The cervix is located below the body of the uterus and is the passage from the vagina to the uterus. Under normal circumstances, the cervix has various defensive functions. The mucus plug formed by the cervical mucus resists the invasion of pathogens into the uterine cavity and is an important line of defense against vaginal pathogens invading the uterine cavity. However, when the body’s resistance decreases, or when the cervix is damaged, it is susceptible to pathogenic infections, which can lead to cervicitis. Chronic cervicitis is usually caused by acute cervicitis. As the mucous membrane of the cervical canal has many folds, once the infection occurs, it is difficult to remove the pathogens completely, which can easily lead to chronic cervicitis.
Generally speaking, simple cervicitis does not pose much of a health threat, but often the various symptoms caused by cervicitis can affect a person’s mood, work and cause a decrease in quality of life. From the perspective of cancer prevention, cervical cancer is closely related to chronic inflammatory irritation of the cervix. In recent years, it has been found that infection with certain viruses such as herpes simplex virus type II, human papilloma virus and human cytomegalovirus through sexual intercourse may have a relationship with the development of cervical cancer. It means that active treatment of chronic cervicitis and effective preventive measures are of great significance to protect women’s health and prevent cervical cancer.
Cervicitis classification
(1) Acute cervicitis.
It is an acute infection of the cervical mucosa and submucosa tissue from the ectocervix up to the endocervix. The pathogens that cause acute cervicitis are mainly bacteria, such as staphylococcus, streptococcus, Escherichia coli, gonococcus and anaerobic bacteria. The main symptoms of acute cervicitis are: increased leucorrhea, purulent and smelly; lower abdominal swelling and discomfort, lower back pain, accompanied by frequent urination, urinary urgency and painful intercourse. In the case of gonococcal infection, the symptoms are more obvious, often with yellow purulent leucorrhea, along with acute urethritis, vaginitis and endometritis, with varying degrees of fever and leukocytosis. The treatment of acute cervicitis is mainly directed at the pathogen and symptomatic. The combination of systemic and local medication and the principles of treatment are timely, adequate, standardized and thorough, as well as treatment of sexual partners.
(2) Chronic cervicitis.
It is a chronic pathological process with multiple etiologies. Long-term chronic irritation and surgical operation injury are the main causative factors of chronic cervicitis. Childbirth, abortion and surgical injuries and unclean sex can cause tiny fissures in the cervix. These tiny injuries can be the gateway for pathogenic bacteria to invade. Long-term immersion of the cervix in the leucorrhoea of vaginitis causes the squamous epithelium to fall off, creating conditions for pathogenic bacteria to invade; in addition, douching the vagina with highly concentrated acidic or alkaline solutions or putting in highly corrosive drug suppositories can also cause inflammation of the cervix.
Etiology
Chronic cervicitis is often caused by the transformation of acute cervicitis, often due to incomplete treatment of acute cervicitis, and the pathogens are hidden in the cervical mucosa to form chronic inflammation. It is often seen after childbirth, miscarriage or surgical injury to the cervix, where pathogens invade and cause infection. In some cases, there are no symptoms of acute cervicitis and chronic cervicitis occurs directly. The pathogens of chronic cervicitis are mainly Staphylococcus, Streptococcus, Escherichia coli and anaerobic bacteria. Currently, chronic cervicitis caused by Chlamydia trachomatis and Neisseria gonorrhoeae infections is increasing. In addition, herpes simplex virus may also be associated with chronic cervicitis. The pathogens invade the cervical mucosa where they are latent and often form chronic inflammation because the infection is not easily cleared due to the many folds of the cervical mucosa. Chronic cervicitis is the most common type of gynecological disease, and more than half of all married women suffer from it to varying degrees.
[Pathological types
(1) Cervical erosion.
It is a common pathological change in chronic cervicitis. The appearance of the vaginal part of the cervix at the ectocervix is a fine-grained red zone of cervical erosion. The boundary of the erosion surface is clearly defined from the normal cervical epithelium. The erosion surface is covered by an intact monolayer of cervical canal columnar epithelium, which is prone to inflammation due to low resistance of the cervical canal columnar epithelium to pathogens. In the early stage of inflammation, the erosion surface is only covered by a single layer of columnar epithelium with a flat surface, called simple erosion; subsequently, due to excessive proliferation of glandular epithelium with interstitial hyperplasia, the erosion surface is uneven and granular, called granular erosion; when the interstitial hyperplasia is significant, the surface unevenness is more obvious in the form of papillae, called papillary erosion. Cervical erosion is medically classified as mild, moderate or severe according to the size of the erosion. Mild cervical erosion is less than 1/3 of the entire cervical area; moderate cervical erosion is 1/3 to 2/3 of the entire cervical area; and severe cervical erosion is more than 2/3 of the entire cervical area. According to the depth of erosion can be divided into simple, granular and papillary type.
(2) Cervical hypertrophy.
Due to the long-term stimulation of chronic inflammation, the cervical tissue is congested and edematous, the glands and interstitium are hyperplastic, and there may be mucus retention in the deep part of the glands to form cysts, making the cervix hypertrophy of different degrees, but the surface is mostly smooth, and sometimes the protrusion of retention cysts can be seen. Finally, due to the proliferation of fibrous connective tissue, the hardness of the cervix increases.
(3) Cervical polyp.
It is the result of local mucosal hyperplasia of the cervical canal due to long-term stimulation of chronic inflammation. The uterus has a tendency to exclude foreign bodies, so that the hyperplastic mucosa gradually protrudes from the base to the ectocervix and forms polyps, one or more, generally about 1 cm in diameter, red, tongue-shaped, soft and brittle, easy to bleed, with a long and thin tip. The roots are mostly attached to the ectocervix of the cervical canal, and a few are in the wall of the cervical canal. Light microscopy showed that the polyp centered on connective tissue with congestion, edema and inflammatory cell infiltration, and covered with a layer of highly columnar epithelium, the same as the epithelium of the cervical canal. Due to the presence of inflammation, polyps can recur after removal.
(4) Cervical glandular cysts.
During the healing process of cervical erosion, new squamous epithelium covers the mouth of the cervical glandular duct or extends into the glandular duct and blocks the mouth of the glandular duct. The cyst is formed when the connective tissue around the glandular ducts becomes hyperplastic or scarred to compress the ducts, narrowing or even blocking them, blocking the drainage of glandular secretions, and retaining secretions. During gynecological examination, multiple small greenish-white vesicles containing colorless mucus are seen protruding from the surface of the cervix. If the cysts are infected, they appear as white or yellowish vesicles.
(5) Cervical mucositis (cervical canalitis).
It is a lesion confined to the mucosa and submucosa of the cervical canal. The appearance of the cervical canal is smooth and only purulent discharge is seen blocking the ectocervix, sometimes the mucosa of the cervical canal protrudes towards the ectocervix and the cervical orifice is seen to be congested and red. Due to congestion, edema, inflammatory cell infiltration and proliferation of connective tissue in the mucosa and submucosa of the cervical canal, the cervix can be enlarged.
Clinical manifestations
Chronic cervicitis mostly occurs in married women. The main symptom is increased vaginal discharge. The amount, nature, color and odor of the secretions vary depending on the pathogen, the extent and degree of inflammation. Some of the secretions are milky white mucus-like, sometimes yellowish purulent, and when accompanied by polyp formation there is easily bloody leucorrhea or bleeding after sexual intercourse. When the inflammation spreads to the pelvis along the uterosacral ligament, there may be lumbosacral pain, lower pelvic pain, etc. If an unmarried woman is normally developed and in good health, the chances of retrograde infection via the vagina are rare and the incidence of acquired cervical erosion due to chronic cervical inflammation is very low. If an unmarried woman has persistent leucorrhea increase or with color and texture changes, the cause should be identified. About 15% – 20% of unmarried women can have congenital cervical erosion. This is due to the influence of maternal estrogen in the newborn, which causes the squamous and columnar epithelial junctions of the cervix to migrate outward. If this cervical change persists it can be called congenital celiac disease, which has the appearance of cervical erosion but does not actually have significant cervical inflammation. Congenital cervical erosion can heal spontaneously due to squamous epithelial metaplasia, or it can stimulate infection and cause cervical inflammation.
[Ancillary tests].
Chronic cervicitis should be treated with vaginal discharge examination (routine leucorrhoea), cervical cytology (cancer prevention examination), colposcopy and cervical biopsy if necessary, and local cervical treatment only after excluding malignant lesions and controlling specific or non-specific infections.
[Treatment].
Moderate and severe cervical erosion, especially granular or papillary cervical erosion, should be treated aggressively. Cervical erosion with post-coital bleeding or contact bleeding on examination should also be treated. All these patients should be routinely examined for cancer prevention before treatment. If there are atypical proliferating cells, although it is not certain that cancer will occur, only treatment can actively promote the transformation of the cells to the good side to prevent future problems. The treatment of chronic cervicitis is mainly local treatment. Local treatment is to make the columnar epithelium on the cervical erosion surface necrotic and fall off, so that the new squamous epithelium can cover and achieve the purpose of cure. The main methods are medication and physical therapy.
(1) Medication.
Chronic cervicitis is treated by topical medication of the cervix. Drug topical treatment of chronic cervicitis is only applicable to cases with small cervical erosion and shallow inflammation, and there are more methods, mainly the following.
① Silver nitrate or chromic acid erosion of the eroded cervix, which is now used sparingly.
② Recombinant human alpha-2b interferon (Oping) cervical epithelium: Cervical erosion is known to be associated with several viral and Chlamydia trachomatis infections, which are also cervical cancer triggering factors. Interferons are immune substances released by cells infected with viruses. Interferon alpha is an interferon produced by virus-induced leukocytes. Recombinant human α-2b interferon has antiviral, antitumor and immunomodulatory activities. 1 capsule is inserted deep into the vagina before bedtime, close to the cervical area, once every other day, 7 times as a course of treatment, which can be repeated.
③ EPROCURE cervical and cervical canal epithelium: In recent years, the clinical use of EPROCURE concentrate has achieved certain efficacy in the treatment of cervicitis. To use, dilute the concentrated solution to 1:80~1:100 for vaginal douching, and then remove the long cotton swab soaked with the concentrated solution for 2-3 minutes after turning deep into the cervical canal, or apply the cotton swab soaked with the concentrated solution to the cervical erosion surface until the mucous membrane turns white, 1-2 times a week.
④ Systemic medication: If you have cervicitis, your cervix has a smooth appearance, but there is purulent discharge from the cervical canal, so local medication is not effective and systemic medication is required. Before systemic treatment, cervical canal secretions should be taken for bacterial culture and drug sensitivity testing to find Neisseria gonorrhoeae and Chlamydia trachomatis, and then treated with the appropriate anti-infective drugs according to the test results.
⑤ Chinese herbal medicine treatment: there are many experimental prescriptions of Chinese medicine, which have certain therapeutic effects in clinical application. Jiangxi Provincial Maternal and Child Health Hospital Chinese medicine preparation: the main components of women’s cleansing lotion are Phellodendron and bitter ginseng, generally with 10% of the solution vaginal douche or sitz bath wash vulva, once a day, two weeks for a course of treatment.
(2) Physiotherapy
Physiotherapy for chronic cervicitis is the most effective and shortest course of treatment for cervical erosion. It is suitable for cases with large erosion area and deeper inflammation infiltration. It usually requires only one treatment to cure. In recent years, new treatment instruments have been introduced, which are used clinically one after another, such as laser therapy, cryotherapy, infrared coagulation therapy, microwave therapy and the newest method of the Polaris focused ultrasound therapy.
①Electrocoagulation method: In the past, radiation wire electrocautery was used, which took longer to heal (6-8 weeks), but nowadays it is more often used electrocoagulation method to iron out the whole erosion, so it is also called electroironing method. The specific operation: first place the iron and routinely disinfect the vulva, vagina and cervix. Expose the cervix with a vaginal speculum and place the ironing tip in contact with the erosion surface and iron evenly, slightly exceeding the erosion surface. The depth of ironing is about 0.2 cm, too deep may cause bleeding and slow healing; too shallow affects the efficacy. After the ironing, the trauma surface is sprayed with furacilin powder or coated with gentamycin glycerin.
② Cryotherapy: it is an ultra-low temperature treatment, the cooling source is liquid nitrogen, the temperature is -196℃. The appropriate probe is selected according to the condition of cervical erosion during treatment. To improve the efficacy of the treatment the freeze-thaw-freezing method can be used, i.e. freezing for 1 minute, rewarming for 3 minutes and freezing again for 1 minute. It has the advantage that it is simple to perform and bleeding and cervical canal stenosis rarely occur after the procedure. The disadvantage is that there is much vaginal drainage after the procedure.
③Laser treatment: It is a high temperature treatment, the temperature can reach more than 700℃. It mainly makes the celiac tissue charred and crusted, and after the scab falls off, the trauma is covered by new squamous epithelium. The treatment of cervical erosion usually uses a carbon dioxide laser with an infrared light wavelength of 10.6µm. The preparation before treatment is the same as for electrocautery. It has the advantages of pressure, photochemical and electromagnetic field effects in addition to thermal effects, thus it has anti-inflammatory (stimulating the body to produce a strong defense immune function), analgesic (causing tissue edema to subside and reducing chemical and mechanical stimulation of nerve endings) and promoting tissue repair (enhancing the anabolic effect of epithelial cells, promoting epithelial proliferation and accelerating wound repair) in treatment, so the treatment time is short and the cure rate is high.
Focused ultrasound therapy: The system uses ultrasound to penetrate the tissue and store energy, and the ultrasound acts on the tissue, using its thermal effect, cavitation effect and other biological effects, so that the lesion tissue absorbs energy and warms up rapidly, and produces biochemical reactions, which eventually degenerate the lesion tissue and promote tissue reconstruction and microcirculation improvement to achieve the treatment purpose. Its advantages are mainly as follows
a. Accurate positioning, non-invasive tissue surface and no scar formation. It is the best treatment for chronic cervicitis in women who have not had children.
b. No tissue crusting off process after treatment, which shortens the recovery time of the patient.
c. The treatment period is available from 3-7 days after menstruation.
d. No smoke, no smell, no radiation, no toxic side effects in the treatment, it is a green and environmental protection treatment method.
【Caution for treatment】.
Chronic cervicitis and cervical cancer have some common symptoms, such as increased vaginal discharge, vaginal dripping blood or bloody leucorrhea after sexual intercourse. Therefore, treatment should pay attention to the following matters.
(1) Pre-treatment examination: Before treatment, make sure to do cervical cell cancer prevention examination and colposcopy, and if necessary, cervical biopsy to exclude cancer before treating cervicitis.
(2) Selecting the time of treatment: The time to perform various physical therapies should be within 3-7 days after menstrual cleansing. All physiotherapy is prohibited when there is acute genital inflammation.
(3) Bleeding from vaginal discharge after treatment: Various methods of physiotherapy have increased vaginal discharge, or even a large amount of blood and water-like discharge. There may be a little bleeding when the scab is removed 1-2 weeks after the procedure, and there are a few patients who bleed more when the scab is removed.
(4) Pay attention to personal hygiene and forbid sex: whether it is medication, physical therapy or surgery for cervical erosion, you should keep your vulva clean after treatment and forbid sex, bathing, swimming and vaginal douching until the trauma is completely healed (8 weeks).
(5) Ask medical history before treatment: If freezing, the patient should be asked if they have a history of heart disease before the Hyperthermia Focused Ultrasound treatment, and do an electrocardiogram if necessary. Those with heart disease are prohibited.
(6) Regular review: Regular review is required after treatment to observe the healing of the trauma until it is healed. The presence or absence of cervical canal stenosis should be noted during the review.
Celiac disease and pregnancy
(1) Celiac disease can often affect pregnancy because of the following conditions.
(1) Increased secretions from the cervix mixed with a large number of leukocytes and pathogenic bacteria, dysfunction of the cervical mucus and local reproductive immune function, disruption of the normal physiological environment of the vagina, restriction of sperm motility and shortened survival time leading to infertility.
④The cervical mucosa may grow polyps to block the cervical opening due to inflammatory stimulation of hyperplasia, which directly affects the smooth passage of sperm.
③The mucus of the uterus is sticky and hinders the normal movement of sperm. Abnormal cervical mucus secretion will affect the movement, storage and viability of sperm and cause infertility.
④There are many patients with cervical erosion who are concerned about causing infertility after using physical therapy. Generally speaking, pregnancy is quite possible when celiac disease is healed or improved with proper treatment. On the contrary, if celiac disease is left untreated for a long time, it can be a cause of infertility.
(2) Treatment of cervicitis after pregnancy: First of all, it is necessary to determine whether it is cervicitis. Due to changes in estrogen and progesterone levels in pregnant women during pregnancy, the surface of the cervix can appear like a cervicitis erosion, which is called pseudo-erosion (usually subsides after delivery). If the diagnosis of cervicitis is confirmed by the doctor, there is no need to be overly nervous and anxious. There are no studies that link cervicitis to fetal malformations. If cervicitis is not treated properly during pregnancy, it may cause premature rupture of fetal membranes and preterm delivery. Cervicitis should be treated with local medication under the guidance of a doctor and local physical therapy such as electrocautery should not be used to avoid miscarriage and premature birth of the fetus.
The prevention of chronic cervicitis]
(1) Avoid premature sexual intercourse. The cervical squamous epithelium has not yet developed during puberty, and sex can easily cause cervicitis by shedding squamous epithelial cells.
(2) Good family planning. Avoid premature, excessive and frequent childbirth and abortion. Both childbirth and abortion can cause damage to the cervix, providing opportunities for bacterial invasion.
(3) Normally, attention should be paid to menstrual and puerperal hygiene to prevent infection; avoid as much as possible surgical operations to damage the cervix locally, such as abortion, IUD, IUD removal, etc.
(4) The hygiene and health care of married women during menstruation, pregnancy, childbirth, puerperium, lactation and menopause are very important. Pay attention to vulva and vaginal cleanliness, avoid sexual intercourse during menstruation, abortion, puerperium, and after physiotherapy, and abstain from sexual intercourse during full pregnancy.
(5) Spouse circumcision is too long, the dirt in the coronal sulcus of the foreskin, is an important factor leading to the disease of the female partner. The male foreskin is too long, circumcision should be performed. Both men and women should pay attention to sexual hygiene and develop the habit of washing the vulva frequently.
(6) Chronic cervicitis is sometimes difficult to distinguish from early cervical cancer by general methods. Married women should have at least one cervical cytology examination (cancer prevention examination) every year to facilitate early detection of abnormalities and early treatment.