Cervical stenosis is a congenital or acquired anatomical narrowing of the cervical canal with a violation of its patency. At the reproductive age, it manifests itself with oligomenorrhea, amenorrhea, algomenorrhea, infertility, dyspareunia. In menopause and postmenopause, it can be asymptomatic. It is diagnosed by gynecological examination, probing of the uterine cavity, ultrasound of the pelvic organs, MRI, CT. To restore the patency of the endocervix, its augmentation, laser or radio wave recanalization, cervical conization, and other tracheloplastic operations are performed.
Narrowing (stenosis) of the cervical canal is a frequent consequence of inflammatory, dysplastic, neoplastic diseases of the cervix, leading to cervical infertility. Congenital narrowing of the endocervix with its partial atresia is usually diagnosed in adolescent girls. Acquired stenosis of inflammatory and post-traumatic genesis is usually detected in patients aged 25-35 years. According to experts in the field of obstetrics and gynecology, the prevalence of genital infections and the early onset of sexual life contribute to the rejuvenation of the disease. After 40 years, the narrowing of the endocervix is more often caused by volumetric neoplasms, involutive narrowing or overgrowth.
Causes of cervical stenosis
The emergence of pathology is facilitated by diseases and invasive interventions in which structural changes of the endocervix occur. Temporary cervical stenosis develops due to swelling and swelling of the mucosa during inflammatory processes, persistent narrowing is usually caused by deformation due to scarring or overgrowth of connective tissue. One of the variants of the disease is considered to be incomplete congenital cervical atresia caused by hereditary or dysembriogenetic causes. Etiofactors of acquired cervical stenosis are:
- Chronic endocervicitis. With a prolonged course of the inflammatory process, thickening of the cervical mucosa is combined with pronounced fibrous changes in the organ. As a result, the channel lumen narrows. The most common pathogens of endocervicitis are chlamydia, mycoplasma, ureaplasma, genital herpes virus, gonococci, opportunistic microorganisms, microbial associations.
- Injuries of the cervical canal. Cicatricial constriction occurs after ruptures of the cervix in childbirth, its damage during invasive procedures and surgical interventions. Multiple abortions, rough probing of the uterus, diagnostic curettage, cryodestruction, loop electroexcision, radio wave coagulation, diathermocoagulation, laser vaporization, conization and other cervical operations lead to stenosis.
- Volumetric neoplasms. The cervical canal can be squeezed or blocked mechanically. The patency of the internal pharynx is disturbed by polyps, submucous fibroids, malignant tumors developing in the lower parts of the uterus. Partial or total canal stenosis is characteristic of fibroids, polyps, uterine cervical cancer. Radiation therapy of tumors becomes an additional damaging factor in neoplasia.
- Involution of the neck. A decrease in estrogen levels during menopause and postmenopause is accompanied by reverse development and dystrophic changes in the reproductive organs. Due to the deterioration of blood circulation and a decrease in hormonal stimulation, the cervical mucosa becomes thinner, and the organ itself becomes rigid. The endocervix narrows, shortens, and in extreme cases atrezes.
The mechanism of cervical stenosis is determined by the causes that caused the disease. Inflammation, traumatic injuries lead to structural changes in endocervix tissues, primarily to the replacement of the cervical epithelium with less elastic connective tissue and the formation of strictures. False stenosis in tumors of the lower segment and cervix is caused by the presence of a mechanical obstacle in the area of the internal uterine pharynx or compression of the canal by a neoplasm. The involutive narrowing of the endocervix is based on natural diffuse and atrophic changes of the organ.
Symptoms of cervical stenosis
The clinical symptoms of the disorder depend on the age of the patient. The most characteristic manifestation in menstruating women is a decrease or complete cessation of spotting during menstruation. Violation of the natural outflow of blood from the uterine cavity is accompanied by general malaise, the appearance of cyclic cramping pains in the lower abdomen, radiating to the groin, sacrum, lower back. During the intermenstrual period, small contact or spontaneous spotting is observed, which may have an unpleasant odor. Sexual acts sometimes become painful. Extremely rarely, the uterus stretched by blood is palpated as a tumor-like formation in the abdominal cavity. Often, patients with cervical stenosis cannot become pregnant. Postmenopausal women usually do not complain, stenosis becomes an accidental finding during a planned ultrasound.
One of the most serious consequences of stenosis is a violation of reproductive function. Infertility is usually caused by a violation of the patency of the cervical canal for sperm. At the onset of pregnancy, spontaneous miscarriages and premature birth are more often observed due cervical insufficiency. In childbirth, the neck opens slowly, weakness and discoordination of labor activity are possible. The narrowing of the endocervix, depending on the age of the patient, is complicated by serosometer, hematometer, hematosalpinx, adenomyosis, endometriosis. With suppuration of the contents of the uterus, pyometra, pyosalpinx occur, the likelihood of pelvioperitonitis and the formation of adhesions in the pelvis increases. Ectropion is formed in some patients.
If there is a typical clinical picture that allows you to suspect cervical stenosis, examinations are prescribed to confirm the narrowing and assess the degree of patency of the endocervix. Since the disease is not always accompanied by visible morphological changes, instrumental methods become the leading ones. The survey plan usually includes:
- Examination on the chair. With bimanual palpation, an enlarged uterus can be determined. Examination in mirrors reveals possible signs of scarring of the organ, inflammatory changes in the external pharynx, ectropion. For a more detailed examination of the mucosa, the examination is supplemented with colposcopy.
- Probing of the uterine cavity. With narrowing of the cervical canal, the introduction of a conventional uterine probe is difficult. Thinner button probes of decreasing diameter are consistently used. The complete stenosis of the endocervix is indicated by the impossibility of inserting a probe with a diameter of 1-2 mm into the uterus.
- Transvaginal ultrasound of the pelvic organs. Ultrasound examination of the cervix and uterine body is prescribed to detect fluid and bulky formations in the uterine cavity. If necessary, tomographic methods (CT, MRI) are used to obtain more accurate data on the features of the cervical region.
For timely detection of neoplasms accompanied by narrowing of the cervical canal, cytology of scraping from the neck (pap test) is recommended. Possible infectious and inflammatory diseases are diagnosed using microscopy of a cervical smear, its bacteriological seeding, PCR, RIF, ELISA. Stenosis is differentiated with complete congenital cervical atresia and other anomalies of cervical development, endocervicitis, cervicitis, scarring of the uterine neck, the presence of a septum in the vagina, diseases accompanied by menstrual cycle disorders. If necessary, the patient is consulted by an oncologist, endocrinologist, infectious disease specialist, venereologist.
Treatment of cervical stenosis
Correction of the disorder is indicated in case of violation of the outflow of menstrual blood and the presence of infertility. In the asymptomatic course of stenosis, dynamic follow-up with a preventive examination by a gynecologist and ultrasound monitoring every 6 months is recommended. Restoration of patency of the endocervix is carried out using conservative and surgical approaches:
- Cervical augmentation. The introduction of a special rod (bougie) into the endocervix with a diameter slightly exceeding the size of the anatomical structure allows you to gradually eliminate the existing narrowing. The bougie is performed for several weeks with the replacement of the bougie with a larger one at set time intervals. In menopause, the method is usually supplemented with the appointment of hormone replacement therapy and antispasmodics.
- Prompt elimination of stenosis. With accurate identification of areas of cervical fusion, laser or radio wave recanalization of the organ is performed. Conization of the cervix to restore the free patency of its canal and tracheloplasty are considered more radical interventions. The presence of neoplasias is the basis for their hysteroscopic removal or invasive surgical operations.
Prognosis and prevention
The prognosis for endocervix stenosis depends on the causes of the disease, the timeliness of diagnosis and the correctness of the chosen treatment method. In most cases, competently performed bugirovanie of the cervical canal, conization of the uterine neck can completely restore the patency of the organ and reproductive function. For the prevention of stenosis, pregnancy planning with the use of modern contraceptive methods and refusal of abortions, early diagnosis and adequate treatment of genital infections, tumor processes are recommended. Careful management of labor and reasonable appointment of gynecological invasive procedures play an important role in preventing cervical constriction.