Ectropion

Ectropion is an eversion of the mucous membrane of the cervix, which can occur due to primary or secondary causes. This disease has an unfavorable prognosis in terms of oncopathology, so it is necessary to identify it and identify the main clinical symptoms in time. Some features of the clinic affect the treatment of each case of the disease, so you need an individual approach.

[1], [2], [3], [4], [5], [6], [7]

Causes of the ectropion

Speaking about the reasons for the development of such pathology as ectropion, it is necessary first of all to know the features of the cervical canal structure in the norm. Anatomical features of internal female organs are as follows: the vagina passes into the cervix, which begins with the external uterine yawn, then begins the cervical canal of the cervix, which ends with the internal uterine yawn and passes into the uterine cavity. Thus, the cervical canal has the shape of an elongated tube, which is bounded on both sides by the uterine pharynx. Ectropion is a pathology in which such a normal structure is disturbed, and the external throat with part of the cervical canal drops or prolapses into the vaginal cavity.

There are several main reasons for the formation of ectropion. First of all, it is necessary to distinguish the primary ectropion, which is congenital, as well as secondary - the cause of which can be many factors. Congenital ectropion happens infrequently and its main cause is hormonal disorders with a combination of congenital anomalies in the structure of internal genital organs.

Secondary or acquired ectropion develops most often after trauma or surgical interventions. Often this pathology is preceded by trauma after childbirth with a large fetus or by surgery on the uterus and cervix. In this case, the normal structure of the uterine canal is disturbed, and superimposed seams can change the configuration of not only the mucous membrane, but also the muscular. This breaks the contraction and structure of the entire cervical canal, after which a mucosal eversion may occur. Another common cause is abortion at a later date with traumatization of the uterine tissues - which leads to secondary changes in the mucosa.

[8], [9], [10]

Risk factors

For the timely diagnosis and prophylactic medical examination of such patients, it is necessary to identify the main risk factors for this pathology, which include:

1. more than three births in history with a large fetus;
2. presence of surgical interventions on the cervix or uterus;
3. repeated termination of pregnancy, especially at later periods;
4. trauma of the birth canal after childbirth;
5. obstetric pessary;
6. congenital anomalies in the structure of internal genital organs.

These factors increase the risk of developing ectropion, especially at later stages, when there is a physiological impairment of muscle tone and ligament apparatus of internal genital organs. Therefore, the medical examination of this group of patients is very important to prevent neglected cases.

[11], [12], [13], [14], [15]

Pathogenesis

The pathogenesis of the development of ectropion and changes in it is due to the primary effect of the etiological factor. Under the influence of a mucosal injury and a muscular membrane, trophism of cervical canal tissues occurs. In this case, blood supply, nervous regulation of the mucous membrane is disturbed, which provokes dystrophic changes in the cells, and this in turn ends with a dystopia of the endocervix and a prolapse of the mucous membrane. The longer such changes are expressed, the more difficult the treatment and correction of this condition. After all, further pathogenetic changes consist in deepening the dystrophic changes in cells and their metaplasia. The histological structure of the cervical canal of the cervix has its own characteristics. The vagina, which is also called exocervix, is lined with multilayer, flat, nonkeratinized epithelium, and the cervical canal, or endocervix, is constructed from a single-layered cylindrical epithelium. Between these zones there is normally a small border, called the transition zone, and it is normally located at the level of the external pharynx. When the eversion of the mucous membrane occurs with ectropion, this structure is disturbed, and the risk of metaplasia increases significantly, which increases the likelihood of malignant transformation of such an endothelium.

[16], [17], [18], [19]

Symptoms of the ectropion

Speaking about the clinical signs of the development of ectropion, it is necessary to note that the clinic differs depending on the type of pathology. Therefore, there are no specific symptoms, and the course can be asymptomatic for a long time.

According to the clinical course and the main morphological pattern, the following types of ectropion can be distinguished:

• inflammatory;
• erosive;
• ectropion with keratosis.

Inflammatory ectropion is a very conventional concept, since in any case, with the prolapse of the mucous membrane there is also a minor inflammatory reaction. But when it comes to inflammatory ectropion, here we have in mind the pronounced inflammation of a part of the fallen mucous membrane of the cervix. This is very important not only for the diagnosis of pathology, but also for therapeutic tactics. Symptoms of inflammatory ectropion often begin with the appearance of pathological vaginal discharge. There are discharges of green, yellow or white color, with an unpleasant odor, which causes itching and unpleasant sensations. Then there may be a suspicion of an infectious process. At the expressed inflammatory reaction there can be displays of an intoxication syndrome (rising of temperature of a body, an ache in a body, loss of appetite and working capacity).

Erosive ectropion often has a more pronounced clinical picture due to the erosion of the cervical mucosa and the integrity and its protective function is impaired. This form is most common, since the inversion of the mucous membrane is exposed to the action of a weakly acidic environment of the vagina and this promotes irritation of the cells with a violation of the membrane. Such erosion is most often very significant, both in size and depth. This is manifested by various symptoms - spotting outside menstruation, soreness and bleeding during sexual intercourse, dyspareunia (lack of orgasm in a woman). If the process is too tight, infectious agents may be attached. Infertility is also a frequent symptom of erosive ectropion. This is due to the fact that the normal function of the cervix is disrupted, its structure and secret does not allow the normal movement of spermatozoa. If fertilization is realized, then the movement of such a zygote is difficult and implantation is impossible. Therefore, infertility may be the only symptom of ectropion, especially when combined with erosion.

The ectropion of the cervix with keratosis is one of the cases that is peredrakovym and requires immediate action. Typically, these are neglected cases in which there is a prolonged effect of the vaginal secretion on the mucosa. This is a factor under the influence of which there is a reorganization of cells and dysplastic processes in them - this is how keratosis develops - thickening and horny mucosa. This is a dangerous condition, since the initial metaplastic processes in such cells have already begun, and further development of uncontrolled cell growth is possible. This kind of ectropion is often asymptomatic, the only changes can be during sexual intercourse - soreness or discharge.

The first signs of ectropion often develop already with pronounced changes, which is why timely preventive examinations are so important that they can detect the disease in the early stages.

Ectropion and pregnancy are a subject that is widely discussed in terms of future pregnancy and in terms of predicting the course of pregnancy, if it already exists. This disease, although dangerous in terms of infertility, but if in time to treat a woman, then she can easily endure pregnancy and give birth to a normal child. If pregnancy develops against the background of ectropion, the risk of postpartum complications in terms of traumatizing the birth canal and aggravation of the existing changes is increased. This also increases the risk of developing ectopic pregnancy and premature termination of pregnancy due to a short cervix (this happens after ectropion correction). Therefore, the issue of pregnancy with the accompanying ectropion should be carefully studied and planned. It is better before pregnancy to treat already existing pathology in order to reduce the risk of complications of pregnancy and postpartum complications.

[20], [21], [22]

Complications and consequences

The activated ectropion can be very dangerous in terms of the development of complications in the future. After all, changing the topic of the mucous membrane and the constant effect of the secretion of vaginal juice on the eversion of the mucosa can cause metaplasia of the epithelium, and in the future this entails the development of cervical cancer. Therefore, one of the complications of eversion can be considered oncopathology. Also, the consequences of untimely correction of this pathology in women of young age can be manifested in the form of infertility. This is due to the disruption of the normal structure of the cervical canal and its reproductive function, which prevents normal implantation of the ovum.

[23], [24], [25], [26], [27], [28], [29], [30], [31]

Diagnostics of the ectropion

The data of the anamnesis are very important in the diagnosis of ectropion, and especially in the identification of its causes. It is very important to know the number of pregnancies and childbirth in the history, their course, the presence of surgical interventions. Such data provide an opportunity to clarify the risk of developing any complications associated with ectropion. To suspect this pathology only on complaints or data of anamnesis is difficult. The most informative and simple method is to examine the woman in the mirrors. This allows us to detect visual changes not only to the eversion of the mucous membrane, but also to verify the version of ectropion. You can see a small swelling in this area, reddening of the mucous membrane, as well as the presence of an inflammatory plaque on the outer throat of the cervix. Also, it is possible to visually assess the degree of change and the amount of intervention that must be carried out. If we are talking about an erosive ectropion, then it is possible to see with an unaided eye a breach of the integrity of the mucous membrane at the site of eversion. Ectropion with keratosis has the appearance of a portion of the mucosa that rises above the surface and has a darker coloration and keratinization.

To confirm the diagnosis and refine the degree of change, more detailed methods of examination are needed. Analyzes are performed to exclude or confirm the infectious process, as well as to detect the degree of dismetabolic changes in the cells of the mucosa in place of ectropion. For this purpose, a smear from the vagina and cervix of the uterus is applied to the pathological flora, as well as a swab from the cervical canal to the cytological examination. If ectropion is accompanied by an inflammatory reaction, then it is possible to identify a specific pathogen with subsequent targeted treatment. It is very important to carry out a histological examination, since dysplastic processes in cells on the site of ectropion provide for a different amount of intervention, so it is necessary to determine these data. It is also important to know about changes in cells to predict complications. The results of such a study may indicate a high degree of metaplasia or only inflammatory changes.

Instrumental diagnosis is also carried out for the purpose of differential diagnosis. A very important diagnostic method is colposcopy. This examination allows you to enter a special sensor in the vagina and see the cervix in a magnification of several times. It is possible to see the altered parts of the mucosa, as well as erosion, which can not be seen with the naked eye. You can use special dyes - a solution of iodine or Lugol, which will distinguish the boundaries of the normal mucosa from keratosis or erosion with ectropion. Also, when colposcopy is possible to take a sample for biopsy, which will accurately tell about the degree of change and depth of the pathological process.

[32], [33], [34], [35], [36], [37], [38], [39], [40], [41]

Differential diagnosis

Ectropion must be clearly differentiated from many pathologies. First of all, you need to conduct a thorough diagnosis of erosion and erosive form of ectropion. Erosion and ectropion often accompany each other, but self-erosion is a more favorable form. Therefore, it is necessary to differentiate these two pathologies, and if there is an inversion of the mucosa, then even then one can speak about the ectropion.

It is also necessary to differentiate ectropion and prolapse of the cervix. These two pathologies have a similar clinical picture and a history of data on surgery or trauma. But the distinguishing feature of cervical prolapse is prolapse of all layers - both mucous and muscular, whereas in ectropion only the mucous membrane is involved in the pathological process. This can be verified by simple sounding - in case of loss, it can be done with difficulty. Also, with palpation, the tip of the finger in the case of the prolapse of the cervix will feel the muscle layer tension, which should not be the case with ectropion.

If the ectropion of considerable size and extends to the cervical canal and into the womb, it must be differentiated from the uterine myoma. This will help bimanual palpation, which allows you to identify the increase in the uterus in the volume and the presence of a nodal structure of the uterus or its increased density. This is the main diagnostic feature. It is also important in this case to conduct ultrasound, which will help to identify the increase in the uterus itself and the size of fibroids. With ectropion, ultrasound data will remain unchanged, because the process affects only the inner layer of the cervix.

Treatment of the ectropion

During the treatment of ectropion, one must take into account the type of pathology, as well as its etiology. There are cases when medical treatment is shown as the main kind of treatment, and in some cases it is preoperative preparation. The main directions that include the treatment of pathology are correction of the eversion of the mucous membrane, elimination of the inflammatory process or erosion, as well as normalization of the pH and microflora of the vagina and cervical canal. From this it appears that with an inflammatory ectropion it is necessary to perform first anti-inflammatory therapy, and then, with a significant defect in the mucosa, surgical treatment should be completed. Mandatory is the normalization of the anatomical structure of the cervix, as it prevents the development of complications.

As anti-inflammatory agents, it is recommended to use complex agents that act on bacteria, fungi, and also have antiseptic activity.

1. Neotrizol  is a combined remedy that contains two antibacterial drugs (neomycin and ornidazole), an antifungal (miconazole) and a hormonal drug (prednisolone). He thanks to this composition has a wide range of actions and through the course therapy allows you to get rid of many problems at the same time. With inflammatory ectropion, Neotrizol removes the inflammatory reaction of the cervix and allows to reduce symptoms and subsequent drug therapy. The drug is released in tableted pharmacological form and the dosage is one tablet per night for eight days. The way of using the drug - one vaginal tablet should be inserted into the applicator and inserted into the vagina at night using the applicator. After this, it takes some time to lie down in a horizontal position for the best action of the drug. Precautions - during pregnancy is not recommended treatment with this drug because of the hormonal content. Side effects occur rarely due to the local topical effect of the drug, but there may be dizziness and headache, as well as local burning and itching in the vaginal area.

With the erosive form of ectropion, anti-inflammatory treatment can be performed only with the use of a local antiseptic, since bacterial inflammation has not been confirmed.

2. Hexicon is an anti-inflammatory agent of local action, the main active substance of which is the antiseptic chlorhexidine. It inhibits the work of bacterial cells by acting on their membranes and disturbing the synthesis of DNA. The drug is available in the form of a solution and vaginal suppositories and the dosage is one suppository vaginally once a day with a course of treatment of ten days. The way of application of the preparation is the same as for any suppository - it is better to use the suppository at night after hygienic procedures. Precautions - do not use the solution inside. Side effects are possible in the form of itching, dry skin and mucous membranes of the vagina and perianal area.
3. Flamax is an anti-inflammatory suppository, which is recommended for use in severe inflammation of the mucous membrane in the area of ectropion with severe pain syndrome. The active substance of this drug is ketoprofen, which removes the mucosal edema, inflammatory reaction and has a bacteriostatic effect. The drug reduces the severity of the pain syndrome, erosive changes in the mucosa and inflammation, which contributes to a better effect in the preparation for operative treatment of ectropion. Flamax is used in the pharmacological form of rectal suppositories in a dosage of 100 milligrams. Method of administration - enter into rectum two times a day after toilet of genital organs. The minimum treatment period is a week. Precautions - is not recommended for bronchial asthma, gastritis with high acidity and gastroesophageal reflux disease. Side effects can be in the form of action on the mucous membrane of the digestive system and the formation of erosion and ulceration in the form of drug esophagitis and gastritis. It is also possible to suppress hematopoiesis and reduce the number of elements in the peripheral blood.
4. Vagilac is a remedy that helps normalize the microflora of the vagina and can be used in the preoperative and postoperative period. The main active substance of the drug is lactobacilli of different strains that normally colonize the vagina and contribute to the normalization of the pH state and inhibit the multiplication of the pathogenic flora. Dosage of the drug - one vaginal tablet per day, the course of treatment - ten days. The way of using the drug - it is necessary to use the suppository vaginally, but only in the absence of an active inflammatory process. Side effects are possible only in the form of unpleasant sensations of burning or itching in the vagina.

Vitamins and physiotherapeutic treatment of ectropion provides for the active use of such remedies during the remission period, especially in the early postoperative period. The use of laser therapy and electrophoresis prevents the development of adhesions of the cervical canal and fallopian tubes. Vitamins can be used seasonally, which increases local immune mechanisms to protect the vagina and prevents the development of secondary bacterial processes.

Operative treatment of ectropion is based on the destruction of pathological eversion of the mucous membrane and a method is used that takes into account individual characteristics. The main methods of surgical intervention are the use of a laser, high and low temperature.

Diathermocoagulation is a method of treatment in which an electric current is applied to a special scalp, capable of acting on the tissue and cutting the eversion of the mucous membrane.

Laser vaporization is a method using a laser to correct pathology, which implies the use of a laser as a means that simultaneously removes tissue and cauterizes the pathological process in the form of erosion.

Cryodestruction is cauterization of ectropion with nitrogen, which can be used for small defects without significant harm to surrounding tissues. This is the most merciful method that is recommended for use in young women.

Alternative treatment of ectropion

Alternative treatments for ectropion are not the main treatment, as they will not be able to correct anatomical changes. But it is possible to treat using herbs, which remove the inflammatory reaction and prevent the development of complications, and also act on erosive changes. The main recipes for alternative treatment are:

1. A solution from bark of alder and birch helps to normalize metabolic processes in endocervical cells. For cooking you need to take a hundred grams of dry bark of both trees, pour them with boiling water and boil for half an hour. Then, when the solution has cooled, you need to take 100 grams of this infusion instead of tea twice a day.
2. Blossoms of white acacia should be mixed with chamomile leaves and pour boiling water, then, when the solution has cooled, it is necessary to perform douching or sessile baths for fifteen minutes.
3. Birch mushroom should be poured with a liter of boiled warm water, insist in a dark place for three days, and then take a tablespoon three times a day, adding three drops of lemon juice.

Solutions of herbs and tinctures are also widely used:

1. Erosive ectropion can be successfully treated with the help of herbal extracts, which normalize the cell proliferation and repair the mucosal defect. To do this, take the leaves of chamomile, valerian and mint, pour them with water and insist for ten minutes. Such a solution should be drunk in a glass twice a day.
2. The fruit of the viburnum needs to be poured with 500 milliliters of boiled hot water, then insist and drink a glass once a day, adding a lemon slice.
3. Barberry should be insisted in hot water and drink on a tablespoon four times a day. It is especially effective in bleeding from the vagina, as well as with additional treatment in sedentary baths.
4. Grass of sweet clover is effective in ectropion in case of prolonged treatment. For medicinal tinctures, you need to take a hundred grams of grass and add a hundred grams of alcohol, then insist for a week. This tincture should be taken on a tablespoon in the morning on an empty stomach.

Homeopathic treatment can be used in the postoperative period for better tissue regeneration and restoration of hormonal balance. To this end, you can use drugs that affect not only the trophism of tissues, but also the level of hormonal changes.

1. Ruta-plus is a combined homeopathic remedy, which is recommended for the treatment of the inflammatory form of ectropion. The drug is available in the form of homeopathic granules, and its dosage is eight granules per dose three times a day. The method of application - under the tongue, dissolving until completely dissolved after eating. Side effects are not frequent, only allergic reactions are possible. Precautions - it is necessary to take into account the amount of glucose for patients on diabetes mellitus.
2. Sepia - plus is a combined homeopathic remedy, in the form of a liquid. It is available in the form of drops and the dosage of the preparation is eight drops per treatment. Method of application - the solution should be dripped into 100 milliliters of boiled water and drunk half an hour before meals. The course of treatment is not less than three months. Precautions - with recent cerebral trauma and the pathology of the vessels of the brain, use with caution. Side effects are rare, allergic skin reactions are possible.
3. Hina   is a one-component homeopathic preparation, the main active substance of which is the bark of a cinchona plant. The drug is recommended for the treatment of ectropion, which is accompanied by bloody discharge and marked erosiveness of the mucosa. The drug is released in the form of standard homeopathic granules and dosage of it - ten pellets three times a day. The way of application - under the tongue after eating after half an hour. Precautions - do not use for allergies to conifers. Side effects are in the form of a disorder of the menstrual cycle that passes after the correction of the dose.
4. Thuya  is a homoeopathic one-component agent that is used to correct the hormonal background after treatment with ectropion, especially in young women. The preparation is available in the form of drops and granules. Method of application and dosage - seven granules three times a day or ten drops per glass of warm water. Side effects are rare, dyspeptic disorders are possible.

Alternative methods of treatment and homeopathic preparations can be used in complex treatment with antibacterial local remedies, as well as against the background of surgical intervention.

[42], [43], [44], [45], [46], [47], [48]

Prevention

The role of not only the timely diagnosis of such pathology, but also the prevention of the development of ectropion is very important. The main preventive measures are nonspecific and involve avoidance of premature termination of pregnancy, frequent surgical interventions by treating chronic inflammatory diseases of the genital organs. It is necessary to have the correct tactics of conducting childbirth with avoidance of trauma to the birth canal. For the timely detection of ectropion, all routine preventive examinations should be performed at the gynecologist, especially if there are risk factors in the anamnesis. 

[49], [50], [51], [52], [53], [54], [55]

Forecast

The prognosis of ectropion with timely surgical correction and complex medical treatment is favorable, in the case of development of metaplasia it is necessary to conduct as wide a survey and urgent treatment, then the prognosis for recovery is favorable.

Ectropion is a pathology of the cervix, which is characterized by eversion of the mucous membrane with subsequent changes in cells of an inflammatory or dysplastic nature. Often the pathology develops on a background of traumatization at sorts, but there can be other reasons of the given pathology. Symptomatology can appear for the first time only when complications appear, therefore it is very important to prevent the disease by timely examinations.