Clinicopathologic Correlations

Vaginitis is an inflammation of the vagina and vulva that is marked by pain, itching, and vaginal discharge. Normal vaginal discharge consists of mucous secretions from the cervix and vagina, as well as exfoliated vaginal cells. A normal vaginal discharge is thin and transparent and has little odor. When the normal bacterial flora in the vagina is disturbed, one or more organisms can multiply out of their normal proportions. This change in the normal flora may also make the vagina more susceptible to other invading organisms. The rapid growth of organisms produces an excess of waste products that irritate tissues, cause a burning sensation and itching, and produce a discharge with an unpleasant odor. The discharges caused by different organisms have different appearances.

Lesions of the vulva are very common. Figure 19-32 shows the vesicular stage of herpes simplex infection. Figure 19-33 shows a chancre in a woman with primary syphilis. Chancroid is a disease in which 5 to 15 days after exposure small papules or vesicles appear that break down to form tender, nonindurated ulcers. Lymphadenopathy develops. Figure 19-34 shows the classic ulceration of vulvar chancroid.

Figure 19-35 shows several of the common uterine positions.

Pelvic relaxation is a common problem. The consequences include cystocele, rectocele, and uterine prolapse. Figure 19-36 illustrates these sequelae of relaxation of the pelvic floor.

A summary of dysfunctional uterine bleeding is illustrated in Figure 19-37.

Table 19-1 lists the characteristics of common vaginal discharges. Table 19-2 summarizes the clinical features of genital ulcerations.

Although the pelvic examination can reveal many cancers of the female reproductive system, including advanced uterine cancers, it is not very effective in detecting early uterine cancer. The Pap test can reveal some early endometrial cancers, but most cases are not detected

Rectovaginal Examination
Figure 19-31 Cross-sectional view illustrating the rectovaginal examination.

by this test. In contrast, the Pap test is very effective in revealing early cancers of the cervix. For this reason, the American Cancer Society recommends the following:

1. All women should begin screening for cervical cancer about 3 years after they begin having vaginal intercourse or at age 21 years, whichever occurs first. Screening should be performed every year with the regular Pap test or every 2 years with the newer liquid-based Pap test.

2. Beginning at age 30 years, women who have had three normal Pap test results in a row may undergo screening every 2 to 3 years with either the conventional or liquid-based Pap test. Women who have certain risk factors such as DES exposure before birth, HIV infection, or a weakened immune system as a result of organ transplantation, chemotherapy, or chronic steroid use should continue to undergo screening annually.

3. Another option for women older than 30 years is to undergo screening every 3 years (but not more frequently) with either the conventional or liquid-based Pap test and with the HPV DNA test. As mentioned earlier in this chapter, an important risk factor for the development of cervical cancer is infection with HPV. It is now possible to test for the types of HPV that are most likely to cause cervical carcinoma by looking for pieces of their DNA in the cervical cells. The cells are collected in the same manner as with the Pap test.

4. Women 70 years of age or older who have had three or more normal Pap test results in a row and no abnormal Pap test results in the previous 10 years may choose to stop having cervical cancer screening. Women with a history of cervical cancer, DES exposure before birth, HIV infection, or a weakened immune system should continue to undergo screening as long as they are in good health.

5. Women who have had a total hysterectomy may also choose to stop having cervical cancer screening, unless the surgery was performed as a treatment for cervical cancer. Women who have had a hysterectomy without removal of the cervix should continue to follow the guidelines outlined previously.

Figure 19-34 Chancroid.

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