Value-Of-Vaginal-Cervical-Position-In-Estimating-Uterine-Anatomy.pdf

Ulaş Fidan, Ass.Prof.1* Uğur Keskin, Accoc Prof.1 Mustafa Ulubay, Ass Prof.1 Mustafa Öztürk, MD.2 Serkan Bodur, MD.1 Cervical position in the uterine anatomy ¹University of Health Sciences Gülhane Medical Faculty Department of Obstetrics and Gynecology 06010 Keỗiửren-ANKARA TURKEY Bakrkửy Dr Sadi Konuk Education and Reseach Hospital, Obstetrics and Gynecology, Bakırköy, İstanbul, TURKEY *Corresponding Author University of Health Sciences Gülhane Medical Faculty Department of Obstetrics and Gynecology Tel: +903123045814 Fax: +903123045800 e-mail: ulasfdn@gmail.com Post Code: 06010 Keỗiửren-ANKARA TURKEY This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record Please cite this article as an ‘Accepted Article’, doi: 10.1002/ca.22854 This article is protected by copyright All rights reserved Value of vaginal cervical position in estimating uterine anatomy Abstract Introduction: The anatomy of the uterus is defined by the angles of the vagina, cervix and uterine corpus, and subsequently by angles of version and flexion The position of the cervix observed during vaginal speculum examination can provide information about uterine anatomy Material and Methods: In this study, we investigated the place of cervical position in estimating uterine anatomy during the cervical examination We enrolled 240 patients who applied to our routine gynecology outpatient clinic with various complaints We divided these patients into two groups according to the cervical position (anterior or posterior) observed during the speculum examination We also recorded uterine anatomy using transvaginal ultrasonography Results: During the speculum examination we determined that 90% of cases with posterior fornix position were anteverted and 10% retroverted; 64.2% of cases with anterior fornix position were anteverted and 35.8% retroverted Discussion: According to these findings, cervical position observed during the speculum examination could be useful for assessing uterine anatomy regarding the angles of version However, ultrasonographic examination is essential for the definitive determination of uterine anatomy Introduction The anatomical position of the uterus is described with reference to the angles between the vaginal axis, cervical axis and axis of the uterine body The positional This article is protected by copyright All rights reserved Abstract Introduction: The anatomy of the uterus is defined with the angles of the vagina, cervix and uterine corpus Hereunder there are angles of version and flexion The cervical position observed during the vaginal speculum examination, may give information about the uterine anatomy Material and Methods: In this study, we investigated the place of the cervical position in the estimation of the uterine anatomy observed during the cervical examination We enrolled 240 patients in our study, who applied to our routine gynecology outpatient clinic with various complaints We divided these patients into two groups according to the cervical position (anterior cervical position and posterior cervical position) observed during the speculum examination We recorded the uterine anatomy also with the transvaginal ultrasonography Results: During the speculum examination, we determined that 90% of the cases with posterior fornix position were anteverted and 10% retroverted; 64.2% of the cases with anterior fornix position were anteverted and 35.8% retroverted Discussion: According to these findings, cervical position observed during the speculum examination might be useful in the estimation of the uterine anatomy regarding the angles of the version However, the ultrasonographic examination is essential for a definitive determination of the uterine anatomy Keywords Uterine anatomy, vaginal examination, cervical position, ultrasonography This article is protected by copyright All rights reserved relationship between the vaginal and cervical axes is referred to as version and the angle between the cervical axis and the axis of the uterine corpus is referred to as flexion (Anderson et al., 2002) If the angle between the vaginal and cervical axes is directed ventrally, it is defined as anteversion; if it is directed backward, it is defined as retroversion If the angle between the cervical axis and the axis of the uterine corpus is directed ventrally, it is defined as anteflexion; if directed backward, it is defined as retroflexion (Figure 1) The position of the cervix observed during vaginal examination could help in estimating the position of the uterus regarding version and flexion In a study focused on the ultrasonographic determination of uterine position, it was reported that the most common position was anteversion/anteflexion and the least common was retroversion/retroflexion (Nizić et al., 2014) However, a study using magnetic resonance imaging reported ethnic differences regarding the position of the uterus (Rizk et al., 2005) The determination of the exact anatomical position of the uterus is important for many gynecological surgeries as it affects the success rate of the intervention Examples include the proper insertion of the cannula during intrauterine insemination; proper insertion of the uterine manipulator during laparoscopic and robotic hysterectomy (to decrease the risk of perforation); determination of the position of the embryo during curettage; and proper forwarding of the transfer catheter into the uterine fundus when the embryo is transferred during in vitro fertilization If the cervical position of the patient during vaginal speculum examination on the gynecological examination/intervention table is toward the posterior fornix, the uterus could be anteverted/anteflexed If the position is towards the anterior fornix, the uterus could be retroverted/retroflexed Taking anatomical structure into consideration, if the cervix is in the anterior position in the vagina then the uterine axis should be in the posterior position, and if it is in the posterior position in the vagina then the uterine axis should be in the anterior position In this study, we assessed the accuracy of estimation of uterine anatomy by the observed cervical position during cervical examination This article is protected by copyright All rights reserved Materials and Methods We obtained the local ethics committee’s approval for our study (Gülhane Military Medical Academy Ethics Committee, 25 February 2014, Registration number: 32) We enrolled patients who applied to our gynecology and obstetrics outpatient clinic in the tertiary healthcare services center between August 2014 and January 2015, with the following inclusion criteria: women of reproductive age, a regular menstruation cycle, at least 12 months since last delivery, no history of uterine or pelvic surgery (except cesarean delivery), no findings of endometriosis in the anamnesis and gynecological examination, and no mass affecting the anatomy of the uterus (leiomyoma, adenomyosis, other pelvic organ disorders) A total of 240 patients fulfilling these inclusion criteria were included in our study and 630 were excluded All gynecological examinations were carried out with an empty bladder All patients were assessed by vaginal examination and ultrasonography on the gynecological table The position of the cervix was recorded during the vaginal speculum examination Patients with a cervical position towards the anterior fornix were assigned to the 1st Group (anterior cervical position; n=120); those with a cervical position towards the posterior fornix were assigned to the 2nd Group (posterior cervical position; n=120) (Figure 2) Afterwards, the uterine anatomy was assessed by ultrasonography The positions regarding “version” and “flexion” were recorded Also, the menstrual cycle and demographic data (proliferative or secretory endometrium, age, parity and type of delivery) of the patients were recorded Results The demographic characteristics of both groups are shown in Table There was no statistically significant difference between the groups regarding age, parity or caesarean delivery The most commonly encountered position in patients whose cervix was in the anterior position during the speculum examination was anteversion/anteflexion (56.7%) The rate of anteversion/retroflexion was 7.5%, retroversion/anteflexion was This article is protected by copyright All rights reserved 5.8% and retroversion/retroflexion was 30% The rate of anteversion/anteflexion, the most common position, was 72.5% in patients who had a cervix towards the posterior fornix during the speculum examination The rate of anteversion/retroflexion was 17.5%, retroversion/anteflexion was 0.8% and retroversion/retroflexion was 9.2% (Table 2) (Figure 3) Ultrasonographic examination showed that the anteversion rate was 64.2% /77/120) and the retroversion rate 35.8% (43/120) in cases who had a cervix in the anterior position during the speculum examination In cases with a cervix in the posterior position during the speculum examination, the ultrasonographic examination showed that the anteversion rate was 90% (108/120) and the retroversion rate 10% (12/120) The difference between these rates was statistically significant (Table 3) On the other hand, regarding the uterine flexion angle, cases in the anterior position during the speculum examination had a rate of anteflexion of 62.5% (75/120) and a rate of retroflexion of 37.5% (45/120) In cases in the posterior position, the rate of anteflexion was 73.3% (88/120) and the rate of retroflexion 26.7% (32/120) There was no statistically significant difference between these rates (Table 3) Discussion The anatomical structure of the uterus is important for clinicians in respect of many gynecological interventions Correct judgment of the version, which shows the relationship between the vaginal and cervical axes, and of the flexion, which shows the relationship between the isthmic region and the uterine corpus, is the most important step towards success in gynecological interventions For this purpose, the cervical position observed during vaginal examination is partly reliable for estimating the anatomical structure of the uterus, on which several studies have focused Nizic et al reported that the position of the uterus was affected by several etiological factors They emphasized the importance of ultrasonography in the pelvic examination (Nizić et al., 2014) Rizk et al used magnetic resonance imaging and revealed differences in the anatomical position of the uterus among different ethnic groups (Rizk et al., 2005) According to this study, the angle of version was significantly less common in This article is protected by copyright All rights reserved European/Caucasian women than in other ethnic groups (especially in India and Pakistan) Haylen et al investigated whether the anatomical position of the uterus was affected by a full or empty bladder Their study included 480 cases and revealed that the rate of retroversion in the ultrasonographic examination, which was 18% with the empty bladder, declined to 13% with the full bladder This difference was reported as statistically significant (Haylen et al., 2007) To exclude this interference in our study, we investigated the uterine anatomy of our patients after ensuring that they had voided their bladder before the examination Since these data indicate that uterine anatomy can change depending on the bladder’s fullness, ultrasonography provides a more reliable means of assessment Fauconnier et al investigated the relationship between the retroverted uterus and pelvic pain (Fauconnier et al., 2006) They found a significant correlation between the retroverted uterus and dyspareunia and dysmenorrhea Cagnacci et al investigated the relationship between the intensity of menstrual pain measured with the Visual Analog Score and the estimated angle of uterine flexion The results showed that more intense menstrual pain was experienced when the angle of uterine flexion was smaller (Cagnacci et al., 2014) Nevertheless, we considered the value of cervical position observed in the cervicovaginal examination in estimating the uterus We designed our study to be descriptive rather than directed towards an etiological cause of a disorder or the effects of certain disorders on uterine anatomy We found that the uterus was anteverted in 90% of cases if the cervix was in the posterior position, and anteverted in 64.2% if it was in the anterior position For the same positions, the rates of the anteflexed uterus were 73.3% and 62.5% respectively A cervicovaginal examination could help to estimate the anatomical angle of version from these rates However, although there was a statistically significant difference, the rate of the anteversion was 64.2% while the cervix was in the position of the anterior fornix Our study excluded cases with histories of surgery except caesarean delivery, with leiomyoma, and with clinically manifested endometriosis These disorders are common among women of reproductive age Therefore, studies including these cases could be scientifically more informative This article is protected by copyright All rights reserved After grouping the patients according to their menstrual cycle phases, i.e proliferative and secretory, we found that the angles of version (anteversion/retroversion) differed significantly between these two groups However, as we did not design our study accordingly, this difference did not answer the question: what kind of uterine features we will encounter during different phases of the menstrual cycle after the cohort follow-up of the patients enrolled in our study? Large-scale studies designed accordingly will be much more informative about this topic and will clarify how the menstrual cycle affects uterine anatomy An overall assessment of all these data shows that ultrasonography is essential for the definitive determination of uterine anatomy Cervical position observed only during cervicovaginal examination will not provide reliable information on the anatomical structure of the uterus However, in a patient group with no disorder, as selected in our study, the uterus is anteverted in 90% of cases if the cervix is in the position of the anterior fornix; other possibilities are less common Therefore, we recommend ultrasonographic examination before endometrial biopsy (Pipelle, etc.), hysterosalpingography, intrauterine insemination, embryo transfer, and uterine manipulation in laparoscopic or robotic surgery, as there could be adverse consequences if the exact uterine anatomy is not known in advance Conflict of Interest The authors declare no conflicts of interest or any financial association with any company or manufacturer regarding the subject matter or materials discussed in this article This article is protected by copyright All rights reserved References Anderson JR, Genadry R AnatomyandEmbryology In: Berek JS (ed.) Novak’sGynecology 13th Edition.Philadelphia PA,Lippincott Williams &Wilkins, 2002 pp 69-123 Cagnacci A, Grandi G, Cannoletta M, Xholli A, Piacenti I, Volpe A Intensity of menstrualpainandestimatedangle of uterineflexion ActaObstetGynecolScand 2014;93(1):58-63 Fauconnier A, Dubuisson JB, Foulot H, Deyrolles C, Sarrot F, Laveyssière MN, Jansé-Marec J, Bréart G Mobile uterineretroversion is associatedwithdyspareuniaanddysmenorrhea in an unselectedpopulation of women Eur J ObstetGynecolReprodBiol 2006;127(2):252-6 Haylen BT, McNally G, Ramsay P, Birrell W, Logan V A standardisedultrasonicdiagnosisand an accurateprevalencefortheretroverteduterus in general gynaecologypatients.Aust N Z J ObstetGynaecol 2007;47(4):326-8 Nizić D, Pervan M, Kos I, ŠimunovićMarko Flexionandversion of theuterus on pelvicultrasoundexamination ActaMedCroatica 2014;68(3):311-5 Rizk DE, Czechowski J, Ekelund L Magneticresonanceimaging of uterineversion in a multiethnic, nulliparous, healthyfemalepopulation J ReprodMed 2005;50(2):81-3 Figure 1: Corpus, Cervical, Vaginal anatomical axes (Note: Illustrating the most common anatomical position) Figure 2: Cervical position in vaginal examination (with speculum) a Posterior position of the cervix b Anterior position of the cervix Figure 3: Different uterine anatomical positions (except rare positions) a.Anteversion / anteflexion b Anteversion / retroflexion c Retroversion / anteflexion d Retroversion / retroflexion This article is protected by copyright All rights reserved Table 1: Demographic characteristics of the groups Group (n=120)Group (n=120) p Anterior cervical position Posterior cervical position Age 35.17±6.834.8±6.9 0,676 BMI 23,48±2,97 0,001 24,71±2,45 Parity 1.7±0.9 0,341 1.54±0.9 History of caesarean delivery 0.5±0.8 0.4±0.7 0,594 BMI: Body mass index Table 2: The relationship of all the uterine axes to the vaginal cervical position Group (n=120)Group (n=120) Anterior cervical position Posterior cervical position Anteversion / Anteflexion56.7% (n=68)72.5% (n=87) Anteversion / Retroflexion7.5% (n=9) 17.5% (n=21) Retroversion / Anteflexion5.8% (n=7)0.8% (n=1) Retroversion / Retroflexion30% (n=36) 9.2% (n=11) Table 3: The relationship of the angles of uterine version and flexion to the vaginal cervical position Group (n=120)Group (n=120) p Anterior cervical position Posterior cervical position Anteversion64.2% (n=77)90% (n=108)< 0.001 Retroversion 35.8% (n=43)10% (n=12)< 0.001 Anteflexion 62.5% (n=75)73.3% (n=88)0,097 Retroflexion37.5% (n=45)26.7% (n=32)0,097 P