Ultrasonographic Diagnosis and Treatment of a Giant Uterine Cervical Nabothian Cyst

Journal of Medical Ultrasound (2012) 20, 169e172

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CASE REPORT Ultrasonographic Diagnosis and Treatment of a Giant Uterine Cervical Nabothian Cyst

Pei-Ying Wu, Keng-Fu Hsu*, Chiung-Hsin Chang, Fong-Ming Chang

Department of Obstetrics and Gynecology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

Received 2 February, 2012; accepted 2 June, 2012

KEY WORDS Uterine cervical Nabothian cysts are common gynecological diseases in women of reproductive giant Nabothian cyst, age. Although Nabothian cysts are generally small and asymptomatic, giant Nabothian cysts are ultrasonography extremely rare and may be misdiagnosed as other uterine tumors, or even malignancy. Here, we report a case of a giant (8 cm Â 6.5 cm) Nabothian cyst, which was suspected as malignant after computed tomography scanning at another hospital. The patient was referred to our clinic for hysterectomy. In our clinic, the cyst was correctly diagnosed as a giant Nabothian cyst by pelvic examination and ultrasonography before surgery. The patient was then successfully treated with local excision and simple drainage vaginally, without planned hysterectomy. From this case, we recommend giant Nabothian cysts should be taken into consideration for differential diagnosis of cervical tumors. Ultrasonography is of value for the diagnosis of giant Nabothian cysts. ª 2012, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. All rights reserved.

Introduction usually occur at the transformation zone of the uterine cervix, and are a few millimeters to 3e4 cm in diameter [1]. Nabothian cysts are common gynecological conditions in Although Nabothian cysts are usually small and asymptom- reproductive women. They are generally multiple, trans- atic, giant Nabothian cysts are relatively rare and may be lucent or opaque, and whitish to yellow. Nabothian cysts managed as other uterine benign or malignant tumors [2e13]. Here, we report a patient with a giant cervical Nabothian cyst, who was referred for hysterectomy by another hospital after diagnosis of a uterine tumor by * Correspondence to: Dr. Keng-Fu Hsu, Department of Obstetrics computed tomography (CT). Fortunately, it was correctly and Gynecology, National Cheng Kung University Hospital, 138 diagnosed as a giant Nabothian cyst by preoperative ultra- Sheng-Li Road, Tainan 704, Taiwan. sonography, and successfully treated by simple drainage E-mail address: [email protected] (K.-F. Hsu). without hysterectomy.

Case report

A 45-year-old woman, gravida 2, para 2, was referred to our hospital due to a pelvic cystic mass. She complained low abdominal discomfort with a dragging sensation for several weeks. CT was performed at another hospital and revealed a pelvic cystic mass about 8 cm in size (Fig. 1). Hysterec- tomy was recommended for her uterine tumor, and she was referred to our hospital for further management. At our outpatient clinic, pelvic examination revealed a soft huge mass from the posterior fornix protruding into the vagina. Serum levels of tumor markers, including car- cinoembryonic antigen, cancer antigen 125 and cancer antigen 19-9, were all within normal limits. A Papanicolaou (Pap) smear was performed and the result was absence of malignant cells. Colposcopy revealed a silverewhite cyst protruding from the posterior lip of the cervix. Transvaginal ultrasonography at our Ultrasound Labora- tory illustrated an 8.0 cm Â 6.5 cm cervical mass with a multilobulated pattern, arising from the posterior fornix and protruding into the vaginal canal (Fig. 2A). Besides, the uterine corpus and bilateral adnexal areas were unre- markable. Moreover, transabdominal ultrasonography demonstrated a giant cervical cyst located at the posterior fornix and adjacent to the uterine posterior wall (Fig. 2B). Furthermore, color Doppler ultrasonography demonstrated no abnormal vessels or blood ﬂows within the cyst (Fig. 2C). According to the ﬁndings by pelvic examination and ultrasound imaging, a tentative diagnosis of a giant Nabo- thian cyst was made. Without the initial plan of a hysterectomy, the patient was treated by a simple cervical incision and local drainage to reduce the giant Nabothian cyst. Final pathological examination reported multiple cervical tissues with cystic spaces lined by endocervical- type epithelium, which was compatible with a dilated Nabothian cyst. No evidence of dysplasia or malignancy was seen. At a postoperative follow-up 3 months later, she recov- ered very well. Pelvic examination and ultrasonography revealed a normal cervix, without any evidence of recur- rent Nabothian cysts.

Discussion

Benign uterine cervical lesions, such as cervical polyp, cervix erosion and condyloma, may cause many symptoms or signs, such as abnormal bleeding, protruding mass, and low abdominal discomfort. By contrast, Nabothian cysts usually are free of symptoms because they are usually small; only a few millimeters in diameter. Occasionally, Nabothian cysts may reach up to 4 cm or more and cause symptoms and signs [2e4]. However, it is rare for Nabothian Fig. 1 Computed tomography showed a pelvic cystic mass cysts growing up to 8 cm in diameter in the uterine cervix, without solid component. (A) Saggital view; (B) transverse which may cause a variety of symptoms, or even mimic view. uterine tumors or malignancy [2e5]. In the present case, we found a giant Nabothian cyst from the posterior lip of the uterine cervix, which was with only a simple Nabothian cyst to undergo hysterectomy initially misdiagnosed as a uterine tumor, and hysterectomy simply after CT scan and without further pelvic examination was even suggested after CT scan at another hospital. It and ultrasound scanning. From this case, we learn that would cause devastating damage to a reproductive woman detailed pelvic examination and ultrasound scanning are Giant Cervical Nabothian Cyst 171

increase in size to become a giant cyst after years, along with gradual development of symptoms. Our patient had symptoms of pelvic congestion and a dragging sensation only after she was aged 45 years. Although being rare, giant Nabothian cysts may compress the rectum and induce sensations of abnormal defecation, such as tenesmus [6]. In our case, only pelvic congestion and dragging sensation developed, without any relevant rectal or anal symptoms. Perhaps in the future, our patient, without medical intervention, might develop rectal or anal symptoms if the giant Nabothian cyst grows posteriorly and compresses the rectum or anus. In order to differentiate benign or malignant uterine tumors from Nabothian cysts, several examinations, such as colposcopy, ultrasound, CT scan, and magnetic resonance imaging (MRI), are recommended. Among these tests, the first step is to undertake a Pap test, which might detect cervical carcinomas [7]. Besides, colposcopy may serve as an adjunctive test in the evaluation of women with abnormal Pap tests [8]. Moreover, intracervical sonography can be used to visualize cervical lesions of glandular mucosa [9]. Occa- sionally, CT is performed to evaluate the lesions. Further- more, Nabothian cysts may be often depicted as an incidental finding at MRI [10]. MRI may accurately differentiate mucin-producing carcinomas from Nabothian cysts, because the signal intensity on T2-weighted imaging in the cervical stroma is different in these two diseases [3,10,11].In our case, the Pap test was normal, which excluded the possibility of cervical malignancy. Colposcopy revealed a silverewhite cyst protruding from the posterior lip of the cervix, which also favored a diagnosis of a benign lesion. Ultrasonography is useful in differentiating cysts from other tumors, and contributes the most valuable information to the diagnosis of Nabothian cysts. Color Doppler also confirmed it is a benign cyst. However, although CT was misleading in our case, we cannot neglect the value of CT. In our case, MRI was not undertaken due to the expense, and notably, ultrasound had reached an accurate diagnosis of a giant Nabothian cyst. In conclusion, careful preoperative pelvic examination as well as ultrasonographic imaging are necessary for patients with giant Nabothian cysts. Thus, unnecessary hysterectomy can be avoided, and the patient can recover Fig. 2 Ultrasonographic examination demonstrated a large quickly. From our case, we recommend taking into account uterine cervical cyst. (A) Transvaginal ultrasonography. An giant Nabothian cysts in the differential diagnosis of pelvic 8.0 cm Â 6.5 cm multilobulated cyst with homogeneous tumors. Furthermore, ultrasonography may be of value in content was seen. (B) Transabdominal ultrasonography. The reaching and accurate diagnosis and for proper treatment. cyst was located over the uterine posterior wall. (C) Color Doppler ultrasonography showed no abnormal intratumoral vessels or flows. BL Z urinary bladder; IUD Z intrauterine Acknowledgments device. We are grateful for the assistance of all the staff in the Ultrasound Laboratory, Department of Obstetrics and mandatory for every physician when receiving referred Gynecology, National Cheng Kung University Hospital, cases from other hospitals. Nabothian cysts should be College of Medicine, National Cheng Kung University, considered for the differential diagnosis of pelvic tumors, Tainan, Taiwan. even those >8 cm in diameter. On the pathogenesis of Nabothian cysts, one of the possible mechanisms may be due to accumulated secretory References fluid when the Nabothian glands are obstructed by inflam- mation or trauma. In our case, it may be induced by [1] Casey PM, Long ME, Marnach ML. Abnormal cervical appear- repeated traumas from multiple vaginal births. Initially, ance: what to do, when to worry? Mayo Clin Proc 2011;86: Nabothian cysts are free of symptoms. Later, the cyst may 147e50. 172 P.-Y. Wu et al.

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