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.
- www.pathologyresources.com. (Accessed on May 03, 2012).
- Hricak H, Chang YC, Cann CE, Parer JT. Cervical incompetence: preliminary evaluation with MR imaging. Radiology 1990; 174:821.
- Niver DH, Barrette G, Jewelewicz R. Congenital atresia of the uterine cervix and vagina: three cases. Fertil Steril 1980; 33:25.
- Dillon WP, Mudaliar NA, Wingate MB. Congenital atresia of the cervix. Obstet Gynecol 1979; 54:126.
- Rock JA, Schlaff WD, Zacur HA, Jones HW Jr. The clinical management of congenital absence of the uterine cervix. Int J Gynaecol Obstet 1984; 22:231.
- Fujimoto VY, Miller JH, Klein NA, Soules MR. Congenital cervical atresia: report of seven cases and review of the literature. Am J Obstet Gynecol 1997; 177:1419.
- Deffarges JV, Haddad B, Musset R, Paniel BJ. Utero-vaginal anastomosis in women with uterine cervix atresia: long-term follow-up and reproductive performance. A study of 18 cases. Hum Reprod 2001; 16:1722.
- Bugmann P, Amaudruz M, Hanquinet S, et al. Uterocervicoplasty with a bladder mucosa layer for the treatment of complete cervical agenesis. Fertil Steril 2002; 77:831.
- Creighton SM, Davies MC, Cutner A. Laparoscopic management of cervical agenesis. Fertil Steril 2006; 85:1510.e13.
- Singh J, Devi YL. Pregnancy following surgical correction of nonfused müllerian bulbs and absent vagina. Obstet Gynecol 1983; 61:267.
- Geary WL, Weed JC. Congenital atresia of the uterine cervix. Obstet Gynecol 1973; 42:213.
- Casey AC, Laufer MR. Cervical agenesis: septic death after surgery. Obstet Gynecol 1997; 90:706.
- Rock, JA, Carpenter SE, Wheeless CR, Jones, HW. The clinical management of maldevelopment of the uterine cervix. J Pelvic Surg 1995; 1:129.
- Laufer MR. Structural abnormalities of the female reproductive tract. In: Pediatric & Adolescent Gynecology, 6th ed, Emans SJ, Laufer MR (Eds), Wolters Kluwer Lippincott Williams & Wilkins, Philadelphia 2012. p.188.
- Herbst AL, Ulfelder H, Poskanzer DC. Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearance in young women. N Engl J Med 1971; 284:878.
- Belfiore P, Costa E, De Cantis S, et al. Effectiveness and persistence of a topical treatment for cervical ectropion with deoxyribonucleic acid. Minerva Ginecol 2005; 57:461.
- Kerner H, Lichtig C. Müllerian adenosarcoma presenting as cervical polyps: a report of seven cases and review of the literature. Obstet Gynecol 1993; 81:655.
- Van Renterghem N, De Paepe P, Van den Broecke R, et al. Primary lymphoma of the cervix uteri: a diagnostic challenge. Report of two cases and review of the literature. Eur J Gynaecol Oncol 2005; 26:36.
- Baker PM, Clement PB, Bell DA, Young RH. Superficial endometriosis of the uterine cervix: a report of 20 cases of a process that may be confused with endocervical glandular dysplasia or adenocarcinoma in situ. Int J Gynecol Pathol 1999; 18:198.
- Baldauf JJ, Dreyfus M, Ritter J, et al. Risk of cervical stenosis after large loop excision or laser conization. Obstet Gynecol 1996; 88:933.
- Krantz, KE. The anatomy of the human cervix, gross and histologic. In: The biology of the cervix, Moghissi K (Ed), University of Chicago Press, Chicago 1973. p.1.
- Barbieri RL, Callery M, Perez SE. Directionality of menstrual flow: cervical os diameter as a determinant of retrograde menstruation. Fertil Steril 1992; 57:727.
- Yanushpolsky EH, Ginsburg ES, Fox JH, Stewart EA. Transcervical placement of a Malecot catheter after hysteroscopic evaluation provides for easier entry into the endometrial cavity for women with histories of difficult intrauterine inseminations and/or embryo transfers: a prospective case series. Fertil Steril 2000; 73:402.
- Baggish MS, Baltoyannis P. Carbon dioxide laser treatment of cervical stenosis. Fertil Steril 1987; 48:24.
- Luesley DM, Williams DR, Gee H, et al. Management of postconization cervical stenosis by laser vaporization. Obstet Gynecol 1986; 67:126.
- Noyes N. Hysteroscopic cervical canal shaving: a new therapy for cervical stenosis before embryo transfer in patients undergoing in vitro fertilization. Fertil Steril 1999; 71:965.
- Noyes N, Licciardi F, Grifo J, et al. In vitro fertilization outcome relative to embryo transfer difficulty: a novel approach to the forbidding cervix. Fertil Steril 1999; 72:261.
- 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