C h a p t e r 4 0
Disorders of the Female Genitourinary System
1029
The classification of cervical precancerous lesions
has changed over time, and terms from different clas-
sification systems are currently used interchangeably.
6,7
Precancerous cell epithelial lesions are often described as
either atypical squamous cells (ASCs), low-grade intraep-
ithelial lesions (LSILs), or high-grade intraepithelial
lesions (HSILs), and cancerous lesions are termed inva-
sive squamous carcinoma. Atypical squamous cells can
be further divided into “ASC of underdetermined sig-
nificance” (ASC-US) and “ASC, cannot exclude HSIL.”
Precancerous glandular lesions are classified in a similar
manner as atypical glandular cells (AGC). Cancerous
glandular lesions are classified as adenocarcinoma.
6,11,22
The atypical cellular changes that precede frank neo-
plastic changes consistent with cancer of the cervix can
be recognized by a number of direct and microscopic
techniques, including the cytology (Pap smear), colpos-
copy, and cervicography. The appropriate use of Pap
smear cytology in cervical screening programs has been
controversial. The American Cancer Society (ACS), the
American College of Obstetricians and Gynecologists
(ACOG), and the U.S. Preventative Services Task Force
(USPSTF) have developed evidence-based guidelines for
cancer screening.
21–23
The ACOG guidelines recommend
that screening begin at age 21 regardless of sexual his-
tory and be done every 3 years between the ages of 21
and 29 years. For women ages 30 to 65 the preferred
approach is to be screened every 5 years with the com-
bination HPV and Pap smear cytology. Women who
prefer may continue to be screened every 3 years with
Pap smear cytology. It is recommended that women
discontinue screening after the age of 65 if they have
had negative cytology results in the previous 10 years.
Women who have had a total hysterectomy (removal of
the uterus and cervix) for noncancerous reasons should
discontinue cytology and HPV testing. For women who
have had a total hysterectomy because of a cancer diag-
nosis, cytology and HPV testing may still be warranted.
Women who have had a supra-cervical hysterectomy
(the uterus is removed, but the cervix remains) should
continue cytology and HPV testing as recommended by
cervical cancer screening guidelines.
Diagnosis and Treatment.
In its early stages, cervical
cancer often manifests as a poorly defined lesion of the
endocervix. Frequently, women with cervical cancer pres-
ent with abnormal vaginal bleeding, spotting, and dis-
charge. Although bleeding may assume any course, it is
reported most frequently after intercourse. Women with
more advanced disease may present with pelvic or back
pain that may radiate down the leg, hematuria, fistulas
(rectovaginal or vesicovaginal), or evidence of metastatic
disease to supraclavicular or inguinal lymph node areas.
Diagnosis of cervical cancer requires pathologic con-
firmation. Pap smear cytology results demonstrating
squamous intraepithelial lesions often require further
evaluation by colposcopy, during which a biopsy sam-
ple may be obtained from suspect areas and examined
microscopically.
7,24
Diagnostic endocervical currettage
may also be done to determine the extent of endocervi-
cal involvement.
7
Early treatment of cervical cancer involves removal
of the lesion by one of various techniques. Biopsy or
local destruction of the affected cervical tissue may be
therapeutic in and of itself. Electrocautery, cryosurgery,
or carbon dioxide laser therapy may be used to treat
moderate to severe dysplasia that is limited to the exo-
cervix (i.e., squamocolumnar junction clearly visible).
Therapeutic conization becomes necessary if the lesion
extends into the endocervical canal and can be done
surgically or with a large loop electrocautery procedure
(LEEP) in the physician’s office.
18
Depending on the stage of involvement of the cer-
vix, invasive cancer is treated with surgery, radiation
therapy, chemoradiation, or chemotherapy.
18
External-
beam irradiation and intracavitary irradiation or
brachytherapy
(i.e., insertion of radioactive materials
into the body) can be used in the treatment of cervical
cancer. Intracavitary radiation provides direct access to
the central lesion and increases the tolerance of the cer-
vix and surrounding tissues, permitting curative levels
of radiation to be used. External-beam radiation elimi-
nates metastatic disease in pelvic lymph nodes and other
structures, as well as shrinking the cervical lesion to
optimize the effects of intracavitary radiation. Surgery
can include extended hysterectomy (i.e., removal of the
uterus, fallopian tubes, ovaries, and upper portion of
the vagina) without pelvic lymph node dissection, and
radical hysterectomy with pelvic lymph node dissection.
The choice of treatment is influenced by the stage of the
disease as well as the woman’s age and health.
Disorders of the Uterus
The uterus is subject to a number of disorders, the most
common being infectious processes, endocrine imbal-
ances, neoplasms, and defects in uterine support.
Infectious Disorders of the Uterus
and Pelvic Structures
The uterus and pelvic structures are subject to infections
by a number of agents, including the sexually transmit-
ted organisms
N. gonorrhoeae
and
C. trachomatis
, as
well as endogenous microorganisms such as anaerobes,
Haemophilus influenzae
, enteric gram-negative rods,
and streptococci. Tuberculosis salpingitis is rare in the
United States but more common in developing countries.
Endometritis.
The endometrium and myometrium
are relatively resistant to infections, primarily because
the endocervix normally forms a barrier to ascending
infections. Acute endometritis is uncommon and usually
occurs after the cervical barrier is compromised by abor-
tion, delivery, or instrumentation.
6,7
Curettage (scraping
of the uterine cavity) is diagnostic and often curative
because it removes the necrotic tissue that has served as
a site for microbial growth.
Chronic inflammation of the endometrium is asso-
ciated with intrauterine devices (IUDs), pelvic inflam-
matory disease, and retained products of conception
after delivery or abortion. The presence of plasma cells
