Chronic cervicitis is one of the most common diseases in gynecology and is caused by untreated or improperly treated acute cervicitis or long-term incubation of pathogens such as non-specific septic bacteria in the cervical mucosa. It is mostly seen after childbirth, abortion or cervical surgery, and also after acute infection with sexually transmitted diseases such as Neisseria gonorrhoeae and Chlamydia trachomatis. However, the various pathogens mentioned above, especially Chlamydia trachomatis and Neisseria gonorrhoeae, may not cause acute infection symptoms, but directly manifest as chronic cervicitis symptoms.
I. Reconceptualization of chronic cervicitis
For a long time, the obstetrics and gynecology community in China has referred to cervical erosion, endocervicitis, cervical polyps, cervical hypertrophy and cervical glandular cysts collectively as chronic cervicitis, and cervical erosion as the most common and major clinical manifestation of chronic cervicitis. It is well known that cervical erosion is an acute inflammatory manifestation in which the epidermis of the cervix is destroyed, the subepidermal mesenchyme is congested and edematous, and a large number of multinucleated leukocytes are infiltrated.
There is no similar condition in chronic cervicitis, so why does this kind of naming not match the name? This starts with the histological structure of the normal cervical epithelium and its physiological variants. The cervical epithelium is composed of a single layer of columnar epithelium with a bright red surface in the cervical canal, a composite squamous epithelium with a peachy surface in the vaginal part of the cervix, and a chemoepithelium with a bright red surface. The initial junction of columnar epithelium and squamous epithelium is the original squamocolumnar junction.
After the columnar epithelium has been transformed, the original squamocolumnar junction becomes squamous junction, at this time, the junction of the chemosynthetic epithelium and the columnar epithelium above it is the new squamocolumnar junction, and the area between the original squamocolumnar junction and the new squamocolumnar junction is called the cervical transformation zone or migratory zone. However, the position of the primitive squamocolumnar junction varies from person to person, and there are generally 3 different arrangements.
(1) The primitive squamocolumnar junction is located in the cervical canal at or near the ectocervix, and the entire vaginal part of the cervix and even a small part of the lower part of the cervical canal are covered by squamous epithelium, with a smooth cervical surface and a peach color similar to the normal vaginal mucosa;
(2) The primitive squamocolumnar junction is located in the vaginal part of the cervix, forming an oval bright red area around the ectocervix, but the surface is still smooth, this is the most common condition;
(3) the primitive squamocolumnar junction is located in the vaginal part of the cervix away from the ectocervix, and almost most or even the entire vaginal part of the cervix is covered by bright red smooth columnar epithelium. Although all 3 of these arrangements are normal, beginners incorrectly assume that the latter two are a manifestation of cervical erosion.
In fact, as early as 1925, when colposcopy was used in clinical practice, when this name was found to be inappropriate, it was renamed “pseudo-erosion” to distinguish it from true cervical erosion in acute inflammation, but it is contrary to common scientific knowledge to confuse the true with the false, so it was subsequently renamed “ectropion” of the cervix. The name “eversion” was later changed to “ectocervix” (eversion). But because the cervical ectropion refers to the cervical ectocervix tearing, the endocervical lining proliferates and bulges outward, which is different from celiac disease, so it is also inappropriate.
The main reason for this is probably that it is not possible to find an appropriate name for it in foreign countries, so it is better to agree on a common practice and keep the same name. In the last two years, foreign journals and reference books have replaced cervical erosion with endocervical ectopia.
The connotation of the term ectopia is more in line with the actual situation. However, if the term is translated into Chinese, it is similar to “ectopic” in endocervical ectopia or ectopic pregnancy, which gives the suspicion of disease, so our scholars think that the translation seems inappropriate. However, if “ectopic” is translated as “displaced” or “ectopic”, it reflects the actual situation of normal cervical endometriosis and will not be misdiagnosed as chronic inflammation of the cervix.
Among these two translations, it seems that “external migration” is closer to the real variation of the normal cervix than “displacement”, so we would like to propose it here and call on fellow gynecologists to discuss it. In recent years, foreign studies have found that under normal circumstances, the original squamocolumnar junction of the cervix in women gradually moves upward as women age. After menopause, regardless of the original arrangement, the primitive squamocolumnar junction usually regresses into the cervical canal, the cervix atrophies and becomes smaller, and the vaginal part of the cervix is completely covered by several thin layers of squamous epithelium.
The normal cervicovaginal area may be covered by columnar or septated epithelium, but the columnar epithelium may also be a high risk factor for infection. However, it is inconclusive whether the columnar epithelium migrates first and promotes the infection or whether the infection comes first and induces the columnar epithelium to migrate.
Nevertheless, it is clinically certain that the ectopic monolayer columnar epithelium or septic epithelium is exposed to the vagina for a long time, and various intravaginal flora and possible pathogens tend to cause subepithelial mesenchymal hyperplasia and edema, thus changing the flat red columnar epithelium into granular or even papillary bright red plaques, and is often accompanied by increased discharge or discomfort during intercourse, and lumbar and abdominal pain. At this point, the original normal cervix can be diagnosed as chronic cervicitis or endocervical ectocervix with infection.
It can also be clinically classified into I, II and III degrees according to the extent of endometriosis, and granular and papillary according to the degree of inflammation. Therefore, the clinical diagnosis can be expressed in the following forms: granular type of degree I(II, III) or papillary type of degree I(II, III) of cervicitis. In addition to the aforementioned endocervical ectopia with infection, other clinical types of chronic cervicitis present differently. Endocervicitis is mainly manifested by redness and swelling of the mucosa of the cervical orifice with purulent secretions, and the mucosa of the cervical orifice may form tipped polyps with blood in the secretions or contact bleeding due to long-term inflammation;
The presence of cervical glandular cysts is due to the blockage of the glandular opening of the former by the squamous epithelium of the vaginal part of the uterine cervix during the process of its evolution to the squamous epithelium, which prevents the discharge of the secreted mucus. The result of retention. It is because of the different clinical types of chronic cervicitis that the clinical diagnosis of chronic cervicitis is generally rarely made in a general way, but rather the clinical type is diagnosed directly.
It should also be noted that, because the vaginal part of the cervix is in long-term contact with a variety of vaginal bacteria and the interstitium is mostly infiltrated with lymphocytes, it is histopathologically possible to diagnose chronic cervicitis in more than 95% of normal cervixes. Since the clinical diagnosis of chronic cervicitis is completely different from the histopathological diagnosis of chronic cervicitis, a distinction should be made. In order to avoid confusion between the two, in the future, it may also be considered that the name chronic cervicitis is no longer used clinically but directly diagnosed by its clinical type.
Treatment of chronic cervicitis
Some people believe that endocervical ectocervix (previously known as cervical erosion) is a precursor to cervical cancer, thus leading to unnecessary medications, especially physical therapy. In fact, endometriosis does not increase the incidence of cervical cancer, but rather it is just difficult to distinguish early cervical cancer from endometriosis when observed with the naked eye. In addition, in areas with less developed medical conditions, early invasive cervical cancer is often mistaken for chronic cervicitis and physiotherapy is performed, which leads to the spread of cancerous tissues through the blood stream and eventually leads to the death of the patient.
In order to avoid the above two erroneous tendencies of over-treatment and blind diagnosis and treatment, regular and routine cervical smear examination before physiotherapy of the cervix is indispensable. Clinically, different treatments should be used depending on the different manifestations of chronic cervicitis. In cases of endocervicitis, the secretions from the cervical canal should first be taken for smear examination and relevant culture. In case of positive Neisseria gonorrhoeae, oral ceftorenpiride or levofloxacin can be administered, as can intravenous cephalosporins.
In case of positive chlamydia, oral azithromycin or doxycycline should be given. Local medication is not effective. In case of cervical duct polyps, the excised polyps should be sent for pathological examination and the root of the stump should be electrocautery to stop bleeding and prevent recurrence. Cervical glandular cysts and cervical hypertrophy have no clinical symptoms and disappear after menopause as the cervical atrophy becomes smaller.
Therefore, when patients do not have symptoms such as increased discharge or contact bleeding, regular follow-up is usually sufficient and no treatment is needed. In some women, the discharge may prevent sperm from entering the cervical cavity and lead to infertility.
In the above cases, it is necessary to take appropriate treatment measures. In the past, China has long used corrosive agents such as potassium dichromate, silver nitrate and other local rubbing for treatment, which has long been abandoned due to poor efficacy. At present, the efficacy of various local anti-inflammatory and antiseptic suppositories promoted throughout the country is not satisfactory, and it is difficult to achieve the therapeutic purpose of promoting the transformation of cervical monolayer columnar epithelium into squamous epithelium. To date, physiotherapy is still the most effective treatment for cervicitis.
The principle is to use physical methods to destroy the monolayer columnar epithelium and chemosynthetic epithelium in the vaginal part of the cervix, which will be covered by new squamous epithelium gradually after its necrosis and shedding. At present, the physiotherapy commonly used in clinical practice includes electric ironing, laser, freezing, microwave, infrared treatment and cervical circumferential electrosurgery. Among the various treatments mentioned above, electro-ironing, laser and microwave therapy have been used in China for many years, and there are more reports about freezing therapy abroad.
The cure rate for chronic cervicitis is around 90% for all the above treatments. Cervical loop electrosurgery is a new technology that has emerged in recent years. It is simple, inexpensive and has the advantages of short operation time, minimal patient pain and little postoperative bleeding. In addition to the treatment of chronic cervicitis, cervical loop electrosurgery is also a major treatment for cervical intraepithelial neoplasia and early invasive cervical cancer, and its excised specimens can be used for pathological examination, which is therefore popular among physicians and patients.
Focused ultrasound treatment for chronic cervicitis is another new treatment after cervical loop electrosurgery. Unlike traditional physical therapy methods, it uses the good tissue penetration and localization of focused ultrasound to focus the sound waves on the deep cervical lesions instead of directly destroying the surface mucosal layer, and through the thermal, cavitation and mechanical effects produced by ultrasound at the focal point, after destroying the deep lesion tissue, from deep to superficial, the Promote the regeneration of healthy tissues and reconstruction of the epidermis.
Although the efficacy of focused ultrasound in the treatment of chronic cervicitis is the same as that of other physical therapies, it has the advantages of less postoperative drainage and bleeding, less chance of local infection and faster recovery because there is no acute tissue necrosis and crusting and shedding at the irradiated area. However, the efficacy of focused ultrasound for the treatment of cervical atypical hyperplasia needs to be confirmed by further studies.