Examination, before application of acetic acid, reveals moderate to excessive cervical and vaginal secretions, which may sometimes indicate the nature of underlying infection. In T. vaginalis infection (trichomoniasis), which is very common in tropical areas, there is copious, bubbly, frothy, malodorous, greenish-yellow, mucopurulent discharge. Bacterial infections are associated with thin, liquid, seropurulent discharge. The secretion may be foul-smelling in the case of anaerobic bacterial overgrowth, bacterial vaginosis, and Trichomonas infection. In the case of candidiasis (moniliasis) and other yeast infections, the secretion is thick and curdy (cheesy) white with intense itching resulting in a reddened vulva. Foul-smelling, dark-coloured mucopurulent discharges are associated with inflammatory states due to foreign bodies (e.g., a retained tampon). Gonorrhoea results in purulent vaginal discharge and cervical tenderness. Small vesicles filled with serous fluid may be observed in the cervix and vagina in the vesicular phase of herpes simplex viral infection. Herpetic infections are associated with episodes of painful vulvar, vaginal and cervical ulceration lasting for two weeks. Excoriation marks are evident with trichomoniasis, moniliasis and mixed bacterial infections.
A large coalesced ulcer due to herpes, or other inflammatory conditions, may mimic the appearance of invasive cancer. Chronic inflammation may cause recurrent ulceration and healing of the cervix, resulting in distortion of the cervix due to healing by fibrosis. There may be associated necrotic areas as well. A biopsy should be directed if in doubt. Rare and uncommon cervical infections, due to tuberculosis, schistosomiasis and amoebiasis, cause extensive ulceration and necrosis of the cervix with symptoms and signs mimicking invasive cancer; a biopsy will confirm the diagnosis.
If the infectious process is accompanied by marked ulceration (with or without necrosis), the ulcerated area may be covered with purulent exudate, with marked differences in the surface level of the cervix. There may be exudation of serous droplets.
Longstanding bacterial, fungal or protozoal infection and inflammation may lead to fibrosis, which appears white or pink, depending on the degree of fibrosis. The epithelium covering the connective tissue is fragile, leading to ulceration and bleeding. Appearances following acetic acid and iodine application are variable, depending on the integrity of the surface epithelium.
In the case of cervicitis, the columnar epithelium is intensely red, bleeds on contact and opaque purulent discharge is present. The columnar villous or grape-like appearance may be lost due to flattening of the villi, to repeated inflammation and to the fact that there are no clearly defined papillae (Figure 9.1
). Extensive areas of the cervix and infected vaginal mucosa appear red due to congestion of the underlying connective tissue.