Cervix and Vaginal Pathology Study Notes

Overview

  • Speaker: Sean Wysak

  • Focused mostly on cervix and a little on vaginal pathology.

  • Reference provided in textbooks.

Cervix Pathology

Nabothian Cysts

  • Extremely common findings in the cervix.

  • Recognition is crucial for documentation decisions.

  • Named after German anatomist Martinus Neboth (1707).

Characteristics:

  • Mucus-filled cervical cysts.

  • Usually not clinically significant.

  • Can be associated with subclinical cervicitis due to low-grade inflammation.

  • Asymptomatic blockage of mucus duct leads to cyst formation.

Sonographic Appearance:

  • Typically small, measuring 5 to 20 millimeters.

  • Smooth thin walls with well-defined back wall enhancement.

  • May display internal echoes (not always anechoic).

  • Frequently, multiple cysts may be present.

Example Observations:

  • Sagittal view: posterior lip of the cervix shows a Nabothian cyst.

  • Coronal view: similar appearance with one or two cysts.

Cervical Polyps

  • Benign, asymptomatic masses in the cervical canal or extending into the vagina.

  • Arise from the cervical canal, can be sessile (wide base) or pedunculated (narrow stalk).

  • Often linked to inflammation.

Sonographic Observation:

  • Solid mass in cervical canal appears echogenic.

  • Small amounts of fluid may be noted but typically not significant unless advised by a radiologist.

Myomas in the Cervix

  • Also referred to as fibroids; can present similarly to those found in the uterus.

  • Risk for issues in labor/delivery due to obstructing the cervical canal.

  • Sonography features exhibit same characteristics as myomas elsewhere in the uterus.

Observations:

  • Subserosal cervical myoma could be noted with claw sign indication.

  • Potential for prolapse into cervical canal; careful evaluation required.

Cervical Cancer

  • Diagnosis typically not made via ultrasound; relies on clinical exam & biopsy.

  • Imaging may assess for urinary obstruction or changes from treatment.

Patterns of Spread:

  1. Local Extension: growth into neighboring organs (e.g., bladder, rectum).

  2. Lymphatic Spread: enlargement of pelvic/abdominal lymph nodes.

  3. Hematogenous Spread: rare cases may see metastasis (e.g., liver).

Sonographic Indicators:

  • Enlarged, irregular cervix most often detected via ultrasound.

  • Presence of fluid in uterine cavity surrounding cervical lesion considered significant.

  • Identifying hydronephrosis could indicate obstruction.

Treatment Approaches for Cervical Cancer

  • Radiation therapy (internal, not external).

Types of Radiation Therapy:

  1. Intracavitary Brachytherapy:

    • Applicator placed in cervical canal emitting radiation into the tumor.

    • Sonographic appearance as hyperechoic linear structures with reverb.

  2. Interstitial Brachytherapy:

    • Radioactive seeds inserted close to or into the tumor.

    • Produces distinct hyperechoic lines, with potential for common tail artifacts.

Radiation Effects

  • Radiogenic changes can cause bladder wall thickening (radiation cystitis).

  • Fluid dynamics in bladder may reveal signs of radiation effects.

Vaginal Pathology

Vaginal Cancer

  • Increased incidence linked to in-utero DES exposure.

  • Typical diagnosis ages around 19 years.

Sonographic Indicators:

  • Thickened posterior vaginal wall may indicate malignancy.

  • Presence of heterogeneous mass (e.g., rhabdomyosarcoma) seen with transabdominal or transvaginal ultrasound.

Vesicovaginal Fistula

  • Abnormal channel between bladder and vagina.

  • Common causes include childbirth trauma, surgical interventions, or biopsies.

Sonographic Indicators:

  • Demonstrated fluid in vagina communicating with the bladder.

  • Dynamic maneuvers like Valsalva may enhance visibility of fistula.

Additional Considerations

Cervical Stenosis

  • Abnormal narrowing of the cervix potentially obstructing it.

  • Causes: postmenopausal atrophy, tumors, or radiation fibrosis.

  • Symptoms include uterine enlargement due to fluid accumulation.

Sonographic Indicators:

  • May yield a normal appearance even amid history suggestive of stenosis.

  • Document abnormal findings for radiologist review.

Cervical Incompetence

  • Premature dilation of cervix in pregnancy leading to possible miscarriage.

  • Causes could include idiopathic issues or in-utero DES exposure.

Treatment Approach:

  • Cerclage placement (stitching of cervix) to maintain closure during pregnancy.

  • MERZALINE tape commonly used for closure.

Artifacts and Pitfalls

  • Awareness of different artifacts to avoid misdiagnosis.

  • Plicae palmatate may mimic pathology, especially with increased fluid.

Normal Anatomy Observations:

  • Significant cervical folds known as plicae palmatate can appear prominent with proper sonography.

  • Understanding physiological changes during the menstrual cycle impacts sonographic interpretations.

Conclusion

  • Review findings and pathology carefully, understanding normal variations and artifacts in sonographic studies.

  • Further exploration of both cervical and vaginal pathologies will be discussed in later parts.