Patient's question:
BR>Leukorrhea is yellow in color, often accompanied by a sensation of lower abdominal heaviness, and frequently presents with symptoms of urinary tract infection. Current condition: Generally well. Previous diagnosis and treatment history and effectiveness: A few days ago, the doctor told me I had cervicitis and prescribed me Acyclovir. I would like to ask the doctor, how effective is this medication? Thank you.Doctor's answer:
Hello! First of all, I wish you a speedy recovery! Below, I will discuss "chronic cervical cervicitis." Chronic cervical cervicitis is one of the most common gynecological diseases and may occur after acute cervical cervicitis or due to various reasons causing cervical laceration and deformation of the cervix, making it easily susceptible to external bacterial infections. Due to the symptoms of chronic cervical cervicitis often being masked by other gynecological diseases, it is often discovered during routine gynecological examinations. Through colposcopy, visible signs such as bright red, fine-grained erosions on the cervix and purulent mucopurulent discharge from the cervical canal can lead to a diagnosis. In some cases, the cervix may show local congestion and hypertrophy. After ruling out malignant lesions and controlling specific or non-specific infections, local treatment is primarily used to allow the columnar epithelium on the erosion surface to necrose and fall off, subsequently being covered by new squamous epithelium.1) Drug Therapy – There are numerous drug treatment methods for chronic cervical cervicitis, commonly including the following:
1. Local vaginal irrigation and topical medication: This is the most commonly used treatment. Irrigation solutions may include 1:5000 permanganate solution, 1:1000 povidone-iodine solution, 1% acetic acid solution, or 0.5–1% lactic acid solution. For mild superficial cases, cotton swabs dipped in 5–10% tincture of iodine or 5–10% silver nitrate solution can be used to locally erode the erosion surface, once a week, promoting healing. However, care must be taken to avoid the solution leaking to normal mucosa outside the affected area. After applying silver nitrate, physiological saline cotton balls are gently wiped. This method is now rarely used.
Local application of chlorocortisone tablets (250 mg chloramphenicol and 5 mg prednisone) can be placed in the deep vagina nightly or every other night for 10 uses per course, with effects comparable to general disinfectant irrigation. Selection can be based on the condition.
2. Vaginal lateral fornix closure: Refer to other therapy chapters for closure therapy. This can be used for chronic cervical cervicitis combined with parametritis, lumbosacral pain, and significant cervical motion pain severely affecting sexual life.
3. Chinese herbal washes (Jie Er Yin): Suitable for various acute and chronic cervical cervicitis. Its main ingredients include cinnabar, phellodendron amurense, and polygonum multiflorum. Generally, a 10% solution is used for vaginal irrigation or sitz baths, once daily, with two weeks constituting one course.
2) Physical Therapy – This is currently the most effective and shortest-course method for treating cervical erosion. It is suitable for cases with large erosion areas and deeper inflammation. Generally, only one treatment is needed for healing.
1. Electrocoagulation – Previously, radiant electrocautery was used, with longer healing times (6–8 weeks). Currently, electrocoagulation is preferred, smoothing the entire erosion area, hence also known as electroironing. According to a summary of 2,095 cases from Shandong Medical University Affiliated Hospital, the effectiveness rate of electroironing therapy for cervical erosion is 100% with a single treatment.
The procedure involves properly setting up the electroironing device, disinfecting the external genitalia, vagina, and cervix. The cervix is exposed using a vaginal speculum, and the electroironing head is applied to the erosion area for uniform electroironing, slightly extending beyond the erosion. The depth of electroironing is about 0.2 cm; excessive depth may cause bleeding and slower healing, while excessive depth may reduce effectiveness. After electroironing, the wound is sprinkled with furacilin powder or coated with tetracycline cream.
2. Cryotherapy – This is a cryogenic treatment with a coolant of liquid nitrogen at -196°C. During treatment, appropriate probes are selected based on the erosion condition. To enhance efficacy, the freeze-thaw-freeze method can be used: freeze for 1 minute, rewarm for 3 minutes, and freeze again for 1 minute. The advantages are simple operation, minimal postoperative bleeding, and reduced cervical canal stenosis. The disadvantage is excessive vaginal discharge postoperatively.
3. Laser Therapy – This is a high-temperature treatment, with temperatures exceeding 700°C. It primarily carbonizes and forms scabs on the erosion tissue, which are later replaced by new squamous epithelium after scab shedding. For cervical erosion treatment, carbon dioxide lasers with an infrared wavelength of 10.6 μm are commonly used. Preoperative preparation is similar to electroironing. The advantages include not only thermal effects but also pressure, photochemical, and electromagnetic field effects. Thus, it has anti-inflammatory effects (stimulating the body to produce a stronger defensive immune function), analgesic effects (reducing tissue edema and minimizing chemical and mechanical stimulation of nerve endings), and promoting tissue repair (enhancing epithelial cell synthesis, promoting epithelial hyperplasia, and accelerating wound healing). Therefore, treatment time is short, and the cure rate is high.
Physical therapy should be performed 3–7 days after the menstrual period. It is contraindicated during acute genital inflammation. Postoperatively, vaginal discharge may increase, so external genital hygiene should be maintained. Between postoperative weeks 4–8,, sexual intercourse, and vaginal irrigation should be avoided. If cryotherapy is performed, the patient’s medical history should be checked for heart disease, and an electrocardiogram may be necessary if required. Patients with heart disease should not undergo cryotherapy.
Acute cervical inflammation tends to become chronic due to the numerous folds of cervical mucosa and grape-like glands, making it difficult to eradicate pathogens once they invade deeply, leading to recurrent and prolonged chronic infections. This is similar to how tonsillitis, sinusitis, or dental caries can cause systemic inflammation such as arthritis or rheumatism, affecting overall health.
3) Various Local Manifestations of Chronic Cervical Cervicitis – Cervical erosion is the most common local feature during the inflammatory process of chronic cervical cervicitis. The red lesions on the cervix surface result from the shedding of squamous epithelium, replaced by columnar epithelium, with subepithelial blood vessels exposed. The erosion surface has a clear boundary with normal squamous epithelium. Since it is not true erosion, it is also called "pseudo-erosion." Depending on the severity of inflammation and the growth rate of columnar epithelium, cervical erosion can be classified into three types:
1. Simple Type – In the early stages of inflammation, the erosion surface is covered by a single layer of columnar epithelium, appearing flat and smooth externally.
2. Granular Type – Due to excessive proliferation of cervical glandular epithelium and stromal hyperplasia, the erosion surface becomes uneven, resembling granules.
3. Nipple Type – Significant glandular epithelial and stromal hyperplasia makes the surface more uneven, forming nipple-like projections.
Clinically, erosion is classified as mild (I°), moderate (II°), or severe (III°) based on the area of erosion: less than one-third of the cervix surface is mild; one-third to one-half is moderate; and more than one-half is severe.
Healing Process of Cervical Erosion – Under slightly weakened inflammation, adjacent squamous epithelium grows downward, gradually pushing the glandular epithelium, eventually being fully covered by squamous epithelium for healing. Although direct replacement by squamous epithelium occurs, indirect replacement is more common. Under the columnar epithelium, smaller round cells called basal cells or reserve cells proliferate during healing, eventually differentiating into squamous epithelium. Healing often occurs in patches. Since the newly formed squamous epithelium grows on an inflammatory tissue base, superficial cells are easily shed and thin, making them prone to recurrence of erosion. Thus, healing and inflammation alternately occur, making complete treatment difficult.
This healing process also occurs in hidden glands and columnar epithelium covering hyperplastic glandular spaces, replacing it with stratified epithelium. This glandular epithelial stratification and epidermalization is called "squamous metaplasia." The degree of metaplasia varies greatly, sometimes completely replacing glandular epithelium, other times only partially, or even forming solid cell clusters within the cervical stroma. Due to the high incidence of chronic cervical cervicitis, squamous metaplasia is found in cervical biopsies at a rate of about 70–80%. Squamous metaplasia is a change in the healing process of erosion and does not carry a tendency to cancer; it is not a precancerous lesion and should not be confused with dysplasia or atypical hyperplasia.
4) Additional Causes of Cervical Erosion –
1. Congenital Erosion – During late embryonic development, both the vagina and the vaginal part of the cervix are covered by transitional epithelium. By the sixth month, this epithelium extends into the cervical canal, and by full term, columnar epithelium grows outward beyond the external cervical os. About one-third of newborn girls retain this state, resembling adult inflammatory cervical erosion, hence the term "congenital cervical erosion." However, it typically persists for only a few days and resolves naturally after the estrogen level from the mother decreases.
2. Erosion Due to Columnar Epithelial Hyperplasia – This appears similar to inflammatory erosion but occurs only during the fertile age of ovary function, not during puberty or postmenopause, and is more common during pregnancy, often resolving spontaneously postpartum. While patients may experience increased leukorrhea, it is clean mucus. Pathological examination shows no inflammatory cell infiltration or only a few lymphocytes under the columnar epithelium, with features of papillary and glandular erosion. These findings suggest that this erosion may be caused by hormonal imbalance rather than inflammation, though secondary inflammation may develop on the erosion base. However, this is a consequence, not the cause of erosion. Erosion may be due to estrogen effects, but animal experiments have shown that testosterone injections can induce similar glandular erosion in humans. Thus, androgens may cause cervical epithelium to change into mucous and form glands, while progesterone has a similar effect, and estrogen promotes epithelial hyperplasia into highly keratinized stratified squamous epithelium.
In summary, cervical erosion is primarily caused by inflammation in most cases but may also be due to endocrine disorders. Differential diagnosis should consider the onset period, presence of inflammatory triggers or signs, and pathological examination. Treatment may also vary slightly.
Cervical Glandular Retention Cysts (Nabothian Cysts) – During chronic cervical cervicitis, cervical glands and surrounding tissues proliferate. When glandular ducts are compressed by surrounding tissue and blocked, secretions accumulate, causing glandular dilation and forming cystic tumors of varying sizes, known as "cervical glandular retention cysts" or Nabothian cysts. The contained mucus is usually clear and transparent but may become purulent if infected. These cysts are generally small and scattered, sometimes protruding from the cervix surface. Small ones are the size of millet grains, while larger ones can resemble corn kernels, appearing pale greenish-white and sometimes accompanied by erosion but often found on smooth cervix surfaces. Due to prolonged chronic inflammation, cervical tissue undergoes repeated congestion, edema, inflammatory cell infiltration, and fibrous tissue hyperplasia, leading to cervical hypertrophy, which can exceed normal size by more than double in severe cases. After inflammation subsides, congestion and edema may decrease or resolve, but due to fibrosis, the cervix remains hypertrophied even with full squamous epithelial coverage and smooth surface. Cervical glandular cysts also retain their protruding cystic shape.
5) Clinical Manifestations
1. Increased Leukorrhea – Sometimes the only symptom of chronic cervical cervicitis. It is usually viscous mucus or purulent mucus. Occasionally, blood streaks or small amounts of blood may be present, or contact bleeding may occur. Leukorrhea irritation may cause external genital itching.
2. Pain – Lower abdominal or lumbosacral pain may occur frequently, sometimes extending to the upper abdomen, thighs, or hip joints, worsening during menstruation, defecation, or sexual intercourse. If inflammation spreads backward along the uterosacral ligaments or downward along the broad ligament base, forming chronic parametritis or thickening of the main uterosacral ligaments, pain intensifies. Touching the cervix may immediately cause iliac fossa or lumbosacral pain, sometimes nausea, and may affect sexual life.
3. Bladder and Bowel Symptoms – Chronic cervical cervicitis may spread via lymphatic channels or directly affect the trigone area or surrounding connective tissue of the bladder, causing frequent urination or difficulty urinating, though urine is clear with normal urinalysis. Some cases may develop secondary urinary tract infections due to further spread of inflammation along lymphatic pathways connecting the cervix, bladder trigone, and ureters. The incidence of chronic pyelonephritis in adult women is much higher than in men, possibly related to this condition. Bowel symptoms are less common, with some patients experiencing pain during defecation.
4. Other Symptoms – Such as menstrual disorders, dysmenorrhea, pelvic heaviness, and infertility.
6) Differential Diagnosis –
- Acute Vaginitis Spreading to the Cervix vs. Cervical Canal Endometritis – It is rare for cervical inflammatory lesions to be limited to the cervical canal. Both conditions show smooth cervical surfaces, but cervical canal endometritis may have purulent mucus plugs at the external os, while acute vaginitis spreading to the cervix may have clear and transparent cervical canal mucus despite significant vaginal inflammation.
- Cervical Erosion vs. Early Cervical Cancer – Early cervical cancer is generally harder, brittle, and prone to bleeding, while cervical erosion is softer and more lubricated, with bleeding tendency only during examination, leaving bloodstains on gloves. However, most early cervical cancers cannot be differentiated from erosion without other diagnostic methods. Therefore, routine cervical scraping for cancer cells is recommended for those with erosion, and biopsy under colposcopy may be necessary if needed.
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