How should a nabothian cyst of the cervix be managed in a reproductive‑age woman?

Management of Nabothian Cysts of the Cervix

Nabothian cysts are benign mucous retention cysts of the cervix that typically require no treatment in reproductive-age women; small asymptomatic cysts need only reassurance, while large or symptomatic cysts may warrant imaging to exclude malignancy and surgical excision if they cause symptoms or diagnostic uncertainty. 1, 2

Understanding Nabothian Cysts

Nabothian cysts form when cervical mucus accumulates inside blocked cervical crypts, creating non-neoplastic mucinous cystic lesions. 1 They are extremely common benign findings in women of reproductive age and are usually discovered incidentally during routine pelvic examination or imaging. 1, 2

Size-Based Management Approach

Small Asymptomatic Cysts (Most Common)

• No intervention is required for small nabothian cysts, which are typically a few millimeters to 1-2 cm in diameter. 1
• These cysts are clinically insignificant and should be documented as benign findings requiring no follow-up. 1, 3
• Reassurance to the patient is the only management needed. 1

Large or Complex Cysts (≥4 cm)

• Cysts reaching 4 cm or larger are extremely rare but pose a diagnostic challenge because they can mimic malignant tumors, particularly adenoma malignum (minimal deviation adenocarcinoma). 1, 2, 4
• Imaging with ultrasound and MRI is crucial to differentiate large nabothian cysts from malignancy before any surgical intervention. 1, 2
• On ultrasound, nabothian cysts appear as anechoic or multiloculated cystic lesions with no solid components or vascularity. 1, 2
• MRI provides superior tissue characterization and can confirm the benign nature of the cyst by demonstrating typical fluid signal characteristics without enhancement or solid components. 1

When to Consider Surgical Excision

Surgical removal is indicated when:

• The cyst causes persistent symptoms such as dyspareunia, pelvic pain, or pressure symptoms. 1, 5
• The cyst is large enough to cause mechanical obstruction (e.g., obstructing labor passage or causing uterine prolapse). 5, 4
• Imaging findings are equivocal and malignancy cannot be confidently excluded, necessitating tissue diagnosis. 2, 3
• The patient experiences recurrent symptoms despite conservative management. 1

Surgical Approach

• Laparoscopic excision is the preferred minimally invasive technique for large symptomatic nabothian cysts, allowing for complete removal while preserving the uterus and enabling rapid recovery. 1, 3
• Simple drainage or aspiration may be performed in emergency situations (e.g., obstructing labor), but this is only a temporizing measure as cysts often recur. 4
• Total hysterectomy should be avoided unless there are other indications for uterine removal, as nabothian cysts are benign and can be excised separately. 1, 2
• Laparoscopic hysterectomy may be technically challenging when giant nabothian cysts distort cervical anatomy, requiring careful bladder dissection and ureteric identification. 3

Critical Diagnostic Pitfalls to Avoid

• Do not assume all large cervical cystic masses are benign without proper imaging evaluation—adenoma malignum is a rare but important malignant differential that requires histopathologic exclusion. 2, 4
• Do not perform hysterectomy without preoperative imaging confirmation of the benign nature of the cyst, as unnecessary radical surgery can be avoided with proper diagnosis. 1
• Multiple large nabothian cysts can coexist and may reach up to 4 cm each; this multilocular appearance should not automatically suggest malignancy if imaging characteristics are benign. 2
• In pregnant women presenting with large cervical masses, consider nabothian cysts in the differential and plan delivery management accordingly, as they can obstruct the birth canal. 4

Special Clinical Scenarios

• During pregnancy: Large nabothian cysts may obstruct labor passage and require drainage to allow vaginal delivery; definitive excision can be performed postpartum if the cyst persists. 4
• With uterine prolapse: Giant nabothian cysts can unmask latent pelvic organ prolapse by increasing the degree of prolapse; excision of the cyst may reveal persistent prolapse requiring separate surgical correction. 5
• Perimenopausal women: While nabothian cysts are most common in reproductive-age women, they can occur in perimenopausal women and should still be managed conservatively unless symptomatic. 5

Pathologic Confirmation

• Histopathologic examination after excision confirms the diagnosis and definitively excludes malignancy, showing benign cervical glandular epithelium with mucin accumulation. 1, 2, 3
• Aspiration of cyst fluid typically yields clear or yellowish mucinous fluid; cytologic examination is generally not necessary but can provide additional reassurance. 3