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 Gỹlhane Medical Faculty

Department of

Obstetrics and Gynecology 06010 Keỗiửren-ANKARA TURKEY
2

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:

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

1

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.

2

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 1. 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
3

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
4

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.
5

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.

6

This article is protected by copyright. All rights reserved.


References
1. Anderson JR, Genadry R. AnatomyandEmbryology. In: Berek JS (ed.).
Novak’sGynecology. 13th Edition.Philadelphia PA,Lippincott Williams
&Wilkins, 2002. pp. 69-123.
2. Cagnacci A, Grandi G, Cannoletta M, Xholli A, Piacenti I, Volpe A. Intensity of
menstrualpainandestimatedangle of uterineflexion. ActaObstetGynecolScand.
2014;93(1):58-63.
3. 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.
4. 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.
5. Nizić D, Pervan M, Kos I, ŠimunovićMarko. Flexionandversion of theuterus on
pelvicultrasoundexamination. ActaMedCroatica. 2014;68(3):311-5.
6. 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

7

This article is protected by copyright. All rights reserved.

Table 1: Demographic characteristics of the groups
Group 1 (n=120)Group 2 (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 1 (n=120)Group 2 (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 1 (n=120)Group 2 (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<0.05 indicates significant difference (independent two-sample t test).

8

This article is protected by copyright. All rights reserved.


Clinical Anatomy

Figure 1: Corpus, Cervical, Vaginal anatomical axes (Note: Illustrating the most common anatomical
position)
295x209mm (96 x 96 DPI)

John Wiley and Sons, Inc.
This article is protected by copyright. All rights reserved.

Page 10 of 12


Page 11 of 12

Clinical Anatomy

Figure 2: Cervical position in vaginal examination (with speculum)
a. Posterior position of the cervix
b. Anterior position of the cervix

295x209mm (96 x 96 DPI)

John Wiley and Sons, Inc.

This article is protected by copyright. All rights reserved.


Clinical Anatomy

Figure 3: Different uterine anatomic positions (except rare positions)
a.Anteversion / anteflexion
b. Anteversion / retroflexion c. Retroversion / anteflexion
retroflexion

295x209mm (96 x 96 DPI)

John Wiley and Sons, Inc.
This article is protected by copyright. All rights reserved.

Page 12 of 12

d. Retroversion /