Cervicitis is inflammation of the cervix, most often from Chlamydia trachomatis or Neisseria gonorrhoeae; other causes are Mycoplasma genitalium, Trichomonas, herpes simplex virus, and noninfectious irritation. Many cases have no identifiable organism, and many infections are asymptomatic.

Pelvic inflammatory disease is infection of the upper genital tract — endometritis, salpingitis, tubo-ovarian abscess (TOA), and pelvic peritonitis — caused by organisms ascending from the cervix and vagina.

• Causes: N. gonorrhoeae and C. trachomatis (the classic causes, but found in fewer than half of cases now); vaginal flora and BV-associated anaerobes (including Gardnerella), gram-negative rods such as E. coli, streptococci, H. influenzae; M. genitalium
• Why damage occurs: inflammation destroys the ciliated epithelium of the fallopian tubes and causes scarring, adhesions, and tubal blockage → infertility, ectopic pregnancy, and chronic pelvic pain, even after one episode
• Risk factors: age under 25, multiple or new sex partners, a partner with an STI, prior PID or STI, no barrier method, douching; brief increased risk in the first 3 weeks after IUD insertion (from existing cervical infection — not from long-term IUD use)
• Ascent is more likely during or just after menses (open cervix, retrograde flow) and after uterine procedures

Genital tuberculosis — spread of Mycobacterium tuberculosis (usually from the lungs, through the blood) to the fallopian tubes and endometrium. It causes granulomatous inflammation, tubal blockage, and endometrial scarring; the most common presentations are infertility and chronic pelvic pain, often with few other symptoms. It is not sexually transmitted.

Cervicitis

• Often no symptoms; mucopurulent discharge from the cervix, friable cervix that bleeds on contact (postcoital or intermenstrual bleeding), dysuria

PID — severity ranges from subtle to life-threatening

• Lower abdominal or pelvic pain (usually bilateral), dyspareunia, abnormal discharge, irregular bleeding, dysuria
• Fever, chills, nausea, vomiting in more severe cases
• Cervical motion tenderness, uterine tenderness, adnexal tenderness on bimanual exam
• Right upper quadrant pain (perihepatitis — Fitz-Hugh–Curtis syndrome)
• TOA: palpable, tender adnexal mass; high fever
• Ruptured TOA / peritonitis: rigid abdomen, rebound tenderness, high fever, tachycardia, hypotension — a surgical emergency

Genital TB — infertility, chronic pelvic pain, menstrual changes (scant menses, amenorrhea), sometimes weight loss or night sweats; history of TB exposure or prior pulmonary TB.

History — last menstrual period (pregnancy must be ruled out), sexual history, contraception (IUD, condoms), recent procedures, prior STIs.

• Pregnancy test first — ectopic pregnancy can mimic PID, and pregnancy changes treatment and location of care
• NAAT for gonorrhea and chlamydia (vaginal, cervical, or urine specimen) — the preferred test; test for trichomoniasis, HIV, and syphilis; M. genitalium testing for persistent or recurrent cervicitis or PID
• Saline microscopy of vaginal fluid — white blood cells are usually abundant in PID; their absence makes PID unlikely
• PID is a clinical diagnosis (CDC minimum criteria): in a sexually active young woman or anyone at risk with pelvic or lower abdominal pain and no other cause, one or more of: cervical motion tenderness, uterine tenderness, or adnexal tenderness
  • Supporting findings: temperature > 38.3 °C (101 °F), mucopurulent discharge or cervical friability, raised ESR or C-reactive protein, confirmed gonorrhea or chlamydia
• Transvaginal ultrasound or MRI — thickened, fluid-filled tubes, tubo-ovarian abscess; laparoscopy for uncertain cases
• CBC (leukocytosis), blood cultures if septic
• Genital TB: endometrial biopsy with histology (granulomas), AFB culture, and TB NAAT; hysterosalpingography or laparoscopy (tubal beading, adhesions, tubercles); chest x-ray; IGRA or tuberculin skin test support but do not confirm

Treat early and presumptively — delay increases the risk of tubal damage. Clients are treated at the first visit without waiting for test results.

Cervicitis (CDC)

• Doxycycline 100 mg orally twice daily for 7 days (covers chlamydia)
• Add ceftriaxone 500 mg IM once when gonorrhea risk is present or confirmed (1 g if weight 150 kg or more)
• In pregnancy, chlamydia is treated with azithromycin 1 g orally once (doxycycline is avoided), with a test of cure about 4 weeks later

PID (CDC 2021)

Hospitalize when: a surgical emergency (e.g., appendicitis, ectopic pregnancy) cannot be excluded, tubo-ovarian abscess, pregnancy, severe illness, nausea and vomiting, or oral temperature above 38.5 °C (101.3 °F), inability to follow or tolerate oral therapy, or no response to oral therapy within 72 hours.

• IUD: it does not need to be removed; consider removal if no improvement within 48–72 hours
• TOA: IV antibiotics; drainage (image-guided) or surgery if large or not responding; rupture requires emergency surgery
• Genital TB: standard 6-month multidrug regimen (isoniazid, rifampin, pyrazinamide, ethambutol for 2 months, then isoniazid and rifampin for 4 months); surgery only for abscesses or failed therapy. Tubal damage often persists — in vitro fertilization is usually the route to pregnancy

Drug safety

Listed in priority order.

1. Recognize sepsis and peritonitis — fever, tachycardia, hypotension, rigid abdomen, rebound tenderness (ruptured TOA) → rapid response, IV access, cultures, notify provider, NPO for possible surgery
2. Administer antibiotics promptly and monitor for allergic reactions and adverse effects; maintain IV fluids in hospitalized clients
3. Monitor response within 72 hours — temperature, pain, tenderness, WBC; lack of improvement → reassess for abscess or other diagnosis
4. Comfort and drainage — semi-Fowler's position to promote pelvic drainage and localize infection; heat to the abdomen or back and analgesics for pain; rest during the acute phase with early, progressive ambulation as tolerated
5. Infection control — standard precautions; perineal hygiene; no tampons or douching; change pads frequently
6. Genital TB — pulmonary TB must be excluded; airborne precautions only if pulmonary disease is present; directly observed therapy and liver-function monitoring
7. Partner notification and treatment and STI counseling — confidential and nonjudgmental
8. Emotional support — fear of infertility, stigma; answer honestly and explain that prompt, complete treatment protects fertility

• Take all antibiotics for the full 14 days even when pain improves; return in 72 hours (or as instructed) if not better
• No sexual intercourse until treatment is complete, symptoms have resolved, and partners are treated (at least 7 days after single-dose therapy)
• Partners: anyone with sexual contact in the 60 days before symptoms (or the most recent partner if longer ago) should be tested and treated, even without symptoms; expedited partner therapy may be available
• Retest for chlamydia and gonorrhea about 3 months after treatment (reinfection is common)
• Prevention: consistent correct condom use, fewer partners, annual chlamydia and gonorrhea screening if sexually active and under 25 or at increased risk; do not douche
• Doxycycline: upright with water, sun protection, avoid taking with milk, antacids, or iron
• Long-term risks after PID: ectopic pregnancy — seek care early in any future pregnancy and immediately for pain or bleeding; infertility; chronic pelvic pain
• Genital TB: take every dose for the full 6 months (directly observed therapy); expect orange urine and tears with rifampin; use nonhormonal contraception; report yellow skin, dark urine, numbness, or vision changes
• Condoms and oral contraceptives: hormonal contraception does not protect against STIs

• Main causes of cervicitis/PID: chlamydia and gonorrhea; anaerobes and vaginal flora also contribute
• PID minimum criterion: pelvic pain plus cervical motion, uterine, or adnexal tenderness
• Rule out pregnancy first (ectopic can mimic PID)
• NAAT is the preferred test for chlamydia and gonorrhea
• Outpatient PID: ceftriaxone 500 mg IM once + doxycycline + metronidazole for 14 days
• Hospitalize: surgical emergency not excluded, TOA, pregnancy, severe illness/vomiting/high fever, no response in 72 hours
• An IUD need not be removed in PID
• Semi-Fowler's position, heat, analgesia; no douching or tampons
• Treat partners from the prior 60 days; no intercourse until treatment complete and partners treated; retest in 3 months
• Complications: infertility, ectopic pregnancy, chronic pelvic pain, TOA
• Doxycycline: upright with water, photosensitivity, not in pregnancy (chlamydia in pregnancy → azithromycin)
• Genital TB → infertility; diagnose by endometrial biopsy and culture; 6-month TB regimen; isoniazid needs liver monitoring and pyridoxine for those at risk of neuropathy