Uterine atresia is an anomaly of the cervix or body of the uterus, manifested by their overgrowth and obstruction. Uterine atresia is characterized by false amenorrhea, pain during periods of alleged menstruation, the development of hematometers and hematosalpinx (in severe cases – pyometers and pyosalpinx). Diagnosis includes gynecological examination: examination, ultrasound, MRI. Treatment is operative, with atresia of the cervical canal, its patency is restored by bougie or laser recanalization.
By origin, uterine atresia is divided into acquired and congenital, representing cases of abnormal intrauterine laying and development of internal genitalia. According to the localization of obstruction, gynecology distinguishes atresia of the cervix and the body of the uterus. Atresia of the cervical canal can be observed at the level of the external or internal pharynx, sometimes throughout the cervical canal. Uterine atresia is often accompanied by abnormalities in the development of the urinary tract.
Congenital uterine atresia often occurs as a result of the influence of teratogenic factors acting during the embryonic or fetal period. Normally, the uterus and the proximal part of the vagina are formed as a result of the fusion of the distal Muller ducts. Depending on the area where the fusion and sewerage of the ducts did not occur, one or another type of uterine atresia develops. Unfavorable exogenous factors can be maternal infections (herpes, chlamydia, toxoplasmosis, syphilis, etc.), ionizing radiation, medications, alimentary causes that cause disruption of cell division and metabolism.
Acquired atresia is most often caused by rough curettage of the uterine cavity, cauterization of the cervical canal with silver nitrate or electrocoagulation, endocervicitis, endometritis, medical intakes (artificial termination of pregnancy), cervical cancer. As a result of traumatic manipulations or inflammatory phenomena, the granulating surfaces in contact with each other fuse, causing uterine atresia or the formation of intrauterine synechiae (Ascherman syndrome). In some cases, hypertrophic scarring leads to uterine atresia. In old age, spontaneous atresia of the cervical canal is occasionally observed.
Manifestations of uterine atresia
The clinical significance of congenital atresia is obtained during puberty. The leading manifestation of uterine atresia is false amenorrhea – that is, the absence of external menstrual bleeding with monthly cyclic changes in the body. Menstrual discharge, lingering above the atresia zone, leads to the development of hematometry – the accumulation of blood masses in the uterus with stretching of the organ.
The development of hematometry in uterine atresia is accompanied by acute, cyclically recurring pain, with which patients are often hospitalized in a surgical hospital. The pain with a hematometer is spastic in nature and is so pronounced that it can cause nausea, impaired bowel and bladder functions, and loss of consciousness. Blood from the uterine cavity can penetrate into the fallopian tubes, contributing to the development of hematosalpinx. The addition of a secondary infection contributes to the development of a purulent process in the uterus and tubes – pyometra and pyosalpinx. Uterine atresia is the cause of anatomical infertility.
If there is a suspicion of uterine atresia, a woman needs a qualified consultation with a gynecologist. The examination consists in the collection of anamnesis, assessment of sexual and general physical development, examination of the genitals. During the gynecological examination on the chair, flattening of the vaginal arches and smoothing of the cervix are determined. The uterus is palpated in the form of a painful globular formation. With hematosalpinx, sedentary elastic painful formations – fallopian tubes – are detected on the sides of the uterus.
The diagnosis of cervical canal atresia is confirmed during its probing. With the help of ultrasound of the pelvic organs and ultrasound hysterosalpingoscopy, the correctness of the interpretation of the examination data is documented. Ultrasound reliably determines the parameters of the uterus, the thickness of the endometrium, the presence of partitions, the size and thickness of the walls of the hematometer.
In the diagnosis of complex and atypical uterine atresia, preference is given to MRI in frontal, axial and sagittal projections. Endourological examinations (urethrocystoscopy) are indicated for combined genitourinary abnormalities. Usually, this set of studies is sufficient to determine uterine atresia and choose the method of surgical intervention.
In case of uterine atresia, the anatomical obstacle is eliminated and the hematometer is emptied. Treatment of cervical canal atresia consists in its augmentation or laser recanalization. Recurrent atresia often serves as an indication for the installation of an alloplastic implant that prevents the walls from touching and the growth of the cervical canal. In some cases, the formation of an anastomosis of the cervical canal with the vagina is required.
With intrauterine splices (synechiae), their dissection is performed under the control of a hysteroscope, laser reconstruction of the uterine cavity. In case of rupture of the hematometer and hematosalpinx, revision and drainage of the abdominal cavity is required, often – hysterectomy, supravaginal amputation of the uterus or pangisterectomy (removal of the uterus in combination with adnexectomy).
In gynecology, prevention of the development of secondary uterine atresia involves the prevention and timely treatment of inflammation of the uterus and cervical canal, careful intrauterine manipulations (termination of pregnancy, diagnostic curettage), careful management of childbirth, improvement of methods of operations on the cervix and the body of the uterus.
Prevention of congenital uterine atresia includes careful management of pregnancy, exclusion of adverse factors affecting the fetus. After elimination of cervical canal atresia and preservation of the uterus, pregnancy becomes possible.