Cervicitis is an inflammation of the tissues of the cervix caused by bacteria, viruses or other pathogens, which can occur in an acute or chronic form. Clinical symptoms are more often absent, there may be discharge, itching, burning, pain. For diagnosis, a smear from the external pharynx, simple and extended colposcopy are used. Bacteriological methods and PCR diagnostics help to establish the pathogen, the condition of the cervix is additionally assessed using ultrasound. Treatment is carried out with medications, destructive and surgical methods are used according to indications.
N72 Inflammatory disease of the cervix
Cervicitis is more often detected in women 19-45 years old who are sexually active. Inflammation rarely occurs in isolation. The cervix forms a single system with the vagina and vulva, so cervicitis is combined with vulvitis and vaginitis. Pathology is found in 70% of women of reproductive age, the exact prevalence has not been established due to the possible asymptomatic course of the disease. Chronic cervicitis, combined with infection with the human papillomavirus (HPV), increases the risk of developing neoplastic processes of the cervix.
Causes of cervicitis
In healthy women, mucus from the cervical canal acts as a protective factor that prevents the growth of pathogenic microflora. Infection prevents the normal biocenosis of the vagina, the production of lactic acid by Dederlein sticks. If their content decreases, conditions arise for the reproduction of opportunistic flora or the penetration of pathogens. The following types of infection lead to symptoms of cervicitis:
- Conditionally pathogenic microorganisms. They are the main cause of the disease. Gram-negative flora (Klebsiella, E. coli, enterococci), non-clostridial anaerobes (proteus, bacteroids) are more often determined. Staphylococci, streptococci may be detected.
- Viruses. In women with symptoms of chronic cervicitis, HPV is diagnosed in 80% of cases. Viral infection is characterized by a subclinical or latent form, sometimes the pathogen is detected only with an in-depth examination. Cytomegalovirus, herpes virus, and rarely adenovirus can also act as a pathogenic agent.
- Chlamydia. They are the causative agent of acute cervicitis. They are found in 45% of patients. In its pure form, chlamydia infection is uncharacteristic for the symptoms of chronic inflammation, its association with obligate flora is more common.
- Trichomonads. They are determined in 5-25% of women who have turned to a gynecologist with symptoms of inflammation. Cervicitis often occurs with minimal signs of infection. The peak incidence occurs at the age of 40 years.
- Gonococci. They cause acute vaginitis and cervicitis, which can be combined with symptoms of urethritis. Chronic infections are detected in 2% of patients. They often spread to the overlying parts of the reproductive system, which causes a combination of symptoms of cervicitis with manifestations of chronic endometritis, adnexitis.
- Candida. Fungal infection develops with a decrease in immune factors, violation of the biocenosis of the vagina. Candidiasis cervicitis is supplemented by symptoms of colpitis. Exacerbations can provoke chronic diseases, antibacterial therapy, hormonal changes.
The cause of the disease may be pathogens of syphilis, tuberculosis. Sometimes there is a combination of several infections. Abortions and any traumatic manipulations that damage the cervix are a risk factor for the development of cervicitis. The probability of pathology increases with ectopia or ectropion of the cervix. Low sexual culture, frequent change of sexual partners, refusal of barrier contraception contributes to the spread of sexual infections.
Exocervix performs a protective function. Its cells contain blocks of keratin, which provide mechanical strength, and glycogen is a nutrient substrate for the vaginal microflora. The cylindrical epithelium of the endocervix performs a secretory function, mucus is secreted in it, the composition of which changes in each phase of the cycle. The peculiarity of the secret is the content of immunoglobulins.
With a decrease in protective functions, neck injury, pathogenic microorganisms penetrate the epithelium of the exo- or endocervix. After the alteration stage, desquamation of the surface epithelium is triggered, the basement membrane is exposed, and the glands are damaged. The composition of the secret changes, as a result, intercellular contacts are disrupted, immune cells are activated: macrophages, lymphocytes, histiocytes. The inflammatory reaction leads to a violation of the nuclear-cytoplasmic ratio in cells.
During the transition of acute cervicitis to chronic, the infection penetrates into the deep layers of tissues, destructive changes are observed in the cells. Cellular regeneration is activated, while apoptosis slows down, which leads to the appearance of young undifferentiated cells. When chronic cervicitis is combined with papillomavirus, dysplastic changes occur that can turn into cancer.
Cervicitis is classified on the basis of the clinical and morphological picture, features of the course of the disease. The duration of the inflammatory process and its prevalence are taken into account. Particular attention is paid to the severity of changes in the stromal and epithelial components of cervix tissues. It is possible to determine the type of cervicitis during colposcopy and with the help of histological examination:
- Acute cervicitis. Pronounced symptoms of an inflammatory reaction, serous-purulent discharge are characteristic. The cervical mucosa is edematous, prone to bleeding. Pathology can be focal, when delimited rounded foci appear on the surface of the exocervix, and diffuse, when inflammation spreads to a significant part of the neck.
- Chronic cervicitis. Hypertrophy of the cervix is observed, thickened folds of the mucous membrane of the cervical canal are formed. The cells are dystrophically altered. With endocervicitis, there is no hyperemia around the external pharynx, cloudy mucus is released, sometimes with an admixture of pus.
The structure of the outer part of the cervix differs from the mucous membrane of the endocervix. The epithelium is multilayered flat on the outside, cylindrical in the cervical canal. The inflammatory reaction may cover one of these areas, then cervicitis is classified as follows:
- Endocervicitis. An inflammatory reaction that occurred in the cervical canal.
- Exocervicitis. The epithelium of the vaginal part of the cervix became inflamed.
The etiological classification of cervicitis is based on the types of pathogens that caused inflammation. It is necessary to choose the method of therapy, the correct selection of medications and to determine the prognosis. The type of infection can be assumed by the colposcopy picture, confirmation is obtained by culture examination or PCR. The following types are distinguished:
- Nonspecific cervicitis. Symptoms appear with the reproduction of obligate microflora (E. coli, staphylococci, streptococci), as well as with hormonal changes in the body.
- Specific cervicitis. Manifestations of pathology occur after infection with sexually transmitted infections. More often it is chlamydia, trichomoniasis, gonorrhea, HPV. Less often, specific cervicitis develops with syphilis, tuberculosis.
Symptoms of cervicitis
Symptoms are often absent, manifestations depend on the nature of the course and the type of pathogen. With acute cervicitis, mucous, or pus-like discharge appears. Symptoms are more pronounced when cervicitis is combined with colpitis. Discharge is accompanied by itching and burning, discomfort when urinating. Sometimes soreness during sexual intercourse bothers. Rarely there are pulling or aching pains in the lower abdomen, in the lumbosacral region.
The signs of chronic cervicitis are similar, but less pronounced. Exacerbation of the process is provoked by menstruation, hypothermia, change of sexual partner. Sometimes painful sensations over the womb persist without aggravation, they increase during intimate relationships. A characteristic symptom of chronic inflammation is contact bleeding. Spotting is noted after sex, doctor’s examination, smear sampling.
The causative agents of nonspecific cervicitis give approximately the same symptoms, with specific infections, the clinical picture may vary. The chlamydial process is more often asymptomatic, quickly turns into a chronic form. Gonorrheal cervicitis is characterized by vivid symptoms: abundant purulent discharge, dysuric disorders. When infected with trichomonas, greenish discharge and an unpleasant odor appear.
Deterioration of the general condition in cervicitis is not detected. Fever, abdominal pain, signs of intoxication indicate the spread of infection to the uterus and appendages. If cervicitis is detected simultaneously with vaginitis, endometritis, salpingitis, the amount of discharge increases, the pain syndrome increases. The symptoms of cervicitis are more often nonspecific, not allowing to suspect exactly inflammation of the cervix.
The danger is a severe prolonged course of cervicitis and the lack of timely treatment. Severe chronic inflammation provokes ulceration of the cervix, during healing, scar tissue forms, which deforms the neck, leads to stenosis of the cervical canal. This becomes a risk factor for infertility. Cervix stenosis causes complications in childbirth, the neck loses its ability to open, ruptures form.
Infection from the endocervix often spreads to the endometrium and then ascending into the appendages, there is inflammation of the pelvic organs, which eventually leads to menstrual disorders, infertility. Chronic cervicitis without treatment leads to the development of dysplasia. This is a precancerous disease, which is characterized by the appearance of atypical cells. A particular danger is the combination of inflammation with the detection of HPV of high oncogenic risk.
Examination of women with cervicitis is carried out by an obstetrician-gynecologist. If gonorrhea is suspected, a dermatovenerologist is connected to the diagnosis and treatment. The absence of symptoms in the acute stage often leads to a late start of treatment due to untimely examination. A combination of several diagnostic methods is used to confirm the diagnosis:
- Gynecological examination. In the mirrors, an inflamed hyperemic neck is determined in the acute type of cervicitis. Petechial hemorrhages may appear on the exocervix. Touching with a tampon causes bleeding. In endocervicitis, the external pharynx protrudes in the form of a bright red rim. Mucopurulent discharge may be noticeable.
- A smear from the vagina. The composition of the microflora is being investigated – with cervicitis, the number of lactobacilli is reduced, cocci are present, gonococci, intracellularly located trichomonads can be detected. Increased white blood cell count, a lot of mucus.
- PAP test. In a cytological smear from the exo- and endocervix, signs of dyskeratosis may appear, which disappear after treatment – this distinguishes cervicitis from neoplasia. Epithelial cells have signs of cytoplasmic degeneration, hypertrophied nuclei. If symptoms of dysplasia are detected, a biopsy is necessary.
- Colposcopy. After treatment with acetic acid, cervicitis is manifested by whitening of the epithelium and fine red punctuation. Treatment with Lugol’s solution normally causes the appearance of brown spots, this does not happen with cervicitis. The epithelium looks embossed. Fine-grained iodine staining may persist.
- Biopsy. For histological examination in patients with chronic cervicitis, a section of the epithelium is taken during colposcopy. Symptoms of acute inflammation are a contraindication for a biopsy.
- PCR diagnostics. The DNA of the causative agents of cervicitis is determined. The method is valuable for diagnosis in the absence of pronounced clinical symptoms and minimal changes in the cervix. With the help of PCR, papillomaviruses are detected, their oncogenic type is specified.
Treatment of cervicitis
The purpose of pathology treatment is to suppress the inflammatory process with the help of etiotropic antibacterial, antiviral, antifungal therapy. Immunomodulatory drugs can be used at the same time. Treatment is carried out by local or systemic means, followed by restoration of the biocenosis of the vagina.
In the acute process, treatment is selected depending on the type of pathogen. Local exposure is allowed for candida infection, nonspecific inflammation. In the presence of symptoms of chlamydia, trichomonas or viral cervicitis, systemic therapy is necessary. The following groups of drugs are used for etiotropic treatment:
- With candidiasis. Clotrimazole, nystatin vaginal tablets, butoconazole cream can be used topically in the form of candles or cream. In some cases, treatment is carried out with fluconazole capsules. With manifestations of candidiasis colpitis and cervicitis, anti-relapse therapy is carried out more often than 4 times a year after the suppression of the acute process.
- With chlamydial cervicitis. Local treatment is ineffective, systemic antibacterial therapy is prescribed. The drug of choice is azithromycin. Alternative remedies belong to the groups of tetracyclines, macrolides, quinolones. After completion of the course, the control of healing is necessary.
- With trichomonas. Trichomonads belong to the simplest microorganisms, a drug with an antiprotozoal effect is used against them – metronidazole. With the resistance of trichomonads detected in 2-5% of women, tinidazole is prescribed.
- With gonococcal infection. When determining the symptoms of gonorrheal cervicitis, broad-spectrum antibiotics are used. Generation 3 cephalosporins in combination with azithromycin are recommended. The second–line drug is doxycycline. Treatment is carried out for both sexual partners.
- With HPV. A single antiviral treatment regimen has not been developed. The drug based on inosine pranobex has proven itself well. It is used for long courses simultaneously with immunocorrection using candles with interferons.
- With herpes. The main drug that suppresses the activity of the herpes simplex virus is acyclovir. It is used in the acute phase in the presence of clinical symptoms – vesicles with liquid contents on the exocervix. The drug of the additional line is famciclovir.
- With mixed infection. Most often, with exacerbations of chronic cervicitis, a combination of nonspecific microflora and fungi occurs. Combined medications are prescribed, including antibiotics of different groups and antimycotics.
The subsequent restoration of microflora is carried out by local preparations, which include lactobacilli. Treatment results can be improved by eliminating the causes of cervicitis, correcting neuroendocrine shifts. Lifestyle changes, dosed physical activity, proper nutrition help. Effective treatment with the help of physiotherapy methods: diadynamic currents, magnetotherapy, electrophoresis.
Methods of destructive treatment of cervicitis are used only when inflammation is combined with other background processes in the cervical area. With the symptoms of papillomatosis, polyps, leukoplakia, ectropion, true erosion in nulliparous women, gentle methods are first used. If they are ineffective, an additional examination is carried out and the approach is changed. Treatment is allowed in the following ways:
- Chemical moxibustion. It is performed with preparations representing solutions of acetic, nitric, oxalic acid. Medicines are applied to a tampon and applied to the hearth. This type of treatment does not lead to the formation of scarring, it is well tolerated.
- Cryodestruction. A solution of liquid nitrogen or carbon is used. A prerequisite for treatment is that the size of the focus should correspond to the diameter of the cooling nozzle, therefore, with diffuse exocervicitis, the technique is not shown. After exposure to liquid nitrogen, the pathological cells freeze out. Tissues do not scar or deform during healing.
- Laser vaporization. Pathological areas on the neck are removed by aiming with a laser, which warms up the altered cells and leads to their death. The method of treatment does not cause severe complications, scarring of the cervix, can be used in non-pregnant patients.
- Radio wave treatment. Produced by the Surgitron apparatus. The procedure is painless, a tender young epithelium is formed in place of the altered tissues. During treatment, healthy cells remain intact, radio waves affect only the pathological epithelium.
- Argonoplasmic ablation. It is carried out contactless with the help of radio waves amplified by the action of inert argon gas. The procedure can be prescribed to women of any age, including those planning pregnancy. Healing is fast, rough scars are not formed.
Surgical treatment of cervicitis is recommended in case of simultaneous diagnosis of dysplasia, cervical polyps or papillomatosis. The indication for surgery is cicatricial deformation of the cervix. Hospitalization in the department of gynecology is necessary. Cervical polyps are removed, the bed is cauterized with liquid nitrogen. Other methods of treatment may also be used:
- Loop electrosurgical excision. It is carried out after the relief of acute inflammation of the cervix. With the help of an electric mesh, the altered tissue area is removed, at the same time the vessels are sealed, which reduces the risk of bleeding. The resulting tissues are examined histologically.
- Knife conization of the neck. Performed with a scalpel. A cone-shaped section of tissue is removed, the apex directed into the cervical canal. The operation may be complicated by bleeding, currently rarely used. After manipulation, the resulting tissues are sent for histological analysis.
Prognosis and prevention
With timely treatment, it is possible to eliminate the symptoms of cervicitis, prevent its transition into a chronic disease, the appearance of complications. Prevention consists in preventing infection with STIs. It is necessary to refrain from casual sexual contact, use barrier contraception. It is possible to prevent cervical injuries by refusing abortions. If it is necessary to terminate pregnancy, it is safer to carry out the procedure at an early stage by medication.