endocervical mucosa and is generally regarded as the female counterpart of urethritis in men. The major defined causes are Chlamydia trachomatis and Neisseria gonorrhoeae, but in common usage MPC usually implies chlamydial or other nongonococcal infection. Mycoplasma genitalium may cause some cases. Herpes simplex virus (HSV) and Trichomonas vaginalis can cause MPC as well, usually in conjunction with ectocervicitis. Bacterial vaginosis (BV) is associated with MPC, but the causal relationship is uncertain. As for urethritis in men, the cause of MPC remains obscure for at least half of the cases. Accurate diagnosis of MPC can be difficult and strongly depends on provider training and experience. Some signs, such as edematous cervical ectopy and purulence of endocervical secretions, are subjective, especially for providers with limited clinical experience. Examination of Gram-stained endocervical secretions for semiquantitation of polymorphonuclear leukocytes has been used successfully to help define the syndrome for research purposes, but has been difficult to employ in clinical settings due to problems in standardization and frequent lack of ready access to microscopy.

Pelvic inflammatory disease is the primary recognized complication but is clearly linked only with MPC caused by chlamydial infection or gonorrhea. It is not known whether idiopathic MPC, without an identified pathogen, carries important health consequences for patients or their sex partners, and agreement is lacking on the need for antibiotic therapy in the absence of C. trachomatis, N. gonorrhoeae, and M. genitalium. Treatment with azithromycin or doxycycline is indicated while awaiting the results of diagnostic tests for gonorrhea and chlamydia, especially in younger women. Patients with idiopathic MPC that persists after one or two courses of antibiotic therapy should be evaluated for associated infections such as herpes, trichomoniasis, and BV. If cervicitis persists after these have been excluded or treated, repeated courses of antibiotics are unlikely to be beneficial.

EPIDEMIOLOGY

Incidence and Prevalence

• Accurate statistics not available

• Present in 10–20% of women in most STD clinics, but highly variable, due in part to varying clinical recognition 

Transmission

• As for gonorrhea and chlamydial infection

• No data exist on transmission frequency and risks for etiologically undefined MPC

• Uncommon in sexually inactive women, implying sexual acquisition or association with intercourse

Age

• Most common in teens, in whom physiologic cervical ectopy may predispose to C. trachomatis and other inflammatory factors

• MPC in women ≤25 years old is especially likely to be due to chlamydial infection or gonorrhea

Other Risk Factors

• Cervical ectopy, i.e., endocervical columnar mucosa extending onto ectocervix

° Ectopy is normal in adolescence and is a physiologic response to hormonal influences (e.g., pregnancy, oral contraceptives)

° Physiologic ectopy may increase infection risk by exposing susceptible epithelium

° Transient ectopy can result from cervical edema due to inflammation, causing eversion that exposes

endocervical mucosa

• Pregnancy and hormonal contraception appear to increase risk of MPC

HISTORY

Incubation Period

• Uncertain; probably usually 1–4 weeks, as for chlamydia and gonorrhea

Symptoms

• Most cases asymptomatic

• Increased vaginal discharge

• Intermenstrual bleeding, often manifested as postcoital bleeding

• Dysuria may be present due to concomitant urethritis

• Genital malodor absent except in cases associated with BV or trichomoniasis

Epidemiologic History

• STD risk factors usually present

• Especially common in sexually active teens

PHYSICAL EXAMINATION

• Mucopurulent exudate emanating from cervical os

• Purulence (yellow color) of cervical secretions; best assessed on swab examined outside vagina (“swab test”)

• Edematous ectopy of exposed endocervical mucosa 

• Endocervical bleeding induced by gentle swabbing (sometimes called “friability”)

• Mild cervical tenderness may be found on bimanual pelvic examination

LABORATORY EVALUATION

• NAATs for C. trachomatis and N. gonorrhoeae

• Examine and test vaginal secretions for T. vaginalis (by NAAT, if available), BV, and yeasts 

• NAAT or culture for HSV if:

° Ectocervicitis or ulceration 

° Mucocutaneous vesicles, pustules, or ulcers

° HSV exposure history

DIAGNOSIS

The diagnosis of MPC can be considered firm in presence of two or more of the following criteria. Presumptive therapy for gonorrhea and chlamydial infection may be warranted in presence of only one criterion, especially in women <25 years old.

• Mucopurulent cervical exudate, by direct visualization or positive “swab test”

• Edematous cervical ectopy

• Swab-induced endocervical bleeding

• Gram-stained endocervical smear showing increased PMNs, often within strands of mucus

MANAGEMENT

Treatment

• Treat as for uncomplicated chlamydial infection 

° Azithromycin 1.0 g PO (single dose); or

° Doxycycline 100 mg PO bid for 7 days

• Also give treatment for gonorrhea in patients and settings at high risk for gonococcal infection 

° Ceftriaxone 250 mg IM, single dose; or

° Cefixime 400 mg PO, single dose

• Physical ablation of cervical mucosa (e.g., cryotherapy, laser cautery) sometimes is attempted for persistent, antibiotic-resistant MPC, but efficacy is unknown and such measures are generally not recommended

Partner Management

• Male partners should be evaluated and treated presumptively for chlamydia, and for gonorrhea if indicated by risk profile

• EPT has not been studied except for confirmed gonorrhea or chlamydia, but is an option when partners are unlikely to attend for professional care

• Treatment generally is not recommended for partners of patients with MPC that persists after antibiotic treatment 

Follow-up

• As for chlamydial infection or gonorrhea

• Clinical follow-up usually not required unless symptoms persist

PARTNER MANAGEMENT AND PREVENTION

• Depending on suspected or documented cause, manage partners as described for gonorrhea, chlamydial infection, or NGU 

• General STD prevention measures (partner selection, condoms) presumably reduce risk of MPC 

18–1. Mucopurulent cervicitis. a. Edematous cervical ectopy and mucopurulent exudate
in cervical os. b. Gram-stained smear of endocervical secretions, showing PMNs in mucus
strands; a few lactobacilli but no gram-negative diplococci are present. Mucus indicates
endocervical origin of secretions, because vaginal mucosa lacks mucus glands.  

CASE 1

Patient Profile Age 16, high school student

History Slight increased vaginal discharge for 10 days; responded to partner notification after her boyfriend was diagnosed with NGU 

Examination External genitals normal; cervix showed edematous ectopy, mucopurulent exudate in os

Differential Diagnosis MPC, probably due to C. trachomatis; possible gonorrhea, trichomoniasis, herpes

Laboratory Gram-stained endocervical smear showed numerous PMNs in mucus strands, without gram-negative diplococci (GND); vaginal fluid pH 4.0; negative KOH amine odor test; no yeasts, clue cells, or trichomonads seen on wet-mount microscopy; cervical NAATs for C. trachomatis (positive) and N. gonorrhoeae (negative); RPR and HIV serology (both negative)

Diagnosis MPC due to C. trachomatis

Treatment Azithromycin 1.0 g PO, single dose

Comment This patient presented with typical chlamydial MPC and would have qualified for presumptive treatment for chlamydial infection regardless of exposure to infected partner. 

18–2. Mucopurulent cervicitis; bleeding
induced by endocervical swab.  

CASE 2

Patient Profile Age 33, clerk-receptionist

History Intermittent increased vaginal discharge without abnormal odor; married for 5 years, no extramarital partners; several years’ history of intermittent, unexplained vaginal discharge, postcoital blood spotting, and Pap smears with inflammatory changes, unresponsive to previous courses of antibiotics and cervical cryotherapy; patient presented to STD clinic to “make sure once and for all” that no STD was present

Examination External genitals normal; cervix showed mucopurulent exudate in os and brisk endocervical bleeding induced by swabs used to collect culture specimens

Differential Diagnosis Mucopurulent cervicitis; rule out gonorrhea, chlamydial infection, trichomoniasis, herpes

Laboratory Endocervical smear showed many PMNs, no GND; vaginal fluid pH 4.5 with negative KOH amine odor test; no yeasts, clue cells, or trichomonads seen microscopically on wet mount; cervical NAATs for C. trachomatis and N. gonorrhoeae (both negative); cultures for T. vaginalis and HSV (both negative); VDRL, HIV, HSV-1, and HSV-2 serology (all negative); Pap smear showed inflammation, otherwise normal and negative for HPV DNA

Diagnosis Idiopathic (apparently persistent or recurrent) MPC 

Comment Treatment was deferred at the patient’s initial visit, because both medical history and patient’s age made chlamydial infection and gonorrhea unlikely. She returned after 1 week with persistent symptoms and unchanged examination. Her husband denied other sex partners, was examined and found to have no evidence of urethritis, and had negative tests for C. trachomatis and N. gonorrhoeae. Both were treated with doxycycline 100 mg PO bid for 7 days. The patient’s symptoms persisted on therapy, then improved over the next 2 months, but repeat examination was unchanged. The patient was seen several years ago; current management would include NAAT for M. genitalium if available, treatment with azithromycin, and trial of metronidazole or tinidazole for possible trichomoniasis. The patient and her husband were reassured that no long-term adverse consequences were expected 

18–3. Mucopurulent cervicitis due to N. gonorrhoeae. a. Mucopurulent
endocervical exudate. Note that the purulence of cervical exudate does not
correlate well with gonococcal or nongonococcal etiology, unlike urethritis in
men. b. Gram-stained endocervical smear, showing a single PMN with ICGND. 

18–4. Mucopurulent cervicitis due to C. trachomatis; edematous cervical ectopy 

and scant mucoid exudate.  

18–5. Edematous ectopy with incipient endocervical bleeding in a patient with
mucopurulent cervicitis; her chief complaint was postcoital bleeding.  

18–6. Erosive cervicitis in primary genital herpes. 

REFERENCES

H. Hunter Handsfield, MD, Color Atlas & Synopsis of Sexually Transmitted Diseases, Third Edition.