patho sheet(1st of Dr faisal) - Ruba Jassar

بسم الله الرحمن الرحيم

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patho 1st of dr faisal.docx

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بسم الله الرحمن الرحيم
*** Pathology of female genital tract (FGT)
Deseases affecting female genital tract mainly result in inflammation, such as in case of infection, but not all causes of inflammation are infections, especially if the inflammation starts in vulva because vulva is covered by skin so in case a desease that’s related to skin affects any part of the body and then extends to reach vulva it will lead to inflammation in vulva and then to genital tract.
Inflammation occurs due to:
- Infection (virus, bacteria, protozoa, fungi…)
- Skin disease
- Affected by sweat, perfumes, chemical substances…
- Trauma
- Others…
When inflammation occurs in this area it is associated with Discoloration, Ulceration, and Erosion… lesions affect this area especially the vulva
This infection could be sexually transmitted in some cases while not in others
Vulva when inflamed appears red with brownish hair
***Infection in this area is due to:
1) BACTERIA
There are lots and lots of types affecting vulva, the most important are:
a- Gonorrhea >>> we’ll talk about it soon (Gonococcal infection)
b- Chlamydia >>> has many subtypes affecting different areas in the body with different forms of infection
• Vulva
• Inguinal region >>> appears as lymphogranuloma which might grow big
• Conjunctiva of eye >>> trachoma
It is not very common in our country unlike in Pakistan, Afghanistan, and South of Asia….
It might also affect neonates while being delivered
c- Gordnerella >>> a common cause of infection in vulva and vagina
It causes irritation and itching but not more than this, it might involve little discharge but the most annoying is the smell
It does not develop into malignancy or infection into deeper tissues or anything else, it is just superficial.
d- Donavanosis >>> causes granuloma inguinale
Affects the inguinal region
It may extend to lower genital tract and GI tract as well
e- Spirochetes >>> Syphilis, Treponema Pallidum

 NOTE: c,d,e are localized, i.e.: they only affect the female lower genital tract causing vulvovaginatis… while there are other types extend to affect the upper parts (fallopian tube, ovaries…)
 NOTE: when mentioning the vulval infection always vagina is involved>>> that is why it is called vulvovaginatis.
2) Protozoa
- It causes Trichoma Vaginalis or Trichoma Vaginatis or Trichoma Vulvovaginatis.
- Very irritant condition
- Itching
- Abrasion
- If severe, associated with vulvovaginal discharge
3) Viruses
- So many kinds, some are very important
- Some are localized in lower genital tract ( which is vulva & vagina)
- Some might extend to cervix
- Some only causes warts while others are very dangerous and develop malignancy
a- HPV (Human Palpilloma Virus)
 Most imp among all
 Has more than 100 subtypes but only 30-40 are related to FGT (Female Genital Tract)
 Generally speaking, HPV viruses infecting FGT can be divided into:
• Low grade >>> make lesions in FGT but doesn’t produce malignancy
• High grade >>> usually associated with malignant changes in certain parts of FGT especially in lower portions
*** Infection with HPV results in:
 Candyloma Acuminatum (Genital Warts in public)
- Results from low grade HPV type 6 mainly and mostly but also can be produced by type 11
- Sexually transmitted and affects both sexes males and females
- In some books you can find that type 8 for example causes warts, this is possible but very rare… so mainly 6 & 11 (stress on 6 coz 70-80% of cases are related to type 6)
- These warts have regular 3D shape (تشبه القرنبيط بلا تشبيه)
- Some might have finger like projections resembling papilloma
- Whether cauliflower shaped with smooth surface or finger like projections with rough surface, warts must be above surface (not at equal level with surrounding tissue).

NOTE: Warts that appear on different parts of the body are related to type of HPV called Verruca vulgaris.

NOTE: It was very common that when a girl get warts she should bring an eggplant (a big one) and roast it then go to an empty place like a graveyard and burry the eggplant without being seen!!! After 2-3 days, warts disappear!!

There are many characteristics for condyloma accuminatum but we want to stress on the presence of Koilocytes. Histologically, the lesions consist of a sessile or branching epithelial proliferation of stratified squamous epithelial cells, some of which may display perinuclear cytoplasmic clearing with nuclear atypia (koilocytic atypia)>>> Benign not Malignancy
Therefore, the nucleus is wrinkled (raisin-like) surrounded by clear halos.
NOTES:
 Koilocytes: benign in stratified squamous epithelium where the nucleus is wrinkled (raisin-like) surrounded by clear halos.
 It usually occurs at lower FGT and may extend to cervix
 It is elevated with some exceptions especially in the cervix where it looks flat >>> that is why in this region it is sometimes mixed up with malignancy.
 Some recent reports say that it’s very rarely to become malignancy, so particularly it’s benign but it might be adjacent to malignancy
 % adjacent to malignancy more than % general population
 Some HPV involves malignancy and those are usually of high grade.
 Infection with HPV also results in:
 Cervical dysplasia and carcinoma
 Vulvular carcinoma
 Others (epdemodysplasia verr, laryngeal papilloma 6&8)
NOTE: the lower FGT can be infected by large number of types of viruses but the HPV is the major family and every once and while we will talk about one of them…
b- Herpes simplex
- It causes Kaposi Sarcoma which is related to herpes simplex type 8
- Actually, we’re not concerned about type 8 now coz we’re talking about FGT where TYPE 2 is the most important
- Herpes simplex type 2 mainly and type 1 rarely may affect the FGT
- Some notes about type 1:
• Usually affects the lips and oral mucosa that’s why as a dentist you should know much about it
• Transmitted by kissing or touching
• Very rarely causes infection in GT whether in males or females

- Some notes about type 2:
• Usually affects the lower genitalia (external) and may increase to reach vagina and cervix.
• Incubation period: few days – few weeks (1-3)
• After this period, small ulceration appears which is painful
• Usually, it’s sexually transmitted
• Reinfection may occur if there was an infection before whether there was ulceration or not
• Transmitted from one side to another or between partners
• Usually, superficial but Sometimes reaches nerve ganglia
• Traumatic, irritant
In many cases, neonatal herpes might develop when pregnant woman is infected and this is very dangerous because more than 50% (up to 60%) of neonates with neonatal herpes develop Encephalopathy or encephalitis
Therefore, a pregnant woman with herpes type 2, during delivery the passenger might catch the infection, that’s why it’s recommended to deliver by caesarian surgeries in this case (to prevent neonatal infection while passing through the tract)

4) Fungus (other local infection)
- Candidal infection in vulvovagina might or might not be sexually transmitted, related or not related to bad hygiene >>> i.e.: it could affect normal women, and generally, 5-15% of women in a community suffer from it.
- In some cases, women with candidal infection are given drugs and therapy several times but still they are not cured!! In this case, we suspect that they have diabetes esp. if at old age, so we send them to the lab and usually they are found to be diabetic but they do not know they are.
- So diabetes result in Candida esp. at old age and so do pregnancy because in these cases good medium for Candida is presented in vulvovaginal area
- Usually painless but sometimes it flares up and becomes severe esp. if sexually transmitted

*** PID:
- Pelvic Inflammatory Disease
- Affects lower and upper FGT (note that all infections mentioned before affect lower tract only)
- In each community the cause differs from others
- In our community it's not very common but in general it's common in western countries
- PID refers to an ascending infection that begins in the vulva or vaginal glands but then spread upward through the entire genital tract potentially involving all structures.
- There are at least 3 known causes of PID:
1. the gonococcus >>> most common (as a part of gonorrheal infection)
2. chlamydial infection
3. postabortal and postpartum infection >>> usually caused by staphylococci. Streptococci, coliform bacteria…(polymicrobial)
- We will only focus on the gonococcal infection:
-affects urinary tract (urethra) in males and females
- In males: sometimes easy to treat other times it is most difficult
- Same applied to women
- There are glands in this area, the vulvovaginal glands (Bartholin glands)
- If these glands are infected it will be associated with puss formation and becomes like a cyst… then it grows to become as big as an egg causing pain, discomfort, Fever…
- Later this cyst will extend upwards to Fallopian tube (recall that PID affects upper FGT too)
- At the opening of the tube where it communicates with ovary and peritoneum, accumulation of abscess occurs leading to multiple complications:
1. prevent the ovum from moving through the tube so ovulization of ovum will occur inside the tube leading to ectopic pregnancy
2. infertility >>> coz sperm cannot easily reach it
3. pelvic periotonitis
4. intestinal lesions and obstructions
5. bacteremia
*** gonococcal infection has tendency to reach up the cervix but it's superficial
*** polymicrobial infection has the same tendency but it affects the deep soft tissue and reaches the blood vessels up in the ovaries and fallopian tube

MORPHOLOGY:
1- Trachoma vulvovaginatis and candidal infection causes vaginal discharge that is greenish in case of Trachoma vulvovaginatis & thick whitish in case of candidal infection (كالحليب المقطع), it was described as psuedomembrane (something like farfa6!!)
This infection is associated with itching

NOTE: Candida also affects oral cavity, esophagus, … beside FGT
2- candidal infection at large shows manifestations of discharge and itching not more… but if sexually transmitted or she has diabetes or takes certain drugs, antibiotics… more manifestations and severe conditions develop
*** TO CONCLUDE:
- large number of bacteria, viruses, protozoa, fungi… cozes infection in FGT
- some grows in depth to reach soft tissues, affect lymphatics and blood vessels…. others are superficial
- some affect lower FGT… others affect both upper and lower

*** Final note:
Leukoplakia: term was used in some pathology books and still used in some
Refers to whitish discoloration in oral cavity with increase in thickness
In FGT it refers to something like this but with or without increase in thickness of covering (simple squamous epithelium)

THE END
Comments & Corrections are more than welcomed
Done by: Ruba M. Jassar
Patho lec in sun 13\3
The 1st with Dr. Faisal Kamal