1. Introduction
Nabothian Cysts are common and benign gynecologic finding in women of reproductive age, generally without clinical significance. They are a result of the retention cyst that develops when a mucous gland of the cervix is obstructed. This retention is caused by the chronic inflammation after minor trauma or childbirth.
We will discuss through an original observation the probable implication of this entity in the context of infertility.
2. Case Report
A 33-year-old woman presented with primary infertility of 7 years. She had an irregular menstruation with oligomenorrhea. On physical examination, she didn’t have any abnormalities. Transvaginal ultrasound showed multiple anechoic images located to the cervix (Figure 1).
The hysterosalpingography showed distal opacification of the cervix, without opacification neither of the uterine cavity nor the fallopian tubes. A reflux of the product into the vagina at the moment of hyper pressure was noticed (Figure 2).
The MRI revealed multiple nabothian cysts (Figure 3).
The spermogram and cervico-vaginal smear were normal.
The hysteroscopy revealed normal cervical mucosa.
A cervical canal dilatation was performed by the mini 5 Fr hysteroscope which led to visualization of a normal uterine cavity. The postoperative outcome was verified by a 6 Fr catheter.
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Figure 1. Anechoic images at the cervix.
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Figure 2. Distal opacification of the cervix and reflux of the product into the vagina.
3. Discussion
Nabothian cysts are common and benign lesions of the cervix due to mucus retention [1] . They are generally asymptomatic and rarely reach a size above 4 cm. Clinically, the cervix is seat of small cysts (whitish to yellow); single or multiple. Sometimes the cervix is normal in appearance.
In their symptomatic form, Naboth cysts can manifest as chronic pelvic pain, feeling of heaviness in the vagina, irregular menstruation, obstruction of the cervical canal or digestive signs following rectal compression [2] [3] [4] .
Aruna et al. reported a first case in the literature of a large Nabothian cyst causing prolapse in a nulliparous female, 21 years of age [5] .
Nabothian cysts may pose some diagnostic pitfalls by mimicking a polycystic ovary [6] .
A cervical adenocarcinoma can mimic Nabothian cysts on MR images, hence the interest of the biopsy in any diagnostic doubt [7] .
In our case, the patient consults for primary infertility and for whom the clinical examination does not show abnormalities. Would it be a case of infertility by obstruction of the cervix?
A case was reported in the literature of a spontaneous pregnancy after obstructive nabothian cyst treatment [8] .
Cervicitis may contribute to infertility by fibrosis and cervical stenosis [9] .
To differentiate between benign and malignant cervical lesions, some examinations are recommended such as: sonography, colposcopy, CT scan, MRI and biopsy.
Transvaginal sonography also affords a mean to evaluate several types of cervical masses and disorders, the probe is usually placed a few centimeter into the vagina so that the cervix can be delineated [10] [11] .
CT scan is more efficient than ultrasound to evaluate these types of lesions.
MRI may accurately differentiate minimal deviation adenocarcinoma from Nabothian cysts, because the signal intensity on T2-weighted imaging in the cervical stroma is different in these two diseases. The T1 signal is variable ranging from isointensity to hypointensity [12] [13] [14] [15] .
Naboth Cysts are often discovered on MRI.
A solid component separating or surrounding cysts is considered an index to differentiate minimal deviation adenocarcinoma (adenoma malignum) from benign lesions such as Naboth cysts. However, it is not always easy to make the difference, hence the interest of the biopsy [16] .
Generally Naboth cysts do not require any treatment.
In cases where nabothian cysts are symptomatic, the treatment is based on wide excision or simple drainage [3] [5] . The main disadvantage of surgical treatment is the possibility of fibrosis, which can lead to dyspareunia [3] [17] .
4. Conclusion
Naboth cysts are often small and asymptomatic. A great interest is in imaging for the diagnosis of these lesions. If any doubt, a biopsy is recommended to eliminate a malignant tumour. The involvement of Naboth cysts in infertility is possible.