Anterior vaginal cyst mimicking pelvic organ prolapse: Case report and literature review

Abstract

Introduction and importance

Large Anterior vaginal cysts can manifest as symptomatic genital prolapse, posing a diagnostic challenge due to their uncommon clinical presentation.

Case presentation

A 22-year-old primiparous woman with no previous medical history is admitted for delivery. Examination revealed a cystic mass on the anterior vaginal wall. Perineal ultrasound confirmed an independent cyst measuring 45x40x35 mm. The cyst was successfully aspirated, and the patient delivered without complications. At 12 months, the cyst reappeared, requiring vaginal surgical excision. Histological examination identified a Gartner cyst. During follow-up at 6 and 12 months, the patient remained asymptomatic.

Clinical discussion

Vaginal cysts typically present as small, solitary, and symptomless. However, they can grow in size, mimicking other conditions and often being misdiagnosed as cystoceles. Consequently, surgical excision of the vaginal cysts is the preferred treatment option, yielding positive anatomical outcomes and high patient satisfaction levels.

Conclusions

In this report, we describe a rare case of a Gartner cyst found on the anterior vaginal wall. The report also underscores the crucial role of imaging in accurately identifying the cyst's location, assessing its association with adjacent tissues, and guiding the surgeon in devising an effective operative plan.

Highlights

• •Anterior vaginal cysts occur rarely.
• •It can cause a variety of symptoms and is often misdiagnosed as cystocele.
• •Clinical examination and ultrasound of the pelvic floor establish the diagnosis.
• •Surgical excision via a vaginal approach gives good results for patients.

Abbreviations

MRI

Magnetic Resonance Imaging

AVW

anterior vaginal Wall

1. Background

In routine gynecological practice, the occurrence of benign masses in the periurethral region is uncommon, affecting approximately 4 % of patients. Among these cases, the presence of cysts in the anterior vaginal wall is less frequently observed, with an estimated prevalence of around 1 %. The diverse clinical presentation and extensive range of potential differential diagnoses make preoperative diagnosis challenging. This difficulty can lead to urinary issues, dyspareunia, vaginitis, and sexual dysfunction.These cysts typically arise from residual embryonic remnants of the Müllerian and Gartnerian ducts [1].

When a mass is present in the anterior vaginal region, many diagnostic options need to be considered, including benign conditions, as well as the possibility of malignant lesions of urethral or vaginal origin [2].

We report the case of a 22-year-old woman who presented to our department for delivery and whose clinical examination revealed an anterior vaginal wall cyst. This case report has been reported in line with the SCARE Criteria [3].

2. Case report

We report the case of a 22-year-old primiparous woman with no prior medical history, including unknown exposure to diethylstilbestrol while in utero, who presented to our department at 38 weeks of pregnancy for delivery. Upon examination, a prominent protrusion originating from the anterior vaginal wall (AVW) was observed, presenting as a cystocele.

Upon palpation, a distinct solid oval mass measuring 50 × 40 mm was detected, visibly protruding from the AVW. No abnormal discharge was noted from the urethra (Fig. 1).

Fig. 1.

On pelvic examination Anterior vaginal wall mass mimicking a cystocele.

Retrospective analysis of the patient's medical history revealed functional signs such as nocturia, a feeling of fullness in the vagina, and dyspareunia. Perineal ultrasound showed a well-defined cystic image (45x40x35 mm), with an anechoic appearance without septations, located distal to the urethra. There was no communication with surrounding tissues, indicating an independent lesion (Fig. 2).

Fig. 2.

Perineal ultrasound showed a well-defined cystic image distal to the distal urethra and no communication with surrounding tissues (C:cyst,B:blader,U: urethra).

Following the patient's active labor, the cyst volume can pose a hindrance to the fetal head's passage. Consequently, an aspiration was conducted, resulting in the production of transparent fluid. The patient delivered a healthy newborn vaginally. Subsequent post-partum follow-up examinations revealed no abnormalities.

Management consisted of active surveillance with regular check-ups at six and twelve months. At the 12-month check-up, the patient reported a sensation of an intravaginal ball, and examination revealed the reappearance of a 5-cm cyst of soft, painless consistency.

A pelvic endovaginally ultrasound was performed, showing a well-defined cystic image (52x43x30 mm), anechoic in appearance with no septations, distal to the urethra.

In the operating room, under the administration of spinal anesthesia, vaginal retractors were inserted to ensure adequate visualization. The mucosa near the cyst was then infiltrated with adrenaline serum. Surgical excision was performed via the vaginal approach, involving a superficial vertical incision of the cyst's epithelium, followed by meticulous dissection around the cyst and bladder. The cyst was successfully and completely removed during the procedure.

The closure of the vaginal defect was accomplished through a two-layer approach using interrupted sutures with coated Vicryl 1.

On histological examination, the cyst walls revealed a squamous lining, as well as chronic inflammation, giant cell reactions, and granulation tissue. The epithelium was positively stained with mucicarmine, suggesting a Gartner cyst. During the 6-month and 12-month follow-up assessments, the patient remained asymptomatic with no reported symptoms.

3. Discussion

3.1. Embryology

Understanding the embryology of the urethra and female genital tract helps explain the origin of vaginal cysts. The most common cysts in the AVW are embryonic remnants called müllerian cysts and Gartnerian duct cysts. During embryonic development, the Mullerian ducts fuse to form the uterus, cervix, and upper vagina, leaving behind remnants such as Gartner's canal. These cysts can be found along various areas, from the mesosalpinx to the cervix and vaginal wall. Meanwhile, the development of the female urethra also gives rise to Skene's glands, located near the urethra, which can form cysts. These cysts are generally benign and made up of glandular tissue [2] (Fig. 3).

Fig. 3.

Schematic diagram depicting the development of the mammalian reproductive tract and gonadal differentiation. (A) At 5 weeks of gestation in humans, the undifferentiated gonads possess embryonic Müllerian and Wolffian ducts. (B) Gonadal differentiation initiates, with the testes producing AMH and testosterone, leading to regression of the Müllerian ducts and differentiation of the Wolffian ducts, which is typically finalized by around 10 weeks. (C) By birth, both gonadal and ductal differentiation are fully established [13].

3.2. Diagnosis

AVW cysts are usually single, small, and cause no symptoms. However, in some patients, they may enlarge and cause symptoms such as a feeling of pressure or fullness in the vagina, as well as irritating urinary symptoms or obstruction. They can also cause problems during sexual intercourse. It is important to note that these cysts can be easily confused with other conditions, such as a cystocele [4].

Transvaginal ultrasonography enables the detection of the cystic properties and provides an assessment of its connection with neighboring structures, with a particular focus on the urethra [5].

Magnetic resonance imaging (MRI) exhibits a high level of sensitivity and demonstrates exceptional positive and negative predictive values. MRI provides excellent visualization of pelvic anatomy and is very useful for preoperative surgical planning. While MRI is especially effective in visualizing soft tissues due to its multiplanar imaging capabilities and improved tissue contrast, it remains a costly choice. Conversely, ultrasound offers the advantage of being a real-time diagnostic procedure that is both inexpensive and readily available [6].

Histological analysis is required to distinguish between vaginal cysts of mullerian and mesonephric origin. Müllerian cysts may be lined with various types of epithelium, whereas mesonephric cysts are lined with low cuboidal cells. Although the embryological distinction has no clinical significance, it is important to consider the possibility of malignant tumors, such as adenocarcinomas, developing in paraurethral and vaginal Mullerian cysts [7].

3.3. Management

The traditional management method entails surgical removal of the vaginal cyst. Total cystectomy may require extensive tissue dissection, raising the possibility of bladder or urethral injury. Another option is partial cystectomy, which offers favorable outcomes and minimizes the risks of surgical complications [4].

Non-surgical approaches, such as cyst aspiration and sclerotherapy, can be used. These minimally invasive procedures are an alternative to surgery. However, their effectiveness depends on the specific characteristics and location of the cyst [8].

Table 1 displays the clinical and histological characteristics, as well as the diverse therapeutic strategies employed in various circumstances.

Table 1.

anterior vaginal cyst mimicking pelvic organ prolapse: a literature review.

Study	year	Age	GP	Genital activity	Medical history	Duration	Symptoms	Site	Size of the masse(cm)	consistance	Imaging investigation	Imaging characteristics	Management	Histology	Final diagnosis
Yu etal [13]	2012	26	N	F	No	One yaer	Non-tender mass Urinary urgency	AVW	No data	Soft	Perineal ultrasonography	Well-defined hypo-echoic tumor between the urethral and vaginal mucosa.	Surgical excision via a vaginal appr oach	Irregular or dilated cyst focally lined by stratified squamous or ciliated columnar epithelium and walled by inflammatory stroma	Gartner duct cyst
Emily et Al [14]	20,017	53	M	PM	Sexual difuclty	Severalyears	Protrusion of the AVW	AVW	4	Firmer and less reducible	MRI	T2: pedunculated, well-circumscribed cyst with smooth walls that appeared to arise lateral to the cervix (3,3 × 4,6 × 8,4 cm)	Surgical excision via a vaginal appr oach	Cyst wall with squamous lining, chronic inflammation, giant cell reactions, granulation tissue, and ulceration	Gartner duct cyst
Jong et Al [15]	2008	33	M	F	No	2 Weeks	Vaginal bulging and pelvic pressure	1 cyst protruding from AVW 2 cysts, atached to the left upper vaginal wall	3 1 and 1,5	No data	Transvaginal ultrasound MRI	Hypoechoic cystic mass measuring 2 × 3 cm. Non-septated homogenous vaginal cyst. The size was about 3 cm	Surgical excision via a vaginal appr oach	Granulation tissue with focal areas of mucinous epithelial lining	Benign mullerian cyst.
Tsiapakidou et Al [16]	2022
Case 1		45	N	F	No	6 moths	Fullness in vagina	Upper right lateral vaginal wall	4.3 × 5.3 cm	Soft, non-tender cystic lesion	Trans-perineal 2D/3D	Well- defined, round, thick-walled unilocular cystic lesion containing sub-echogenic contents without a septum,	Surgical excision via a vaginal appr oach	Low cuboidal no mucinous epithelium, advocating for a Gartner ´s cyst	Gartner ´s cyst
Case 2		38	M	F	No	3 years ´	Bulge in the vagina Sexual problems dyspareunia.	tumefaction at the anterolateral wall	No data	cystic lesion, painless, mobile with a soft	trans-perineal 2D/3D	well- defined, round, thick-walled unilocular cystic lesion containing sub-echogenic contents without a septum, (2.9 × 2.1 × 6.7 cm	surgical excision via a vaginal appr oach	low cylindrical - cuboidal cells	Gartner ´s cyst
Case 3		28	M	F	No	One yeasr	Bulge on her vagina dyspareunia.	upper right anterior vaginal wall	3.8 × 2.8 × 5.1 cm	Non tender, painless with soft consistency cystic	Trans-perineal 2D/3D	well- defined, round, thick-walled unilocular cystic lesion containing sub-echogenic contents without a septum.	surgical excision via a vaginal appr oach	Mucinous - columnar epithelium	Müllerian cyst
Cil et Al [6]	2007	36	V	F	schizophrenia	5-month	vaginal bulging and pelvic pressure	cystic mass pro- truding from the vagina surrounded by the intact hymenal ring	The cyst was not examined due to the risk of hymen laceration	The cyst was not examined due to the risk of hymen laceration	Trans-abdominal pelvic ultrasound Pelvic MRI	Hypoechoic cystic mass measuring 42 × 20 mm in the vagina 2 AVW cysts: The first, measuring 3 × 2 cm, in the midline beginning from the vaginal orifice The second, 4 × 3 cm, from the end of the first cyst continuing caudally along the right side of the vagina	A vertical incision and excision of the capsule of the first and seconde cyst	Cyst revealed mucus-secreting tall columnar cells	Müllerian cyst
Clifford et Al [17]	2003	24	M	F	No	3 years	Vaginal bulge, with pelvic pressure and dyspareuni Mixed urinary incontinence,	AVW First: smooth cystic mass approximately 2 cm inferior to the external urethral meatus. Seconde cystic lesion protruding into the vaginal canal immediately posterior to the first cyste.	First:2 Second: 3	No data	Pelvic MRI	A number of non septated homogeneous vaginal cysts. The largest of these measured 4 cm	Surgical excision via a vaginal approach rupturing the cyst and dissecting on the finger	The cysts were composed of vascular fibromuscular tissue lined by a low cuboidal or a ciliated columnar epithelium	Müllerian cyst
JM Montella et Al [18]	2004	34	M	F	No	No data	Vaginal pressure.	cystic mass extending over the AVW	No data	No data	Pelvic MRI	AVW cyst and not a urethral diverticulum	Surgical excision via a vaginal approach	The cyst revealed mucus-secreting tall columnar cells	Mullerian cyst
Ismail et Al [19]		38	M	F	No	No data	Vaginal fullness mixed pattern of urinary incontinence.	Cystocel	No data	AVW was rather tense and the cystocele could not be reduce	No	No	Laparoscopic repair of the AVW converted to aspiration and excision of the cyst AVW.	Cystic area lined by stratified squamous epithelium, with areas of mucinous columnar epithelium and granulation tissue	Paravaginal Mu ¨llerian-derived cyst

AVW: Anterior vaginal wall.

V.: virgin.

N: nulliparous.

M: Multiparous.

F: Fertile.

3.4. Differential diagnosis and Management

3.4.1. Cystocele

Cystocele, a bladder herniation through the vaginal wall, has varying frequency worldwide, influenced by age, obstetric history, and lifestyle. Symptoms encompass pelvic pressure, urinary incontinence, incomplete bladder emptying, and a visible vaginal protrusion. Treatment options range from conservative measures to surgery, tailored to symptom severity and individual factors [9].

3.4.2. Skene's duct cysts

Skene duct cysts are rare masses near the urethra, derived embryologically from the urogenital sinus. They present with symptoms such as dyspareunia, dysuria, vaginal discharge, and sometimes urinary retention. Physical examination reveals a painless, erythematous mass near the urethral meatus. Treatment includes aspiration, and partial or complete excision depending on associated inflammation [10].

3.4.3. Urethral diverticulum

Urethral diverticula are protrusions at the front of the urethra. Symptoms include urinary disorders and recurrent infections. Diagnosis may require video cystourethrography and cystoscopy. Treatment consists of surgical excision with reconstruction of the urethra if necessary [1].

3.4.4. Bartholin's gland cysts

The Bartholin glands are two small glands located deep in the perineum, at the entrance to the vagina. Bartholin gland cysts are not technically masses of periurethral tissue or the AVW, but they can be confusing. The cysts are usually asymptomatic, unilateral, tense, and painless. The initial treatment is surgical excision [11].

3.4.5. Endometriosis

The presence of endometriosis in the vagina is rare. Implants appear as dark-brown cysts along the vaginal wall. Patient complaints typically include menstrual pain, pain during intercourse, or dysuria. Diagnosis is made histologically. Treatment includes primary excision, electrocoagulation, or laser [2].

3.4.6. Urethral caruncle

The urethral caruncle, a prevalent benign exophytic lesion located at the urethral meatus, has an unknown exact cause. It can be asymptomatic or associated with dysuria, hematuria, or urethral discharge. Although typically benign, there have been rare instances of malignant conditions resembling urethral caruncles. Conservative treatment with topical estrogen cream is initially recommended for symptomatic lesions, while persistent ones should be surgically excised and histologically examined [12].

3.4.7. Prolapsed ureterocele

Ectopic ureterocele prolapse is a rare condition characterized by an intralabial mass in neonates and young girls. Ureterocele in adolescents and adults is uncommon, with less than 5 % of cases involving prolapse through the urethral meatus. Ureterocele is a cystic dilation of the terminal ureter, and its embryological mechanisms are still debated. Symptoms of a prolapsed ureterocele may include hematuria, urinary stream interruption, retention, or pain. Treatment depends on the presence of sepsis or bladder outlet obstruction, with lower urinary tract surgery offering minimal complications and serving as the definitive treatment [12].

3.4.8. Leiomyoma

Urethral and periurethral leiomyomas are rare benign tumors originating from the smooth muscle of the urethra and anterior vagina or vesicovaginal septum. These masses, resembling uterine leiomyomas histologically, constitute 4 % to 5 % of periurethral masses in middle-aged women. Symptoms vary based on mass size and location, with surgical resection recommended for symptom relief [2].

3.4.9. Polyps, granulomas, and hemangiomas

Fibroepithelial polyps in the urethra are rare, occurring in newborns, children, and individuals aged 30–50. Periurethral granulomas and urethral hemangiomas are also rare complications requiring complete resection to prevent recurrence. [12].

4. Conclusion

Vaginal cystic lesions are not commonly encountered and typically be identified during vaginal examinations. However, the variability in their clinical presentation and the broad range of potential differential diagnoses make it challenging to establish a preoperative diagnosis. A thorough and meticulous clinical assessment, with an ultrasound scan of the pelvic floor, is considered an appropriate means of making a diagnosis. Pelvic MRI is recommended if there is a suspicion of multiple cysts or communication with surrounding tissues and is a valuable aid in planning surgery. Surgical excision of these cysts generally has a good outcome for patients, with no significant complications.

CRediT authorship contribution statement

Abdelhamid Benlghazi, Moad Belouad,Yassine Bouhtouri were responsible for the patient's diagnosis and clinical management. Abdelhamid Benlghazi wrote the manuscript. Abdelhamid Benlghazi and Saad Benali contributed to the analysis, supervision, writing, reviewing, and editing of the manuscript for intellectual content. All authors have read and approved the final manuscript.

SCARE criteria

The work has been reported in line with the SCARE criteria.

Sources of funding

None.

Ethical approval

Ethics approval has been obtained to proceed with the current study.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Guarantor of submission

The corresponding author is the guarantor of submission.

Declaration of competing interest

The authors declare no conflict of interest.

Data availability

Supporting material is available if further analysis is needed.