Pathology and office treatment of chronic endocervicitis

PATHOLOGY

AND OFFICE TREATMENT ENDOCERVICITIS

HARVEY BURLESON MATTHEWS,

M.D.,

OF CHRONIC

F.A.C.S.

CIinicaI Professor of Obstetrics and GynecoIogy, Long IsIand MedicaI CoIIege; Attending Obstetrician GynecoIogist, Long IsIand CoIIege and Methodist-Episcopal HospitaIs; Director, Department of Obstetrics, Coney IsIand HospitaI

and

BROOKLYN, NEW YORK

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T

has been about seventy-five years since Thomas Addis Emmett began his studies on “Erosions of the Cervix.” During these many years much has been written by innumerabIe and diverse authors on a11 phases of cervica1 infections, including the far reaching systemic infection resuIting from the underIying peIvic pathoIogy. It may be readiIy conceded, therefore, that it would be extremeIy dificult, if not impossible at the moment, to bring forth a singIe new fact regarding chronic endocervicitis. Certainly if such a fact were estabhshed it wouId be front page medica news. On the other hand, medica progress demands, from time to time, the segregation of known facts on a given subject and these, coupIed with the correIation of a sufficiently wide cIinica1 experience, are of definite practical vaIue. This is my only excuse for presenting another paper on chronic endocervicitis. The most important desideratum in the study of chronic endocervicitis is a thorough understanding of the anatomy, physiology, pathology and bacterioIogy of the cervix and those structures in juxtaposition that are reached by its lymphatic drainage. Pathologica anatomy, here as elsewhere in medicine and surgery, must be understood if we are to comprehend the modus operandi of disease processes. In both structure and function the cervicaI mucosa differs wideIy from the endometrium of the corpus uteri. The former is composed IargeIy of high coIumnar epitheIium beneath which are deep penetrating racemose.gIands whose ostia open onto the surface of the endocervica1 mucous membrane; whiIe the latter is composed of

a stroma with penetrating tubular gIands Iined with cuboidal epithelium which is constantly passing through the active changes that are essential to menstruation and deciduation. The cervica1 mucosa therefore is very prone to bacteria1 infection, particuIarly the gonococcus; while the endometrium of the corpus uteri is usually immune. ConsequentIy endocervicitis should be a very common pathologica Iesion, whereas endometritis should be seIdom encountered. PathoIogic study has proved beyond doubt the truth of this assumption. The organisms most commonly producing endocervicitis are the gonococcus, staphylococcus, streptococcus and coIon bacihus, the gonococcus and staphylococcus being by far the most prevalent. No habitat is more inviting to the gonococcus than the cohrmnar epithehum of the endocervix and the underIying compound racemose glands. Trauma, as lacerations during childbirth, instrumental diIatation, curettage, inadequate and improper cauterization, conization or surgical diathermy, the constant irritation of a stem pessary, opens up avenues for infection and are therefore predisposing factors in the production of chronic endocervicitis. Trauma, however, is onIy a contributory cause for it is ordinariIy not the extent of the trauma but the incidence and viruIency of the infection that produces the underlying pathology. In chiIdren vulvovaginitis from any cause, the exanthemata, especialIy scarlet fever and diphtheria, and the general debihtating diseases often give rise to chronic endocervicitis. Thus the hematogenous 233

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infections of the cervix cannot be denied. We have ample chnical evidence that, particularly folIowing scarIet fever, acute pelvic infection in the form of salpingitis, ovaritis, and/or endocervicitis occur. The mucosa of the cervica1 cana when chronically infected is edematous, swoIlen and often everted, while the mucosa of the portio about the externa1 OS presents a circumscribed area of gIandular prohferation. The columnar epitheIium covering the mucosa of the cervical cana1, under constant stimuIation of the infection present, actually “pushes” itself out on to the vagina1 aspect of the cervical rim, repIacing the stratified epitheIium which is normaIIy present in this situation, thus producing the so-caIIed erosion. This erosion or “red area ” about the externa1 OS, therefore, is not an uIceration, but a new formation of gIand tissue and may, under certain conditions, become maIignant. There is produced under the stimulation of continued infection, a hypersecretion from the gIanduIar structures. Sooner or Iater the crypts of these gIands become occIuded with subsequent formation of cysts (Nabothian cysts). This cystic condition, which may or may not be visabIe on inspection, increases the bulk of the aIready hypertrophied cervix and thereby interferes with its circuIation and muscular contraction. It is this pathology that is very IargeIy responsibIe for the premenstrua1 and postmenstrua1 metrorrhagia, pIus the copious mucopurulent Ieucorrhea, so constantly observed in chronic cystic endocervicitis. Beyond the confines of the cervix there is aIways some degree of posterior ceIIuIitis, particuIarIy about the uterosacral Iigaments. Likewise, particularIy when Iacerations are present, there is apt to be some degree of IateraI parametritis aIong the bases of the broad Iigaments which may extend aIong the lymphatic channeIs for a variabIe distance. Microscopicahy there may be the usua1 findings of a chronic inflammation. Often, however, there is very IittIe inflammatory changes in the stroma, and, except for a

preponderance of gIand tissue, sections appear almost as norma cervical tissue. Section of a Nabothian cyst shows a Iarge sac Iined with columnar epitheIium filled with cIear mucus or mucopus. Surrounding this there is apt to be found a chronic inflammatory zone as evidenced by small round ceil infiItration, edema, congestion or diIated lymph spaces, which of course produces more congestion and hypertrophy and this augments the pathologica picture. Infections of the cervix are characterized by a chronicity not characteristicahy found in other structures of the body, except those in the tonsils, the sinuses and the teeth. In fact, due to its similarity of behavior, the cervix has been aptIy called “the tonsi of the vagina.” The cIinica1 course therefore is sIow and insidious with IittIe or no tendency to spontaneous cure. The symptoms of chronic cervica1 inflammation are variable. Leucorrhea is aIways present; sometimes scanty, oftentimes profuse. In consistancy it may vary from cIear mucus to mucopuruIent to aImost pure pus. There may be no other symptom. On the other hand, the symptoms may be many and severe-such as low backache, bearing down sensation in the pelvis, duI1 aching pain across the Iower abdomen extending down into the peIvis, bladder urgency and frequency, with or without pain. Genera1 maIaise, headache, achy pains in the muscles and joints which may be associated with “stiff” muscles are frequent complaints. Dysmenorrhea, menorrhagia, and, in severe cases with much erosion, metrorrhagia. Dysparunia is often present. SteriIity is a frequent compIaint and must be reckoned as one of the sequeIs of chronic endocervicitis, as evidenced by the frequency with which conception foIIows its relief or cure. The prognosis in chronic endocervicitis is doubtfu1. When the infection is superficial and the concurrent inffammation mild and treatment is instituted early, compIete recovery may ensue. On the other hand, when the infection is viruIent and the coincident inff ammation severe and treat-

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the prognosis progresment inadequate, siveIy becomes more uncertain. Not only does the chronic inflammatory changes in the cervix progress but the associated lesions, as metritis, parametritis and posterior cehulitis, are continuousIy advancing. Furthermore, chronic cervical inflammation, which means Iong continued irritation, may be considered a prodrome of cervical cancer, for it is but a step from the extreme ceI1 proIiferation with an orderly arrangement that occurs in marked hyperpIastic cystic endocervicitis to the disorderIy arrangement of embryona1 ceIIs found in cancer. Modern trends in medicine are towards prevention. Education of the doctor, as we11 as the Iayman, has brought this idea to the forefront. The oId adage “an ounce of prevention is worth a pound of cure” has become the modern vogue. Gonorrhea is responsibIe for a very Iarge group of infected cervices. Prevention in this group has been a big job yieIding very poor resuhs. In the future, however, due to the recent renewed activity of a11 interested groups in the prevention and controI of gonorrhea and syphiIis, we may expect better resuIts. In the prevention of another very large group of cervical infections we must begin with the deIivery of the chiId. Good obstetrics reduces to a minimum earIy and late sequels, thereby Iessening disability. The cervix is spared much trauma if ful1 diIatation is obtained before delivery is attempted. It may be “oId fashioned” to keep the membranes intact unti1 fuI1 cervical dilatation is accomplished but nevertheIess the best obstetricians are stiI1 “out of step” with the idea of premature rupture of the membranes as a routine procedure. Only on indications do we rupture the membranes before complete or nearly compIete diIatation of the cervix. Dry Iabor is always more exhausting to the mother and Iikewise more traumatizing to the cervix. Under any condition, when a fuI1 term chiId passes through the cervix, it is lacerated either microscopicahy or macroscopically,

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usuaIly macroscopicaIIy. The extent of the Iaceration, in so far as the infection is concerned, is not of prime importance, for bacteria may enter through microscopic or macroscopic Iacerations with equat faciIity. However, adequate postpartum attention, taking care of cervical Iacerations unti1 heahng is compIeted, accomphshes much in minimizing or preventing the entrance of infection, and should be the routine after every dehvery. Extensive cervica1 lacerations, where feasible, should be repaired immediately foIIowing delivery. With a11 our admonition regarding the prevention of cervica1 infections, we stih have chronic endocervicitis occurring in 60 per cent to 80 per cent of the women seen in private and hospita1 practice. Effective treatment of chronic cervical infection is based upon the axim that “without a correct diagnosis there can be no intehigent treatment.” Furthermore a clear understanding of the underlying pathoIogy and the correct employment of the various methods at hand constitute indispensible adjuncts in the proper treatment of chronic endocervicitis. Choose a good method; perfect the technique and success is apt to foIIow its use. This we have found true in the cauterization method by the use of the smaI1 nasal type etectric cautery. * In order to more cIearIy outIine the treatment by the cautery method, all cases of chronic endocervicitis may be placed in one of the foIIowing four groups: Group I. Th e recentIy lacerated cervix of four to tweIve weeks duration of a superficia1 infection. The nulliparous cervix the seat of a miId gonorrhea1 or non-specific infection. Group 2. The Iacerated, eroded cervix of three to tweIve months duration with somewhat more and deeper infection than in Group I with perhaps a few superficia1 cysts. This may obtain in a moderately infected nuIIiparous cervix. * Other perfectIy satisfactory methods for of&e treatment of chronic endocervicitis are Hyam’s conization. accompIished by a high frequency current and coagulation diathermy.

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Group3. Th e 1acerated, everted, eroded cervix of two to five or more years duration, moderateIy deeply infected and with or

ing douche (sodium bicarbonate, borax, or sodium chloride, 4 drams to 2 quarts of hot water) once a day foIlowed immediateIy by

1 2 FIG. I. Nasal type of cautery;

No. I, bIade tip, generally used for striping or flat cauterization; Ioop used for puncturing cysts. It may aIso be used for striping

without visabIe cysts. This is found in the moderate1 y deep1y infected nuhiparous cervix with or without erosion and cyst formation. Group 4. The old lacerated, everted, eroded, hypertrophied, cystic cervix deepIy and extensiveIy infected and of long duration (from ten to forty or more years). The same condition is found in the extensiveIy infected cystic hypertrophied nuIIiparous cervix. * Such groupings, while more or less arbitrary, simpIify treatment. For exampIe, a11 of the cases in Groups I and 2 and the upper half of Group 3 may be successfully treated with the electric cautery. The cases falIing in the lower haIf of Group 3 and a11 those in Group 4 cannot be successfuIIy treated with the cautery; the Sturmdorf excision of the infected area only or amputation, using a modified Sturmdorf technique, gives exceIIent resuIts. The procedure for each group is as foIIows : Group I. Often in this earIy group we find a retroverted uterus, a few weeks that shouId be corrected. postpartum, When corrected and held in pIace with a pessary, involution of both uterus and cervix is stimuiated and hence the cervica1 discharge is lessened. LocaI application of silver nitrate “stick” or a 20 per cent soIution once a week, using an aIkaIine cleans* The author’s grouping in Christopher’s Textbook of Surgery, Phila.. W. B. Saunders Co., 1936.

No. 2, wire

the knee chest position for five to ten minutes, wiI1 destroy superficia1 infections and promote kindIy heaIing of the Iacerated tissues. Tincture of iodine 334 per cent or 4 per cent mercurochrome may be used with success. Far better, however, than any Iocal appIication, even in the treatment of these very earIy cervica1 lesions, is the use of the eIectric cautery. With the smaI1 nasa1 type cautery using the blade or Iooped wire (Fig. I, No. I and No. 2) Iinear striping (incisions) of the Iacerated eroded surface is accompIished without pain (Fig. 2, No. I). The stripings are pIaced about I cm. apart and extend 3 to 5 mm. deep, both Iips being striped at the first sitting. In these earIy Group I cases merely cauterizing the erosion with the flat surface of the cautery bIade often sufhces. Mercurochrome 4 per cent should be painted over the cauterized cervix and a cIeansing douche shouId be taken twenty-four hours Iater and repeated daiIy thereafter. Vaginal tampons in this type of offrce work are never used since we are not convinced of their accredited value. In three to eight weeks there is no sign of erosion. Inversion rather than eversion has taken pIace. HeaIing has been accompIished and the cervix is now a norma looking muItiparous cervix free of infection and therefore of discharge (Fig. 2, No. 4); Group 2. In this group the infection has gone deeper in to the cervical tissues, particuIarly the mucous membrane and

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gIands, hence topica apphcations are absolutely useless. The technique of striping is the same as in Group I, except that in this

FIG. 2. Method

of striping and process of healing. Cervix exposed and heId in pIace bv ordinarv bivalve sDecuIum. SmaIl fine single tenaculum helps mobiIize cervix, but is usuaIIy not necessary. Cautery tip (Fig. I, No. I.) heated to white heat (never blazing red) before making stripes or puncturing cysts. (Matthews. Am. Jour. Surg., 6: 414-417, 1929.)

group the cauterization must be deeper and more extensive. Begin by cauterizing only one Iip at a sitting. The striping must extend from high up in the cana1, to or nearIy to the interna OS, out over and through the everted, eroded area to normal cervicovagina1 mucous membrane, I to 1.5 cm. apart and 5 to 7 mm. deep (Fig. 3, No. I). The remaining lip may be cauterized in two weeks. When heahng has compIeteIy taken place in eight to sixteen weeks we have a fairly norma appearing multiparous cervix with very Iittle if any discharge (Fig. 3, No. 3). A note of warning shouId be sounded regarding striping (cauterization) in the canal of the cervix, for if too much of the mucous membrane with its epitheIia1 covering is destroyed epitheliaIization cannot take place in a normal manner and hence some degree of stricture or stenosis wiII result. “ IsIands ” of epitheIium must be Ieft in situ, otherwise re-epitheliaIization

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of the cervica1 cana cannot take pIace. The penci1 type cautery therefore shouId never be used in this type of work.

FIG. 3. SimiIar to Figure 2, except stripings are much deeper and cauterization generally more extensive due to Ionger standing and deeper seated infection. AI1 visible cysts are punctured after method shown in Figure 4. (Matthews. Am. Jour. Surg., 6: 414-417, 1929.)

Group 3. Th is is the borderIine group. The cautery is not successfu1 in a11 cases in this group particularly where extensive cyst formation and marked hypertrophy are present. Resort to operation by the Sturmdorf technique or amputation may be necessary. Experience counts for a great deal. CarefuI, thorough and deep cauterization is caIIed for if success is to foIIow. For the beginner faiIure is quite probable. For one experienced in cauterization complete success is certain only for those cases faIIing in the upper haIf of this group; whiIe for those in the lower half, with more extensive cyst formation and hypertrophy 0nIy partia1 success or even failure may result. Some form of anesthesia, usuaIIy IocaI, may have to be used, particuIarIy for the inexperienced hand that misdirects the hot cautery tip in an aIready apprehensive patient. Furthermore there is IikeIy to be some parametrial reaction foIIowing this type of cauterization and hence rest in bed for two or three days is in order. A warning

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must be given in this connection, viz., never cauterize this group in the presence of acute or subacute inff ammation. Marked

with the cautery but are improved, depending upon the thoroughness with which the cautery is used. Since these cases often come for the reIief of steriIity as we11as for Ieucorrhea, any form of treatment that will give at Ieast some reIief is commendable. Operation on such cervices, especiaIly amputation is not desirable. In fact arnputation of the cervix during the childbearing age is absoluteIy contraindicated, except under very specia1 circumstances. CONCLUSIONS

FIG. 4. Method of puncturing cysts. May be used aIone or in conjunction with stripings as shown in Figures z and 3. This method is appIicabIe to nuIIiparous cervix, particuIarIy gonorrheaI. Note smaI1 size of wire cautery tip. May also be used to destroy Iatent infection or abscess of Skeene’s gIands. (Matthews. Am. Jour. Surg., 6: 414-417, 1929.1

IocaI, as we11as systemic, reaction is aImost sure to follow. In fact in a11 cautery work acute and subacute inflammatory Iesions in the pelvis are very strict contraindications to its use. Group 4. This is the hopeIessIy infected cervix of Iong duration with many cysts and much hypertrophy, that nothing short of the remova of the infected area by the Sturmdorf cone operation or by amputation wiI1 reIieve the symptoms. The cautery wiI1 not remove the infected area and therefore wil1 not reIieve the symptoms, especiaIIy the IeucorrheaI discharge. The infected nuhiparous cervix (gonorrhea1 or other infection) may be also treated successfully with cautery. In the earIier stages, after a11 acute symptoms have subsided, stripings simiIar to those for Groups 2 and 3 may be carried out. Any cysts may be punctured as iIIustrated in Figure 4. Early cases properIy cauterized give exceIIent resuIts. Late cases with many deep cysts are not so successfuIIy handled

I. A cIear conception of the underlying pathology of chronic endocervicitis is essentia1 for its successfu1 management. 2. Prophylaxis against trauma, Iaceration and/or infection of the cervix is most important. Likewise the prevention of gonorrhea1 infection. 3. Efforts directed toward the postpartum heaIing of a11 cervical lacerations are paramount. 4. EarIy recognition and treatment of chronic cervica1 inff ammation gives the best resuIts. 5. The procIivity towards the deveIopment of cancer in long continued chronic cystic endocervicitis must be kept constantly in mind; notwithstanding that a few eminent authorities question the truth of this statement. 6. The grouping herein proposed makes for more successful treatment, because the diagnosis of the extent of the infection is more nearIy correct. The more extensive and deeper the infection the less successful wiI1 be the cautery treatment. 7. There is a large group of chronic endocervicitis cases in which no form of offrce treatment wiI1 effect a cure. The Sturmdorf operation or amputation of the infected cervix is therefore indicated in these cases (some in Group 3; all in Group 4). Amputation should not, unIess imperative, be performed during the childbearing period. 8. The probIem is difficuIt; opinions differ; however, with meticulous care in diagnosis and a skiIIfu1 technique, success wiI1 ordinariIy foIIow the use of the cautery.