Cervical elongation is a pathological enlargement of a part of an organ in which its length exceeds 3.5 cm. If there are no signs of omission, the disease is asymptomatic. Clinically, it can manifest itself with complaints about the sensation of a foreign body in the vagina and genital slit, discomfort during sex, incontinence with loads of urine and gases, difficulty urinating. It is diagnosed by gynecological examination, ultrasound of the pelvic organs with cervicometry. Treatment is only surgical. Depending on the complexity and severity of the pathology, one of the operations is performed for amputation of the cervix, fixation of the uterus in a physiological position, hysterectomy.
N88.4 Hypertrophic elongation of the cervix
Normally, the cervix has a length of 3.0 ± 0.5 cm, during pregnancy it can increase to 4.0 cm. The elongation of the organ is spoken of in cases when its dimensions in a non-pregnant patient are more than 3.5 cm. Previously, the disease affected older women more often. Currently, gynecologists note its rejuvenation – ESM is detected during preventive examinations in women starting from the age of 28, about a third of patients have pathology before the age of 45.
Such dynamics is associated with an increase in the frequency of undifferentiated connective tissue dysplasia in women of reproductive age, with which neck elongation is associated. The relevance of early diagnosis of the disorder is associated with the possibility of successful surgical correction at the initial stages to preserve the possibility of childbirth.
The etiology of the disease is still being clarified. The data of morphological, immunohistochemical, and clinical studies allow us to reasonably assert that connective tissue dysplasia (CTD) of varying severity, detected in 80-84% of patients, plays a key role in the pathological elongation of the uterine neck. Most likely, collagenopathy is hereditary.
Specialists in the field of obstetrics and gynecology have identified a number of presumptive factors that provoke elongation in women with connective tissue dysplasia:
- Obstetric pathology. The weakening of the pelvic floor muscles, which occurs after pathological childbirth with ruptures of the perineum and vagina, potentiates a faster lowering of the elongated neck. Birth trauma often serves as an additional marker of connective tissue pathology, unable to cope with significant loads during the birth of a large fetus or several children with multiple pregnancies.
- Significant physical activity. During heavy physical labor and sports training, which are associated with lifting weights, intra-abdominal pressure increases. This factor contributes not so much to an increase in the length of the uterine neck, but rather to a faster clinical debut of the disease with the omission and loss of the organ. The situation is aggravated in the presence of collagenopathy, characteristic of elongation.
- Hormonal disorders. With dishormonal conditions, the physiological relationship between the various types of connective tissue fibers forming the cervix and the ligamentous apparatus that supports the reproductive organs is disrupted. The likelihood of developing a disorder increases with the onset of menopause, the presence of oophoritis, adnexitis, ovarian cysts, and other diseases with impaired secretion of female sex hormones.
Taking into account the multiple organicity of disorders in CTD, a number of marker conditions are distinguished in which, due to the functional failure of connective tissue, the probability of detecting an elongated cervix increases. Among the diagnostically significant criteria include:
- asthenic complexion;
- flat feet;
- juvenile osteochondrosis, scoliosis, kyphosis;
- articular hypermobility;
- the tendency to rapid bruising, the appearance of striae;
- increased dryness of the skin;
- the presence of varicose veins, hemorrhoids;
- vegetative-vascular dystonia;
- fast or rapid childbirth in the anamnesis.
Relatives of patients with first-line ESM often suffer from prolapse of the internal genitalia. More severe markers indicating functional insufficiency of connective tissue are ventral hernias, splanchnoptosis, nephroptosis, habitual dislocations of joints, mitral valve prolapse.
The basis of cervical elongation is a violation of the formation of collagen and the processes of formation in the supporting connective tissue, against which its morphofunctional failure occurs. Collagenopathy in ESM is manifested by a change in the ratio of collagen types I, III, IV, an increase in the fraction with thinner fibers, a disorder of the topography of the distribution of connective tissue, increased deposition in fibroblasts and extracellular matrix. Collagenopathy affects not only the stroma of the organ, but also blood vessels, muscle tissue.
Intramuscular collagenization of argyrophilic structures is accompanied by increasing atrophy of the uterine neck musculature. The organ gradually stretches (lengthens). Its elasticity decreases, the lower part is hypertrophied, the upper one is thinning. As a result of progressive sclerosis and disorganization of fibers, trophic, supporting, shaping functions of connective tissue are disrupted, its resistance to loads decreases. Together, these processes cause inferiority of the cervix, and risk factors aggravate the situation.
Taking into account the increase in the size of the neck, there are three degrees of elongation. At 1 degree, the organ lengthens to 5 cm, at 2 — to 6-8 cm, at 3 — the length exceeds 8 cm. An important criterion for the systematization of clinical forms of elongation is a violation of the anatomical topography of the uterine neck with a displacement relative to the entrance of the vagina and the involvement of other reproductive organs in the process. This approach is justified by the difference in the methods of treatment of individual forms of the disease. There are three types of elongation:
- Isolated cervical prolapse. The organ is enlarged in size and lowered in comparison with the physiological position. The vaginal walls are not involved in the process of omission. An isolated variant of pathology is observed in no more than 1.7-3.5% of cases.
- Cervical elongation and vaginal prolapse. The most common form of EMS, detected in half of the patients. Due to the weakness of the perineal muscles and the supporting ligamentous apparatus of the uterus, there is a lowering of the cervix and vaginal walls.
- Elongation of the cervix and prolapse of the uterus. With such a prolapse of the reproductive organs, the elongated neck is located outside the vagina. Uterine prolapse can be either partial or complete. This form of pathology occurs in 45.5-47.3% of patients.
Symptoms of cervical elongation
With the first degree of the disease, symptoms are usually absent. As the length increases and the position of the cervix changes, complaints arise about the feeling of a third-party inclusion in the vagina or perineal area, discomfort and difficulty during sexual contacts. Grade II elongation with vaginal prolapse and uterine prolapse is characterized by urinary incontinence during physical exertion, sneezing, coughing. In far-reaching cases, urine leakage is observed even at rest. Up to 25-26% of patients with grade III elongation have difficulty urinating. Gas incontinence occurs in 14-15% of patients.
Elongation is one of the causes of reproductive dysfunction in women of childbearing age. In such patients, cervical infertility is more often observed, incorrect attachment of the placenta, cervical rigidity during childbirth, difficulties in passing the child through the birth canal, birth trauma are noted. The development of the disease during menopause and postmenopause is complicated by the formation of cystocele and rectocele with significant impairment of pelvic organ function. With the constant presence of the cervix outside the vagina, the risk of its traumatic damage, the attachment of an infectious process (colpitis, exocervicitis, endocervicitis, endometritis) increases.
Detection of cervical elongation is a relatively simple diagnostic task. To solve it, patients with a complex of typical complaints are prescribed a physical and instrumental examination, which allows to reliably confirm the elongation of the organ and determine its possible displacement. The most informative for diagnosis are:
- Examination on the chair. With bimanual palpation of an isolated enlarged organ without its omission, a deepening of the vaginal arches is noted. The cervix is mobile, tight-elastic, painless. When lowered, it is located in the lower parts of the vagina, the vestibule or outside the genital slit.
- Transvaginal ultrasound with cervicometry. The method allows to obtain accurate data on the size, structure and position of the cervix, to assess the mobility of the vaginal walls, to measure the urethro-vesical angle, to identify the deformation of the rectum. The diagnostic value of the technique increases during the Valsalva test.
As additional studies aimed at assessing the condition of the cervix, identifying signs of infectious-inflammatory or neoplastic processes, it may be recommended:
- vaginal smear microscopy
- bacterial seeding with an antibioticogram
- PCR diagnostic, ELISA
- biopsy of doubtful areas with histological analysis of the obtained materials.
Differential diagnosis is performed with omission or prolapse of the internal female genitalia without cervical elongation, cervical hypertrophy, scar deformity, vaginal or cervical cancer. According to the indications, the patient is consulted by an oncologist, urologist, proctologist, infectious disease specialist.
Treatment of cervical elongation
There are no conservative methods of correcting the disease. When choosing the type of surgical intervention, the degree and form of elongation, the presence of concomitant changes in the tissues of the cervix, surrounding organs, the age and reproductive plans of the woman are taken into account. Taking into account the severity of pathology with an elongated uterine neck , the following types of operations are recommended:
- When lengthening without omission, the operations of choice are wedge-shaped amputation or partial resection of the organ along the side walls with strengthening of the ligamentous apparatus supporting the neck. An additional indication for such interventions is the presence of scarring, erosion, ulcerative defect of the mucosa in the area of the external pharynx. The advantage of operations is the preservation of fertility.
- In case of elongation with omission or prolapse, high amputation of the cervix or Manchester surgery with strengthening of the pelvic floor muscles is recommended. Interventions effectively eliminate urinary incontinence, characteristic of this form of the disease. Due to a significant shortening of the length of the organ and an increase in the risk of premature termination of future pregnancy, patients planning to have children are not carried out.
- For cervical elongation and uterine prolapse, a wide range of operations has been proposed — from cervical amputation in combination with techniques that fix the uterus in the correct position (colpoperineolevatoroplasty, ventrosuspension, ventrofixation, sacrovaginopexy, median colporaphy), to extirpation of the uterus without appendages. The disadvantage of such interventions is the impossibility of carrying a child.
Prognosis and prevention
Properly performed surgical correction of elongation allows you to get rid of uncomfortable sensations, incontinence of gases and urine, significantly improve the quality of life of the patient, prevent the omission of other pelvic organs. Some of the surgical interventions disrupt the reproductive function.
Prevention of the disease involves giving up heavy physical exertion, performing special exercises to strengthen the pelvic muscles when identifying markers of connective tissue dysplasia and factors that increase the risk of developing the disorder. Careful management of labor, careful suturing of ruptures of the cervix, vagina and perineum play an important role in preventing pathological elongation.