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Benign cervical lesions and congenital anomalies of the cervix

Benign cervical lesions and congenital anomalies of the cervix
Literature review current through: Jan 2024.
This topic last updated: Jun 01, 2023.

INTRODUCTION — Benign abnormalities of the uterine cervix (Latin for neck) are commonly seen on pelvic examination. The relative ease of cervical examination allows observation of physiologic changes that occur in response to normal cyclic variations in ovarian hormone secretion, as well as a variety of structural abnormalities and pathologic conditions (infection-related, benign neoplasms, premalignant, malignant, or congenital anatomic anomalies). Diagnosis and management may require a combination of gross visualization, palpation, cervical cytology, testing for human papillomavirus or other infections, examination under magnification (colposcopy), or pelvic imaging.

The diagnosis and management of congenital anomalies and benign cervical lesions will be reviewed here. Congenital anomalies of the hymen, vagina, and uterus are discussed separately. (See "Congenital anomalies of the hymen and vagina" and "Congenital uterine anomalies: Surgical repair".)

EMBRYOLOGY, NORMAL ANATOMY, AND HISTOLOGY

Embryology — At approximately post-fertilization day 54, the paired müllerian ducts fuse and result in formation of the uterovaginal canal, which is the precursor of the uterine corpus, cervix, and upper vagina (figure 1) [1]. The caudal end of the uterovaginal canal migrates down to meet the urogenital sinus at a point termed the müllerian tubercle, which eventually becomes the vaginal orifice and hymen. At approximately day 66, stratification of cells in this area gives rise to the sinovaginal bulbs, which proliferate to form a solid vaginal plate by day 77. The central cells of the vaginal plate then break down to form the vaginal lumen. Endocervical glands and the vaginal fornices appear between 91 days (13th week) and 15 weeks, thereby providing the first clear signs of the cervix.

Anatomy — The normal cervix is fusiform in shape, with the narrowest portions at the internal and external os. In prepubertal girls, the cervix is twice the length of the uterine corpus; this ratio reverses with age. After menarche, the cervix accounts for one-half to one-third of the length of the uterus and measures 3 to 5 cm in length and 2 to 3 cm in diameter.

The portio vaginalis, or cervical portio, is the visible portion of the cervix that protrudes into the vagina. The portio vaginalis is surrounded by a reflection of the vaginal wall on each side termed the anterior, posterior, and lateral fornix (figure 2 and figure 3). The supravaginal cervix is the intra-abdominal portion of the cervix that lies above the point of attachment of the vaginal vault; the peritoneum posterior to the supravaginal cervix forms the lining of the posterior cul-de-sac (pouch of Douglas).

The cervical canal, which averages 3 cm in length and a few millimeters in width, connects the uterine cavity with the vagina [2]. The external cervical os (where the canal opens to the vagina) is small, round, and centrally placed in nulliparous patients. In parous patients who have labored into the third stage, it is more likely to be a patulous, transverse slit (figure 4). The internal cervical os (where the canal opens to the uterine cavity) is normally no more than 3 mm in diameter in nonpregnant patients, even if parous [2]. The vagina is at a 90 degree angle to a normal anteverted uterus (figure 5), thus the external cervical os faces toward the posterior wall of the vagina. In the sagittal axis, the cervix lies between the bladder and rectum.

The cervix is supported by the uterosacral ligaments, which surround the cervix and vagina and extend laterally and posteriorly toward the second to fourth sacral vertebrae, and the cardinal ligaments, which are fibromuscular bands that fan out laterally from the lower uterine segment and cervix to the lateral pelvic walls. The blood supply comes from a descending branch of the uterine artery, and lymphatic drainage is to the parametrial nodes, then to the obturator, internal iliac, and external iliac nodes with secondary drainage to the presacral, common iliac, and paraaortic lymph nodes. The nerve supply is autonomic (sympathetic and parasympathetic). The nerves enter the upper cervix on either side and form two lateral semicircular plexuses, called Frankenhäuser plexus, a terminal part of the presacral plexus.

Surgical pelvic anatomy is discussed in detail separately. (See "Surgical female pelvic anatomy: Uterus and related structures", section on 'Uterine cervix'.)

Histology — In contrast to the body of the uterus, which is principally made up of soft muscle, the cervical stroma is predominantly collagen, with some elastic tissue and smooth muscle cells.

The portio vaginalis of the normal cervix is completely covered with smooth, pink, stratified, nonkeratinized squamous epithelium, similar to the lining of the vagina. The cervical canal is lined by glandular columnar epithelium. The squamocolumnar junction is the point at which the squamous epithelium covering the portio meets the glandular epithelium of the cervical canal. The junction can be identified as the line of demarcation between the pale pink squamous epithelium that covers the portio and the bright red columnar epithelium that lines the canal (picture 1). The division shifts position from further out on the portio to further inside the canal depending upon age and reproductive or hormonal factors. The glandular epithelium often extends well beyond the external os in newborn infants and during puberty and adolescence (see 'Ectropion' below). In postmenopausal patients, the squamocolumnar junction may be high in the canal where it cannot be seen.

The transformation zone is an area of squamous metaplasia that forms the border between the squamocolumnar junction and the rest of the squamous epithelium. The squamocolumnar junction of the cervix and the transformation zone are the areas at greatest risk for neoplasia.

The cervical and vaginal epithelia, including the mucus-producing columnar epithelium, are responsive to changes in estrogen and progesterone concentrations. Estrogen stimulates production of profuse, watery, alkaline mucus, whereas progesterone causes a thick, scant, acidic mucus.

NORMAL VARIANTS AND BENIGN NEOPLASMS — Clinicians may encounter normal variants and benign neoplasms of the cervix on pelvic examination. The ability to determine through visualization alone that a lesion is benign is based on extensive experience. If there is doubt, the lesion should be biopsied or the patient referred for biopsy to exclude cervical precancer or cancer. For patients with a cervical lesion, the clinician should perform routine cervical cancer screening if the patient is due for this. (See "Screening for cervical cancer in resource-rich settings".)

Cervical neoplasms can be asymptomatic but also may present with vaginal spotting (especially postcoitally), discharge, or dyspareunia.

Ectropion — Ectropion occurs when eversion of the endocervix (cervical canal) exposes columnar epithelium to the vaginal milieu (picture 1). The everted epithelium has a reddish appearance similar to granulation tissue and may be covered by a yellow turbid discharge.

Ectropion has also been called erosion, which is a poor term because it implies that the superficial squamous cells have eroded away to expose underlying tissue. Although this can occur, most "erosions" represent areas on the portio of the cervix where squamous cells have been replaced by overgrowth of columnar epithelium.

Ectropion is common in adolescents. After adolescence, it may be observed in patients who are pregnant, taking estrogen-progestin contraceptives, or who had a cervical laceration during labor and delivery.

In parous patients, the endocervical epithelium may be visible intermittently. The external os is wide and patulous as a result of changes from prior labor and delivery (figure 4). In some of these patients, opening a vaginal speculum to inspect the cervix causes the anterior and posterior lips to separate, exposing the endocervical canal. As the speculum is withdrawn, the anterior and posterior lips fall together, and often the ectropion disappears.

Ectropion does not need to be treated except in the rare occurrence of excessive mucous discharge or spotting that is very bothersome to the patient. In such cases, malignancy should be excluded before undertaking any treatment.

Since cases that require treatment are rare, there is no evidence to guide choice of treatment. In our experience, a two-week trial of an acidifying agent, such as boric acid suppositories 600 mg vaginally at bedtime for two weeks, may be effective. Another option is an ablative procedure using cryosurgery or electrosurgery, but this is invasive and will result in copious vaginal discharge until healing is completed, which may take weeks. Ablative treatment can also result in cervical stenosis, which can adversely affect future fertility and, if pregnancy is achieved, labor and delivery. (See "Cervical intraepithelial neoplasia: Ablative therapies".)

Cystic lesions — Cervical cysts are usually asymptomatic but may cause dyspareunia or a pressure sensation.

Nabothian cysts — Nabothian cysts (also called mucinous retention cysts, epithelial inclusion cysts) are a common finding on pelvic examination. These lesions are discrete cystic structures that form when a cleft of columnar epithelium becomes covered with squamous cells and the columnar cells continue to secrete mucoid material. The cysts vary from microscopic to several centimeters in size; the larger ones project above the surface of the portio. They may appear translucent or opaque (picture 2A-B). Nabothian cysts may occur following minor trauma or childbirth.

Nabothian cysts are typically asymptomatic. The only indication for treatment is relief from pain or a bothersome feeling of fullness in the vagina; although if the diagnosis is unclear, the cyst can be opened, drained, and a portion or all can be sent for pathologic evaluation. Ablation of the cyst using electrosurgery is the usual approach; however, if the diagnosis is uncertain, excision to evaluate for cervical neoplasia is advised. The main disadvantage to surgical treatment is the possibility of causing scar tissue, which itself can lead to dyspareunia or cervical stenosis.

Mesonephric cysts — Microscopic remnants of the mesometanephric (Wolffian) duct may be found deep within the cervical stroma when tissue removed at conization is examined pathologically. Occasionally, one or more of these remnants form a cyst, which may be confused with Nabothian cysts. Mesonephric cysts seldom reach a size greater than 2.5 cm.

Intervention is not necessary in asymptomatic patients. Treatment similar to that recommended above for Nabothian cysts is indicated if the patient has bothersome symptoms. A large cyst may be marsupialized.

Noncystic lesions

Polyps — Cervical polyps commonly occur during the reproductive years, especially after age 40 years. The etiology is unknown. Chronic inflammation of the cervical canal may play a role, as may hormonal factors, since endometrial hyperplasia and cervical polyps coexist more frequently than one would expect by chance alone. Differential diagnosis includes an endometrial polyp or prolapsed leiomyoma. (See "Endometrial polyps" and "Uterine fibroids (leiomyomas): Prolapsed fibroids".)

Single or multiple cervical polyps usually arise from the endocervical canal but can also originate from the portio (picture 3). The tear-shaped or lobular structures appear red, purple, or flesh-colored, depending upon the vascularity and congestion present, and usually look succulent and glistening. The size is typically less than 3 cm in diameter; however, polyps large enough to fill the vagina or presenting at the introitus have been described. The pedicle is usually long and thin but may be short and broad-based. Histologically, cervical polyps are characterized by vascular connective tissue stroma covered by epithelium, which may be columnar, squamous, or squamocolumnar.

Polyps should be removed if they are symptomatic (eg, bleeding, excessive discharge), large (≥3 cm), or appear atypical. Polypectomy can usually be accomplished by grasping the base of the polyp with forceps and twisting it off. If visible, the base can be cauterized to prevent bleeding and reduce the chance of recurrence. If the base is wide, such as is the case with a sessile polyp, the main portion of the polyp should be removed with a biopsy forceps and the base destroyed with electrosurgery or laser to reduce the likelihood of recurrence. In pregnancy, both the presence of a cervical polyp and its removal have been associated with preterm birth. This is discussed in detail separately. (See "Spontaneous preterm birth: Overview of risk factors and prognosis", section on 'Cervical and uterine factors'.)

Malignancy is rarely found in a cervical polyp [3,4]; however, polyps that are removed should be submitted to the laboratory for histological study.

Endometriosis — Cervical endometriosis, which is very rare, appears as red or brownish/blackish areas ("powder burns") that do not blanch on compression or as firm nodules on the portio vaginalis. Affected patients may be asymptomatic or may have discharge, dysmenorrhea, or dyspareunia. Clinical manifestations other than discharge are most likely due to implants at other sites in the pelvis, such as the ovary or uterosacral ligaments. (See "Endometriosis in adults: Pathogenesis, epidemiology, and clinical impact".)

Histologically, these lesions are the same as endometriosis at other sites. Excision or biopsy and pathologic evaluation are the keys to definitive diagnosis. Superficial endometriosis has been confused with endocervical glandular dysplasia and adenocarcinoma, which can only be excluded by biopsy [5]. Differential diagnosis also includes cervical gestational trophoblastic disease and normal hyperemia related to early pregnancy, both of which can be excluded by negative results on human chorionic gonadotropin testing.

Asymptomatic lesions do not require treatment. If the implants are tender and are causing dyspareunia, electrosurgery ablation is therapeutic. Indications for systemic therapy of endometriosis are reviewed separately. (See "Endometriosis: Treatment of pelvic pain", section on 'Medical treatment options'.)

Adenosis — Cervical adenosis is a lesion consisting of columnar epithelium surrounded by fibromuscular stroma. Although it usually occurs deep in the cervix, it may arise superficially. Adenosis can be associated with intrauterine diethylstilbestrol (DES) exposure (see below) or be a variant of normal. (See "Outcome and follow-up of diethylstilbestrol (DES) exposed individuals".)

Superficial adenosis appears as cherry red dots. Colposcopically, these red dots appear similar to gland openings observed near the transformation zone. The lesions are usually asymptomatic but can be associated with an increase in clear or white discharge and, rarely, dyspareunia. Electrosurgery ablation is only indicated if symptoms are bothersome.

Papillomas — Papillomas of the cervix are rare. They arise from the ectocervix near the squamocolumnar junction (transformation zone) and are usually less than 1 cm in diameter. Microscopically, a central core of connecting tissue supports a covering of squamous cells.

If the papilloma has a long stalk, it can be twisted until it detaches from the cervix. Papillomas can also be excised using biopsy forceps, laser, or loop electrosurgical excision procedure (LEEP); the choice depends on their size and location on the cervix. The base of the papilloma should be cauterized to prevent bleeding and recurrence.

Papillomas are rarely malignant; nevertheless, any tissue that is removed should be submitted for histopathologic analysis. Differential diagnosis includes epithelial tags resulting from obstetric injury, condylomata acuminata, or exophytic squamous cell carcinomas (see individual topic reviews).

Leiomyomas — Leiomyomas are the most common tumors of the uterus, but it is rare to find them isolated to the cervix. Leiomyomas of the cervix can be subserosal, intramural, or submucosal and can distort the cervical canal or upper vagina. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history".)

Leiomyomas of the cervix are often not visible on speculum examination but may be palpable on bimanual examination. They may also be detected on imaging or during pelvic surgery. A pedunculated lesion prolapsing through the cervix may be a cervical polyp, prolapsed fibroid from the uterine cavity, or a cervical fibroid. (See "Uterine fibroids (leiomyomas): Prolapsed fibroids".)

Pedunculated leiomyomas are often removed because of their propensity to twist and infarct or bleed. Myomectomy is indicated if there are bothersome symptoms (bladder or bowel dysfunction due to mass displacement, bleeding, dyspareunia) or if the leiomyoma prevents adequate evaluation of the cervix. The removal of large, intramural cervical myomas can be complicated because of proximity to the bladder, bowel, or ureter. Hysterectomy can be considered if childbearing is no longer a concern and the cervical mass is large and symptomatic.

Warts — Vulvar, perineal, and anogenital warts are frequently associated with coexistent vaginal and cervical lesions. Single or multiple condylomata acuminata due to human papillomavirus infection may be visible grossly and are asymptomatic. These warts are often flat, in contrast to condyloma in other areas of the anogenital region, which are typically papular.

When swabbed with a solution of 3 to 5 percent acetic acid, they become white and thus more visible to the naked eye. Cytology/colposcopy may reveal squamous intraepithelial neoplasia. These lesions are discussed separately. (See "Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis".)

Ulcers — Genital ulcers related to sexually transmitted diseases typically occur on external genitalia, but the cervix may be involved. The chancre of syphilis develops at the site of inoculation, which can be the cervix. This ulcer is painless, in contrast to the other two major causes of genital ulcers: herpes simplex virus and Haemophilus ducreyi (chancroid). (See "Approach to the patient with genital ulcers".)

PREMALIGNANT AND MALIGNANT LESIONS — Examination of the cervix should include evaluation for precancer or cancer, as appropriate. If a patient has a grossly visible cervical lesion, biopsy should be performed. If biopsy cannot be performed at that visit, cervical cytology should be collected, and the patient should have a biopsy as soon as possible.

Premalignant cervical lesions and cervical carcinoma are discussed in detail separately. (See "Cervical intraepithelial neoplasia: Terminology, incidence, pathogenesis, and prevention" and "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis".)

CONGENITAL ABNORMALITIES — If one or both müllerian ducts fail to fuse, or if development of one or both ducts does not occur, or is incomplete, duplication or agenesis of the cervix can occur. Coexistent anomalies of the vagina, uterus, and urinary tract are common since anomalies of the mesometanephric duct frequently occur in association with those of the müllerian ducts. (See "Congenital anomalies of the hymen and vagina" and "Congenital uterine anomalies: Clinical manifestations and diagnosis" and "Overview of congenital anomalies of the kidney and urinary tract (CAKUT)".)

Duplication — Duplication of the cervix (cervix duplex) may result in two distinct cervices or two fused cervices (figure 6A-B and picture 4 and picture 5). On pelvic examination, it may be difficult to differentiate and determine if there are two separate cervices or if there is a single cervix with a septum. Cervical duplication usually occurs in association with two uteri but can occur with a single uterine structure with two uterine cavities and two cervices. In cases of two cervices, even when fused, great thought should be given prior to consideration of a unification procedure of the two cervices due to risk of cervical incompetence.

Nonobstructive duplication of the cervix is usually asymptomatic and does not require intervention. Obstructive lesions require surgical intervention if hematometra or pyometra occurs. These patients may present with pelvic pain, irregular and prolonged vaginal bleeding (if there is a fenestration in the septum), or with fevers if the obstructed blood products become infected. In cases of cervical duplication with a longitudinal vaginal septum or an obstructed hemivagina, great care should be taken when removing the septum so as not to compromise the blood supply to the individual cervices. (See "Congenital anomalies of the hymen and vagina", section on 'Anomalies of the vagina'.)

Agenesis/hypoplasia — Cervical agenesis and hypoplasia are rare. With complete agenesis, both the cervix and the upper vagina must be absent, as the proximal portion of the vagina does not form in the absence of a cervix during embryonic development (figure 7A-B and figure 8). When the cervix is present, but hypoplastic, the vagina can be normal (figure 9A-B). As shown in the figure, the amount of cervix present may vary, and the presence or absence of an internal os may also vary. (See "Congenital anomalies of the hymen and vagina", section on 'Vaginal agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)'.)

Cervical hypoplasia is typically recognized at menarche. Adolescents may present with primary amenorrhea, cyclic or chronic abdominopelvic pain, or a pelvic mass (from hematometra). Imaging with ultrasound and magnetic resonance are helpful in defining the anatomy.

Historically, the preferred treatment for cervical agenesis or hypoplasia without an internal os was hysterectomy, given that these conditions were not considered compatible with future fertility [6,7]. However, with advances in assisted reproduction, less aggressive surgical procedures have been developed, and it is the author's practice to use menstrual suppression with hormonal therapy until the patient has reached adulthood and can make a definitive decision regarding surgical interventions.

Since patients vary widely in their degree of cervical hypoplasia, clinicians should select a surgical procedure carefully and be certain of the diagnosis (eg, differentiate between a high transverse vaginal septum and cervical agenesis) [8]. A safe, successful surgical procedure is more likely when there is normal cervical tissue that just lacks a patent cervical canal than when there is significant cervical agenesis. One procedure uses molds and both skin and "mucosal" grafts to create an upper vagina and endocervical tract to allow menstruation and potentially enable spontaneous conception and successful pregnancy [9-14]. The disadvantages of this approach are the risks of recurrent obstruction and ascending infection, which can lead to sepsis and death [15,16]. Placement of a levonorgestrel intrauterine device (LNG IUD) at the time of surgery has been described, and may decrease the risk of hematometra, infection, and need for reoperation [17]. Due to the rarity of these conditions and the high risk of complication, a referral to a surgeon with experience with these conditions would be prudent.

Advances in reproductive care and assisted reproduction have enabled patients to avoid the need for surgical reconstruction. Despite obstruction of menstrual flow, long-term use of medications that suppress menstruation (eg, combination estrogen/progestin therapy, continuous progestin only, or a gonadotropin-releasing hormone [GnRH] agonist with add-back therapy) can prevent development of hematometra, dysmenorrhea, and chronic pelvic pain. When pregnancy is desired, these medications can be stopped, and conception may be attempted using assisted reproductive techniques (zygote intrafallopian transfer [ZIFT] or gamete intrafallopian transfer [GIFT]) with planned cesarean delivery. Successful pregnancies have been reported [18].

Diethylstilbestrol induced changes — Intrauterine exposure to diethylstilbestrol (DES), a synthetic nonsteroidal estrogen, results in congenital cervical anomalies and an increased risk of vaginal and cervical cancers. DES was first synthesized in 1938. From approximately 1940 to 1971 in the United States and until the early 1980s in some other countries, DES was given to pregnant patients in the mistaken belief it would reduce the risk of pregnancy loss and complications.

In 1971, DES was shown to cause clear cell carcinoma, a rare vaginal tumor in females who had been exposed to this drug in utero [19].

In addition to its neoplastic potential, DES has also been shown to be teratogenic and associated with cervical hypoplasia, collars, hoods, and polyps. Gross cervical abnormalities can be seen in approximately 20 percent of exposed females. Cancer is rare (1 case per 1000 to 2000 exposed daughters).

Cervical adenosis is another histologic change that may occur in females exposed in utero to DES because remnants of the müllerian anlage persist beneath the vaginal plate of squamous epithelium, an area where glandular elements are not normally found. Most of the glands are lined by mucin-secreting columnar cells. They may be buried beneath the epithelium, but often glands and their secretions are visible away from the transformation zone on the cervix. Cervical adenosis is typically accompanied by vaginal adenosis.

DES-related structural cervical abnormalities do not require treatment. There may be an increased risk of cervical insufficiency during pregnancy; such patients require close prenatal monitoring and may be candidates for placement of a cerclage.

Effects of DES exposure are discussed in detail separately. (See "Outcome and follow-up of diethylstilbestrol (DES) exposed individuals".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Congenital female reproductive tract anomalies".)

SUMMARY AND RECOMMENDATIONS

Clinical significance – Benign lesions of the uterine cervix are commonly seen on pelvic examination. These may be physiologic changes (ectropion), infectious (eg, warts, ulcers), or benign (eg, polyps, leiomyomas) neoplasms. Cervical neoplasms can be asymptomatic but also may present with vaginal spotting (especially postcoitally), discharge, or dyspareunia. (See 'Normal variants and benign neoplasms' above.)

Further evaluation – Further evaluation of a cervical lesion may require a combination of gross visualization, palpation, cervical cytology, testing for human papillomavirus or other infections, examination under magnification (colposcopy), or pelvic imaging. The ability to determine through visualization alone that a lesion is benign rather than malignant is based on extensive experience. If there is doubt, the lesion should be biopsied or the patient referred for biopsy to exclude cervical precancer or cancer. (See 'Normal variants and benign neoplasms' above and 'Premalignant and malignant lesions' above.)

Common findings – The most common cervical findings include the following:

Ectropion – Ectropion occurs when eversion of the endocervix exposes columnar epithelium to the vaginal milieu (picture 1). Treatment is unnecessary except in the rare occurrence of excessive mucous discharge or spotting that is very bothersome to the patient. For patients with bothersome symptoms of ectropion, we suggest a trial of an acidifying agent (eg, boric acid vaginal suppositories) rather than ablation (Grade 2C). An ablative procedure using cryosurgery or electrosurgery is effective but is invasive and will result in copious vaginal discharge until healing is completed. (See 'Ectropion' above.)

Cysts – Nabothian (picture 2B) and mesonephric cysts occur on the portio vaginalis and have a similar appearance. If these lesions are associated with bothersome symptoms (discharge, pressure, dyspareunia), we suggest ablation rather than excision (Grade 2C). (See 'Cystic lesions' above.)

Polyps – Cervical polyps are common and usually originate from the endocervical canal (picture 3). We suggest removal of symptomatic (spotting) or large polyps (Grade 2C). This can usually be accomplished by grasping them at the base with forceps and twisting. If the base is wide, the main portion of the polyp is removed with a biopsy forceps and the base destroyed with electrosurgery or laser. Differential diagnosis includes leiomyoma and endometrial polyps. (See 'Polyps' above.)

Congenital abnormalities

If one or both müllerian ducts fail to fuse, or if development of one or both ducts does not occur, or is incomplete, duplication (picture 4 and picture 5) or agenesis (figure 7A) of the cervix can occur. Coexistent anomalies of the vagina, uterus, and urinary tract are common since anomalies of the mesometanephric duct frequently occur in association with those of the müllerian ducts. (See 'Congenital abnormalities' above.)

Nonobstructive duplication of the cervix is usually asymptomatic and does not require intervention. Obstructive lesions require surgical intervention if hematometra or pyometra occurs. (See 'Duplication' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Donald Peter Goldstein, MD, who contributed to an earlier version of this topic review.

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References

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