What is the recommended treatment for a nabothian cyst in a young to middle‑aged woman?

Treatment for Nabothian Cysts

Most nabothian cysts require no treatment at all, as they are benign cervical retention cysts that are typically asymptomatic and clinically insignificant. 1, 2

Understanding Nabothian Cysts

Nabothian cysts are mucinous retention cysts formed when cervical mucus accumulates inside blocked cervical crypts, creating non-neoplastic cystic lesions on the uterine cervix. 2 They represent a common benign gynecological finding in women of reproductive age. 3, 2

Management Algorithm

Small, Asymptomatic Cysts (Most Common)

• No intervention is required for small nabothian cysts discovered incidentally during routine examination or imaging. 1, 2
• These cysts are clinically insignificant and can be followed with routine screening only. 1
• Reassurance is the primary management strategy. 2

Large or Symptomatic Cysts (Rare)

When nabothian cysts become large (>4 cm) or cause symptoms, active management becomes necessary:

Indications for Treatment:

• Chronic pelvic pain or dyspareunia 2
• Urinary retention or bladder symptoms 4
• Mechanical symptoms such as vaginal bulging or prolapse 3
• Diagnostic uncertainty requiring exclusion of malignancy (particularly adenoma malignum) 2, 5

Treatment Options:

Local cystectomy (preferred for symptomatic cysts):

• Laparoscopic excision is the recommended minimally-invasive approach for large symptomatic nabothian cysts, allowing fast recovery while preserving the uterus. 2, 6
• This approach avoids unnecessary hysterectomy in women who wish to preserve fertility or the uterus. 2
• Aspiration alone may provide temporary relief but carries high recurrence risk. 1

Hysterectomy:

• Reserved for cases with concurrent pathology (e.g., persistent uterine prolapse, abnormal uterine bleeding, other uterine pathology). 3, 4
• May be necessary when cysts are deeply embedded or when laparoscopic excision is technically challenging. 6, 4

Diagnostic Workup Before Treatment

Imaging is crucial to differentiate benign nabothian cysts from malignancy:

• Ultrasonography is the preferred initial imaging modality, showing anechoic or multiloculated cystic lesions with no solid components. 1, 2, 5
• MRI should be performed when ultrasound findings are indeterminate or when large complex cysts raise concern for malignancy, as it provides superior soft-tissue characterization. 1, 2
• Large nabothian cysts can mimic mucin-producing carcinomas (adenoma malignum), making preoperative imaging essential to avoid unnecessary radical surgery. 2, 5

Critical Pitfalls to Avoid

• Do not perform hysterectomy without proper imaging characterization—large nabothian cysts can be mistaken for malignancy, leading to overtreatment. 2, 5
• Do not assume all large cervical cystic masses are benign—histopathologic confirmation is recommended when imaging is equivocal or solid components are present. 3, 5
• Do not overlook associated pathology—large nabothian cysts may unmask underlying pelvic organ prolapse or other conditions that require separate management. 3
• Recognize that aspiration alone has limited utility—while it may provide temporary symptom relief, recurrence is common and definitive excision is preferred for symptomatic cases. 1

Follow-Up After Treatment

• For cysts managed conservatively with observation, routine gynecologic screening is sufficient. 1
• After surgical excision, follow-up at 6-12 months with physical examination ensures no recurrence. 1
• Patients who undergo hysterectomy for concurrent pathology require standard postoperative care. 3, 4