Cervical polyp

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Synonyms and Keywords: Polypoid cervical lesion; Cervical polypoid lesion; Polypoid cervical growth

Overview

Cervical polyps are defined as polypoid benign overgrowths of endocervical tissue. Usually, cervical polyps are growths projecting into the cervical canal. Cervical polyps are the most common cause of intermenstrual vaginal bleeding.There are no established causes for cervical polyps. They can be classified according to their morphological features such as: distribution, shape, size, and the presence of a pedicle. The pathogenesis of cervical polyp is characterized by chronic inflammation of the endocervical canal. Typically, cervical polyps arise from the endocervical canal and tend to protrude into the external cervix. The estimated prevalence of cervical polyps is approximately 1.5–10% in the general population. Common risk factors of the development of cervical polyps, include: chronic inflammation, hormonal factors, presence of endometrial hyperplasia, and previous history of pregnancy. Cervical polyps are more commonly observed among perimenopausal and postmenopausal women. Early clinical features may include abnormal vaginal bleeding, postcoital vaginal bleeding, and abnormal vaginal discharge. The diagnosis of a cervical polyp is made with a cervical biopsy, findings may include: inflamed and dilated endocervical (mucus) glands and myxoid stroma. Ring forceps in conjunction with biopsy is the most common approach for the treatment of cervical polyps.

Historical Perspective

Cervical polyps were first described by Peterson and Novak in 1956 following the description of endometrial polyps.[1][2]

Classification

Based on polyp location, cervical polyps can be classified into two types:

  • Ectocervical polyps
    • Develop from the outer surface layer cells of the cervix.
    • More commonly seen in postmenopausal women.
  • Endocervical polyps
    • Develop from cervical glands inside the cervical canal.
    • The majority of cervical polyps are endocervical polyps.
    • More commonly seen in premenopausal women.

Pathophysiology

Anatomy

  • The normal cervix is fusiform in shape, with the narrowest portions at the internal and external os. It measures 3 to 5 cm in length and 2 to 3 cm in diameter.
  • The portio vaginalis, is the visible portion of the cervix that protrudes into the vagina and is surrounded by a reflection of the vaginal wall on each side termed the anterior, posterior, and lateral fornix.
    • The supravaginal cervix is the intra-abdominal portion of the cervix that lies above the point of attachment of the vaginal vault
    • The peritoneum posterior to the supravaginal cervix forms the lining of the posterior cul-de-sac (pouch of Douglas).
  • The external cervical os is small, round, and centrally placed in nulliparous women.
  • In parous women who have labored into the third stage, it is more likely to be a patulous, transverse slit.
  • The internal cervical os is normally less than 3 mm in diameter in nonpregnant women, even if parous .
  • In the sagittal axis, the cervix lies between the bladder and rectum.
  • The cervix is supported by the uterosacral ligaments, which surround the cervix and vagina and extend laterally and posteriorly toward the second to fourth sacral vertebra, and the cardinal ligaments, which are fibromuscular bands that fan out laterally from the lower uterine segment and cervix to the lateral pelvic walls.

Blood Supply

  • The blood supply comes from a descending branch of the uterine artery.
    • The lymphatic drainage is to the parametrial nodes, then to the obturator, internal iliac, and external iliac nodes with secondary drainage to the presacral, common iliac, and para-aortic lymph nodes.

Nerve Supply

  • The nerve supply is autonomic (sympathetic and parasympathetic).
  • The nerves enter the upper cervix on either side and form two lateral semicircular plexuses, called Frankenhäuser plexus, a terminal part of the presacral plexus.

Pathogenesis

  • The pathogenesis of cervical polyp is characterized by chronic inflammation of the endocervical canal.
  • The exact mechanism of cervical polyps origin is not clearly understood. However, cervical polyps are believed to occur due to:
  • Cervical polyps arise from the endocervical canal and tend to protrude in the external cervix.
  • There are no genes associated with the development of cervical polyp.
  • On gross pathology, flesh-colored, single finger-like growth, 1 cm size, are characteristic findings of cervical polyp.
  • On microscopic histopathological analysis, inflamed and dilated endocervical (mucus) glands and myxoid stroma are characteristic findings of cervical polyp.

Causes

There are no established causes for cervical polyps.[2]

Differentiating Cervical Polyp from other Diseases

Cervical polyp must be differentiated from other diseases that cause abnormal vaginal bleeding, dyspareunia, and abnormal vaginal discharge

Abnormal Uterine bleeidng differential diagnosis
Ob-Gyn neoplasm and diseases Clinical manifestations Para-clinical findings Gold standard
Symptoms Physical exam Lab Findings Imaging Histopathology
Abnormal

vaginal bleeding

Other Genitourinary/ Gastrointestinal symptoms Abdominal pain Pelvic

pain

B symptoms Gynecological examinations Abdominal

mass

HPV

Pap smear

STI panel

Other labs Ultrasound Other

imagings

Cervical polyp[3]
  • Mass on exam
  • Hyper/hypoechogenic masses with or without cysts
  • Filling the endocervical or vaginal canal
Cervical cancer[4][5][6][7][8][9][10][11]
  • Postmenopausal
  • Intermenstrual
  • Postcoital
  • Bleeding after pelvic exam
+ + +
  • Cervical mass on exam
+ ± HPV T2-weighted MRI :
  • Ovoid, heterogeneous tumor distending the cervical canal with stromal involvement. PET/CT scan:
Cervical intraepithelial neoplasia:
Cervical leiomyoma[12][13][14][15][16][17][18][19][20]
  • Heavy/prolonged menstrual bleeding
  • Intermenstrual bleeding
+ + ±
  • Well circumscribed hyperechoic mass
T2-weighted MRI:
  • Hypointense masses
  • Homogeneous

enhancement

  • Red degeneration
  • Clinical diagnosis/ and
Cervical lymphoma[21][22][23]
  • Difficulty urinating
  • Post-coital pain
+ + +
  • Irregularity
+ Pap smear: Immunohistochemistry markers:
  • Well-defined, solid, concentric, hypoechoic mass
MRI:
  • Intramyometrial infiltrative nodules
  • Small tumor cells with large nuclei
  • High mitoses and proliferation
Cervical sarcoma[24][25][26][27] + + ±
  • Cervical mass
  • Lump protruding from vagina/vulva
+ Leiomyosarcoma markers: MRI:
  • Endometrial polypoid mass
  • Hypointense hypervascular solid components
Cervical erosion(Ectropion)[28][29][30][31][32]
  • Post-coital pain
  • Painful cramps
+ +
  • Red, glandular area around os of cervix
N/A N/A N/A
Cervicitis[33][34][35][36][37]
  • Intermenstrual bleeding
  • Postcoital
  • Pain during urination
+ +
  • May have fever only
STI panel:
MRI:

May be detected as retention cysts in cervix.

  • Non-specific, lymphocytic infiltration may be seen in microscopic histology.
  • Koilocytic changes in case of HPV as cause of chronic cervicitis.
Adenemyosis[38][39][40][41][42][43]
  • Abnormal uterine bleeding
  • Painful menstruation
+ +
  • Subendometrial striations
  • Myometrial cysts
  • Asymetrical thickness in myometrium walls
  • Heterogenous echotexture of myometrium
MRI:
  • Thickened junctional zone
  • Presence of ectopic endometrial glands into the myometrium.
Cervical ectopic pregnancy[44][45] +
  • Soft and disporportionally enlarged uterus.
± T2-weighted MRI:
  • Hypointense large mass

T1-weighted MRI:

  • Partially hyperintense mass
Nabothian cyst[46][47][48][49]
  • Postcoital bleeding
  • Majority of them are asymptomatic due to their small size( few milimeters)
N/A
  • Anechoic well defined cystic lesions
T1-weighted
  • Intermediate or slightly high signal intensity T2-weighted
  • High signal intensity on T2-weighted images
  • Benign cystic lesion
  • Multiple benign cystic masses, usually few milimieters in diameter.

Epidemiology and Demographics

The estimated prevalence of cervical polyps is approximately 1.5–10% in the general population.[2]

Age

  • Cervical polyps are more commonly observed among patients aged 40 to 55 years old.
  • Cervical polyps are more commonly observed among perimenopausal and postmenopausal women.[2]

Race

  • There is no racial predilection for cervical polyps.[2]

Risk Factors

Common risk factors in the development of cervical polyps include:[2]

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

The diagnosis of cervical polyp is made with a cervical biopsy. Characteristic findings in a biopsy of a cervical polyp include:[2]

Symptoms

  • Cervical polyp is usually asymptomatic.[2]
  • Symptoms of cervical polyp may include the following:

Physical Examination

  • Patients with cervical polyps are usually well-appearing.
  • Digital examination findings of the cervix, may include:[2]
  • Sessile or broad-based finger-like growth

Laboratory Findings

There are no specific laboratory findings associated with cervical polyps.

Imaging Findings

  • Ultrasound is the imaging modality of choice for cervical polyp.
  • On ultrasound, cervical polyp is characterized by the following findings:[2][50]
  • Sessile or pedunculated well-circumscribed masses within the endocervical canal
  • May be hypoechoic or echogenic
  • Identifying the stalk attaching to the cervical wall helps differentiate it from an endometrial polyp
  • The image below shows a cervical polyp characterized as a well-circumscribed mass within the endocervical canal.

Other Diagnostic Studies

  • Cervical polyp may also be diagnosed with colposcopy.
  • Findings on colposcopy may include:
  • Protruding polypoid mass
  • Smooth, red or purple, fingerlike growths on the cervix
  • Cervical bleeding
  • Cervical friableness
  • A cervical biopsy will most often show cells that are consistent with a benign polyp.

Treatment

Medical Therapy

  • There is no medical treatment for cervical polyp; the mainstay of therapy is surgical excision.[2]
  • Response to surgery can be monitored with regular ultrasound screenings every 6 or 12 months.
  • If the polyp is infected, an antibiotic may be prescribed.

Surgery

  • Surgery is the mainstay of therapy for cervical polyp.
  • Ring forceps in conjunction with biopsy is the most common approach to the treatment of cervical polyp.
  • Surgical string may also be performed for patients with a cervical polyp.
  • Other therapies, include: laser or cauterization.

Prevention

  • Effective measures for the primary prevention of cervical polyp include periodic ultrasound and cervical screening.[2]
  • Once diagnosed and successfully treated, patients with cervical polyp are followed-up every 6 or 12 months.
  • Follow-up testing includes pelvic examination, vaginal ultrasound, and colposcopy.

References

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  50. Cervical polyp. Dr. Henry Kenipe. Radiopedia. http://radiopaedia.org/articles/cervical-polyp Accessed on March 31,2016

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