NABOTHIAN CYSTS

NATIJAH SYUHADA BINTI ZUBIR

C111 12 812

Resident Supervisor:
dr. Arini Estiastuti

Specialist Supervisor:
dr Nugraha Utama P., SpOG (K)
 INTRODUCTION
The mucosa of the cervical canal is composed of a
single layer of very high ciliated columnar epithelium
that rests on a thin basement membrane. Numerous
cervical glands extend from the surface of the
endocervical mucosa directly into the subjacent
connective tissue. These glands furnish the thick,
tenacious cervical secretions. If the ducts of the
cervical glands are occluded, retention cysts, known as
nabothian cysts, are formed. 2
ANATOMY AND HISTOLOGY
o The cervix is an extension
of the lower uterine
segment of the uterus,
between the isthmus and
the opening of the uterus
into the vagina
o The cervix varies in size and
shape depending on the
woman’s age, parity and
hormonal status, averaging
3 to 4 cm
 The cervix is lined by squamous and columnar
cells. The transition from columnar cells to
squamous cells occurs in the region of the cervical
os known as the transformation zone.
(squamocolumnar junction)
Numerous cervical glands extend from the
surface of the endocervical mucosa directly into the
subjacent connective tissue. These glands furnish
the thick, tenacious cervical secretions.
Squamocolumnar junction (SCJ) (x 10)
DEFINITION OF NABOTHIAN CYST
Nabothian cysts or inclusion cysts are formed in
the cervix when the opening of a nabothian duct,
located within the cervix, is covered by epithelial cells
and the fluid is “retained”.
 PATHOPHYSIOLOGY
Nabothian cysts occurs as a result of metaplasia. The cervical
canal glandular or columnar mucosa is always in the process of
transformation to the pink, smooth, squamous cells that compose
the ectocervix at the active transformation zone of the cervix. As
the squamous tissue evolves toward the canal, occasionally the
glandular cells remain active and continue to secrete mucus while
becoming trapped under the more dense squamous tissue. The
secretions usually stop over time, but if they do not, mucus collects,
creating the smooth, often shiny bulge on the cyst.
Squamous Metaplasia
When the cells are repeatedly
destroyed by vaginal acidity in the
columnar epithelium in an area of
ectropion, they are eventually
replaced by a newly formed
metaplastic epithelium. The
irritation of exposed columnar
epithelium by the acidic vaginal
environment results in the
appearance of sub-columnar
reserve cells.
These cells proliferate producing a
reserve cell hyperplasia and
eventually form the metaplastic
squamous epithelium.
 Development of squamous metaplastic
epithelium

(a) The arrows indicate the appearance of the

subcolumnar reserve cells
(b) The reserve cells proliferate to form two layers
of reserve cell hyperplasia beneath the
overlying layer of columnar epithelium
(c) The reserve cells further proliferate and
differentiate to form immature squamous
metaplastic epithelium. There is no evidence
of glycogen production
(d) Mature squamous metaplastic epithelium is
indistinguishable from the original squamous
epithelium for all practical purposes
 Chronic
inflammation Vaginal
of the uterine Acidity
cervix

Etiology
 SIGNS AND SYMPTOMS
• Asymptomatic and not problematic unless they are
sizeable & present with secondary symptoms.
• Are usually associated with chronic cervicitis
• Larger cysts can block the cervical opening and cause
irregular bleeding as well as vaginal discharge
• Patients may experience severe pain in the cervical
region, especially during an intercourse
• In rare cases, it may compress the rectum and induce
sensations of abnormal defecation, such as tenesmus
 Clinical Manifestation
• Common gynaecological finding in women of reproductive age without
clinical significance
• Firm bump
• Single or multiple-opaque nodules
• Whitish to yellow on the cervix -> mucious retention cyst / epithelial cyst
• Small in size, rarely reach a size above 4cm
• Larger cysts block cervical opening
– Irregular bleeding
– Vaginal discharge
• Some experience severe pain in cervical region, especially during
intercouse
 DIAGNOSE
• Most cases are detected accidentally, during pelvic examinations &
ultrasound.
• Physical examination.
– Multiple-opaque nodules (whitish to yellow) on the cervix (<4cm)
– usually are confined to the super ficial portion of the cervix, they have
been reported to extend through the wall of the cervix.
• No laboratory testing is needed unless the cyst seems atypical
• Transvaginal USG: fluid-filled masses with smooth borders and
enhanced transmission, and may demonstrate refractive edge
shadowing.
• Magnetic Resonance Imaging
 Multiple nabothian cysts in the mature
squamous metaplastic epithelium
occupying the ectocervix

Long-axis view transvaginally of the

cervix in an anteverted uterus. A
rounded, fluid-filled mass (arrows,
with refractive edge shadows
distally) is consistent with a nabothian
cyst.
 MANAGEMENT AND TREATMENT
• Will frequently resolve on its own with further evolution of the transformation zone and
therefore no treatment is required. Evolution of transformation zone = 12 weeks
• Therapy is recommended when a patient becomes symptomatic with pain or when the lesion
character is not clear & malignancy cannot be ruled out

1. Puncture with 21 gauge needle and extrude with pressure from a cotton-tipped swab
2. Cyst excision
3. Cryotherapy
4. Electrocautery
5. Referral is indicated if the clinician is unsure of the benign nature of the observed cyst, or if
the cyst seems atypical or bleeds on contact
6. Very rarely nabothian cyst needs hysterectomy
 DIFFERENTIAL DIAGNOSE
• cervical neoplasia
– mucin-producing carcinoma : visible abnormal blood vessels and bleeding on
contact
• cystic mass in the cervical stroma :
– adenoma malignum, deep nabothian cysts, other benign tumours of cervix
and well-differentiated adenocarcinoma.
• benign tumours of the uterine cervix :
– Endocervical polyps, leiomyomas, endometriosis, squamous papilloma,
microglandular hyperplasia
• Cervical myomas are solitary tumours of the cervix, but may become
degenerated, pedunculated through the vagina and need pathologic
evaluation for diagnosis
PROGNOSIS AND COMPLICATION
Despite nabothian cysts are benign and common
findings of gynecology practice, they may unusually
present with giant mass. If the cystic mass in the cervix
is large and deeply located total excision is required to
exclude malignancy. 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 quickly.
 CASE REPORT
1. 2012, Taiwan : USG Diagnosis and treatment of a Giant Uterine Cervical Nabothian
Cyst.pdf
- 45 years old woman, Gravida 2 Para 2, diagnose with uterin tumor and was
refer for hysterectomy with CT revealed pelvic cystic mass 8cm in size
- Complained low abdominal discomfort with dragging sensation for several
weeks
- Pelvic examination: soft huge mass from posterior fornix protruding into vagina
- Tumor marker, Pap smear are negative for malignancy
- Transvaginal USG: 8cm x 6.5cm cervical mass with multilobulated pattern
- Made another tentative diagnosis, treated by a simple cervical incision and
local drainage
- Patient recovered well
2. 2015, India : An unusual presentation of nabothian cyst.pdf
- 43 years old woman, Gravida2 Para 2 (history of 2 cesarean sections – 15 and
12 years back respectively)
- Presented with continuous, clear & copious watery discharge per vaginum since
7 years which disturbed her daily activities
- DD: vesico-cervical fistula, chronic cervicitis, vesicouterine fistula
- Speculum examination: continuous watery fluid coming through cervical canal
- Vaginal examination: bulky uterus, anteverted, mobile & fornices were free
- Microscopic & biochemical examination negative for urine
- Transvaginal sonography: slightly bulky uterus & multiple tiny heterogenous
hypoechoeic cysts (1cm-3.5cm in size)
- Diagnosis confirmed on MRI
- Total abdominal hysterectomy was performed, as a last resort
- Patient recovered well and satisfies with the result
3. 2015, Turkey :Large Nabothian Cyst obtrsucting laboring passage.pdf
- 38 years old woman, Gravida 4 Para 2 Abortion 1, with 38 weeks of gestation
presented with labour pain and protuding mass out of vagina
- was in active phase of labour with 4cm cervical dilation and regular contraction
- there was a soft and smooth surface mass (6x7cm) on anterior lip of cervix
compressing cervical canal
- performed simple drainage and the discharge was mucoid, vaginal delivery was
allowed. 4130gram male baby was born without hemorrhagic or infectious
complication
- postpartum follow-up: revealed persisting soft and smooth surface of cystic
mass in cervix (40x50mm) 2months after delivery
- USG: homogenous hypoechoic cystic dilation (40x50mm)
- performed total cervical excision, patient recovered well
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