C h a p t e r 4 0
Disorders of the Female Genitourinary System
1027
hygiene, intestinal parasites, or the presence of foreign
bodies.
Candida albicans, Trichomonas vaginalis
, and
bacterial vaginosis are the most common causes of vagi-
nitis in the childbearing years, and some organisms can
be transmitted sexually
15,16
(see Chapter 41).
The decrease in estrogen levels that occurs during peri-
menopause and post menopause can lead to an atrophic
form of vaginitis. Estrogen deficiency results in a lack of
regenerative growth of the vaginal epitheliumand changes
in the vaginal pH and flora, rendering these tissues more
susceptible to infection and irritation. Döderlein bacilli
disappear, and the vaginal secretions become less acidic.
The symptoms of atrophic vaginitis include itching,
burning, and dyspareunia. These symptoms usually can
be reversed by local application of estrogen.
Every woman normally experiences vaginal discharge
during the menstrual cycle, but it should not cause burn-
ing or itching or have an unpleasant odor. These symp-
toms suggest inflammation or infection. Because these
symptoms are common to the different types of vagi-
nitis, precise identification of the organism is essential
for proper treatment. A careful history should include
information about systemic disease conditions, the use
of drugs such as antibiotics that foster the growth of
yeast, dietary habits, stress, and other factors that alter
the resistance of vaginal tissue to infections. A physical
examination usually is done to evaluate the nature of
the discharge and its effects on the genital structures.
Microscopic examination of a saline wet-mount smear is
the primary means of identifying the organism responsi-
ble for the infection.
15
Culture methods and deoxyribo-
nucleic acid (DNA) probe tests may be needed when the
organism is not apparent on a wet-mount preparation.
Cancer of theVagina
Primary cancers of the vagina are extremely rare,
accounting for approximately 1% to 2% of all can-
cers of the female reproductive system.
6,7,11
Like vulvar
carcinoma, cancer of the vagina is largely a disease of
older women, with a peak incidence between 60 and 70
years of age.
7
Vaginal cancers may also result from local
extension of cervical cancer, from exposure to sexually
transmitted HPV, or rarely from local irritation such as
occurs with prolonged use of a pessary. Smoking and
human immunodeficiency virus (HIV) infection also
increase the risk of vaginal cancer.
Approximately 70% of vaginal cancers are squamous
cell carcinomas, with other less common types being
adenocarcinomas (15%), malignant melanomas (9%),
and sarcomas (up to 4%).
17
Squamous cell carcinomas
begin in the epithelium and progress over many years
from precancerous lesions called
vaginal intraepithelial
neoplasia
(VAIN). Not infrequently, squamous cell car-
cinoma develops some years after cervical or vulvar car-
cinoma, a sequence that supports the carcinogenic effect
in the lower genital tract related to HPV infection.
The most common symptom of vaginal carcinoma
is abnormal bleeding. Other signs or symptoms include
an abnormal vaginal discharge, a palpable mass, or
dyspareunia. Most women with preinvasive vaginal
carcinoma are asymptomatic, with the cancer being
discovered during a routine pelvic examination. The
anatomic proximity of the vagina to other pelvic struc-
tures (urethra, bladder, and rectum) permits early spread
to these areas. Pelvic pain, dysuria, and constipation are
associated symptoms.
Since most preinvasive and early invasive cancers are
silent, the routine use of vaginal cytology (Papanicolaou
[Pap] smear) is the most effective method of detection.
Diagnosis requires biopsy of suspect lesions or areas.
Because vaginal cancer is rare, there is not standard
treatment.
11
Both radiation and surgical methods are
used, with the treatment plan being determined by the
cancer type, stage of the disease (i.e., size, location, and
spread), and the woman’s age.
11
Disorders of the Uterine Cervix
The cervix is composed of two types of epithelial tis-
sue: stratified squamous and columnar epithelium. The
exocervix, or visible portion, is covered with stratified
squamous epithelium, which also lines the vagina. The
endocervix, which is the canal that leads to the endo-
metrial cavity, is lined with columnar epithelium that
contains large, branched mucus-secreting glands. The
amount and properties of the mucus secreted by the
gland cells vary during the menstrual cycle. Blockage of
the mucosal glands results in trapping of mucus in the
deeper glands, leading to the formation of dilated cysts
in the cervix called
nabothian cysts
. These are benign
cysts that require no treatment unless they become so
numerous that they cause cervical enlargement.
The junction of the squamous epithelium of the exo-
cervix and mucus-secreting columnar epithelium of the
endocervix (i.e., squamocolumnar junction) appears at
various locations on the cervix at different points in a
woman’s life (Fig. 40-8). During childhood, the squamo-
columnar junction is located just inside the external os.
High levels of hormones which occur during puberty, first
Squamous
epithelium
Columnar
epithelium
A
B
C
D
A. Menarchial
B. Menstruating
C. Menopausal
D. Postmenopausal
FIGURE 40-8.
Location of the squamocolumnar junction
(transformation zone) in menarchial, menstruating,
menopausal, and postmenopausal women.
