II. Inflammatory and Infectious Diseases
After completing this section you will be able to:
- list the infectious diseases involving the cervix
- specify the etiologic agents and mode of transmission
- describe/recognize clinical lesions
- describe/identify characteristic histologic features
- state clinical behavior/complications
- Noninfectious (Nonspecific) Cervicitis
This is inflammation of the cervix caused by chemical (e.g. douche, deodorant)
or mechanical (e.g. tampon, diaphragm) irritation. It is often acute but may
Noninfectious cervicitis is often asymptomatic. The cervix appears red and
The histologic features are nonspecific. The inflammatory infiltrate may
comprise neutrophils or plasma cells and lymphocytes or a combination of these
Squamous metaplasia of the endocervical glandular epithelium is common in
chronic cervicitis. Often some of the mucous glands are obstructed and dilate
to form mucus-filled cysts called nabothian cysts.
- Clamydia trachomatis Cervicitis
Clamydia trachomatis is an obligate, gram-negative intracellular pathogen
of columnar epithelial cells that causes venereal infections. Clamydial cervicitis
is caused by serotypes D through K and is the most common sexually transmitted
disease in the developed countries. It may coexist with Neisseria gonorrhoeae
Question: Why is C. trachomatis an obligate intracellular organism?
The disease may be symptomatic or asymptomatic. In symptomatic cases there
is a mucopurulent cervical discharge with a reddened, congested and edematous
cervix. It may be associated with urethritis in the patient and/or partner.
The subepithelial connective tissue of the endocervix shows a nonspecific,
diffuse dense infiltrate of lymphocytes and plasma cells and also macrophages.
Occasionally, many subepithelial lymphoid follicles with germinal centers,
a condition called follicular cervicitis, are present. Follicular cervicitis
is semi-specific for clamydial cervicitis. Intracytoplasmic inclusions in
endocervical glandular or metaplastic epithelium may be seen in some cases
but is not specific for diagnosis. Diagnosis is confirmed by demonstrating
the organisms in glandular epithelial cells by immunohistochemical or immunofluorescent
techniques or by culture.
The cervix serves as a nidus for ascending infection. Endometritis occurs
in 40% and salpinghitis in 11% of cases. These are often subclinical. Postinfectious
sequelae include generalized infection of the pelvic adnexal organs (pelvic
inflammatory disease) and tubal blockage with infertility or ectopic pregnancy.
Infants born to mothers with C. trachomatis cervicitis may develop inclusion
conjunctivitis or neonatal pneumonia.
- Herpes simplex virus (HSV) Cervicitis
See section on Vulva.
Lesions involving the ectocervix are usually asymptomatic or cause profuse
watery discharge. Cervical involvement can be detected in 90% of women with
primary genital HVS infections. However, only up to 20% of women with recurrent
infections have cervical involvement. Ulceronecrotic lesions are observable
on the cervix. In some cases the lesions are so extensive as to be confused
clinically with carcinoma.
Question: How is HSV cervitis diagnosed?
- Human papilloma virus (HPV) Infection
HPV infection of the cervix is common. Over 20 serotypes infect the female
genital types. They cause a variety of lesions with the different serotypes
associated with different lesions.
Condyloma. This develops in the squamous epithelium of the ectocervix
and in foci of squamous metaplasia in the endocervix. The lesions may be flat
or exophytic condylomma acuminatum. More than 90% are flat.
Flat condylomas are not apparent grossly unless the cervix is painted with
acetic acid and examined colposcopically, when they appear as sharply demarcated,
white, slightly raised plaques.
Exophytic condyloma acuminatum can be caused by any HPV serotype but more
commonly by types 6 and 11. It appears white, the degree of whiteness depending
on the thickness of surface hyperkeratosis. Many small, maculo-papular, slightly
raised lesions may be seen in some cases.
Cervical condyloma. Note white macular lesions.
Mild dysplasia is usually caused by "low risk" HPV serotypes,
6 and 11 (see CIN).
High- grade dysplasia is caused by "high (16 and 18) and moderate
(31,33,35) risk" HPV serotypes (see CIN).
In flat condyloma, the epithelium is hyperplastic and, in absence of neoplastic
change, the cells show orderly differentiation with regular nuclear features.
Koilocytes are present in the upper and middle layers of the epithelium. The
presence of mild atypical cellular changes correlates strongly with infection
by HPV serotypes 6 and 11. High and inter-mediate risk serotypes are associated
with more severe grades of atypia and invasive carcinoma.
HPV with extensive koilocytosis.
HPV with CIN 1
The histologic features of cervical condyloma acuminatum are identical to
those seen in the vulva.
HPV infection is associated with increased risk of subsequent cervical cancer.
The entire lower genital tract is a target area for HPV infection and so long-term
follow-up with attention to the cervix, vagina and vulva is necessary.