stenosis of the uterine cervix

Stenosis of the uterine cervix is the pathologic narrowing of the uterine cervix. The term cervical stenosis is clinically defined as cervical narrowing that prevents the insertion of a 2.5 mm wide dilator through the cervical os.

Epidemiology

One-fifth of patients have a history of exposure to diethylstilbestrol whilst in utero. Often associated with endometriosis.

Clinical presentation

Women of reproductive age may have retrograde menses, raising the risk of endometriosis. Dysmenorrhea is present in up to 50% of patients with cervical stenosis. If the stenosis is severe enough it may result in proximal obstruction resulting in:

• hematometra: women of childbearing age with cervical stenosis are less likely to show evidence of hematometra than postmenopausal patients
• hydrometra 
• pyometra
• hematosalpinges

Other potential consequences include:

• infertility
• impediment to assisted fertility techniques 
  • embryo transfer
  • intrauterine insemination

Pathology

Etiology

Any pathological process that can cause inflammation of the cervical mucosa, resulting in erosion and regeneration can result in cervical stenosis. This includes:

• congenital cervical stenosis
• chronic infection (chronic cervicitis)
• trauma 
  • from previous instrumentation
    • cone biopsy/loop electrosurgical excision procedure (LEEP)
    • cryotherapy
    • laser treatment
• stenosis secondary to a tumor/mass:
  • cervical polyp
  • carcinoma of the cervix
• post radiation therapy
• cervical endometriosis

Microscopic appearance

Histology reflects etiology; essentially the basic pathological processes of inflammation, erosion, repair and regeneration at any stage may be visualized. Juxtaposed and closely abutting cervical stromal tissue may demonstrate adhesions.

Radiographic features

Hysterosalpingogram

May appear as narrowing of the endocervical canal (normal diameter: 0.5-3.0 cm), or it may manifest as complete obliteration of the cervical os, preventing insertion of the hysterosalpingographic catheter.

Ultrasound

The endocervix may be thickened or normal in appearance. Although it is difficult on imaging to the directly visualize the stenosis, visualization of an underlying mass in the appropriate location may suggest an accompanying stenosis especially if it is complicated by proximal dilatation of the female genital tract (see complications). There may be fluid distension of the endometrial cavity. If due to irradiation, the cervix may demonstrate loss of the normal zonal architecture.

CT

Complications associated with cervical stenosis may be apparent, including hydro- and hematometra. Although the cervix may be normal in appearance, the uterine cavity may be fluid distended. Further complications such as hematosalpinges may also be visualized. Ancillary findings can point towards the underlying cause, such as an underlying mass lesion, or bowel wall thickening associated with radiation treatment.

Treatment and prognosis

In selected situations, gradual dilatation of the cervix, often performed with ultrasound guidance, can be an effective treatment. Other treatment options include insertion of laminaria tent, hysteroscopic excision of cervical tissue; or in extreme circumstances total hysterectomy.

Differential diagnosis

General considerations include:

• external compression of the uterine cervix from a mass lesion, e.g. cervical leiomyoma, malignancy
• congenital abnormalities
  • cervical/vaginal atresia
  • vaginal stenosis
  • complete transverse vaginal septum
  • imperforate hymen

Siehe auch:

• vaginal stenosis
• Leiomyom der Zervix uteri

und weiter:

• haematosalpinx
• cervical stenosis