What is the management of a Nabothian cyst?

Management of Nabothian Cysts

Nabothian cysts are benign cervical lesions that typically require no treatment unless they become symptomatic or unusually large.

What Are Nabothian Cysts?

Nabothian cysts are mucus-filled retention cysts that form on the cervix when squamous epithelium blocks the opening of nabothian glands, causing mucus accumulation. They are:

• Common in women of reproductive age
• Usually small and asymptomatic
• Typically discovered incidentally during routine pelvic examinations
• Benign lesions with no malignant potential

Diagnostic Approach

When a nabothian cyst is suspected:

• Pelvic examination to visualize the cervix and assess cyst size and location
• Ultrasound is the preferred initial imaging modality for characterization
• MRI may be used for larger cysts to rule out malignancy and determine extent
• Biopsy may be recommended for atypical presentations to exclude malignancy

Management Algorithm

For Asymptomatic Nabothian Cysts:

• No treatment required
• No follow-up imaging necessary
• Patient reassurance about benign nature

For Symptomatic or Large Nabothian Cysts:

1. Conservative management for mildly symptomatic cysts:

   • Observation
   • Pain management with appropriate analgesics if needed

2. Intervention indicated when cysts cause:

   • Significant pain or discomfort
   • Dyspareunia (painful intercourse)
   • Abnormal uterine bleeding
   • Urinary symptoms (rare cases of urinary retention) 1
   • Protrusion through vaginal canal 2
   • Size >5 cm with mass effect

3. Surgical options for symptomatic or large cysts:

   • Local excision/cystectomy (preferred for isolated cysts)
   • Laparoscopic excision for larger or deeper cysts 3
   • Hysterectomy only in cases with concurrent gynecological indications 1, 4

Special Considerations

• Differential diagnosis: Large nabothian cysts must be differentiated from:

  • Adenoma malignum (minimal deviation adenocarcinoma)
  • Other cervical malignancies
  • Cervical fibroids
  • Endometriotic cysts

• Unusual presentations: Giant nabothian cysts (>4 cm) may present with:

  • Pelvic pressure or pain
  • Urinary retention 1
  • Apparent uterine prolapse 2
  • Dyspareunia

• Imaging pearls: On ultrasound, nabothian cysts appear as:

  • Well-defined anechoic or hypoechoic lesions
  • May be single or multiple
  • No internal vascularity on Doppler
  • May appear multiloculated in complex cases 5

Follow-up Recommendations

• No routine follow-up needed for asymptomatic cysts
• For treated symptomatic cysts, one follow-up visit to ensure resolution of symptoms
• No long-term surveillance required after successful treatment

Pitfalls to Avoid

• Misdiagnosing large nabothian cysts as malignant lesions, leading to unnecessary extensive surgery
• Overlooking symptoms caused by large nabothian cysts
• Performing hysterectomy for isolated nabothian cysts when local excision would suffice
• Failing to consider nabothian cysts in the differential diagnosis of cervical masses

Unlike other cystic conditions that may require regular monitoring (such as ovarian cysts or hepatic cysts), nabothian cysts generally follow a benign course and do not require surveillance imaging or follow-up unless they become symptomatic 6, 7.