Congenital cervical anomalies and benign cervical lesions
- Marc R Laufer, MD
Marc R Laufer, MD
- Professor of Obstetrics, Gynecology, and Reproductive Biology
- Harvard Medical School
Benign abnormalities of the cervix (Latin for neck) are commonly seen in gynecological practice. The relative ease of cervical examination allows observation of physiologic changes that occur in response to normal cyclic variations in ovarian hormone secretion, as well as a variety of structural abnormalities and pathologic conditions (premalignant, malignant, infection-related, benign neoplasms). Diagnosis and management require a combination of visual, tactile, and laboratory assessment.
EMBRYOLOGY, NORMAL ANATOMY, AND HISTOLOGY
Embryology — Fusion of the paired müllerian ducts at about day 54 postfertilization results in formation of the uterovaginal canal, which is the precursor of the uterine corpus, cervix, and upper vagina . The caudal end of the uterovaginal canal migrates down to meet the urogenital sinus at a point termed the müllerian tubercle, which eventually becomes the vaginal orifice and hymen. At about day 66, stratification of cells in this area give rise to the sinovaginal bulbs, which proliferate to form a solid vaginal plate by day 77. The central cells of the vaginal plate then break down to form the vaginal lumen. Endocervical glands and the vaginal fornices appear between 91 days (13th week) and 15 weeks, thereby providing the first clear signs of the cervix.
Anatomy — The normal cervix is fusiform in shape, with the narrowest portions at the internal and external oses. After menarche, the cervix accounts for one-half to one-third of the length of the uterus, and measures 3 to 5 cm in length and 2 to 3 cm in diameter (in prepubertal girls, the cervix is twice the length of the fundus; this ratio reverses with age). The portio vaginalis is the visible portion of the cervix that protrudes into the vagina. The portio vaginalis is surrounded by a reflection of the vaginal wall on each side termed the anterior, posterior, and lateral fornix. The supravaginal cervix is the intraabdominal portion of the cervix that lies above the point of attachment of the vaginal vaults; the peritoneum posterior to the supravaginal cervix forms the lining of the posterior cul-de-sac (pouch of Douglas).
The cervical canal, which averages 3 cm long and a few millimeters wide, connects the uterine cavity with the vagina . The external cervical os (where the canal opens to the vagina) is small, round, and centrally placed in nulliparous women, but is more likely to be a patulous, transverse slit in women who have labored into the third stage (figure 1). The internal cervical os (where the canal opens to the uterine cavity) is normally no more than 3 mm in diameter in nonpregnant women, even if parous . The vagina is at a 90 degree angle to a normal anteverted uterus, thus the external cervical os faces toward the posterior wall of the vagina and the cervix lies between the bladder and rectum.
The cervix is supported by the uterosacral ligaments, which surround the cervix and vagina and extend laterally and posteriorly toward the second to fourth sacral vertebrae, and the cardinal ligaments, which are fibromuscular bands that fan out laterally from the lower uterine segment and cervix to the lateral pelvic walls. The blood supply comes from a descending branch of the uterine artery and lymphatic drainage is to the parametrial nodes, then to the obturator, internal iliac, and external iliac nodes with secondary drainage to the presacral, common iliac, and paraaortic lymph nodes. The nerve supply is autonomic (sympathetic and parasympathetic). The nerves enter the upper cervix on either side and form two lateral semicircular plexuses, called Frankenhäuser plexus, a terminal part of the presacral plexus.
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- EMBRYOLOGY, NORMAL ANATOMY, AND HISTOLOGY
- CONGENITAL ABNORMALITIES
- Diethylstilbestrol induced changes
- CYSTIC LESIONS
- Nabothian cysts
- Mesonephric cysts
- NONCYSTIC LESIONS
- CERVICAL STENOSIS
- PREMALIGNANT AND MALIGNANT LESIONS
- SUMMARY AND RECOMMENDATIONS