Nabothian Cyst

The nabothian cyst contains mucus and often appears like a tiny swelling on the anterior surface of the cervix. The size of nabothian cyst may vary from 2-40 mm. The color of the mucus is also variable ranging from clear, yellow to a greenish yellow.

Nabothian Cyst is the result of anatomic/foreign processes.

Presentation

Nabothian cysts are generally first identified by gynecologists during a pelvic exam. They rarely cause symptoms unless they are large. The majority of women with a nabothian cysts do not even known they have such a cyst as there are no symptoms. These lesions often appear as tiny cyst or vesicle on the anterior surface of the cervix. The nabothian cyst may be single, a collection of cysts in a cluster or a large complex multiloculated cyst. The color may vary from reddish white and a fluid (mucus) may be visible inside the cyst. Only in rare cases where the cyst is large, symptoms develop. Anecdotal case reports indicate that the symptoms from a large nabothian cyst may include vaginal bleeding, vague pelvis discomfort or a pressure like sensation. Sometimes a large nabothian cyst may obstruct the cervical orifice and lead to lower abdominal discomfort, especially during the menstruation.

Workup

There is no blood test that is diagnostic of a nabothian cyst. If a nabothian cyst is suspected, one may order a pelvic ultrasound. However, a transabdominal ultrasound is not very sensitive and is likely to miss small cysts. A transvaginal ultrasound performed by a radiologist or an obstetrician is more sensitive for a nabothian cyst. However, cysts smaller than 1 cm can be missed.

Colposcopy may help differentiate whether the lesion is benign or malignant. Any suspicious areas are usually biopsied and analyzed by the pathologist for presence of malignant cells [4] [5].

Pelvic MRI may be used to look for nabothian cysts, which may appears as either localized cystic swellings or multiloculated cystic lesions within the superficial layers of the cervix. This method is not the test of first choice and often only done when the patient is symptomatic and the diagnosis of a nabothian cyst is not made with any other means. CT scan can be used to detect nabothian cysts but small cysts may be missed [6] [7] [8].

Treatment

The majority of nabothian cysts are discovered incidentally and are asymptomatic. Most require no treatment. The cysts are benign and have no malignant potential. If the cyst is large, there are several options for treatment [9]. Aspiration of the mucus fluid can be attempted but recurrence rate is high. For large cysts that are causing symptoms a formal surgical excision may be required. The surgery may be done under spinal or regional anesthesia and good access to the anterior cervix is required. Surgery is sometimes done when the cyst appears multiloculated and there is a need to confirm the presence of absence of a malignancy. Since nabothian cysts are not very deep, superficial excision may be adequate. There are isolated reports of use of laser, electrocautery or liquid nitrogen to treat the cyst. Sometimes multiple treatment sessions are required to completely eradicate the cysts. There are not enough data on how common recurrences are after treatment.

Prognosis

The prognosis is excellent for all sizes of nabothian cysts. While they do not resolve spontaneously, they generally do not cause any symptoms.

Etiology

Nabothian cysts are not commonly seen in young girls or in females who have not given birth. These cysts often arise after the birth of a child or a result of surgery (hysterectomy). The new cell lining that grows over the cervix sometimes blocks the ducts of the nabothian glands, which lie near the surface of the cervix. Once the opening of the nabothian gland is blocked, a small cystic structure develops. The mucus secreted by the nabothian gland cannot be discharge in the surface of the cervix and consequently a swelling is the result.

Epidemiology

The exact number of women with nabothian cysts is unknown because many women have no symptoms. In addition, unless a physical exam of the pelvis is done, these cysts are often not visible. Radiology reports indicate that nabothian cysts are common and may be seen in 12% of women who undergo imaging studies of the pelvis for another cause. Nabothian cuts occur in women of all races and are most common in women who have given birth. Nabothian cysts may also be seen in post-menopausal women who have a decrease in estrogen and a consequent thinning of the cervix. In rare cases, a nabothian cyst may develop in women with chronic cervicitis.

Sex distribution
Age distribution

Pathophysiology

Nabothian cysts occur as a result of healing after normal healing or traumatic injury to the superficial lining of the cervix. For example during birth, there is always some loss of superficial cells of the cervix. During healing the new cells plug up the ducts from the nabothian gland, which leads to retention of the mucus secretion and development of cysts.
Sometimes nabothian cysts may occur as a delayed complication of a hysterectomy. The transformation layer of the cervix is internalized and this results in obliteration of the ducts of the nabothian glands, which eventually results in development of cysts.
The majority of nabothian cysts range from 2-10 mm in diameter but there are some rare women who may develop cyst that are the size of a grape or about 4-6 cm.
When the ducts of the nabothian gland are close to each other, one can even see a cluster of nabothian cysts. Microscopy usually reveals multicystic dilatation of the gland.
When a cystic structure appears on the cervix, the differential diagnosis includes the following:
- Adenoma malignum
- Adenocarcinoma of the cervix
- Bartholin gland cyst

Prevention

There is no way to prevent a nabothian cyst. Most are incidental and the cause is iatrogenic.

Summary

A nabothian cyst is also known as retention cyst, mucus retention cyst, nabothian follicle or an epithelial inclusion cyst. These non-neoplastic cystic structures appear as tiny bumps on the anterior surface of the cervix. Nabothian cysts occur when the superficial layer of the cervix gets traumatized or is erased and the growth of the new layer closes of the opening of the nabothian glands underneath. The progressive accumulation of mucus leads to cystic enlargement and a bump on the cervix. Nabothian cysts are commonly found in women of child bearing age and vary in color from yellow to whitish red. They are not tender and the majority produce no symptoms. Even though most nabothian cysts cause no symptoms, some may enlarge over time. Nabothian cysts are benign cystic lesions but often need to be differentiated from other malignant lesions that also occur on the cervix [1][2] [3].

Patient Information

A nabothian cyst, also known as a retention cysts of the cervix, is a tiny lump on the surface of the cervix, the lower part of the uterus. It is filled with mucous and usually harmless. Because the cause of nabothian cysts is not known there is no way of preventing them. However, once a nabothian cyst is diagnosed, the patient should be assured that the lesion is benign and does not cause symptoms in most cases

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References

  1. Tran TA, Niu G, Tomasello CA, Tran HV, Ross JS, Carlson JA. The spectrum of grossly visible pigmented lesions in the uterine cervix: a prospective study. Int J Gynecol Pathol. 2014 Jan;33(1):89-99.
  2. Temur I, Ulker K, Sulu B, Karaca M, Aydin A, Gurcu B. A giant cervical nabothian cyst compressing the rectum, differential diagnosis and literature review. Clin Exp Obstet Gynecol. 2011;38(3):276-9.
  3. Liu S, Zhang M, Qu Y, Pan Y, Zhang Y. Increased iodine uptake in the Nabothian cyst. Clin Nucl Med. 2013 Feb;38(2):157-8
  4. Casey PM, Long ME, Marnach ML. Abnormal cervical appearance: what to do, when to worry? Mayo Clin Proc. 2011 Feb;86(2):147-50;
  5. Bin Park S, Lee JH, Lee YH, Song MJ, Choi HJ. Multilocular cystic lesions in the uterine cervix: broad spectrum of imaging features and pathologic correlation. AJR Am J Roentgenol. 2010 Aug;195(2):517-23
  6. Sosnovski V, Barenboim R, Cohen HI, Bornstein J. Complex Nabothian cysts: a diagnostic dilemma. Arch Gynecol Obstet. 2009 May;279(5):759-61.
  7. Okamoto Y, Tanaka YO, Nishida M, Tsunoda H, Yoshikawa H, Itai Y. MR imaging of the uterine cervix: imaging-pathologic correlation. Radiographics. 2003 Mar-Apr;23(2):425-45; quiz 534-5.
  8. Oguri H, Maeda N, Izumiya C, Kusume T, Yamamoto Y, Fukaya T. MRI of endocervical glandular disorders: three cases of a deep nabothian cyst and three cases of a minimal-deviation adenocarcinoma. Magn Reson Imaging. 2004 Nov;22(9):1333-7.
  9. Young RH, Clement PB. Pseudoneoplastic glandular lesions of the uterine cervix. Semin Diagn Pathol. 1991 Nov;8(4):234-49.

  • A practical manual on visual screening for cervical neoplasia - R Sankaranarayanan, RS Wesley - 2003 - books.google.com
  • A comparative analysis of cross sectional imaging techniques in minimal deviation adenocarcinoma of the uterine cervix - K Itoh, T Toki, S Shiohara, O Oguchi - Journal of Obstetrics , 2005 - Wiley Online Library
  • Adenoma malignum: MR appearances mimicking nabothian cysts. - Y Yamashita, M Takahashi - American Journal of , 1994 - Am Roentgen Ray Soc
  • Adenoma malignum: MR appearances mimicking nabothian cysts. - Y Yamashita, M Takahashi - American Journal of , 1994 - Am Roentgen Ray Soc


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