Sexually transmitted infections: Vaginitis and cervicitis: Pathology review

Definitions & Key takeaways

Vaginitis and cervicitis are two conditions that can affect the female reproductive tract. Vaginitis refers to inflammation of the vagina, while cervicitis refers to inflammation of the cervix, the lower part of the uterus that opens into the vagina. Symptoms of vaginitis may include itching, burning, discharge, and pain or discomfort during intercourse or urination.

Common causes of vaginitis and cervicitis include infections like chlamydia, gonorrhea, and trichomoniasis. Both chlamydia and gonorrhea infections can progress to pelvic inflammatory disease, which presents with lower abdominal pain that worsens with movement, and tubo-ovarian abscesses, which all might complicate into an ectopic pregnancy, infertility, and Fitz-Hugh-Curtis syndrome.

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Case Study0:00–1:07

A 26 year old female named Anna comes to the clinic one day with complaints of painful and more frequent urination, as well as pain during sexual intercourse, and increased vaginal discharge for the past 5 days.
Upon further questioning, Anna tells you that she’s had multiple sexual partners lately. On physical examination, there's purulent vaginal discharge.
You obtain a discharge sample with a swab and perform a Gram stain, which reveals the presence of gram-negative diplococci bacteria within neutrophils.
You prescribe her a combination of azithromycin and ceftriaxone. A year later, Anna comes back with similar complaints, but this time she also has a fever; and lower abdominal pain that worsens when she moves.
Upon further questioning, Anna reveals that she’s had two more episodes of vaginal infections over the past year, but she didn’t seek medical attention.
On physical examination, you notice that Anna has a fever, and when you perform a gynecological exam, movement of the cervix elicits pain.

Pathology1:07–2:07

Now, based on the initial presentation, Anna seems to have vaginitis or cervicitis caused by a sexually transmitted infection, or STI for short.
STIs are mainly transmitted from person to person during sexual contact through body fluids, such as vaginal secretions, semen, or blood.
The ones most at risk of contracting an STI are sexually active individuals, particularly those who have unprotected sex or multiple sexual partners.
But, it’s important to note that sexually transmitted infections can also be transmitted via contact with skin or mucous membranes, including eyes, mouth, throat, and anus.
And that’s a high yield fact!Now, STIs that may cause vaginitis and cervicitis include chlamydia, which is caused by Chlamydia trachomatis; gonorrhea, which is caused by Neisseria gonorrhoeae; and trichomoniasis, caused by Trichomonas vaginalis.Now, let’s begin with Chlamydia trachomatis, which is a gram-negative obligate intracellular bacterium, meaning that it needs to infect and enter a host cell to be able to replicate.

Chlamydia2:07–6:56

For your exams, it’s important to remember that Chlamydia trachomatis has 15 serotypes. Serotypes A through C are typically transmitted through contact with secretions from the eyes, nose, or throat of an infected person, and cause chlamydial conjunctivitis, also called trachoma.
If untreated, trachoma can ultimately destroy the cornea, resulting in total blindness. Serotypes D through K of Chlamydia trachomatis are typically transmitted via sexual contact and cause the STI chlamydia.
Now, keep in mind that, in both sexes, chlamydia is usually an asymptomatic infection of the genitourinary tract. But what’s important to know for your exams is that symptomatic individuals typically present with mucopurulent discharge, dysuria or pain and burning during urination, and increased urinary frequency.
In males, serotypes D through K can infect the urethral mucosa, causing urethritis. Also, it can cause inflammation of the epididymis, or epididymitis, as well as testicular pain and swelling.
Sometimes the infection can spread to the prostate, resulting in prostatitis. On the other hand, some females may also develop urethritis, but most often, chlamydia affects the lower genital tract, causing vulvovaginitis or inflammation of the vulva and vagina, and cervicitis when the cervix is involved.
This may present with changes in vaginal discharge, intermenstrual and post-coital vaginal bleeding, and dyspareunia or pain during sexual intercourse.
Now, an important complication in females is pelvic inflammatory disease, which is when the infection spreads to the uterus, fallopian tubes, and ovaries, leading to lower abdominal pain and fever.
If left untreated, chlamydia can cause infertility in both males and females. Now, in some cases, chlamydia can trigger reactive arthritis, which is an autoimmune condition that leads to inflammation of joints, and what’s important to remember is that reactive arthritis develops up to three weeks after the initial infection.
Now, if chlamydia affects a pregnant individual, there is a risk for the infection to be passed down to the baby during vaginal delivery.
This can result in neonatal conjunctivitis, which appears 1 to 2 weeks after birth. Alternatively, if the bacteria make their way down the baby’s respiratory tract, it can result in neonatal pneumonia.
The most characteristic symptom of neonatal pneumonia is staccato cough, meaning short, repetitive coughing with deep inspiration after each single cough.Lastly, serotypes L1, L2, and L3 of Chlamydia trachomatis are also transmitted through sexual contact, but they cause a disease called lymphogranuloma venereum, or LVG for short.
LVG is characterized by skin lesions over the genital area, such as painless, small papules or granulomas and shallow ulcers, as well as painful inguinal lymphadenopathy, or enlarged lymph nodes, called buboes.Diagnosis of infection by Chlamydia trachomatis can be confirmed by taking a genital swab or urine sample, and looking for the bacterial DNA with nucleic acid amplification testing or NAAT, or a polymerase chain reaction or PCR.
Keep in mind that Chlamydia trachomatis does not Gram-stain well, mainly because it's an obligate intracellular bacterium.
So infected cells can be examined on a sample smear with a Giemsa stain or direct fluorescent antibody stain, revealing the presence of intracellular or cytoplasmic inclusions with reticulate bodies, which are the replicating forms of Chlamydia trachomatis within the host cells.
Treatment involves antibiotics that inhibit the synthesis of bacterial proteins, such as macrolides like azithromycin, or tetracyclines like doxycycline.
Now, keep in mind that genitourinary infection with Chlamydia is frequently associated with coinfection by Neisseria gonorrhoeae.
For that reason, ceftriaxone is usually added to also cover Neisseria gonorrhoeae. And that’s very high yield!Now, Neisseria gonorrhoeae is a gram-negative diplococcus that causes the STI gonorrhea, which has a clinical presentation that’s very similar to chlamydia.

Gonorrhea6:56–8:38

So, individuals typically present with mucopurulent discharge, as well as dysuria, and increased urinary frequency. And in males, gonorrhea can result in urethritis, epididymitis, or prostatitis; while in females, it may cause vaginitis, cervicitis, and pelvic inflammatory disease.
However, differently from chlamydia, Neisseria gonorrhoeae can spread through the bloodstream and directly infect a joint, causing septic arthritis.
Now, infection during pregnancy can spread to the baby during vaginal delivery, and results in early neonatal conjunctivitis, which appears 2 to 5 days after birth.Diagnosis of gonococcal infection can be done by taking a genital swab or urine sample, and looking for the bacterial DNA with NAAT or PCR, or by growing the bacteria on Thayer-Martin agar, which is a selective medium for Neisseria gonorrhoeae.
Additionally, on gram staining you’d find pink coffee-bean shaped bacteria within neutrophils. Treatment for gonococcal infections is with third-generation cephalosporins, typically ceftriaxone, which is typically combined with antibiotics against chlamydia, so azithromycin or doxycycline, due to frequent coinfection.

Pelvic Inflammatory Disease8:38–11:21

Now, an important complication of vaginitis and cervicitis is pelvic inflammatory disease, or PID for short. This occurs when the infection spreads from the vagina or cervix into the upper female reproductive system.
This can involve the uterus, causing endometritis; the fallopian tubes, causing salpingitis, and the ovaries, causing oophoritis.
Now, the vast majority of cases are due to chlamydia and gonorrhea. But occasionally, PID can be caused by other types of bacteria introduced in the reproductive tract during procedures like surgery or even vaginal childbirth.
Most of the time, the infection is caused only by one type of bacteria, but in some cases, it becomes polymicrobial.Now, PID may present with fever, dyspareunia, and lower abdominal pain that worsens with sudden movement.
In fact, a telltale sign of PID is cervical motion tenderness, which is when mobilizing the cervix during a vaginal exam causes pain or discomfort.
And that’s a high yield fact! In addition, the strong inflammatory response in PID results in damage to the fallopian tubes, which become filled with pus, so individuals typically present with purulent discharge.
As the damaged tissue heals, scar tissue forms in the fallopian tubes. This scarring can lead to a number of complications, such as chronic pelvic pain, as well as adhesions and strictures of the fallopian tubes, subsequently increasing the risk of ectopic pregnancy and infertility.
If pus builds up in the scarred tube and ovary, it can turn into an tubo-ovarian abscess, which is an encapsulated pocket of pus that can rupture and spread into the bloodstream, leading to sepsis.
One last complication of PID is Fitz-Hugh-Curtis syndrome or perihepatitis, which occurs when the infection spreads to the peritoneum and, from there, to Glisson’s capsule, which is a layer of connective tissue that surrounds the liver.
This results in “violin string” adhesions of scar tissue that attach the liver to the peritoneum, and may cause tenderness in the right upper quadrant of the abdomen.
Diagnosis of PID includes testing vaginal discharge for the bacterial cause, and since PID can be polymicrobial, treatment involves a combination of broad-spectrum antibiotics, such as ceftriaxone, doxycycline, and metronidazole.
Occasionally, surgery may be needed to treat the complications.Another high yield STI that may cause vaginitis and cervicitis is trichomoniasis, also called trichomonas vaginalis, which is caused by the protozoan parasite Trichomonas vaginalis.

Trichomoniasis11:21–12:43

In males, trichomoniasis is usually asymptomatic, but it can cause symptoms like urethral discharge and dysuria. On the other hand, in females, symptoms include a foul-smelling, greenish, purulent vaginal discharge, along with burning and itching in the genital area.
There may also be dysuria, increased urinary frequency, lower abdominal pain, and dyspareunia. What’s also high yield to remember is that, upon examination, the cervix may appear erythematous with punctate hemorrhages, and that’s called a strawberry cervix.
For diagnosis of trichomonas vaginalis, upon saline wet mount microscopy on a discharge sample, the most high yield finding is the presence of motile pear-shaped trichomonads.
In addition, the vaginal pH should be above 4.5, which favors the growth of the trichomonads. For treatment, it’s very important to know that both the affected individual and their sexual partners should get antibiotics like metronidazole.
All right, as a quick recap… STIs that may cause vaginitis and cervicitis include chlamydia, gonorrhea, and trichomoniasis.

Recap12:43–14:13

Chlamydia is caused by serotypes D through K of Chlamydia trachomatis, and primarily presents with mucopurulent discharge and dysuria; in addition, chlamydia may cause urethritis or prostatitis in males, and vulvovaginitis or cervicitis in females.
On the other hand, gonorrhea is caused by Neisseria gonorrhoeae, and is very similar to chlamydia. Both chlamydia and gonorrhea can be diagnosed with NAAT or PCR, and are usually treated with a combination of azithromycin or doxycycline plus ceftriaxone.
An important complication of both chlamydia and gonorrhea is pelvic inflammatory disease, which presents with lower abdominal pain that worsens with movement; and complications include ectopic pregnancy, infertility, tubo-ovarian abscesses, and Fitz-Hugh-Curtis syndrome.
Finally, trichomoniasis is caused by Trichomonas vaginalis, and presents with foul-smelling, greenish, purulent vaginal discharge, along with burning and itching in the genital area, and a strawberry cervix.
Important findings for diagnosis include motile pear-shaped trichomonads on a discharge sample, as well as a vaginal pH above 4.5, and treatment involves antibiotics like metronidazole.Okay, back to our case!

Summary14:13–15:25

Anna is a 26 year old female sexually active individual, who presented with complaints of dysuria and increased urinary frequency, as well as dyspareunia and purulent vaginal discharge.
This, combined with the fact that she’s had multiple sexual partners, should make you suspect a sexually transmitted infection.
The key here is the discharge swab, which revealed the presence of intracellular gram-negative diplococci bacteria within neutrophils, making this a pretty straightforward case of gonorrhea caused by Neisseria gonorrhoeae.
Anna was prescribed a combination of azithromycin and ceftriaxone. A year later, Anna comes back with a similar presentation, along with a fever; and lower abdominal pain that worsens with movement.
An important clue is that she had two more episodes of vaginal infections over the past year, but didn’t seek medical attention.
This should make you suspect that the infection might have spread into the upper female reproductive system. The final clue is the fact that Anna has cervical motion tenderness, which is typical of pelvic inflammatory disease.
Sexually transmitted infections: Vaginitis and cervicitis | Osmosis