What is the uterine position of a 28-year-old nulligravid (having never given birth) woman with deep dyspareunia (painful intercourse) and difficulty conceiving, whose cervix is tilted posteriorly and uterine fundus is directed toward the sacral promontory?

Retroversion of the Uterus

The patient's uterine position is retroversion (retroverted uterus), characterized by the uterine fundus directed toward the sacral promontory and the cervix tilted posteriorly in the vaginal canal.

Understanding Uterine Positioning

Uterine position is typically classified based on the orientation of the uterine fundus and cervix. In this case, the physical examination findings clearly indicate a retroverted uterus:

• The uterine fundus is directed posteriorly toward the sacral promontory
• The cervix is tilted posteriorly in the vaginal canal
• The cervix cannot be visualized on speculum examination (consistent with posterior displacement)

Clinical Significance of Retroversion

Retroversion is a normal anatomic variant found in approximately 20-30% of women. In this patient, the retroversion appears to be contributing to:

1. Deep dyspareunia - The patient's complaint of sharp pelvic pain during intercourse, especially when supine, is consistent with pressure on a retroverted uterus during deep penetration. In the supine position, the penis can directly impact the posteriorly positioned uterine fundus.

2. Difficulty conceiving - While retroversion itself is not a direct cause of infertility, the altered position can potentially affect:

   • Sperm transport and pooling
   • Mechanical factors related to intercourse discomfort leading to less frequent attempts at conception

Diagnostic Considerations

The diagnosis of uterine retroversion is made through bimanual pelvic examination, as demonstrated in this case. The examiner can feel:

• The uterine fundus directed posteriorly toward the sacrum
• The cervix pointing posteriorly in the vaginal canal

Ultrasound examination can confirm the diagnosis if needed, with transvaginal ultrasound providing the best assessment of uterine position 1.

Management Implications

For this 28-year-old nulligravid woman with dyspareunia and difficulty conceiving:

1. For dyspareunia:

   • Position modifications during intercourse (avoiding positions that cause deep penetration or trying positions where the woman has more control over depth)
   • Consider evaluation for other causes of deep dyspareunia that may coexist with retroversion, such as endometriosis 2, 3

2. For fertility concerns:

   • Reassurance that retroversion alone rarely causes infertility
   • Evaluation for other potential causes of infertility
   • If severe symptoms persist, consideration of uterine suspension procedures may be warranted in select cases

Important Distinctions

It's important to distinguish retroversion from other uterine positions:

• Anteversion (normal position): uterine fundus directed anteriorly toward the bladder
• Retroflexion: uterine corpus bent posteriorly relative to the cervix
• Anteflexion: uterine corpus bent anteriorly relative to the cervix

Retroversion should also be distinguished from fixed retroversion due to adhesions, which may be associated with endometriosis or pelvic inflammatory disease and can cause more significant symptoms 1.