08: A clitoral cyst of “epidermal” proportions

Abstract

To show the surgical excision and reconstruction of an epidermal inclusion cyst found in the clitoral hood of a patient in the absence of trauma. Epidermal inclusion cysts are commonly found on the face, ears and trunk. Rarely, they are found on the vulva, most often associated with prior trauma. Our case is a 22 year old nulliparous patient with a seven year history of a vulvar mass with anorgasmia over the prior year. On exam she had a 4cm vulvar mass, fusion of the labia with hypestrogenic epithelium and no visible clitoris. Imaging revealed a cyst localized to the clitoral hood without communication with the urethra or the clitoris. The patient underwent surgical excision of the cyst with goals to restore normal anatomy, avoid injury to the dorsal clitoral nerve and minimize bleeding. A transverse incision was made at the inferior aspect of the cyst. The cyst wall was identified and the overlying vaginal epithelium was sharply dissected away from the cyst using traction and counter-traction with our instruments as well as digital manipulation. The cyst wall was isolated and removed without compromising surrounding tissue utilizing tenotomy scissors for greater precision. The cyst was opened off the surgical field with contents consistent with an epidermal inclusion cyst. Pathologic findings confirmed the diagnosis. The labia were reconstructed with a series of interrupted monocryl stitches. Six weeks following surgery, she had no residual pain and had restored sensation to the clitoris. Surgical resection and reconstruction of this clitoral cyst allowed for return of function in our patient. In the absence of trauma, risk factors for epidermal inclusion cysts of the clitoral hood include hypoestrogenism and labial fusion as similar cases have been reported in the literature. Most reported cases of clitoral cysts occur in premenarchal girls, supporting the role of estrogen in the development of such cysts.