Management of Nabothian Cysts
Nabothian cysts are benign retention cysts of the cervix that typically require no treatment unless they cause symptoms or show concerning features. These cysts form when cervical mucus accumulates in blocked cervical crypts, creating non-neoplastic mucinous cystic lesions in the uterine cervix 1.
Diagnosis and Evaluation
Initial imaging: Transvaginal ultrasound combined with transabdominal ultrasound is the first-line imaging study for evaluating cystic lesions in the genital area 2
- Include Doppler color to evaluate vascularity of any solid components
- Use the O-RADS classification to stratify risk and guide treatment
Additional imaging: MRI with contrast is recommended for characterizing indeterminate masses or large cysts 2, 1
- MRI helps differentiate nabothian cysts from other conditions, particularly malignancies
Management Algorithm
Asymptomatic Small Nabothian Cysts
- Most nabothian cysts are small and asymptomatic, requiring no treatment or intervention 1
- Simple cysts ≤3 cm require no further management 2
- Optional follow-up at 1 year may be considered for documentation
Larger Asymptomatic Cysts (>3 cm but <10 cm)
- Follow-up ultrasound in 8-12 weeks, preferably during the proliferative phase 2
- Annual ultrasound surveillance for persistent cysts
- Refer for specialist evaluation if:
- Morphology changes
- Vascular components develop
- Rapid growth occurs
Symptomatic Nabothian Cysts
- Surgical excision is the treatment of choice for cysts that are 2, 1:
- Causing discomfort or pain
- Creating difficulty walking
- Showing growth during follow-up
- Presenting with suspicious features
- Causing dyspareunia
- Large enough to cause pressure symptoms (e.g., urinary retention) 3
Surgical Approach
Laparoscopic excision is recommended as the first-line treatment for symptomatic nabothian cysts 2, 1
- Advantages include less postoperative pain, shorter hospital stay, fewer infections, and better cosmetic results
- Complete surgical excision provides definitive histopathological diagnosis and prevents future complications
For very large cysts causing significant symptoms, hysterectomy may be considered, particularly in perimenopausal or postmenopausal women with other gynecological issues 4, 3
Special Considerations
Pregnancy
- In pregnant women with nabothian cysts:
- Simple drainage may be performed if the cyst is obstructing the birth canal during labor 5
- Most cysts can be managed conservatively during pregnancy
Differential Diagnosis
- Large or complex nabothian cysts must be differentiated from:
- Adenoma malignum (minimal deviation adenocarcinoma)
- Other mucin-producing carcinomas
- Cervical fibroids 4
Post-Treatment Follow-Up
- For patients who undergo surgical excision:
- Follow-up examination at 2-4 weeks post-procedure
- Additional follow-up at 3-6 months to ensure complete resolution
- Use O-RADS classification for any residual cyst to guide follow-up 2
Complications to Monitor
- Urinary retention (in cases of large cysts) 3
- Obstruction of labor passage (in pregnant women) 5
- Exacerbation of pelvic organ prolapse in predisposed individuals 6
By following this management approach, most nabothian cysts can be appropriately monitored or treated with minimal intervention, while ensuring that symptomatic or concerning cysts receive proper surgical management.