Management of Vaginal Cysts
Jun 2011 – by F. Ling, MD
1. A 21 year old woman complains of painful intercourse. Examination reveals a 2 cm x 4 cm cystic mass in the right anterior vaginal fornix.
a. The differential diagnosis of cysts in this region of the vagina includes a vaginal inclusion cyst, possibly related to previous surgical repair of a vaginal laceration or obstetrical tear; and a Gartner's Duct cyst, a remnant of the Wolffian duct. If the patient were significantly older, or if the cystic nature of the mass were in doubt, the differential diagnosis could also include defects of the vaginal wall such as a cystocele or enterocele. Assuming that the patient does not have a history of surgery to repair a vaginal laceration or obstetrical tear, the most likely diagnosis in this young patient is a Gartner's duct cyst.
b. Although the scenario being described already provides the physical finding of a vaginal cyst, the discussion will briefly describe what the patient's evaluation would be in an actual clinical setting. Since the patient's chief complaint is one of dyspareunia, the history should expand on issues including whether the pain is present when she is not having sex, or if sex has always hurt in the same fashion, or if the pain is "insertional" pain or "deep thrust" dyspareunia. Following the history, the physical should attempt to identify the source of dyspareunia. Without the foreknowledge that there is a vaginal cyst, the clinician should check the introitus for a source of insertional dyspareunia using a cotton-tipped swab to gently touch the labia major, labia minor, and the vestibule (specifically the Skene's and Bartholin's gland duct openings), looking for tenderness that recreates the chief complaint. Touching the urethral meatus is also done to identify the source of pain. Gentle insertion of an appropriate-sized speculum will allow visualization of the vagina, with either a Grave's or Pederson speculum potentially appropriate. After visualization of the vagina, a bimanual and rectovaginal examination conclude the physical. Palpation of the pelvic floor muscles, the urethra, the bladder, the uterus, and adnexa should be done to differentiate which, if any of those anatomic sites, is/are painful. At any time during the examination, should there appear to be tenderness, the patient should be asked whether or not that pain recreates her chief complaint. Asking her this question avoids the likelihood of a cause of tenderness other than her primary problem. Laboratory evaluation would likely include a urinanalysis with culture and sensitivity if the urethra and/or bladder were tender. Unless an acute infection is suspected, bloodwork would have little value. An ultrasound of the pelvis could be warranted if there is suspicion that the bimanual examination recreates the pain.
c. Management of the problem is based upon the patient being symptomatic, i.e. if the cyst were either an inclusion cyst or a Gartner's duct cyst, surgical treatment would be needed to address her dyspareunia. Although expected to eliminate the pain, the patient should be made aware that either excision or marsupialization of the cyst may or may not be totally successful. If the described cyst is found incidentally on physical examination of an asymptomatic patient, it is appropriate to inform the patient of its presence and not intervene unless symptoms develop subsequently.
2. A 20 year old woman presents with a 4 cm fluctuant mass at 7 o'clock of the introitus. The mass is non-tender and non-erythematous.
a. The differential diagnosis of a mass at the introitus could include an inclusion cyst (as described in the scenario above), a Bartholin's gland abscess, or a Bartholin's gland cyst. Unlikely would be a mass representing a hematoma or abscess arising from the perineum pushing toward the introitus. Because it is neither tender nor erythematous, an inflammatory process is less likely making a Bartholin's gland cyst the most likely diagnosis.
b. Evaluation is likely to be relatively straightforward. A history of previous episode(s) of a similar mass on the other side of the introitus strongly suggests a Bartholin's gland abscess, particularly if a drainage procedure was done for symptomatic pain. If this is a first time episode, it can be due to obstruction of the duct, resulting in a Barthlin's gland cyst, filled with mucoid material. In the case of either a Bartholin's gland cyst or abscess, the physical examination should reveal a mass that can be grasped between thumb and forefinger. It is likely to be well-defined and localized with no other findings associated to the isolated mass. Laboratory evaluation could include cultures for gonorrhea and Chlamydia if a sexually transmitted infection is suspected. No imaging procedures are expected to be of help in this case.
c. Management of the cyst will depend on the patient's symptoms and desires. If it is not bothering her, the patient can be counseled that a procedure is available at a later time when becomes symptomatic. Should she be symptomatic now or if she merely wishes for it to be resolved, the initial procedure can be drainage procedure performed in the office. With the mass being stabilized in one hand, a #15 blade is used to make an incision on the medial aspect of the mass where the Bartholin's duct orifice would normally be visualized. Irrigation with some sterile saline and/or exploration of the cavity with a hemostat is sometimes recommended to break up loculations and promote further drainage. Insertion/inflation of a Word catheter completes the procedure. It should be left in place for 10-14 days if possible to maximize epithelialization of a drainage track. If a Word cather is not available, a pediatric Foley catheter can be inserted, inflated, then tied off and cut short. Any catheter left in place can usually be tucked into the vagina to reduce discomfort. Patients can be reassured that coitus is possible with the catheter in place. The procedure can usually be done in the office with no anesthesia needed. Insertion of a catheter is preferred over a simple incision and drainage procedure because in the latter case, there is a significant likelihood that the opening will scar over relatively quickly, resulting in a reoccurrence of the mass. In recurrent cases, a surgical marsupialization or excision may be needed. In older patients, a biopsy of the wall of the mass is recommended to rule out the unlikely possibility of a neoplasm.
3. A 30 year old woman is found to have an asymptomatic 1 cm cystic mass in the midline of the anterior vagina.
a. The primary options in this differential diagnosis are urethral diverticulum and an inclusion cyst of the vaginal wall. An abscess or cyst related to the Skene's gland is also a consideration.
b. Evaluation in an asymptomatic mass reverts to physical examination, laboratory, cysto-urethroscopy and possibly imaging. If a diverticulum is found, in further history-taking, the patient will recall dysuria, urgency, frequency, and post-void dribbling. Palpation of the mass with milking of the urethra can sometimes cause a urethral discharge from a diverticulum to be visible grossly. This technique is particularly useful when done at the time of urethroscopy. The opening to a suburethral diverticulum can be even more evident. A urine culture should be used to rule out a concomitant infection. In addition to traditional urethrography with contrast, ultrasound, MRI, and CT scans have all been reported to be of use in the diagnosis of a diverticulum.
c. Management of an asymptomatic mass may not be necessary. If symptomatic, urethral diverticulum can be associated with repeated urinary tract infections and dyspareunia. Surgical management is needed in the case of either a diverticulum or an inclusion. The enclosed figures show an excision of a symptomatic suburethral inclusion cyst that was evaluated preoperatively with cystourethroscopy and not found to be connected to the urethra. The steps of the procedure were typical for excision of any similar mass: superficial incision over the mass, gentle blunt and sharp dissection to separate the underlying cyst from the vaginal wall, removal of the mass, achieving hemostasis, excision of excessive vaginal tissue, then reapproximation of the vaginal edges. In the case of a diverticulum, similar steps are taken, but care to maintain the integrity of the urethra are critical. Management of a distal diverticulum can be a marsupialization procedure (Spence procedure) rather than excision.