Hypertrophic elongated cervix (elongation of cervix)

Fairly common gynecological condition presenting as a "lump at vulva".

1. Hypertrophic elongated cervix (Elongation Of The Cervix) Yapa Wijeratne Faculty of Medicine University of Peradeniya

2. The normal length of the cervix is about 2.5cm. The vaginal and the supravaginal parts are of equal length. The elongation may affect either part of the cervix.

3. Anatomy of the cervix.. In detail The cervix is narrower than the body of the uterus and is approximately 2.5 cm in length. Due to antiflexion or retroflexion , the long axis of the cervix is rarely the same as the long axis of the body of the uterus. Anterior and lateral to the supravaginal portion is cellular connective tissue, the parametrium . The posterior aspect is covered by peritoneum of the pouch of Douglas. The ureter runs about 1 cm laterally to the supravaginal cervix. The vaginal portion projects into the vagina to form the fornices .

4. The upper part of the cervix mostly consists of involuntary muscle , whereas the lower part is mainly fibrous connective tissue. The mucous membrane of the endocervix has anterior and posterior columns from which folds radiate out, known as the arbor vitae. It has numerous deep glandular follicles that secrete a clear alkaline mucus, the main component of physiological vaginal discharge. The epithelium of the endocervix is cylindrical and is also ciliated in its upper two-thirds and changes to stratified squamous epithelium around the region of the external os . This squamocolumnar junction is also known as the transformation zone and is an area of rapid cell division; approximately 90% of cervical carcinoma arises in this area.

5. Causes Elongation of the supravaginal part is commonly associated with the uterine prolapse. Vaginal part is always elongated congenitally. Chronic cervicitis may produce some hypertrophy and makes the cervix bulky.

6. Supravaginal elongation of cervix in prolapse

7. Mechanism Vaginal part — There is chronic congestion which may lead to hyperplasia and hypertrophy of the fibromusculoglandular components. These lead to vaginal part becoming bulky and congested. Addition of infection leads to purulent or at times blood stained discharge from ulceration. Supravaginal part — The supravaginal part becomes elongated due to the strain imposed by the pull of the cardinal ligaments to keep the cervix in position, whereas the weight of the uterus makes it fall through the vaginal axis. Chronic interference of venous and lymphatic drainage favours elongation.

8. Symptoms There is no specific symptom for supravaginal elongation. However, congenital elongation of vaginal part may present the following Sensation of something coming down Dyspareunia Infertility

9. Congenital elongation of cervix

10. Pelvic examination

11. Supravaginal elongation Congenital elongation Associated uterine prolapse. Fornix shallow deep. Vaginal cervix normal length elongated Uterine body normal in size normal in size Uterocervical canal increased in length evidenced by introduction of an uterine sound. This indirectly proves that the increase is in the supravaginal part. increased in length, evidenced by uterine sound.

12. Congenital elongation of cervix with prolapse

13. Treatment Supravaginal elongation As it is associated with uterine prolapse, its treatment protocol will be the same as that for prolapse. Manchester repair Congenital elongation The excess length of the cervix is amputated (cervical amputation). In presence of congenital prolapse, some form of cervicopexy has to be done.

14. Cervicopexy / Sling Operation ( Purandare’s Operation) The operation is indicated in congenital or nulliparous prolapse without cystocele where the cervix is pulled up mechanically through abdominal route. Strips of rectus sheath of either side passed extraperitoneally are stitched to the anterior surface of the cervix by silk.

15. Reference Dutta -Gynecology Gynaecology by Ten Teachers 19th Ed