The term mucopurulent cervicitis refers to the clinical diagnosis of active cervical infection. Definitive criteria to establish the diagnosis are gross visualization of yellow mucopurulent material and the presence of ten or more polymorphonuclear (PMN) leukocytes per microscopic field using 1,000× magnification to observe Gram-stained material obtained from the endocervix. Special care must be taken in obtaining cervical smears to establish a diagnosis of mucopurulent cervicitis. Initially, a large cotton swab is used to absorb the vaginal secretions from the upper vagina and wipe away the mucus from the exocervix. Next, a small white cotton swab is inserted in the endocervical canal. The small cotton swab is inspected for the presence of yellow purulent material. The swab is then rolled on a glass slide, and the slide is dried and Gram stained. The slide is scanned to identify strands of mucus-containing areas of inflammatory cells. If ten or more PMNs are seen at a magnification of 1,000× a positive diagnosis is made. If the patient is having her menstrual flow or if sperm or vaginal squamous cells are identified, the microscopic test is not valid. Endocervical leukocytes are a normal response to menstruation and to the presence of sperm in the endocervical canal.

Chlamydia trachomatis is the main cause of cervical abnormal discharge in most women with mucopurulent cervicitis. Neisseria gonorrhoeae seems capable of residing in the endocervical cells without always promoting a purulent response. In the nonpuerperal woman, infection of the upper genital tract is predominantly by direct spread along mucosal surfaces from an initial infection of the cervix. The presence of mucopurulent cervicitis should prompt the clinician to screen for Chlamydia trachomatis and Neisseria gonorrhoeae. The endocervical mucus resists upward bacterial spread, especially during the secretory phase of the menstrual cycle. However, instrumentation of an infected cervix at any phase of the menstrual cycle is likely to predispose to upper genital infection, including endometritis and myometritis.

Chlamydial or gonococcal cervicitis may be asymptomatic and yet be associated with tubal infertility. Symptomatic patients complain of abnormal vaginal discharge, intermenstrual or postcoital spotting, and dyspareunia. Most cases of chlamydial or gonococcal cervicitis persist if untreated. Infection may spread to the endometrium and fallopian tubes to culminate in silent or acute salpingitis.

During physical examination, certain signs may assist in making the diagnosis of chlamydial or gonococcal cervicitis. After absorbing the upper vaginal secretions and wiping away the mucus from the exocervix, the classic mucopus may be evident. In some cases the columnar epithelium of the endocervix is friable and bleeds on contact with a cotton-tipped swab. Tenderness may be elicited on palpation or motion of the cervix.

If the diagnosis of mucopurulent cervicitis is made, the patient should be treated for gonococcal and chlamydial cervicitis. Treatment is by intramuscular injection of a β-lactamase–resistant second-generation cephalosporin (125 mg ceftriaxone intramuscularly [IM], for example) followed by doxycycline (100 mg every 12 hours for 1 week). For women allergic to β-lactam antibiotics or to doxycycline, a single 1-g dose of azithromycin administered orally is effective for treatment of chlamydial infection. Since as many as 30% of patients with chlamydial cervicitis are coinfected with Neisseria gonorrhoeae, these women must also be treated with either ofloxacin (400-mg single dose orally), ciprofloxacin (500-mg single dose orally), or with spectinomycin (2-g IM single dose).

Genital ulcer disease is a common condition of women with HIV disease, but may be seen in women who are not infected with HIV. Most infectious ulcers of the cervix are caused by herpes simplex or an initial infection with Treponema pallidum. Ulcers secondary to infection with the agent of granuloma inguinale (Calymmatobacterium granulomatis), with the agent of chancroid (Haemophilus ducreyi), or because of lymphogranuloma venereum (L1, L2, or L3 strains of Chlamydia trachomatis) are very rarely seen on the cervix and for this reason will not be further discussed in this chapter.

Tuberculosis is endemic in underdeveloped countries. In many parts of the world, including the United States of America, the resurgence of tuberculosis is linked to the increasing incidence of HIV infection. The prevalence of active tuberculosis in homeless persons in the United States is estimated to be >6%, and estimates of latent infection range between 18% and 50%. Genital tuberculosis usually results from hematogenous spread of pulmonary tuberculosis. The genital organs most frequently affected are the fallopian tubes. Spread to the endometrium and cervix reflects the blood distribution of the tubes and corpus of the uterus. There is direct extension to the uterus in about 50% of cases where the fallopian tubes are involved, and to the cervix in up to 15% of these cases. Cervical tuberculosis is seen in approximately 1% of cases of congenital tuberculosis. When the cervix is involved, it is markedly irregular and may be ulcerated, giving the appearance of a malignant tumor. A biopsy of the cervix, however, will reveal granuloma with epithelioid cells surrounded by lymphocytes and Langhans-type giant cells. Mycobacterium tuberculosis may be recovered by culture in specialized media. Treatment of genital tuberculosis is similar to that required for pulmonary tuberculosis. The duration of treatment is between 6 and 9 months and includes administration of two to four anti-tuberculosis drugs (isoniazid, rifampin, ethambutol, and pyrazinamide). Management of pelvic tuberculosis should be carried out in consultation with an infectious diseases specialist.