Alignment of the Cervix with the Vagina in Uterine Retroversion: A Possible Risk Factor in Uterine Prolapse

Abstract

Multiple observational studies have found an association of uterine prolapse with uterine retroversion. Mechanisms proposed to explain this apparent association assume that the cervix of a retroverted uterus will usually insert at the apex of the vagina, with resultant alignment of the cervix with the vagina. The angle of the axis of the cervix with the axis of the vagina was measured by two readers on 323 sagittal pelvic MRI scans and sagittal reconstructions of pelvic CT scans performed for clinical purposes. One reader observed and recorded the anatomic relations of the uterus that differed by insertion site and version: 44 of 49 retroverted uteri (89.8%) inserted at the vaginal apex, and 13 of 274 anteverted uteri (4.7%) inserted at the vaginal apex. This difference was found to be statistically significant (p < 0.05) by the Chi square test. The urinary bladder, vaginal walls, and rectum were inferiorly related to anteriorly inserted anteverted uteri. Only the vaginal lumen and the rectum at a shallow oblique angle were inferiorly related to apically inserted retroverted uteri. Most retroverted uteri insert at the apex of the vagina. Apically inserted retroverted uteri appear to receive less support from adjacent structures than anteriorly inserted anteverted uteri.