Anterior Cervical Changes in Women with and without Cystocele

Objectives: It has been hypothesized that cystocele creates a downward traction force on the anterior wall, lengthening it, and pulling the cervix down. Halban and Tandler’s dissections of prolapse show a characteristic anterior lip “ski slope nose” deformity (SSN), suggesting it might result from such a traction force, yet the occurrence of this abnormality and factors associated with this deformity and its biomechanical meaning are unknown, as are its clinical implications for surgery. Our objective was to examine the anterior cervix shape in women with and without cystocele and relate it to other support factors to test the hypothesis that this abnormality is associated with apical descent and anterior vaginal lengthening.

Methods: This is a secondary analysis of Stress 3D MRI scans of 30 women with anterior vaginal wall-predominant prolapse (cases) and 30 asymptomatic women with normal support (controls). Three raters blinded (to the extent possible) to case/control status categorized rest and strain mid-sagittal images as: ‘Yes’ – observed characteristic change in shape of anterior lip, ‘No’ – unaltered anterior lip and fornix from normal, or ‘Intermediate’ – unclear (Figure 1). A single category difference by one rater was assigned based on the majority rating. One subject with three different ratings was assigned as Intermediate. Analysis included the frequency of SSN in both cases and controls. We also report the differences among ‘Yes’, ‘Intermediate’ and ‘No’ groups by cystocele size (the distance from most dependent bladder point to perineal membrane, similar to POP-Q Ba point), anterior vaginal wall length, and anterior fornix location measured at maximal Valsalva on MRI relative to the PICS line.

Results: The characteristic SSN phenomenon (‘Yes’ group) was observed in 28 cases and 1 control subject. There were 6 subjects (2 cases and 4 controls) in the ‘Intermediate’ group, and 25 subjects in the ‘No’ group. Single category disagreement occurred in 16 subjects. The SSN occurred in a large majority of our cases (28/30) which was statistically significant at p=0.01 from the proportion occurring in the controls (1/30). Based on ANOVA analysis, the ‘Yes’ group was significantly (p < 0.05) associated with: 1) larger cystocele size compared to ‘Intermediate’ and ‘No’ groups, 2) more inferior location of anterior fornix compared to ‘No’ group, and 3) larger vaginal lengths compared to ‘Intermediate’ and ‘No’ groups (Figure 2).

Conclusions: The definite SSN phenomenon is almost exclusively found in women with cystocele and is associated with larger prolapses and more apical descent based on location of anterior fornix. Comment: Knowledge of this deformity can help guide surgeons in accessing the vesicocervical space efficiently without going through the thickened cervix that extends well away from the external os. Its influence on abdominal sacrocolpopexy when the cervix is left in situ or with hysteropexy is unknown.