Schistosomiasis of the female genital tract and cervix is a terminology that is utilized for Infection of the parasite Schistosoma within the female genital tract and cervix. Schistosomiasis is also referred to as Bilharziasis after a German physician who was called Theodor Bilharz, who did describe the first case of urinary schistosomiasis in 1851. Schistosomiasis tends to be more common in Africa and Middle East. Schistosomiasis is uncommon within the United States of America and Europe. In Schistosomiasis endemic areas of the world, the prevalence of female genital tract schistosomiasis does range from 30% to - 75%. With regard to the female genital tract, the cervix is commonest organ to be infected by Schistosoma. The female genital tract tends to be most commonly infected by Schistosoma haematobium. Some of the other Schistosoma organisms that tend to infest the female genital do include: Schistosoma Mansoni and Schistosoma Japonicum. The clinical presentations of Schistosomiasis of the cervix / genital tract include Irregular menstruation, pelvic pain, vaginal discharge as well as bleeding from the vagina. The cervix could appear inflamed, ulcerated, nodular and friable, which could simulate a carcinoma of the cervix clinical, Schistosomiasis does increase the risk of spread of sexually transmitted infections, infertility as well as pregnancy related disorders but its relationship with cervical cancer is not clear. 

There tends to be increased vascularity within the cervicovaginal mucosa with regard to Schistosome haematobium infection.  HIV patients who have Schistosomiasis of the cervix / genital tract, often do lack a granulomatous response and obvious ova. With regard to the diagnosis of Schistosomiasis of the cervix, the optimal method for the detection of the infection tends to be by direct examination of cervical tissue which has been obtained by forceps biopsy through quantitative compressed biopsy technique. Cytologic examination of cervical smears has tended not to be a reliable method to diagnose genital Schistosomiasis.

Treatment of Schistosomiasis of the cervix and genital tract has tended to be by means of: Praziquantel. The cytology examination features of Schistosomiasis of the cervix and the female genital tract does tend to demonstrate many inflammatory cells including eosinophils, lymphocytes as well as granulomas which include multinucleated cells in association with Schistosoma ova as well as viable ova that tend to measure 150 μ × 50 μm, and which tend to be surrounded by a thick shell. Cytology examination does also demonstrate the egg of Schistosoma. Haematobium which does tend to have a characteristic prominent terminal spine, while Schistosoma. mansoni does have a lateral spine and Schistosoma Japonica tend to be slightly oval with a rudimentary lateral spine. Cytology examination could demonstrate ova in various stages of development. Cytology examination may demonstrate a few eggs which may contain a miracidium, that have brightly eosinophilic cytoplasm and haematoxylin stained nuclei. Cytology examination may also demonstrate non-viable ova that are empty with no internal structure and which may appear collapsed, shrunken, calcified, black or opaque.  Cytology examination of cervical smears may be visualised to be bloody, secondary to extensive vascularization of cervix. If scattered ova are visualised among many inflammatory cells, the diagnosis of Schistosomiasis could be challenging. Clinicians should consider treating individuals from Schistosomiasis endemic areas of the world who present with infertility empirically with Praziquantel as well as to investigate them also for Schistosomiasis of the cervix. Urologists and other clinicians who encounter female patients from Schistosomiasis endemic areas or have travelled to Schistosomiasis-endemic areas who manifest with haematuria should have a high index of suspicion to investigate the patients for haematuria as well as the possibility of having Schistosomiasis of the cervix and female genital tract. 

The World Health Organisation has continued to make efforts to educate individuals globally about Schistosomiasis on various aspects including: its definition, diagnosis., transmission, treatment as well as prevention; nevertheless, Schistosomiasis has continued to infect millions of people globally and hence it is pertinent for clinicians and all individuals globally to be reminded about Schistosomiasis so that all and sundry would have a high index of suspicion for Schistosomiasis which does affect various organs of the body.. The World Health Organisation has made salient concise summations related Schistosomiasis in general as follows: [1]

Pertinent Key facts

Schistosomiasis is a terminology that is utilized for an acute and chronic disease that is caused by parasitic worms.

People tend to bee infected during the process of routine agricultural, domestic, occupational, and recreational activities, that expose them to Schistosoma infested water.

Lack of hygiene and certain play habits of school-aged children including swimming or fishing in infested water do make them especially vulnerable to Schistosoma infection.

The control of Schistosomiasis does focus upon the reduction of Schistosomiasis via periodic, large-scale population therapy with utilization of praziquantel; a more comprehensive approach including potable water, adequate sanitation, and snail control would also help with regard to the reduction of the transmission of Schistosomiasis.

Estimates had shown that at least 236.6 million individuals required preventive treatment for schistosomiasis in 2019, out of which greater than 105.4 million people were reported to have been treated.

Schistosomiasis is a terminology that is used for an acute and chronic parasitic disease which is caused by blood flukes (trematode worms) of the genus Schistosoma [1]. Estimates had shown that at least 236.6 million people had required preventive treatment in 2019. [1] It has been iterated that preventive therapy, which should be repeated over a number of years, would reduce and prevent morbidity related to Schistosomiasis. [1] It has been documented that Schistosomiasis transmission had been reported from 78 countries. [1] Nevertheless, it has also been stated that preventive chemotherapy for schistosomiasis, where people and communities are targeted for large-scale treatment, is only required in 51 endemic countries with moderate-to-high transmission. [1] 

Infection and transmission [1]

The ensuing summations have been made related to infection and transmission of Schistosomiasis: [1] 

People do become infected when the larval forms of the parasite which are released by freshwater snails do penetrate the skin during contact with infested water. [1]

Transmission of Schistosomiasis does occur when people who are suffering from schistosomiasis contaminate freshwater sources with their excreta containing parasite eggs, which hatch in water.[1]

Within the body, the Schistosoma larvae develop into adult schistosomes. [1] The adult worms live within the blood vessels where the females release eggs. [1] Some of the eggs are passed out of the body in the faeces or urine to continue the parasite’s lifecycle. [1] Others tend to become trapped within body tissues, and they cause  immune reactions and progressive damage to organs. [1]

Epidemiology

It has been stated that Schistosomiasis is prevalent within tropical and subtropical areas, especially within poor communities which do not have access to safe drinking water and adequate sanitation. [1] It has been estimated that at least 90% of individuals who do require treatment for schistosomiasis dwell within Africa. [1] 

It has been iterated that there are generally 2 major forms of schistosomiasis including intestinal Schistosomiasis and urogenital Schistosomiasis which are caused by 5 main species of blood fluke as shown in table [1].

Table 1: Parasite species and geographical distribution of schistosomiasis (Reproduced from reference [1]

It has been documented that Schistosomiasis most often tend to affect poor and rural communities, especially, agricultural and fishing populations. [1] It has also been documented that women who do undertake domestic chores within Schistosomiasis infested water, such as washing clothes, are also at risk for the development of Schistosomiasis and they could develop female genital Schistosomiasis. [1] It has additionally been iterated that inadequate hygiene and contact with Schistosomiasis infected water do tend to make children especially vulnerable to Schistosomiasis infection. [1]

It has been documented that migration to urban regions and population movements have been introducing Schistosomiasis to new areas. [1] It has additionally been documented that increasing population size as well as the corresponding needs for power and water often tend to emanate in development schemes, and environmental modifications facilitate transmission [1].

It has been observed that with the rise in eco-tourism as well as in travel “off the beaten track”, increasing numbers of tourists are tending to contract schistosomiasis. [1] At times, tourists do manifest with severe acute infection and unusual problems including paralysis. [1]

It has been documented that Urogenital schistosomiasis is also considered to be a risk factor for HIV infection, especially with regard to women. [1]

Symptoms / Manifestations

Some of the manifestations of Schistosomiasis have been summated as follows: [1]

The symptoms of schistosomiasis tend to be caused by the body’s reaction to the worms' eggs. [1]

Intestinal schistosomiasis could result in the development of abdominal pain, diarrhoea, as well as blood in the stool. [1] Liver enlargement is stated to be common in advanced cases of Schistosomiasis, and this tends to be frequently associated with an accumulation of fluid within the peritoneal cavity and hypertension of the abdominal blood vessels. [1] In such cases there might also be enlargement of the spleen.[1]

The classic sign of urogenital schistosomiasis has tended to be haematuria (blood in urine). [1] Fibrosis of the urinary bladder and ureter, as well as kidney damage have been sometimes diagnosed in advanced cases of Schistosomiasis. [1] Urinary bladder cancer is another possible complication in the later stages of Schistosomiasis. [1] With regard to women, urogenital schistosomiasis could manifest with genital lesions, vaginal bleeding, pain during sexual intercourse, as well as nodules within the vulva. [1] With regard ton men, urogenital schistosomiasis could induce pathology of the seminal vesicles, prostate, and other organs. [1] Schistosomiasis also do tend to be associated with other long-term irreversible consequences, including infertility.[1]

It has been iterated that the economic and health effects of schistosomiasis tend to be considerable and Schistosomiasis does disable more than it does kill. [1] With regard to children, it has been iterated that Schistosomiasis could cause anaemia, stunting and a reduced ability to learn, even though the effects usually tend to be reversible with therapy. [1] It has been documented that chronic schistosomiasis could affect people’s ability to work and in some cases it could emanate in death. [1] It has been stated that the number of deaths attributable to schistosomiasis is difficult to estimate in view of hidden pathologies such as liver and kidney failure, bladder cancer and ectopic pregnancies due to female genital schistosomiasis. [1] 

It has been documented that the death estimates attributable to Schistosomiasis need to be re-assessed, in view of the fact that it does vary between 24 072 [1] [2] and 200 000 [1] [3] globally per year. In 2000, WHO had estimated the annual death rate at 200 000 globally. [1] It was felt that this should have decreased considerably in view of the impact of a scale-up in large-scale preventive chemotherapy campaigns over the past decade. [1]

Diagnosis

The ensuing summations have been made regarding the diagnosis of Schistosomiasis. [1]

Schistosomiasis has tended to be diagnosed via the detection of parasite eggs within stool or urine specimens. [1] Antibodies and/or antigens that have been detected within blood or urine samples are also indications of Schistosomiasis infection. [1]

For urogenital schistosomiasis, a filtration technique utilising nylon, paper or polycarbonate filters is the standard diagnostic technique. [1] Children who have Schistosoma. haematobium almost always do have non-visible blood in their urine (non-visible haematuria) which can be detected by chemical reagent strips. [1]

The eggs of intestinal schistosomiasis could be identified within faecal specimens through a technique that utilizes methylene blue-stained cellophane soaked in glycerin or glass slides, which is known as the Kato-Katz technique. [1] In Schistosoma. mansoni transmission areas, CCA (Circulating Cathodic Antigen) test could also be utilised. [1] 

With regard to individuals who dwell within Schistosomiasis non-endemic or low-transmission areas, serological and immunological tests might be useful in demonstrating exposure to Schistosoma infection and the need for thorough examination, treatment as well as follow-up. [1] 

Prevention and control

Some of the Schistosomiasis prevention and control strategies have been summarized as follows: [1]

The control of Schistosomiasis has tended to be based upon large-scale therapy of at-risk population groups, access to safe water, improved sanitation, hygiene education, and snail control. [1]

The WHO strategy for schistosomiasis control has focused upon reducing the disease through periodic, targeted treatment with praziquantel through the large-scale treatment (preventive chemotherapy) of affected populations.[1] This does involve regular treatment of all at-risk groups. [1] It has been iterated that within a few countries, where there is low transmission of Schistosomiasis, the interruption of the transmission of the disease should be aimed for. [1]

Groups that tend to be targeted for treatment include: [1] 

Pre-school-aged children

School-aged children in endemic areas.

Adults who are considered to be at risk for the development of Schistosomiasis within endemic areas, and people whose occupations do involve contact with Schistosomiasis infested water, such as fishermen, farmers, irrigation workers, and women whose domestic tasks bring them in contact with infested water.

Entire communities who dwell within highly endemic areas.

It has been iterated that the WHO has recommended treatment of preschool aged children. [1] It has also been documented that currently, there is no suitable formulation of praziquantel to include them in current large-scale treatment programmes. [1] 

It has been documented that a paediatric formulation of praziquantel is under development and once it has become available, Pre-school-aged children would be included in large-scale treatment (preventive chemotherapy) campaigns. [1]

The WHO [1] has iterated that the frequency of treatment is determined by the prevalence of infection in school-age children. In high-transmission areas, treatment may have to be repeated every year for several years. Monitoring is essential to determine the impact of control interventions. [1]

The aim of the World Health Organisation (WH) is to reduce the Schistosomiasis disease related morbidity and transmission towards the elimination of the disease as public health problem: periodic treatment of at-risk populations will cure mild symptoms and prevent infected people from developing severe, late-stage chronic disease. [1] Nevertheless, a major limitation to schistosomiasis control had been the limited availability of praziquantel, especially, for the treatment of adults. [1] It has been documented that data for 2019 had shown that 44.5% of people who required treatment were reached globally, with a proportion of 67.2% of school-aged children requiring preventive chemotherapy for schistosomiasis being treated. [1]

It has been stated that Praziquantel is the recommended therapy against all forms of schistosomiasis and that It is effective, safe, as well as low-cost.[1] It had also been stated that although re-infection might occur pursuant to treatment, the risk for the development of  severe disease is diminished and even reversed when the treatment is commenced and repeated in childhood. [1]

The World Health Organization (WHO) had documented that Schistosomiasis control has been successfully implemented over the past 40 years in many countries, including Brazil, Cambodia, China, Egypt, Mauritius, Islamic Republic of Iran, Oman, Jordan, Saudi Arabia, Morocco, Tunisia, etc. In Burundi, Burkina Faso, Ghana, Niger, Rwanda, Sierra Leone, Togo the United Republic of Tanzania, Yemen and Zimbabwe, it has been possible to scale-up schistosomiasis treatment to the national level and have an impact upon the disease in a few years. [1] An assessment of the status of transmission is required in many countries. [1]

WHO had stated that over the past 10 years, there had been scale-up of treatment campaigns within a number of sub-Saharan countries, where most of those at risk dwell. [1]

WHO response [1] 

The WHO’s response to Schistosomiasis has been summated as follows: [1] 

It has been documented that the WHO’s work on schistosomiasis is part of an integrated approach to the control of neglected tropical diseases and that even though medically diverse, neglected tropical diseases do share features which allow them to persist in conditions of poverty, where they cluster and frequently overlap.

WHO does coordinate the strategy of preventive chemotherapy in consultation with collaborating centres and does partner from academic and research institutions, the private sector, nongovernmental organizations, international development agencies, and other United Nations organizations. WHO also does develop technical guidelines and tools for utilization by national control programmes.

Working with partners and the private sector, WHO had advocated for increased access to praziquantel and resources for implementation. A significant amount of praziquantel, to treat greater than 100 million children of the school age per year, had been pledged by the private sector and development partners.

It does appear that Schistosomiasis of the urinary bladder is known and understood by many clinicians and urologists as well as pathologists and the general public. Schistosomiasis of the urinary bladder could occur alone or at times in combination with Schistosomiasis of the cervix and female genital tract but most clinicians could tend to be oblivious of the fact that Schistosomiasis of the female genital tract including the cervix could occur contemporaneously but it could be envisaged that Urologists who treat patients who have Schistosomiasis of the urinary bladder could be oblivious of the possibility that Schistosomiasis of the urinary bladder could exist in addition to Schistosomiasis of the cervix. Considering that generally globally, only sporadic cases of Schistosomiasis of the cervix tend to be reported, there is the likelihood that many clinicians may not be familiar with the manifestations, investigation and management of Schistosomiasis of the cervix. 

To review and update the literature on Schistosomiasis in general but with a focus on Schistosomiasis of the uterine cervix. 

Internet data bases were searched including: Google; Google Scholar; Yahoo; and PUBMED. The search words that were used included: Schistosomiasis of cervix; cervical Schistosomiasis; female genital tract Schistosomiasis; Urogenital tract Schistosomiasis. Fifty nine (59) references were identified which were used to write the article in two parts including (A) Overview of Schistosomiasis in general and some general aspects of Schistosomiasis of the cervix; and (B) Miscellaneous narrations and discussions related to some case reports, case series and studies related to Schistosomiasis of the cervix.

[(A)] Overview 

Definition / general [4] 

Schistosomiasis of the female genital tract and cervix is a terminology that is utilized for Infection of the parasite Schistosoma within the female genital tract [4]

Schistosomiasis is also referred to as Bilharziasis after a German physician who was called Theodor Bilharz, who did describe the first case of urinary schistosomiasis in 1851 [4] 

Epidemiology [4] 

It has been iterated that Schistosomiasis tends to be more common in Africa and Middle East

It has been documented that Schistosomiasis is uncommon within the United States of America and Europe

It  has been stated that in Schistosomiasis endemic areas of the world, the prevalence of female genital tract schistosomiasis does range from 30% to - 75% [5]

Sites

It has been documented that with regard to the female genital tract, the cervix is commonest organ to be infected by Schistosoma [4]

Aetiology [4] 

It is well known that Schistosoma is a helminth and a Trematode (flukes). 

It has been iterated that the female genital tract tends to be most commonly infected by Schistosoma haematobium [4] [6] 

Some of the other Schistosoma organisms that tend to infest the female genital tract have been stated to include: Schistosoma Mansoni and Schistosoma Japonicum.,

Life cycle of Schistosoma Haematobium [4] 

The life cycle of Schistosoma Haematobium has been summated as follows: 

When the skin of human beings does get exposed to Schistosoma contaminated water, the cercariae do penetrate the skin and they then enter the blood stream

Then they then enter the liver where they mature into adult flukes

They later, migrate and reach the venous circulation of the urinary bladder and pelvis

It has been documented that female flukes tend to lay as many as 30 eggs per day, which tend to be excreted through urine

The Schistosoma eggs release miracidia into the water, under optimal conditions

Miracidia do infest Bulinus snail, which is an intermediate host

Within the snail, infective cercariae tend to be produced and they tend to be released into water in order to continue the life cycle. 

Clinical manifestations [4] 

The clinical manifestations of Schistosomiasis of the cervix have been summated as follows; [4]

Women / females who have Schistosomiasis of the cervix / genital tract tend to manifest with Irregular menstruation, pelvic pain, vaginal discharge as well as bleeding from the vagina [4]

It has been iterated that the cervix could appear inflamed, ulcerated, nodular and friable, which could simulate a carcinoma of the cervix clinically

It has been iterated that Schistosomiasis does increase the risk of spread of sexually transmitted infections, infertility as well as pregnancy related disorders [4] [7] but relationship with cervical cancer is unclear [8] 

It has been documented that there tends to be increased vascularity within the cervicovaginal mucosa with regard to Schistosome haematobium infection [9] 

It has been iterated that HIV patients who have Schistosomiasis of the cervix / genital tract, often do lack a granulomatous response and obvious ova [10]

Diagnosis

With regard to the diagnosis of Schistosomiasis of the cervix, the optimal method for the detection of the infection tends to be by direct examination of cervical tissue which has been obtained by forceps biopsy through quantitative compressed biopsy technique [4] [11]

It has been documented that cytologic examination of cervical smears has tended not to be a reliable method to diagnose genital Schistosomiasis [4] [12]

Treatment

It has been iterated that treatment of Schistosomiasis of the cervix and genital tract has tended to be by means of:  [4]

Praziquantel

Cytology examination features

The cytology examination features of Schistosomiasis of the cervix and the female genital tract have been summarized as follows: [4]

Cytology examination does tend to show many inflammatory cells including eosinophils, lymphocytes as well as granulomas which include multinucleated cells in association with Schistosoma ova

Cytology examination tends to demonstrate viable ova that tend to measure 150 μ × 50 μm, and which tend to be surrounded by a thick shell

Cytology examination does demonstrate the egg of Schistosoma. haematobium which does tend to have a characteristic prominent terminal spine, while Schistosoma. mansoni  does have a lateral spine and Schistosoma Japonica tend to be slightly oval with a rudimentary lateral spine. 

Cytology examination could demonstrate ova in various stages of development. 

Cytology examination may demonstrate a few eggs which may contain a miracidium, that have brightly eosinophilic cytoplasm and haematoxylin stained nuclei

Cytology examination may also demonstrate non-viable ova that are empty with no internal structure and which  may appear collapsed, shrunken, calcified, black or opaque

Cytology examination of cervical smears may be visualised to be bloody, secondary to extensive vascularization of cervix

It has been pointed out that if scattered ova are visualised among many inflammatory cells, the diagnosis of Schistosomiasis could be challenging

Differential diagnosis

The differential diagnosis of Schistosomiasis of the cervix / genital tract have been summated to include: [4] 

Empty ova:

Lubricant gel: no spine, not refractile

Plant cells: refractile but no spine

Viable ova:

Other parasitic ova:

Ascaris

Trichuris 

Enterobius 

Taenia (egg)

It has been pointed out that pathologists should pay attention to the morphology, especially they should  look for absence of the spine [4] [8] 

[B] Miscellaneous Narrations And Discussions From Some Case Reports, Case Series and Some Studies Related To Schistosomiasis Of The Cervix. 

Lalaina et al. [13] reported two cases of Schistosomiasis of the cervix as follows: 

Case No. 1

A 57-year-old Malagasy woman, who had dwelled within Mahanjaga (a region in the western part of Madagascar), who was of Betsirebaka ethnic group. The woman had been postmenopausal for 4 years. She had to be examined in view of the fact that she had developed uterine bleeding disorder. She was found upon examination to have a necrotic lesion with erosion within her uterine cervix, which had extended into her vagina for which she underwent cervical biopsy. Four fragments of her biopsy samples were found to be firm and the diameter of the specimens had varied from 0.3 cm to 0.5 cm. Histopathology examination of the biopsy specimens showed an invasive carcinomatous proliferation within her cervical mucosa. The cells were found to have exhibited a moderate cyto-nuclear atypia, and they were organized in clusters, with squamous differentiation without keratinization. The stroma was noted to be fibrous with many calcified Schistosoma ova. The diagnosis based upon pathology examination of the cervical biopsy specimens was well-differentiated, invasive squamous cell carcinoma with cervical schistosomiasis. Her treatment included Praziquantel medication with a dose of 40 mg per kilogram body weight. She also underwent hysterectomy and radiotherapy. 

Case No. 2

A 43-year-old woman who lived in Mahanjaga and who was of Sakalava ethnic group was reported. She had manifested with dysmenorrhea for which she had undergone a gynaecological examination in a hospital within the region. She was found upon examination to have an ulceration of her uterine cervix. Cervical biopsies were performed and the samples were sent to Antananarivo, at JRA University Hospital for pathology examination. Macroscopy examination of the biopsy specimens showed that there were multiple fragments, that measured 2.2 cm × 1.6 cm × 0.5 cm in diameter, in clusters. Histopathology examination of the cervical biopsy specimens demonstrated features that were consistent with an infiltrating tumour proliferation, with squamous differentiation and keratinization. Calcified schistosome eggs which were surrounded by inflammatory granulomas with multinucleated giant cells were also found within the cervical stroma. The diagnosis was a well-differentiated, invasive squamous cell carcinoma with schistosomiasis. She was treated with Praziquantel at 40 mg per kilogram body weight and she underwent hysterectomy.  

Lessons that need to be learned from the two reported cases include the following: 

{1} Even though rare, within Schistosomiasis endemic areas of the world, Schistosomiasis of the cervix could occur and these could manifest as dysmenorrhea, post-menopausal bleeding. 

[2] Even though Schistosomiasis of the cervix could occur alone, because schistosomiasis does cause chronic inflammation, the chronic inflammation could be ensued by the development of squamous cell carcinoma of the cervix so that pathologists that work in Schistosomiasis endemic areas should carefully examination the specimens who are found to have squamous cell carcinoma of there is also an associated Schistosomiasis of the cervix as well as if they find a case of Schistosomiasis of they cervix they should also check if the patient also has a contemporaneous squamous cell carcinoma of the cervix.   

Adeniran et al. [14] reported a 27-year-old woman, who was found to have a low-grade squamous intraepithelial lesion and which was associated with koilocytic changes which was consistent with the diagnosis of human papillomavirus infection based upon routine Papanicolaou test. She was reported to have lived within rural Senegal in West Africa, all of her life, until she moved to the United States 3 years preceding her manifestation. She had recalled having swam in lakes while she lived in Senegal, but she had not had any reported history of abnormal bleeding of the cervix, in her urine, or from her rectum. She had biopsy of her cervix and pathology examination of the biopsy specimen showed moderate dysplasia which had involved her endocervical glands, squamous metaplasia, and severe acute and chronic cervicitis. Calcified eggs were found within in the stroma of the cervix based upon Haematoxylin-eosin staining, original magnification ×20, after decalcification). The eggs were present throughout her cervical stroma and they were found not to be associated with any granulomatous reaction based upon haematoxylin-eosin staining, original magnification ×52, after decalcification. The eggs were found to be nonoperculated and they had a prominent terminal spine based upon haematoxylin-eosin staining, original magnification ×200, after decalcification.. She was treated by means of praziquantel, 1800 mg twice daily for 1 day.  Seven months pursuant to her treatment there was no follow-up information on the patient. The authors and the journal should be congratulated for publishing this case report in that the lessons that need to be learnt from this case report include the following:

Even though Schistosomiasis, is uncommon in the United States of America and other parts of the world, cases of Schistosomiasis including Schistosomiasis of the cervix could be encountered anywhere in the world including Schistosomiasis non-endemic areas of the world because of global travel these days. .

The illustrative pathology examination features of Schistosomiasis of the cervix were included in the article which does represent a source of learning / revision information for pathologists and clinicians what Schistosomiasis looks like upon pathology examination. 

Kameh et al. [15] reported a 37-year-old lady, who was originally from South Africa, who had manifested for gynaecological examination. She had a speculum examination which demonstrated a friable cervical lesion. Pathology examination of both her cervical smear and cervical biopsy revealed intact, viable Schistosome eggs that were consistent with the features of those of Schistosoma haematobium. The lady received appropriate prompt treatment which did avoid significant morbidity. Kameh et al. [15] advised that the diagnosis of female genital schistosomiasis should be considered when a patient does have a history of travel to or residence within Schistosomiasis endemic areas of the world. 

Sharma et al. [16] reported a case history of a lady who was diagnosed as having Schistosomiasis of the cervix based upon investigations of her abnormal cervical smear. Sharma et al. [16] iterated that Schistosomiasis of the female genital tract could manifest with various symptoms and in view of this, there is the need for greater awareness of the diagnosis of Schistosomiasis in view of the number of travellers to Schistosomiasis endemic areas does rise and that travellers to these Schistosomiasis endemic areas should be warned about the risk of swimming within lakes and rivers in Schistosomiasis endemic areas of the world. 

Mosunjac et al. [17] made the ensuing iterations: 

Female genitourinary schistosomiasis (FGS) has tended to be widespread within Schistosomiasis endemic areas of the world causing significant morbidity and mortality.

Recent data had indicated that FGS of the cervix is not only regarded to be a risk factor for contracting different sexually transmitted diseases (STD), but it also does play a significant role with regard to modifying the natural history and immunological response to those infections, in particular HIV and HPV.

Mosunjac et al. [17] reports a 32-year-old lady from Zambia, who had been recently diagnosed as having HIV and high-grade dysplasia with koilocytosis upon examination of her cervical Pap smear. She underwent cervical conization which confirmed moderate cervical dysplasia and also revealed the presence of viable and nonviable Schistosoma eggs within her cervical stroma. Mosunjac et al. [17] also reported that four different HPV types were isolated by PCR, including one “low-risk” (type 6) and three “high-risk” types (types 45, 56, and 58). Mosunjac et al. [17] made the following conclusions: 

The presence of HPV, HIV infection, and cervical schistosomiasis in their patient was likely more than coexistence of multiple agents in the same milieu as cervical schistosomiasis increase susceptibility for other STDs including HIV and HPV.

Therefore, with regard to patients who have schistosomiasis, immediate treatment for schistosomiasis and additional testing for HIV and HPV would be warranted.

Poggensee et al [11] made the ensuing summations related to Schistosomiasis of the cervix: 

Granulomatous inflammation of the cervix uteri has been known to be a common manifestation of infection with Schistosoma haematobium. 

With regard to women the cervix has tended to be the most common site of infection by Schistosoma haematobium. 

Three methods were utilised to assess the performance of three different ways of detecting schistosome eggs in cervical tissue: cytological examination of a cervical smear, histological examination of a cervical biopsy, and direct examination of cervical tissue which has been obtained by forceps biopsy (quantitative compressed biopsy technique [QCBT]).

Out of 228 women who had been studied who dwelled within a Schistosoma. haematobium endemic area within Tanzania, 112 that amounted to 49%, had schistosome eggs detected within the cervix using QCBT. 

Histological examination had detected eggs in 40 out of 228 that amounted to 18%.

The cytological examination of cervical smears had yielded only 6 positive results that amounted to 3% of cases. 

The median egg load within the cervical tissue of cases that was correctly diagnosed by histopathology was significantly higher in comparison with the egg load in the misclassified cases, which did indicate that the sensitivity of histological sectioning increases with egg density. 

Poggensee  et al. [11] concluded that the QCBT is the diagnostic test of choice for the identification of schistosomiasis of the genital cervix.

Rafferty et al. [18] made ensuing iterations related to Schistosomiasis of the female genitalia: 

Female genital schistosomiasis (FGS) has tended to be a neglected tropical gynaecological disease which does affect millions of women within sub-Saharan Africa (SSA).

FGS is caused by Schistosoma haematobium, which is a parasitic carcinogen which is involved in the pathogenesis of squamous cell carcinoma of the urinary bladder.

The incidence of cervical cancer and the mortality are highest in SSA, where pre-cancerous cervical dysplasia has often tended to be detected upon screening with visual inspection with acetic acid (VIA). 

There are no studies which had evaluated the association between VIA positivity and FGS diagnosed by genital PCR.

Rafferty et al. [18] recruited women from the Bilharzia and HIV (BILHIV) study in Zambia a community-based study which compared genital self-sampling to provider obtained cervicovaginal-lavage for the diagnosis of FGS in women aged between 18 years and 31 years. They defined FGS as positive Schistosoma DNA from any genital PCR. Urogenital schistosomiasis diagnostics did include urine circulating anodic antigen, urine microscopy and portable colposcopy. The participants in the study were offered cervical cancer screening utilising VIA at Livingstone Central Hospital. They assessed the associations of PCR confirmed FGS and other diagnostics with VIA positivity with utilisation of multivariable logistic regression. Rafferty et al. [18] summarised the results as follows:

VIA results were available from 237 BILHIV participants. 

A positive Schistosoma PCR in any genital specimen was identified in 14 women that amounted to 5.9% and 28.6% which included 4 out of 14 of these women had positive VIA in comparison with 9.0% who did not have PCR evidence of schistosome infection that amounted to 20 out of 223 women. 

Schistosoma PCR positivity in any genital specimen was found to be strongly associated with VIA positivity (OR: 6.08, 95% CI: 1.58–23.37, P = 0.02).

Rafferty et al. [18] concluded that their study was the first study undertaken to find an association between FGS and positive VIA, a relationship that may be causal. Further longitudinal studies are needed.

Chen et al. [19] stated that Schistosomiasis has remained a major threat to the health of women in many resource poor countries and it is being seen with increasing frequency within developed countries among immigrants as well as tourist who have a history of exposure to fresh water within Schistosomiasis endemic areas of the world. Chen et al. [19] reported a 28-year-old asymptomatic African immigrant who had presented with abnormal PAP test result which showed rare atypical squamous cells. She underwent colposcopy examination which demonstrated pale-yellow, finely granular cervical lesions. Histopathology examination revealed calcified Schistosoma haematobium eggs but Schistosoma haematobium eggs were absent within her urine and stool specimens. She promptly received Praziquantel treatment which avoided her development of significant morbidity. Chen et al. [19] concluded that: 

The differential diagnosis of female genital schistosomiasis should considered patients who do have a history of having resided within or travelled to Schistosomiasis endemic areas of the world, with the inclusion of asymptomatic patients and patients who manifest a long time following exposure.

Kjetland et al. [20] examined a total 51 women who had urinary schistosomiasis haematobium in order to identify diagnostic indicators for female genital schistosomiasis (FGS).  Kjetland et al. [20] selected patients at random from the outpatient department of the Mangochi District Hospital, Malawi.  Kjetland et al. [20] recorded the medical histories according to a pre-designed questionnaire and the women were subjected to a thorough gynaecological examination that included colposcopy and photographic documentation of lesions. Microscopy pathology examination of genital biopsies showed that 33 of the 51 women had Schistosoma. haematobium ova within their cervix, vagina and / or vulva in addition to the presence of ova within their urine. The most sensitive diagnostic procedure was noted to be bedside microscopic examination of a wet cervix biopsy which was crushed between two glass slides, which demonstrated 25 of the 33 genital infections. Kjetland et al. [20] found a significant correlation between the size of genital lesions and the number of ova counted per mm2 of crushed tissue. They also found that women who had FGS had significantly more tumours within their vulva in comparison with women who had schistosomiasis limited to the urinary tract. Majority of the observed genital pathology were easily identified by the naked eye, but colposcopy examination had yielded valuable additional information like the demonstration of neovascularisation around cervical sandy patches. They found and iterated that few of the symptoms previously regarded as indicators for FGS could be linked to the presence of schistosome ova within genital tissue. They additionally stated the following:

Husbands of infertile women who had FGS had children with other women significantly more often than husbands of women who only had urinary schistosomiasis.

This, together with the finding that the majority of the divorced women had FGS, did indicate that the manifestation of  Schistosomiasis of the female genital tract may have implications for the marital and sexual life of the affected women.

Based upon the findings documented in this article taking into consideration that females who have Schistosomiasis of the female genital tract including Schistosomiasis of the cervix could also have demonstration of Schistosoma haematobium ova within their urine would indicate that women who have Schistosomiasis of the cervix could also have Schistosomiasis of the urinary tract including the urinary bladder and hence some patients who have Schistosomiasis of the cervix could also manifest with haematuria alone or haematuria with bleeding from the vagina/cervix or dysmenorrhea and at times urologists may be the first specialists to see some patients who have Schistosomiasis of the cervix. For this reason Urologists who encounter patients that manifest with haematuria should have a high index of suspicion for a synchronous/contemporaneous manifestation of vaginal / cervical bleeding in order to assess them for the possibility of having both urinary tract and genital tract Schistosomiasis so that they can refer their patients to gynaecologists for further assessment. 

Moubayed et al. [21] determined the incidence of carcinoma of the uterine cervix and its relationship to schistosomiasis infection. They undertook a retrospective analysis of a 10-year period, between 1980 and 1990 at the department of histopathology (cancer registry) of the University of Dar es Salaam utilising statistical evaluation of the proportional rate of histomorphology 0diagnosis, clinical symptoms and epidemiological aspects. They summarised the results as follows:

There were 4520 cases that were classified as cervical carcinoma. 

Unexpectedly, only 76 of these that amounted to 1.7% had revealed an association with schistosomiasis.

Precancerous lesions of the squamous epithelium of the uterine cervix were a relatively common feature in carcinoma of both groups. 

Additionally, epidemiological analysis had indicated that the occurrence of cancer and schistosomiasis infection of the cervix was not strictly confined to the population of rural regions, known as Schistosomiasis endemic areas, with low hygienic and socioeconomic standards

This fact was most probably related to the rural people moving into urban areas of the country with the hope to improve upon their quality of life. 

Moubayed et al. [21] concluded that their data did not support the assumption of an etiologic role of schistosomiasis in the oncogenesis of cervical carcinoma.

Swai et al. [22] iterated the following: 

Schistosomiasis does affect the reproductive health of women. 

Some of the described sequelae of Schistosomiasis upon women include: ectopic pregnancy, infertility, abortion, and cervical lesions and symptoms that simulate carcinoma of cervix and STIs.

There are indications that schistosomiasis of cervix lesions could become co-factors for viral infections including HIV and HPV.

Swai et al. [22] undertook a retrospective descriptive histopathology study of clinical specimens that were sent between 1999 and 2005 to the pathology department of a consultant hospital in Tanzania which were reviewed to analyse the occurrence and features of schistosomiasis in female genital organs. Swai et al. [22] summarised the results as follows: 

During the study period, schistosomiasis was diagnosed based upon histopathology examination in 423 specimens from different organs (0.7% of all specimens examined in the study period), out of those 40% were specimens from female and male organs. 

The specimens were sent from 24 hospitals in 13 regions of mainland Tanzania.

Female genital schistosomiasis was diagnosed in 125 specimens obtained from 111 patients. 

The main reported manifestations included; bleeding disorders in 48% of the patients, ulcer in 17% of cases, tumour in 20% of cases, lower abdominal pain in 11% of cases and infertility in 7% of cases.

Most of the cases that had genital schistosomiasis were diagnosed in cervical tissue which amounted to 71 cases. 

The confirmation of cervical cancer was specifically requested for 53 women, but the diagnosis could only be verified for 13 patients which amounted to 25%, in 40 cases only severe cervical schistosomiasis was diagnosed. 

Vulval/labial schistosomiasis was demonstrated in specimens from young women. Infertility was reported in four patients who had schistosomiasis of the Fallopian tubes.

Swai et al. [22] made the ensuing conclusions: 

Genital schistosomiasis does add to the disease burden of women of all age groups. 

Pathological consequences due to the involvement of different genital organs by Schistosomiasis could be damaging for the affected women.

Clinical unawareness of genital schistosomiasis could lead to misdiagnosis and therefore false and ineffective treatment.

Within Schistosomiasis endemic areas cervical schistosomiasis should be considered as differential diagnosis of carcinoma of the cervix..

Bland and Gelfand [23] reported a prospective study of 55 African patients in whom the uterine cervix was removed and examined in which 12 demonstrated definite evidence of bilharziasis and 9 of these had evidence of bilharziasis elsewhere upon routine screening. The 12 patients who had bilharzial cervicitis were clinically analysed in detail. Bland and Gelfand [23] reported that only rarely does bilharziasis of cervix simulate carcinoma of cervix, but it could give rise to suspicious abnormal vaginal bleeding. Bland and Gelfand [23] emphasized the need for careful biopsy of all suspicious cervical lesions in Schistosoma endemic areas of the world, and they stressed the value of anti-bilharzial treatment in proven cases. Bland and Gelfand [23] stated that in their experience, based upon a series of 18 consecutive cases of cervical carcinoma, there was no correlation with cervical bilharziasis.

Wright et al. [24] reviewed the histopathology of 176 cases of gynaecological schistosomiasis that had been reported from Malawi during the period from 1976 to 1980.  Schistosoma infection was found throughout the genital tract, with 60% of cases which had involved the cervix. The dominant tissue reactions to ova were categorized into five histopathology examination groups A to E and for each site the relationship between histopathological and clinical features was explored. Wright et al. [24] reported that no evidence was found that linked schistosomiasis with cancer of the genital tract. Schistosomiasis was found to be a significant cause of gynaecological morbidity, particularly when the infection had involved the lower genital tract; nevertheless, with regard to a proportion of cases Schistosoma ova were found coincidentally in other lesions or normal tissues, and were not apparently causally linked with symptoms.

El-Mahgoub [25] reported that the utilisation of laparoscopy allowed them to diagnose symptomatic pelvic schistosomiasis in 13 infertile women. The lesion was found to be associated with dense pelvic adhesions in all cases and a defective luteal phase in 23.1% of the women and anovulation in 15.4%. Atraumatic adnexolysis, anti-bilharzial therapy and correction of ovulatory defects were ensued by intrauterine pregnancy in 46% of the patients.

Schwartz [26] stated the following:

Schistosomiasis of the uterine cervix is the commonest form of genital schistosomiasis, and it tends to be most frequently associated with Schistosoma haematobium infection. 

Schistosomiasis of cervix does assume medical importance because clinically it might be mistaken for malignancy of the cervix. 

Furthermore, it has been proposed that Schistosomiasis of the cervix may lead to the development of cervical carcinoma.

Schwartz [26] reported a patient who had squamous cell carcinoma of the cervix in association with schistosomiasis of the cervix.

North et al. [27] stated the following: 

HPV is now considered the most important risk factor for the development of cervical intraepithelial neoplasia (CIN) and cancer. 

Even though CIN and cancer had been previously reported in association with schistosomiasis of cervix, those reports had failed to control for the potential coexistence of high-risk HPV. 

North et al. [27] reported two women who Schistosomiasis of cervix and carcinoma of cervix. , 1 patient had high grade CIN and 1 patient had invasive cervical cancer, and they were negative for high-risk HPV subtypes. North et al. [27] reported that evidence of cervical and systemic Schistosoma infestation was evident in both cases. North et al. [27] made the following conclusions:

In support of previously published studies, Schistosomiasis of the cervix does seem to be a possible risk factor for the development of CIN and cancer. 

As populations around the world migrate, North American colposcopists do need to become aware of this association. 

Riffenburgh et al. [28] reported that in order to investigate if Schistosoma haematobium infection does increase the observed frequency of cancer of the cervix, they analysed data from literature in meta-analysis fashion. They reported that the results revealed that cervical cancer is statistically significantly less frequent in the presence of Schistosoma. haematobium infection. They made the ensuing iterations: 

A protective effect might be inferred; nevertheless, they suspected underlying bias with regard to data collection and/or analysis. 

An approach to detecting bias was provided which consisted of: (a) carefully stating and assessing the many components of the scientific method and; (b) identifying and contrasting the populations hypothesised and sampled. 

The approach was illustrated by searching for bias regarding the schistosomiasis-and-cancer reports. 

Sampling discrepancies were detected with regard to patient geography, ages, and states of health, and suspected in disease prevalence sampled as well as in disease prevalence reported. 

They concluded that they reached the conclusion that the effects of bias in the original studies had precluded inference of a "protective" effect of Schistosoma haematobium infection against cervical cancer.

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Olufemi Williams [29] discussed the pathology changes that were associated with infection of the uterine cervix and endometrium by Schistosoma. haematobium with the use of materials from cervical and endometrial biopsies from 14 women in the southern provinces of Nigeria. The variety of lesions and clinical manifestations were emphasized and three principal forms of lesions are described in detail.  Olufemi Williams [29] stated that the over-all frequency of the schistosome infection of the uterus and endometrium could not be accurately estimated but there appeared to be relative rarity of infection of the latter site. Olufemi Williams [29] made the ensuing iterations:

Schistosome infection of the endometrium might be associated with abortion and tuberculosis. 

The presence of ova in choriocarcinoma and other tumours were discussed but there seems to be inadequate evidence to support a possible association between schistosomiasis of the genital tract and malignancy, as had already been established in the case of the urinary bladder.

Szela et al. [30] undertook a study to discover a possible association between schistosomiasis and cervical dysplasia and/or cervical cancer within Ghana, West Africa. They identified two groups of 24 subjects each, in which one group was from a schistosomiasis-endemic area and a control group from a non-endemic area. They performed random cervical biopsies, cervical cytology and human papilloma virus (HP V) DNA testing on all subjects. Szela et al. [30] analysed demographic data with utilization of Student's t-test. They analysed the Histology and DNA findings with utilization of Fisher's exact test. Szela et al. [30] summarised the results as follows: 

-From the endemic area, 46% of the subjects had histology examination evidence of schistosomiasis infection of the cervix. No evidence of dysplasia or cancer on cervical cytology examination was found in this group. Mild dysplasia was found in random cervix biopsies in one patient, and 8 patients had evidence of HPV infection of the cervix. 

No patient from the Schistosomiasis non-endemic area had cytology examination or histology examination evidence of cervical dysplasia or cancer. Eleven subjects in this group had evidence of HPV infection. 

Szela et al. [30] made the following conclusions:

Their study did not demonstrate an association between schistosomiasis of the cervix  and cervical dysplasia or cervical cancer on cytology or histology. 

Both study groups had demonstrated a high degree of infection with HPV, nevertheless, it might be the HPV and not the schistosomiasis which is responsible for the development of cancer of the uterine cervix.

Moubayed et al. [31] undertook a study to determine the presence of human papillomaviruses (HPVs) in cervical cancer among patients within Tanzania and to ascertain their prevalence in cases that were associated with schistosomiasis. With regard to the methods of the study, Moubayed et al. [31] stated that in situ hybridization was applied to 31 carcinomas of the uterine cervix which included 10 in which schistosomiasis had co-occurred. With regard to the results, they summarised the following: 

Twenty-six cases in the series also had exhibited koilocytic dysplasia.

Twenty-six out of 31 cases did show a specific hybridization for HPVs with varying density and distribution. 

A slightly higher labelling of HPV −16 than −18 was demonstrated.

All schistosomiasis-associated cancers had encoded the papillomaviruses. 

The 31 patients were predominantly young adults, a fact which did reflect sexual activity at a very young age in the ethnic communities of Africa. 

Moubayed et al. [31] made the following conclusions:

Their findings had shed new light upon the presumed etiological implication of schistosomiasis in the genesis of cervical cancer. 

In the absence of HPV, schistosomiasis is not the oncogenic causative agent for carcinoma of uterine cervix. 

Moubayed et al. [31] stated the following: 

Schistosomiasis is a chronic disease which does remain a major public health problem.

Schistosomiasis does hold second place among parasitic endemics in the world.

Schistosoma could infect various organs through the blood vessels. 

The genital form of Schistosomiasis does affect at least 16 million women in Schistosomiasis endemic areas, and the uterine cervix is the most common site. 

Moubayed et al. [31] reported two cases of cervical cancer which were associated with schistosomiasis of the cervix. Both of the patients had lived in Mahanjaga, and their ages were respectively 57 and 43 years. They had complained about uterine bleeding disorder and they had manifested with cauliflower lesions with ulceration of the uterine cervix which had extended to the vagina in one case. They had undergone cervical biopsies. The diagnosis was, in both cases, invasive, well-differentiated squamous cell carcinoma with cervical schistosomiasis. 

El-Tabbakh and Hamza [32] stated that the relation between cervical cancer and Schistosoma infection is controversial. They reported a case of well differentiated adenocarcinoma of the cervix that was associated with schistosomiasis of the cervix. They reported a 45-year-old lady who had manifested with intermenstrual bleeding and who was found to have a polypoid ulcerated cervical mass. The cervical mass was biopsied and pathology examination of the biopsy specimen revealed a well differentiated adenocarcinoma and Schistosoma  ova with terminal spine that was embedded within the tumour tissue. 

Poggensee et al. [33] stated that female genital Schistosomiasis (FGS) does represent a neglected disease manifestation of Schistosomiasis. They undertook a cross-sectional study in order to assess in a Schistosomiasis-endemic the proportion of women who are affected by FGS of the lower reproductive tract as well as to compare the frequency of symptoms and signs that are possibly associated with FGS between women with proven FGS that included 134 women, endemic referents that included 225 women that dwell within an endemic site. Urinary Schistosomiasis was diagnosed in 36% of women that amounted 239 women out of 657 women and FGS in 37% that amounted to 134 women out of 359 of women. Cervical lesions were found in 75% of the FGS cases, in 48% of the Schistosomiasis endemic referents, and in 36% of the Schistosomiasis non-endemic referents. Poggensee et al: [33] stated the following: 

The high prevalence of FGS in all age groups and the high levels of pathological cervical alterations such as swollen and disrupted epithelium would support the postulate that FGS might be a risk factor for the transmission of human immunodeficiency virus. 

In this article, Poggensee et al. [7] discussed the public health relevance of female genital schistosomiasis (FGS). They iterated that some of the postulated hypotheses had been  supported only by clinical observations and/or circumstantial evidence as valid epidemiological and immunological data of this disease entity were still very scanty. They also stated that morbidity which had been caused by the presence of Schistosoma eggs within the lower and upper genital tract had been almost completely neglected during the preceding two decades. This had been acknowledged by the WHO and, in 1997, the Gender Task Force of the WHO's Tropical Disease Research Programme (TDR) had included FGS in a list of scientific areas which deserve high research priority.

In their discussion of FGS as a risk-factor acquiring human immunodeficiency virus, Poggensee et al. [34] stated that the individual and public health impact of female genital schistosomiasis (FGS) had been studied. They reported that in a community-based study which was undertaken within Tanzania, 40% of the women of child-bearing age that totalled 5 543 had shown excretion of Schistosoma haematobium eggs within their urine with a median 5 2.2 eggs per 10 ml of urine and 32% that amounted to 5 263 individuals had Schistosoma. haematobium eggs within their cervical tissue. Urinary and genital schistosomiasis were found to have coexisted in 62% of the women, but Schistosoma. haematobium eggs were found within the cervix without detectable egg excretion in the urine in 23% of women. Only 43% of the FGS cases were noted to have had haematuria. Poggeensee et al. [34] iterated that in view of the fact that  FGS frequently does exist in women who have scanty or no egg excretion within their urine and because this disease manifestation is a considerable individual and public health hazard within Schistosoma haematobium-endemic areas, mass treatment which is targeted to women of child-bearing age should be considered. A lesson which should be learnt from this summation is the fact that considering that a number of individuals who are found to have Schistosoma within their urine also do have female genital Schistosomiasis (FGS), Urologists as well as General Practitioners who find that their patients do have Schistosoma within their urine, should have a high index of suspicion to investigate in order to ascertain if the same patients also have contemporaneous Schistosoma within their female genital tract including the cervix. 

Coelho et al. [35] reported that as  part of a mass cytology screening program, cervical scrapings as well as endocervical / endometrial aspirations were taken from 1,250 women who had systemic schistosomiasis. They reported that ova of Schistosoma. mansoni were found that were associated with two cases of carcinoma in situ and one case of invasive squamous cell carcinoma of the uterine cervix. They additionally reported that with regard to  a fourth case, the Schistosoma ova were found to be associated with a benign cervical lesion.

Dzeing-Ella et al. [36] stated that female genital schistosomiasis (FGS) could be under-recognized in Schistosomiasis endemic areas as a cause of cervical dysplasia, neoplasia, infertility, and as a facilitator of the transmission of HIV. They iterated that to the best of their knowledge, few cases of FGS that simulated neoplasia had been reported in travellers. Dzeing-Ella  et al. [36] reported the finding of a 34-year-old white woman who was hospitalized for genital cervical schistosomiasis (CS). Two years prior to her admission, she had travelled to Mali where she took a bath within the Plate Dogon waterfall, which is considered to be an important source of schistosomiasis.  She underwent taking of a cervical smear because she was having persistent intermenstrual bleeding. Examination of the cervical smear showed inflammatory lesions and cytologic changes which were consistent with dysplasia. During her colposcopy, an area of high-grade cervical intraepithelial neoplasia was noted, and a cone biopsy was subsequently undertaken. Pathology examination of the endocervical epithelium demonstrated features of early metaplasia. Examination for Human papilloma virus (HPV) hybridization was negative. Schistosoma haematobium eggs were identified inside the chorion, which was encompassed by granulomatous inflammation without evidence of malignancy. The patient denied having or having had any history of signs and symptoms consistent with urinary tract schistosomiasis, and her clinical examination (gynaecological inspection excluded) was normal. Parasitology examination of her urine was negative for schistosomes eggs. Her HIV screening was negative. She received a single dose of 2.4 g praziquantel as treatment. She tolerated the treatment well, and she patient was re-examined 1 month after her discharge and she was found to be completely asymptomatic. Another cervical smear was undertaken 3 months following her antiparasitic treatment. Parasitology examination of the repeated cervical smear was negative for Schistosoma, and there was no histological abnormality. They summarized their case as follows:

To the best of their knowledge, few cases of FGS simulating neoplasia have been reported in travellers. 

They had reported a clinical case of a 34-year-old white woman who had manifested with a severe cervical dysplasia, without any features of human papilloma virus infection, 2 years after bathing in a waterfall, a source of schistosomiasis, in Mali.

Schistosomes eggs were identified upon the conization. 

Management of the cases had included conization and medical therapy, which had resulted in a full clinical and histologic recovery. 

FGS should be kept in mind as a possible cause of cervical dysplasia in endemic areas. 

Medical therapy with praziquantel does improve this condition 

The message that was relayed in this case summary should alert all clinicians who encounter patients who have travelled to and swam in rivers within Schistosomiasis endemic areas and who present with intermenstrual bleeding or abnormal uterine bleeding should have a high index of suspicion to exclude genital Schistosomiasis including Schistosomiasis of the cervix. 

Christinet et al. [37] stated the following:

In recent years, the control of neglected tropical diseases had been increasingly gaining momentum and interventions against schistosomiasis were being progressively scaled-up through expansion of donated praziquantel and preventive chemotherapy campaigns. 

Nevertheless, the public health importance of female genital schistosomiasis had not been fully recognised nor its control adequately addressed. 

Taking into consideration, a clinical and anatomopathological perspective, they had  evaluated the available literature in order to highlight the importance of female genital schistosomiasis and its connections with two sexually transmitted infections of global importance, Human Immunodeficiency Virus (HIV) and Human Papilloma Virus.

Outside the long list of clinical descriptive reports beginning from 1899, there was at the time of publication of their article a shocking gap in epidemiological assessment and a significant underestimation of the burden of FGS remains. 

The scarcity of integrated approaches to address female genital schistosomiasis does call for more concerted action in the detection, treatment and prevention of female genital Schistosomiasis alongside other concomitant women’s health issues, otherwise female genital schistosomiasis would continue to remain a neglected gynaecological disease.

Pillai et al. [38] stated the following:

Female genital schistosomiasis (FGS) is a terminology that is utilised for a tissue reaction to lodged ova of Schistosoma haematobium in the genital mucosa.

Lesions could make the mucosa friable and prone to bleeding as well as discharge.

Women who have FGS might have an increased risk of acquisition of HIV, and FGS might act as a cofactor in the development of cervical cancer.

Pillai et al. [38] undertook a study in order to explore cytology as a method for the diagnosis of FGS and to discuss the diagnostic challenges in low-resource rural areas of the world. They also explored and discussed the correlation between FGS and squamous cell atypia (SCA). They additionally compared the cytology results to Schistosoma polymerase chain reaction (PCR) in vaginal lavage and urine and in urine microscopy. With regard to the materials and methods, Pillai et al. [38] reported that in their clinical study, 394 women whose ages were between 16 years and 23 years from rural high schools in KwaZulu-Natal, South Africa, did undergo structured interviews and the following laboratory tests: Cytology Papanicolaou (Pap) smears for Schistosoma haematobium ova and cervical SCA, real-time PCR for Schistosoma-specific DNA in vaginal lavage and urine samples, and urine microscopy for the presence of Schistosoma. haematobium ova. Pillai et al. [38] summarized the results as follows: 

In Pap smears, Schistosoma haematobium ova were identified in 8 out of 394 that amounted to 2.0%. 

SCA was found in 107 out of 394 cases that amounted to 27.1%, seven of these had high-grade squamous intraepithelial lesion (HSIL).

Schistosoma specific DNA was identified in 38 out of 394 cases that amounted to 9.6% of vaginal lavages and in 91 out of 394 cases that amounted to 23.0% of urines. 

Schistosoma ova were found microscopically in 78 cases out of 394 that amounted to 19.7% of urines.

Pillai et al. [38] made the following conclusions: 

Schistosoma PCR on lavage was a better way to diagnose FGS in comparison with cytology. 

There was a significant association between Schistosoma haematobium ova in Pap smears and the other diagnostic methods. 

In low-resource Schistosoma-endemic areas of the world, it is important that cytology screeners are aware of diagnostic challenges that exist in the identification of schistosomiasis in addition to the cytological diagnosis of SCA. 

Importantly, in their study, three of eight urines were negative but had shown Schistosoma ova in their Pap smear, and one of them was also negative for Schistosoma DNA in urine. 

In their study, SCA was found not to be significantly associated with schistosomiasis. HSIL detected in this young population might need future consideration.

Venkatesh and Brown [39][ reported two HIV-positive women who had Schistosomiasis of the uterine cervix, a disease which is being increasingly encountered within developed countries. With regard to both cases, there were no Schistosoma ova within the cervical Papanicolaou smears. Both patients did undergo LLETZ procedures which had revealed an absence of a granulomatous response to the Schistosoma ova, a finding which should alert the pathologist to the possibility of HIV infection. They iterated the following:

The absence of ova upon cervical smears of HIV-infected women with schistosomiasis is perhaps related to the absence of granulomatous inflammation in these patients.

 A diligent search should be made for Schistosoma ova in the cervical biopsy of patients who come from Schistosomiasis-endemic endemic areas of the world.

Treatment of schistosomiasis in HIV-infected patients should be prompt and complete in order to prevent recurrent high-risk HPV infection.

Petry et al. [40] stated that cervical cancer is the commonest malignant tumour that is encountered among women in Tanzania and other countries in tropical Africa. They also stated that genital schistosomiasis had been postulated as a possible cofactor in the genesis of this malignant disease which might contribute to its high incidence within regions where bilharzias is endemic. Petry et al. [40] reported that one hundred nine Tanzanian patients from an area with endemic bilharzias who were transferred to a gynaecologic out-patient clinic were age-matched with 109 German controls. Petry et al. [40] also reported that in patients and controls, separate samples were obtained for cytology assessment and human papillomavirus (HPV) DNA detection with utilization of the Hybrid Capture 2 assay (HC2) and PCR (GP5+/6 +). Samples which tested positive for HPV DNA with general primers were re-tested with HPV type-specific primers. After application of 3

• Schistosomiasis / Bilharziasis of the female genital tract and cervix is a terminology that is utilized for Infection of the parasite Schistosoma within the female genital tract 
• Schistosomiasis tends to be more common in Africa and Middle East but because of global travelling Schistosomiasis of organs including the cervix / female genital tract could be encountered anywhere in the world and a high index of suspicion would be required to establish the diagnosis quickly in order to provide prompt treatment.
• Schistosoma haematobium is the most common Schistosoma organism that infects the female genital tract / cervix but some of the other Schistosoma organisms that tend to infest the female genital tract do include Schistosoma Mansoni and Schistosoma Japonicum.,
• Some of the clinical manifestations which tend to be non-specific include: Irregular menstruation, pelvic pain, vaginal discharge, . The cervix could appear inflamed, ulcerated, nodular and friable, which could simulate a carcinoma of the cervix clinically. An individual who has Schistosomiasis of Cervix that is associated with Schistosomiasis of the urinary bladder may present with haematuria and at times the symptoms of the genital tract may not be presented and a high index of suspicion would be required to establish a detailed history. 
• Schistosomiasis does increase the risk of spread of sexually transmitted infections, infertility as well as pregnancy related disorders but its relationship with cervical cancer is unclear. 
• HIV patients who have Schistosomiasis of the cervix / genital tract, often do lack a granulomatous response and obvious ova
• With regard to the diagnosis of Schistosomiasis of the cervix, the optimal method for the detection of the infection tends to be by direct examination of cervical tissue which has been obtained by forceps biopsy through quantitative compressed biopsy technique 
• Cytologic examination of cervical smears has tended not to be a reliable method to diagnose genital Schistosomiasis.
• The treatment of Schistosomiasis of the cervix and genital tract has tended to be by means of Praziquantel 
• Clinicians should consider treating individuals from Schistosomiasis endemic areas of the world who present with infertility empirically with Praziquantel as well as to investigate them also for Schistosomiasis of the cervix. 
• Urologists and other clinicians who encounter female patients from Schistosomiasis endemic areas or have travelled to Schistosomiasis-endemic areas who manifest with haematuria should have a high index of suspicion to investigate the patients for haematuria as well as the possibility of having Schistosomiasis of the cervix and female genital tract.   

Acknowledgements to:

• The World Health Organization (WHO) for supporting efforts at the treatment and reduction of Schistosomiasis as well as providing data on Schistosomiasis including Schistosomiasis of the cervix. 
• Autopsy and Case Reports for granting permission for reproduction of contents and figures from their Journal articles to be reproduced Under Copyright Autopsy and Case Reports. ISSN 2236 – 1960. Copyright @ 2014. This is an Open Access article distributed of terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the article is properly cited. 

None.