Chronic cervicitis refers to inflammation characterized by significant infiltration of lymphocytes and plasma cells, which are chronic inflammatory cells, into the cervical stroma. It may also involve hyperplasia of cervical glandular epithelium and stroma, as well as squamous metaplasia. Chronic cervicitis can result from unresolved acute cervicitis, persistent infections by certain pathogens, or sustained abnormalities in the vaginal microbiota. The causative pathogens are similar to those of acute cervicitis.
Pathology
Chronic Endocervical Mucosal Inflammation
Due to the numerous mucosal folds in the endocervical canal, infections can lead to persistent inflammation of the endocervical mucosa. Clinically, this manifests as increased cervical mucus production and recurrent purulent discharge.
Cervical Polyps
Cervical polyps are caused by localized hyperplasia of the endocervical glandular epithelium and stroma, which protrude through the cervical os. Microscopically, the polyp surface is covered by high columnar epithelium with underlying stromal edema, abundant blood vessels, and chronic inflammatory cell infiltration. Cervical polyps rarely become malignant but require differentiation from cervical malignancies.
Cervical Hypertrophy
Prolonged stimulation from chronic inflammation may cause hyperplasia of glands and stroma. Additionally, deep-seated cervical retention cysts may also contribute to varying degrees of cervical hypertrophy, leading to an increase in tissue firmness.
Clinical Manifestations
Chronic cervicitis is often asymptomatic, although some patients may present with increased vaginal discharge, which may be pale yellow or purulent, postcoital bleeding, or intermenstrual bleeding. Occasionally, discharge irritation may lead to vulvar pruritus or discomfort. Gynecological examination may reveal cervical mucosal ectropion, edema, or erosion-like changes. The cervix may be covered by yellowish discharge, or yellowish secretion may be observed flowing from the cervical os. In severe cases, erosion-like changes may exhibit granular or papillary protrusions. If cervical polyps are present, they may appear as single or multiple, red, soft, and friable masses. They can be tongue-shaped, with stalks of varying widths, and the base may attach to the external os or reside within the cervical canal.
Diagnosis and Differential Diagnosis
A preliminary diagnosis of chronic cervicitis can be made based on clinical presentations. However, it is essential to differentiate between positive findings from gynecological examinations and common physiological or pathological changes in the cervix.
Ectopy of Cervical Columnar Epithelium and Squamous Intraepithelial Lesion (SIL)
Cervical erosion-like changes can result from physiological columnar epithelium ectopy, cervical squamous intraepithelial lesions (SIL), or even early cervical cancer, in addition to chronic cervicitis. Physiological cervical columnar epithelium ectopy describes the outward migration of the columnar epithelium from the cervical canal to the ectocervix, as seen on colposcopy. The red appearance on visual inspection is due to the transparency of thin columnar epithelium revealing the underlying stroma. This was historically termed "cervical erosion" and considered a common subtype of chronic cervicitis. However, it is now clear that "cervical erosion" is not a true pathological erosion caused by epithelial ulceration or loss, nor does it match the inflammatory infiltration seen in chronic cervicitis. Therefore, the term "cervical erosion" is no longer used as a diagnosis for chronic cervicitis. Cervical erosion-like changes represent a clinical observation that may indicate either physiological or pathological processes. Physiological columnar epithelium ectopy is common in females with high estrogen states, such as puberty, the reproductive period, pregnancy, or oral contraceptive use. Under the influence of estrogen, the squamo-columnar junction migrates outward, giving the cervix an erosion-like appearance. Cervical SIL or early-stage cervical cancer may also cause erosion-like changes. In such cases, HPV testing and/or cervical cytology are recommended. Colposcopy and biopsy may be necessary to rule out SIL and cervical cancer.
Cervical Retention Cysts
Cervical retention cysts are predominantly physiological changes. During metaplasia at the cervical transformation zone, newly formed squamous epithelium may cover the openings of cervical glands or extend into glandular lumens, obstructing glandular ducts and leading to retention of glandular secretions, resulting in cyst formation. Localized trauma or chronic cervical inflammation that narrows glandular ducts may also contribute to retention cyst formation. Microscopically, cyst walls are lined by a single layer of flat, cuboidal, or columnar epithelium. Superficial cervical retention cysts may appear as single or multiple pale bluish cysts on cervical examination and are easily diagnosed. However, deep-seated retention cysts may not present visible abnormalities on the cervical surface but instead manifest as cervical hypertrophy, for which differentiation from cervical adenocarcinoma is necessary.
Cervical Malignancies
Malignant tumors of the cervix or uterus can also present as polypoid lesions protruding from the cervical os, necessitating differentiation from cervical polyps. The approach involves excision of the cervical polyp and confirmation through histopathological examination. Additionally, deep invasive cervical cancer, particularly adenocarcinoma, may cause cervical hypertrophy. For cases of cervical hypertrophy, HPV testing, cervical cytology, or cervical canal curettage may be performed, if necessary, for differentiation.
Treatment
Different pathological types require different treatment approaches.
Chronic Endocervical Mucosal Inflammation
Treatment of chronic endocervical mucosal inflammation involves assessing whether Chlamydia trachomatis or Neisseria gonorrhoeae reinfection has occurred, whether the sexual partner has received treatment, and whether persistent dysbiosis of the vaginal microbiota is present. Treatment should target the underlying cause. When the pathogen remains unidentified, no specific effective treatment exists. For cases displaying an erosion-like appearance, asymptomatic physiological ectopy of columnar epithelium does not require intervention. For erosion-like changes accompanied by increased discharge, papillary hyperplasia, or contact bleeding, local physical therapies such as laser, cryotherapy, or microwave can be applied. Additionally, the use of traditional Chinese medicine suppositories such as Baofukang may serve as adjunctive treatment before or after physical therapy. Cervical intraepithelial neoplasia (CIN) and cervical cancer must be excluded prior to initiating therapy.
Physical therapy is the most commonly employed effective treatment for erosion-like changes. The principle of physical therapy involves the destruction of the single-layer columnar epithelium covering the erosion-like area using various physical methods. This leads to necrosis and shedding, after which the area becomes covered with a new layer of stratified squamous epithelium. Wound healing typically requires 4 to 8 weeks. Important considerations for physical therapy include:
- Performing routine cervical cancer screening prior to treatment.
- Excluding acute reproductive tract infections, as they are contraindications for physical therapy.
- Initiating treatment 3 to 7 days after menstruation has ended.
- Increased vaginal discharge and copious watery secretions may occur following the procedure. Mild bleeding may occur 1–2 weeks post-treatment during the formation and shedding of scabs.
- Avoiding activities such as tub bathing, sexual intercourse, and vaginal douching during the wound-healing period (4 to 8 weeks).
- Recognizing the potential risks associated with physical therapy, including postoperative bleeding, cervical canal stenosis, infertility, and infection. Post-treatment follow-ups are necessary to monitor wound healing until complete recovery, as well as to assess for potential complications such as cervical canal stenosis.
Cervical Polyps
Cervical polyps are treated with polypectomy. The excised polyps are sent for histopathological examination to confirm the diagnosis.
Cervical Hypertrophy
Cervical hypertrophy generally does not require treatment.