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4/1/2016

Management of Vaginal Cysts

Vaginal cysts occur in 1% of all women. Most are benign, asymptomatic, discovered incidentally, and should be managed expectantly. Common benign causes of vaginal cysts include remnants of the embryonic Mullerian (paramesonephric) or Wolffian (mesonephric) system; the latter are also called Gartner’s duct cysts. Differentiation between them has little prognostic significance and they are managed similarly. Anatomic abnormalities mimicking vaginal cysts include pelvic organ prolapse (e.g. cystocele) as well as bladder and urethral anomalies. Additional conditions to consider on the differential for a vaginal mass that might mimic a cyst include leiomyoma, ectopic ureter, or vaginal cancer.

Vaginal inclusion cysts and foreign body granulomas are often related to prior repair of obstetrical lacerations or other vaginal surgery and have a different appearance than embryologic remnants. Urethral diverticula may initially present as a vaginal mass as can rarer findings such as a vaginal endometrioma, fibroma, or myoma. Malignancy in a vaginal cyst is rare; adenocarcinoma is reported to occur in 6-9% of urethral diverticula.

The appearance and location on physical exam assists in determining the etiology of the vaginal cyst. Embryologic remnants are typically asymptomatic and benign, ranging in size from 1 to 7 cm.  These cysts are soft with definite borders. They can occur anywhere in the vaginal mucosa with Gartner’s duct cysts commonly located along the lateral vaginal walls. Urethral diverticula are identified in the midline of the anterior vaginal wall.  Inclusion cysts, granulomas, and the other rare causes noted are solid with definite borders and can occur anywhere in the vagina. Laboratory studies are rarely helpful, and in general, should not be part of the evaluation. When imaging is required (e.g. to aid in surgical planning) pelvic or perineal ultrasound remains the first choice. If ultrasound is inadequate, an MRI is indicated.

Most vaginal cysts, including embryologic remnants, inclusion cysts, and granulomas, can be managed expectantly. If found incidentally and the patient is asymptomatic, expectant management with serial physical exams to evaluate for stability are appropriate.  Lesions concerning for malignancy should be biopsied, and drainage with or without antibiotics should be considered for infection.

If a vaginal cyst is acutely changing or concerning for an infectious or malignant source, surgical intervention should be considered. For patients with symptoms such as vaginal pain, dyspareunia, urinary symptoms, or difficulty with tampon use surgical marsupialization or excision may be appropriate.

A urethral diverticulum can be expectantly managed if symptoms are mild or absent.  If complicated by abscess, empiric antibiotics should accompany aspiration of the urethral diverticulum until culture and sensitivity results are available. A symptomatic or recurrent urethral diverticulum may require MRI imaging or cystoscopy prior to surgical excision.

Further Reading:

De Bortoli J, Chowdary P, Nikpoor P, Readman E. Clinical approach to vulvovaginal cysts and abscesses, a review. Aust N Z J Obstet Gynaecol. 2018 Aug;58(4):388-396. doi: 10.1111/ajo.12822. Epub 2018 May 21. PMID: 29781191.

Hoffman BL, Schorge JO, Halvorson LM, Hamid CA, Hoffman B.L., & Schorge J.O., & Halvorson L.M., & Hamid C.A., & Corton M.M., & Schaffer J.I.(Eds.),Eds. Barbara L. Hoffman, et al.et. al; Anatomic Disorders, Williams Gynecology, 4e. McGraw-Hill; Accessed October 23, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2658&sectionid=241010234

Hoffman BL, Schorge JO, Halvorson LM, Hamid CA, Hoffman B.L., & Schorge J.O., & Halvorson L.M., & Hamid C.A., & Corton M.M., & Schaffer J.I.(Eds.),Eds. Barbara L. Hoffman, et al.et. al; Benign Disorders of the Lower Reproductive Tract Williams Gynecology, 4e. McGraw-Hill; Accessed October 23, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2658&sectionid=219458833

Initial Approval: January 2016, Reaffirmed July 2017, January 2019, Revised November 2020; Revised May 2022, Revised March 2024.

 

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