Basics
Description
- First described by German anatomist Martin Naboth in 1707 (4)
- Also called inclusion cysts or retention cysts
- Visible on speculum exam as round or oval cervical lesions, translucent or opaque with ivory-yellow tinge
- Range in size from microscopic to 2 " 4 cm in diameter
- May be single or multiple in number
- Almost always superficial but can be deep, extending to serosa, or surrounding paracervical connective tissue
- Numerous or very large cysts can produce enlargement of the cervix resulting in dyspareunia.
- Cysts farthest from cervical os indicate the extent of the "transformation zone " (the area of squamous metaplasia between the endocervical columnar epithelium and ectocervical squamous epithelium) (1,2).
Risk Factors
- Nabothian cysts are associated with increased age and higher parity.
- Chronic cervicitis may predispose to development of Nabothian cysts (1,2).
Pathophysiology
- The uterine cervix consists of the endocervix, with mucous-secreting columnar epithelium, and the ectocervix, with squamous epithelium.
- Inflammation at the squamocolumnar junction induces a continuous repair process.
- This healing process results in the growth of squamous epithelium over the columnar cells of the ectocervix, which continue to secrete mucus, resulting in cystic dilatation.
- Chronic inflammation (i.e., cervicitis) also leads to stenosis of endocervical glands, resulting in retention of mucous and cystic enlargement (1,2).
Etiology
Benign lesions resulting from normal squamous metaplasia at the squamocolumnar junction or chronic inflammation of the cervix
Diagnosis
History
Signs and symptoms:
- Nabothian cysts are most often asymptomatic.
- Increased size or number can cause clinical symptoms such as:
- Sensation of fullness in vagina
- Dyspareunia
- Low back pain
- Spotting if associated with chronic cervicitis (2,3)
Physical Exam
- Smooth, tense, round, or oval cysts
- Slightly raised from the surface of the cervix
- Few millimeters to 2 " 4 cm in size
- Translucent or opaque with ivory or bluish tinge; may be hemorrhagic
- Single or grouped
- Branching network of vessels visible over the surface in a regular pattern
- With numerous large or deep cysts, cervical enlargement palpable on bimanual exam (1,2,3)
Tests
Lab
Cytology: For evaluation of lesions with atypical features
Imaging
- Imaging is generally not required since most often cysts can be diagnosed clinically.
- Imaging modalities occasionally useful are as follows:
- Transvaginal ultrasound
- For diagnosis of deep cysts or those that are not visible on speculum exam
- CT
- To differentiate Nabothian cysts from endometriosis, Gartner duct cysts or mucoceles
- Not useful for cysts >2 cm, as CT may confuse them with cystic adnexal mass
- MRI
- Cysts appear smooth-walled and do not enhance with intravenous gadolinium.
- For evaluation of deep Nabothian cysts (to differentiate from cystic adnexal mass)
- For evaluation of large diameter (>2 cm) cysts (2,3)
Surgery
- Nabothian cysts can be diagnosed clinically, based on their appearance on vaginal speculum exam.
- Colposcopic examination and biopsy may be useful to diagnose lesions with atypical features.
- Speculum and bimanual exam usually sufficient.
- If atypical appearance:
- Colposcopy with or without biopsy
- Drainage with cytological analysis
- Excision for histopathological assessment (3,4)
Pathological Findings
- Gross examination:
- Round or oval mucin-filled cysts extending from mucosa to endocervical stroma
- Microscopic features:
- Round cysts, lined by single layer of columnar epithelial cells containing variable amounts of cytoplasm
- Basally situated nuclei with fine chromatin and small nucleoli without cytologic atypia (3)
Differential Diagnosis
- Cervical pregnancy
- Gartner duct cyst: Remnant of Wolffian duct, seen on lateral wall of vagina
- Cervical stenosis
- Mesonephric cyst: Remnant of Wolffian duct found deep within cervical stroma forming cysts up to 2.5 cm in size
- Endometriosis: May form cystic structures on cervix that appear red-black and are nonblanching
- Minimal deviation adenocarcinoma: Adnexal adenocarcinoma which mimics cystic mass of cervix with benign appearing glands (5)
Treatment
Additional Treatment
General Measures
Treatment is rarely needed as Nabothian cysts are generally asymptomatic.
Surgery
- For symptomatic large Nabothian cysts:
- Electrocautery
- Cryotherapy
- Aspiration
- For abnormal appearing lesions requiring histopathological assessment:
- Excisional biopsy (3,4)
Ongoing Care
Follow-Up Recommendations
No follow-up necessary unless surgical intervention needed.
Prognosis
- No malignant potential
- No spontaneous resolution (1,2,3)
Complications
Enlargement of the cervix
References
1Casey PM, Long ME, Marnach ML. Abnormal cervical appearance: What to do, when to worry? Mayo Clin Proc. 2011;86(2):147 " 151. [View Abstract]2Bin Park S, Lee JH, Lee YH. Multilocular cystic lesions in the uterine cervix: Broad spectrum of imaging features and pathologic correlation. AJR. 2010;195(2):517 " 523. [View Abstract]3Sosnovski V, Barenboim R, Cohen HI. Complex Nabothian cysts: A diagnostic dilemma. Arch Gynecol Obstet. 2009;279(5):759 " 761. [View Abstract]4Fogel SR, Slasky BS. Sonography of Nabothian cysts. AJR. 1982;138:927 " 930. [View Abstract]5Oguri H, Maeda N, Izumiya C. MRI of endocervical glandular disorders: Three cases of a deep Nabothian cyst and three cases of a minimal-deviation adenocarcinoma. Magn Reson Imaging. 2004;22:1333 " 1337. [View Abstract]
Codes
ICD9
616.0 Cervicitis and endocervicitis including Nabothian (gland) cyst or follicle
ICD10
- N72 Inflammatory disease of cervix uteri
- N88.8 Other specified noninflammatory disorders of cervix uteri
SNOMED
- 24565001 nabothian follicles on cervix (disorder)
- 198203009 cervicitis with Nabothian cyst (disorder)
- 198206001 endocervicitis with Nabothian cyst (disorder)
Clinical Pearls
- Nabothian cysts are common benign cysts of the uterine cervix that do not spontaneously regress.
- They are rarely symptomatic unless very large.
- Symptomatic cysts may be treated in the office setting with electrocautery or cryotherapy.
- Deep cysts may be difficult to differentiate from minimal deviation adenocarcinoma of the cervix.