- Intermenstrual or postcoital bleeding
- A soft, red pedunculated protrusion from the cervical canal at the external os
- Microscopic examination confirms the diagnosis of benign polyp
Cervical polyps are small, pedunculated, often sessile neoplasms of the cervix. Most originate from the endocervix; a few arise from the portio (Fig. 40–12). They are composed of a vascular connective tissue stroma and are covered by columnar, squamocolumnar, or squamous epithelium. Polyps are relatively common, especially in multigravidas over 20 years of age. They are rare before menarche, but an occasional polyp may develop after menopause. Asymptomatic polyps often are discovered on routine pelvic examination. Most are benign, but all should be removed and submitted for pathologic examination because malignant change may occur. Moreover, some cervical cancers present as a polypoid mass.
Polyps arise as a result of focal hyperplasia of the endocervix. Whether this is due to chronic inflammation, an abnormal local responsiveness to hormonal stimulation, or a localized vascular congestion of cervical blood vessels is not known. They are often found in association with endometrial hyperplasia, suggesting that hyperestrogenism plays a significant etiologic role. Most polypoid structures are vascular, often are infected, and are subject to displacement or torsion. Increased discharge and postcoital bleeding are common symptoms.
Endocervical polyps usually are red, flame-shaped, fragile growths. The polyps vary from a few millimeters in length and diameter to larger tumors 2–3 cm in diameter and several centimeters long. These polyps usually are attached to the endocervical mucosa near the external os by a narrow pedicle, but occasionally the base is broad. On microscopic examination, the stroma of a polyp is composed of fibrous connective tissue containing numerous small vessels in the center. There is often extravasation of blood and marked infiltration of the stroma by inflammatory cells (polymorphonuclear neutrophils, lymphocytes, and plasma cells). The surface epithelium resembles that of the endocervix, varying from typical picket-fence columnar cells to areas that show squamous metaplasia and mature stratified squamous epithelium. The surface often has many folds, as is much of the normal endocervical mucosa.
Ectocervical polyps are pale, flesh-colored, smooth, and rounded or elongated, often with a broad pedicle. They arise from the outer cells of the cervix and are less likely to bleed than endocervical polyps. Microscopically, ectocervical polyps are more fibrous than endocervical polyps, with few or no mucus glands, and are covered by stratified squamous epithelium.
Metaplastic alteration of both types of polyp is common. Inflammation, often with necrosis at the tip (or more extensively), is typical of both polyp types.
The incidence of malignant change in a cervical polyp is estimated to be <1%. Squamous cell carcinoma is the most common type of malignancy, although adenocarcinomas have been reported. Endometrial cancer may involve the polyp secondarily. Sarcoma rarely develops within a polyp.
Botryoid sarcoma, an embryonal rhabdomyosarcoma tumor of the cervix (or vaginal wall) resembling small pink or yellow grapes, contains striated muscle and other mesenchymal elements. It is extremely malignant.
Because polyps are a potential focus of cancer, they must be examined routinely for malignant characteristics upon removal.
Intermenstrual or postcoital bleeding is the most common symptom of cervical polyps. Leukorrhea (white or yellow mucous secretion) and menorrhagia have also been associated with cervical polyps.
Abnormal vaginal bleeding is often reported. Postmenopausal bleeding is frequently described by older women. In the setting of infertility, it is reasonable to remove them as a potential contributing factor.
Cervical polyps appear as smooth, red, fingerlike projections from the cervical canal. They usually are approximately 1–2 cm in length and 0.5–1 cm in diameter. Generally they are too soft to be felt by the examiner's finger.
Polyps high in the endocervical canal may be demonstrated by hysterosalpingogram or saline infusion sonohysterography.
Vaginal cytology will reveal signs of infection and often mildly atypical cells. Blood and urine studies are not helpful.
A polyp high in the endocervical canal may be seen with the aid of a special endocervical speculum or by hysteroscopy. Some polyps are found only at the time of diagnostic D&C in the investigation of abnormal bleeding.
Masses projecting from the cervix may be polypoid but are not necessarily polyps. Adenocarcinoma of the endometrium or endometrial sarcoma may present as a mass at the external os or extending beyond. Discharge and bleeding usually occur.
Typical polyps are easy to diagnose by gross inspection, but ulcerated and atypical-appearing growths must be distinguished from other small submucous pedunculated myomas or endometrial polyps arising low in the uterus. Any of these growths may result in dilatation of the cervix, presenting just within the os and resembling cervical polyps. Products of conception, usually decidua, may push through the cervix and resemble a polypoid tissue mass, without other signs and symptoms of pregnancy. Condylomata, submucous myomas, and polypoid carcinomas are diagnosed by microscopic examination.
Cervical polyps may be infected, some by virulent staphylococci, streptococci, or other pathogens. Serious infections occasionally follow instrumentation for the identification or removal of polyps. A broad-spectrum antibiotic should be administered at the first sign or symptom of spreading infection.
Acute salpingitis may be initiated or exacerbated by polypectomy.
It is unwise to remove a large polyp and then perform a hysterectomy several days later. Pelvic peritonitis may complicate the latter procedure. A delay of several weeks or 1 month between polypectomy and hysterectomy is recommended.
Appropriate testing for cervical discharge should be performed as indicated and treatment administered if infection is identified.
Most polyps can be removed in the physician's office. The base of the polyp is grasped with forceps and twisted until the growth is avulsed, usually causing little bleeding. When performing polypectomy it is important to cauterize its base to reduce the chances of the bleeding and to decrease the recurrence rate. Large polyps and those with sessile attachments may require excision in an operating room to allow for administration of anesthesia, use of a hysteroscope, and control of any bleeding.
If the cervix is soft, patulous, or definitely dilated and the polyp is large, hysteroscopy should be performed, especially if the pedicle is not readily visible. Exploration of the cervical and uterine cavities with the hysteroscope allows for further identification of other polyps. All tissue must be sent to a pathologist to be examined for possible underlying malignant or premalignant conditions.
Removal of simple, solitary cervical polyps is usually curative.
- Papillary projection from the exocervix
- The presence of koilocytes with or without cytologic atypia
- Colposcopic identification
Cervical papillomas are benign neoplasms found on the ectocervix. The neoplasms consist of 2 types: (1) The typical solitary papillary projection from the exocervix composed of a central core of fibrous connective tissue covered by stratified squamous epithelium. This is a true benign neoplasm, and the cause is unknown. (2) Condylomata of the cervix, which may be present in various forms ranging from a slightly raised area on the exocervix that appears white after acetic acid application (on colposcopy) to the typical condyloma acuminatum. These usually are multiple and are caused by HPV infection, an STD. Similar lesions of the vagina and vulva are often, but not always, present. Evidence of HPV infection can be found in 1–2% of cytologically screened women. The incidence is much higher in women attending STD clinics.
Contraception with condoms and other barrier methods may prevent primary infection and reinfection.
There are no characteristic symptoms of cervical papillomas; they are often discovered on routine pelvic examination or colposcopic examination for dysplasia revealed by Pap smear.
Cytologic findings of koilocytes—squamous cells with perinuclear clear halos—are strongly suggestive of HPV infection. Dysplastic squamous cells are frequently found in association with koilocytes. HPV type testing of cervical or vaginal secretions may be used to determine whether there are oncogenic risk types. Biopsy of involved epithelium reveals papillomatosis and acanthosis. Mitoses may be frequent, but in the absence of neoplastic change, the cells are orderly with regular nuclear features. Koilocytes predominate in the superficial cells.
Intraepithelial neoplasia is associated with certain types of HPV infection (see Cervical Intraepithelial Neoplasia, Chapter 48). Infection with HPV anywhere in the genital tract, vulva, vagina, or cervix increases the risk of developing squamous cell carcinoma of the cervix.
Solitary papillomas should be surgically excised and submitted for pathologic examination. Likewise, colposcopically directed biopsies of flat condylomata should be submitted for histopathologic examination. Flat condylomata may be completely removed with a biopsy instrument if they are small. More extensive lesions may require cryotherapy, loop excision, or laser vaporization. Dysplasia associated with HPV infection should be managed according to the severity and extent of the dysplastic process (see Cervical Intraepithelial Neoplasia, Chapter 48).
Because the entire lower genital tract is a target area for HPV infection, long-term follow-up with attention to the cervix, vagina, and vulva is necessary.
The paucity of smooth muscle elements in the cervical stroma makes leiomyomas that arise in the cervix uncommon. The corpus leiomyoma/cervical leiomyoma ratio is in the range of 12:1.
Although myomas usually are multiple in the corpus, cervical myomas are most often solitary and may be large enough to fill the entire pelvic cavity, compressing the bladder, rectum, and ureters (Fig. 40–13). Grossly and microscopically they are identical to leiomyomas that arise elsewhere in the uterus.
Large cervical leiomyoma filling true pelvis.
Cervical leiomyomas are often silent, producing no symptoms unless they become very large. Symptoms result from pressure on surrounding organs such as the bladder, rectum, or soft tissues of the parametrium, or obstruction of the cervical canal. Frequency and urgency of urination are the result of bladder compression. Urinary retention occasionally occurs as a result of pressure against the urethra. Heavy vaginal bleeding may occur. Hematometra may develop with obstruction of the cervix.
If the direction of growth is lateral, there may be ureteral obstruction with hydronephrosis. Rectal encroachment causes constipation. Dyspareunia may occur if the tumor occupies the vagina. Large cervical leiomyomas in pregnancy, because of their location, unlike those involving the corpus, may cause soft-tissue dystocia, preventing descent of the presenting part in the pelvis. Cervical leiomyomas of significant size can be readily palpated on bimanual examination.
A plain film may demonstrate the typical mottled calcific pattern associated with cervical leiomyomas. Hysterography may define distortion of the endocervical canal. Intravenous urography may demonstrate ureteral displacement or obstruction. Transvaginal ultrasound or MRI can be helpful in determining the size and location.
Small, asymptomatic cervical leiomyomas do not require treatment. If the leiomyomas become symptomatic, removal may be possible via hysteroscopic resection. If additional multiple leiomyomas are present that cannot be resected with the hysteroscope, uterine artery embolization, abdominal myomectomy, or hysterectomy may be indicated, depending on the patient's desire for preservation of fertility.
Because of the proximity of the pelvic ureter to the cervix, the ureter is at risk of damage in operation involving a cervical leiomyoma. Dissecting the ureters or placement of stent may prevent its injury.
Recurrence of cervical myomas after surgical removal is rare.
Varras M, Hadjilira P, Polyzos D, Tsikini A, Akrivis CH, Tsouroulas M. Clinical considerations and sonographic findings of a large nonpedunculated primary cervical leiomyoma complicated by heavy vaginal haemorrhage: a case report and review of the literature. Clin Exp Obstet Gynecol