Cervical Erosion Etiology When the stratified epithelium ( 复层上皮) which normally covers the vaginal portion of the cervix is replaced by columnar epithelium which is continuous with that of the cervical canal. 2. Most erosion are not infected, nor they are the result of inflammation. 3. Occurs in the newborns, pregnancy, oral contracepives Clinical Features Symptoms The only symptom is a mucoid discharge. A slight postcoital bleeding (but malignancy should be excluded) Signs A red area is seen around the external os. Classification Depends on the depth and area of the lesion Types: simple, granular, papillary Grades: I ( ＜1/3), II (1/3-2/3), III ( ＞2/3) Treatment Erosion found on routine examination should not be treated unless it is causing troublesome discharge. A cervical smear is needed before the treatment, and if necessary, colposcopy ( 阴道镜) and biopsy. Cervical ectropion ( 宫颈外翻) Physical therapy Thermal cauterization, Cryotherapy, Laser therapy Cervical Polyps Small pedunculated neoplasms of the cervix Endocervical polyp: Originating from the endocervix Ectocervical polyp: Originating from the vaginal portion Pathology Gross appearance: Endocervical polyp: Red or pink, rounded or tongue-like Ectoervical polyp: Pale, flesh-colored, smooth, rounded with a broad pedicle Microscopic: Vascular connective tissue stroma covered with columnar or squamous epithelium or both. Congestion, edema or leukocytein filtration may be present. Clinical Features Some are asymptomatic. Slight postcoital bleeding Treatment Cervical polyp should be treated. Malignant change (<1%) Polypoid cervical cancer Twisting off a polyp without an anesthetic and cauterizing the base. Recurrent cases are treated with canal dilation and cauterization of the stalk. Chronic Endocervicitis ( 宫颈粘膜炎) (Infection) Etiology Pathogens: Normal cervical and vaginal flora Pathology Thickened endocervix that produces a whitish pus A cervical os surrounded by a reddish area Hypertrophy of the lacerated cervix Clinical Features 1. Persistent leukohrrea usu. mucopurulent 2. Slight postcoital staining 3. Pains lower abdominal discomfort, lumbosacral backache, dysmenorrhea, dyspareunia 4. Infertility 5. Urinary symptoms frequency, urgency, dysuria due to subvesical lymphangitis not to cystitis Diagnosis The characteristic discharge from external os of the cervix. Cytologic and colposcopic studies are helpful, but only biopsy is definitive. Cultures are not so helpful. Treatment Even if chronic endocervicitis is asymptomatic, it should be treated. 1. Medical treatment Systemic rather than topical Based on culture and sensitivity test 2. Surgical treatment A note of caution: postoperative bleeding, infection, stricture formation, infertility. Methods: thermal therapy, cryotherapy, laser therapy conization, hysterectomy. Transmission 1) Endogenous infection (most often) Vagina, oral cavity, intestinal tract 2) Sexual contact 3) Contacting fomites ( 污染物) Pathogenesis Two phases of candida albicans 1) Yeast spores ( 芽孢相): Asymptomatic parasitism 2) Pseudohyphae ( 菌丝相): Pathogenic 3) Mechanism: a) Candida at the pseudohypha phse penetrate vaginal epithelium for nutrients b) Growing candida albicans release proteolytic enzymes and toxins etc. resulting in inflammation reaction Clinical Picture 1. Vulvovaginal pruritus (main) usually intense, coincident with menses or intercourse 2. Increased vaginal discharge The classic finding is white, thick,curd-like discharge forming patches adherent to the vaginal walls. Diagnosis 1. Wet mount microscopic identification of candida albicans in the discharge Saline: 30-50% 10% KOH: 70-80% 2. Gram’s stain: 80% 3. Culture: higher sensitivity and drug test 4. Measurement of pH value may be useful for discovering cases of complicated infection (4.0-4.7). a pH<4.5 simple infection a pH>4.5 combined infection Treatment 1. Elimination of predisposing factors 2. Topical application of antifungal agents Vaginal suppositories( 栓剂)：1) Miconazole ( 咪康唑/达克宁) a) 200mg/day for 7days b) 400mg/day for 3 days 2) Clotrimazole ( 克霉唑) a) 150mg/day for 7 days b) 150mg, twice a day for 3 days c) 500mg single dose 3) Nystatin ( 制霉菌素/米可定) 100,000units/day for 10-14 days 4) Methyl violet ( 龙胆紫) 0.5-1% , 3-4 times/week for 2 weeks. 3. Systemic medication Oral agents are used only for cases that can not be treated with topical application of antifungal drugs. Fluconazole ( 氟康唑/大扶康) 150mg, single use. 2) Itraconazole( 伊曲康唑/斯皮仁诺) a) 200mg/day for 3-5 days b) 400mg for 1 day divided in two doses 3) Ketoconazole ( 酮康唑) 200mg, once or twice/day until culture result is negative Hepatotoxicity may occur. Points of note for treating VVC Treatment should be followed-up with a premenstrual examination of the vaginal discharge. Approximately 10% of cases will not respond to initial therapy. Prolongation of treatment up to 14 days may cure some patients. Identification and elimination of predisposing factors is important. Recurrent VVC should be treated with oral therapy followed by prophylactic doses. Treatment of sexual partner? No treatment for asymptomatics. 15% should be treated Bacterial Vaginosis 细菌性阴道病Etiology 1. Imbalance of normal vaginal flora Diminution of Doderlein lactobacillus and increase in other bacteria, in particular, anaerobic bacteria. 2. Causative factors of the imbalance are unknown Gardnerella vaginalis ( 加德纳菌) Clinical Picture Symptoms: 1. 10-40% asymptomatic 2. Mild pruritus or burning sensation 3. Increased vaginal discharge and fishy odor Signs: Discharge: thin, greyish-white, homogenous, but not sticky No inflammation reaction (No epithelial edema or erythema) Diagnosis Identification of clue cells *(wet mount in saline) together with 2 of the following 3 items 1. Vaginal discharge: homogenous, thin and white 2. pH>4.5: in virtually all cases, usu. 5.0-5.5 3. Positive Whiff test (with 10% KOH) * Clue cells are desquamated epithelial cells covered with clumps of coccobacili esp. Gardnerella vaginalis ( 加德纳菌), which gives the cells a speckled ( 有小斑点) appearance. Whiff test Treatment (1) 1. Systemic therapy (oral) (80%) 1) Metronidazole 400mg, 2-3 times a day for 7 days 2) Clindamycin ( 克林霉素/氯林霉素/氯洁霉素) 300mg, twice a day for 7 days 2. Topical therapy (80%) 1) Effervescent tablets of metronidazole 200mg/day, for 7-10 days 2) 2% Clindamycin cream, once a day for 7 days 3. Vaginal washing 1-3% H2O2 , 1% lactic acid, 0.5% acetic acid Treatment (2) 1. Systemic or topical treatment has the same cure rate (80%). 2. Patients who are asymptomatic, but scheduled to have a gynecologic surgical procedure should be treated. 3. Patients who are pregnant can be treated with oral metronidazole. 4. Follow-up examination should be given 1-2 and 3-4 weeks (postmenstrual) after the treatment. Criteria for cure: Absence of clue cells with at least 1 of the following items: a) Normal vaginal discharge b) pH≤4.5 c) Whiff test negative Other forms of vulvovaginitis 1. Senile vaginitis ( 老年性阴道炎) Atrophic vaginitis( 萎缩性阴道炎) Infantile vulvovaginitis ( 婴幼儿外阴阴道炎) Differential Diagnosis of vaginitis Bacterial Vaginosis Candidiasis Trichomoniasis Complaints Vaginal discharge Vaginal epithelium Vaginal pH Whiff test Microscopic examination discharge↑mild pruritus severe pruritus burning discharge↑mild pruritus white homogenous fishy white curd-like thin purulent frothy normal edema erythema punctate hemorrhage ＞4.5 (4.7-5.7) ＜4.5 ＞5 (5.6-6.5) ＋－－Clue cells WBC rare Candida WBC some Trichomonad WBC many Inflammation of the Cervix 1. Common: 50% women of reproductive age 2. May lead to pelvic infection 3. Need to identify a venereal disease and differentiate from malignancies Cervicitis: Vaginal portion of the cervix (Ectocervix) Mucosa of the cervical canal (Endocervix) Acute Cervicitis Etiology Neisseria gonorrhoeae ( 淋病奈瑟菌) Chlamydia trachomatis ( 沙眼衣原体) causing superficial infection of the cervical columnar mucosa 2. Staphylococcus ( 葡萄球菌), streptococcus ( 链球菌), enterococcus ( 肠球菌) causing infection after an abortion, puerperium, cervical injury,