Uterine cervical stenosis: from classification to advances in management. Overcoming the obstacles to access the uterine cavity

Abstract

Background: To date hysteroscopy is the gold standard technique for the evaluation and management of intrauterine pathologies. The cervical canal represents the access route to the uterine cavity. The presence of cervical stenosis often makes entry into the uterine cavity difficult and occasionally impossible. Cervical stenosis has a multifactorial etiology. It is the result of adhesion processes that can lead to the narrowing or total obliteration of the cervical canal.

Purpose: In this review, we summarize the scientific evidence about cervical stenosis, aiming to identify the best strategy to overcome this challenging condition.

Methods: The literature review followed the scale for the quality assessment of narrative review articles (SANRA). All articles describing the hysteroscopic management of cervical stenosis were considered eligible. Only original papers that reported data on the topic were included.

Results: Various strategies have been proposed to address cervical stenosis, including surgical and non-surgical methods. Medical treatments such as the preprocedural use of cervical-ripening agents or osmotic dilators have been explored. Surgical options include the use of cervical dilators and hysteroscopic treatments.

Conclusions: Cervical stenosis can present challenges in achieving successful intrauterine procedures. Operative hysteroscopy has been shown to have the highest success rate, particularly in cases of severe cervical stenosis, and is currently considered the gold standard for managing this condition. Despite the availability of miniaturized instruments that have made the management of cervical stenosis more feasible, it remains a complex task, even for experienced hysteroscopists.

Keywords: Cervical stenosis; Hysteroscopy; Infertility; Therapy.

Fig. 1

Uterine cervix with moderate fibrotic synechia during hysteroscopic evaluation

Fig. 2

A Severe fibrotic synechiae completely distorting the cervical canal; B Mild synechia on the left lateral wall

Fig. 3

Technique of adhesiolysis using a 5 Fr grasper. Since moderate fibrotic adhesions hide a clear passage through the cervix, the 5 Fr grasper is passed into the fibrotic tissue A, creating a small opening of the way B. With a continuous opening and closing of the grasp jaws, the lumen is further enlarged allowing the hysteroscope to pass into the uterine cavity C–D

Fig. 4

Severe stenosis of cervical canal with a keyhole-shaped external cervical os A. A 5-Fr bipolar electrode is carefully inserted into the stenotic ostium B, then a cut is made along the four cardinal points performing a star-shaped incision in order to create an adequate access to the uterine caity C

Fig. 5

5 Fr graduated intrauterine palpator used to perform the lysis of severe fibrotic cervical adhesions