CERVICITIS I—EROSIONS, EXTERNAL INFECTIONS
Gonorrhea and chlamydial infections of the cervix are common and can ascend into the upper genital tract with potentially serious sequelae, including chronic pelvic pain, infertility, ectopic pregnancy, and an increased risk of hysterectomy. Any exposure of the mucous glands in the endocervical canal predisposes the cervix to chronic low-grade infection. The most common causes of such exposure are eversions due to congenital defects or childbirth injuries. Congenital eversions are occasionally found in nullipara and present a concentric area of red, granular tissue about the external os. Exposure to increased levels of estrogen is thought to be a predisposing risk factor for such eversions.
The coarse, red appearance of this ectopic tissue is not primarily caused
by infection but is due to the presence of a fine capillary network, which lies
directly under and shines through the single layer of columnar cells. Indeed,
one may find clinically very little infection, with neither ulceration nor true
erosion at all, although evidences of irritation in the underlying stroma are
generally histologically recognizable. In young girls, this anomaly often
causes a noticeable, thin, watery mucous discharge that may have been noted
first even before the menarche. Thereafter, cyclic variations in the estrogen
level cause increased activity of the endocervical glands and create a typical
fluctuating pattern to the complaint of a nonodorous, colorless discharge. Such
a characteristic story may alone be enough to suggest the diagnosis of the
congenitally ectopic cervix in young women. Ulcerations or true erosions in
such areas may result secondarily because of their vulnerability to saprophytic
organisms.
The even, concentric appearance of the congenital lesions just described
contrasts sharply with the jagged papillary eversions. These usually result
from lacerations during childbirth. The gland-bearing surface of the
endocervical canal pouts outward, and infection then may produce true erosions
or loss of the overlying epithelial covering.
Spontaneous healing may fail to occur because inward growth of squamous
epithelium does not adequately cover such exposed and infected areas. In areas
where healing does occur, the epithelium blocks the exit of previously exposed
glands, producing retention cysts of various sizes, the so-called Nabothian cysts. Most healing occurs through squamous metaplasia and presents a
smooth, characteristic appearance when the cervix is viewed through the
colposcope. This metaplasia is stimulated by exposure to the more acidic media
of the vagina.
Monilial infections of the vulva and vagina almost invariably involve the
cervix as well. Patches of white, cheesy discharge are found over the vaginal
epithelium and cervix. The mucosa is fiery red and markedly inflamed. Generally,
the infection causes an acute vulvovaginitis with intense itching. Diagnosis is
usually possible from the characteristic appearance of the discharge, which is
tenacious and difficult to wipe off.
The cervix is also involved in the Trichomonas infection of vulva
and vagina. Similar to the epithelial changes in the vagina, the external
orifice—as a matter of fact, the entire portio vaginalis of the cervix—assumes a
spotted, “strawberry-like” or punctate appearance because of a typical arrangement of red spots on a pale background. This
is present in about 15% of cases and, when seen, is considered pathognomonic.
The slightly yellowish, creamy, sometimes frothy discharge from the orifice,
indicating that the process has spread to the endocervical mucosa, is profuse
and foul.
Chancre, the primary syphilitic lesion on the cervix, is relatively rare.
It is said to account for not more than 1.5% of all primary lesions of the
female genitalia.
Chancre of the cervix consists of a sharply delimited ulceration on an indurated base, surrounded by an inflammatory reaction with marked edema. A grayish slough in the center of the ulcer may make difficult a diagnosis by dark-field examination. The lesion can always be correctly diagnosed by a biopsy from the indurated edge of the crater. Any exophytic lesion on the cervix should be biopsied to determine the diagnosis.
