A Case Report of a Pregnant Woman who Had Urethral Avulsion during Vacuum Extraction Delivery and Ipsilateral Kidney

Background: Gartner's duct cysts are remnants of Wolffian ducts, which are usually found in the upper anterolateral part of the vagina. Gartner's cysts are remnants of mesonephric (Wolffian) ducts, which, in women are present in the uterus, vagina, and hymen until the third month of gestation and which give rise to the ureter. Remnants of the Gartner duct may be detected in up to one fourth of adult women, although Gartner's cysts arise only in approximately 1%–2% of the population. Most Gartner's cysts are small (< 3 cm), and they are usually paravaginal and in the anterolateral position; however, they can be large and cause urethral or even ureteric obstruction. Infrequently, giant Gartner's duct cyst has been reported in the literature.

Kyste de Gartner communiquant avec la vessie et le vagin, associé à un diaphragme vaginal complet

BackgroundIn women, during embryologic development, the paired Müllerian (paramesonephric) ducts fuse distally and develop into the uterus, cervix, and upper vagina. If the Wolffian ducts persist in vestigial form, they can lead to Gartner’s cysts, mainly located in the right wall of the vagina. This is one of the few studies of Gartner’s cysts with a series of consecutive cases over a long period of time who were exclusively subject to clinical observation. Although Gartner’s cysts are found in approximately 0.1 to 0.2 % of women, controversy exists regarding the course of action to be taken.Case presentationWe describe the cases of four women who were 38-years old, 53-years old, 37-years old, and 49-years old at their first appointment and who were of mixed ethnicity, mixed ethnicity, black, and mixed ethnicity respectively. The follow-up of these patients ranged from 2 to 17 years. In these four cases the location of the cysts was the right wall of the vagina. Transvaginal ultrasound was the test of choice for diagnostic confirmation. In the cases presented in this study, the women were asymptomatic and chose to be observed clinically.ConclusionsThis is the first study reporting long-term clinical observation of these lesions. This study shows that conservative treatment can be a safe option for asymptomatic patients with vaginal Gartner’s duct cysts.

A 19-year-old woman with no past medical or surgical history presented to the emergency department stating that she had noticed a growth protruding from her vagina. It has been painless except during intercourse and constant in all characterizations since detection three days earlier. She denies vaginal bleeding, urinary retention, incontinence, fever, injury, and back, abdominal, and pelvic pain. Her vital signs are normal, but her physical examination was significant for a 2.5 cm x 4 cm stalk-like, pedunculated, fluctuant, nontender, mobile, cystic-appearing mass protruding from the right anterolateral vaginal wall. The rest of the genitourinary and abdominal systems were without notable abnormalities and pathology. A blood sample sent to the lab failed to note leukocytosis, and urinalysis and pregnancy tests were negative. A supporting ultrasound was obtained, a Gartner's duct cyst was diagnosed, and gynecological follow-up was made for marsupialization to prevent a recurrence. Gartner's ducts are identified in approximately 25 percent of all adult women, and nearly one percent evolves into Gartner's duct cysts. The mesonephric (Wolffian) ducts develop during embryological development, form their predetermined structures, and later regress. Remnants often remain, however, until they develop a secretory mechanism, cause dilation of surrounding cells, and yield a Gartner's duct cyst, most often during and after late adolescence. Classically, the cysts are solitary, unilateral, less than 2 cm in diameter, and are located in the anterolateral vaginal wall of the proximal third of the vagina. (J Gynecol Surg 2009;1[2]:94; J Pelvic Med Surg 2007;13:141.) Gartner's duct cysts are generally asymptomatic, and most commonly diagnosed upon routine gynecologic examination, but patient complaints can include skin tag, dysuria, pressure, itching, dyspareunia, pelvic pain, or protrusion from the vagina if it enlarges to a detectable size, making it a candidate for surgical removal. (J Diagn Med Sonog 2008;24:344; J Pelvic Med Surg 2007;13:141; J Am Osteopath Assoc Dermatol 2007;8:40.) The cyst can be drained to facilitate delivery if it is large enough to cause obstetrical complications.FigureMRI can be a useful tool to define the course of the Gartner's duct cyst and differentiate it from other pathologic considerations and structures. Histologic examination may be employed to correctly identify the cellular remnants composed of non-mucin secreting low columnar or cuboidal epithelium, but it is not necessary in clinical practice. (J Diagn Med Sonog 2008;24:344.) The differential diagnosis can include but is not limited to Bartholin's gland cyst or abscess, prolapsed urethra, prolapsed uterus, vaginal wall inclusion cyst, endometriosis, leiomyoma, sarcoma botryoides, malignant mass, Skene's gland cyst, or abscess and ureterocele. (J Am Osteopath Assoc Dermatol 2007;8:40.) Only in exceptionally rare and isolated cases has a malignant transformation been identified. (Int J Gynecol Cancer 2009;19[9]:1655.) Patients may be discharged safely from the emergency department with gynecologic follow-up for definitive treatment.

ImageA 19-year-old woman with no past medical or surgical history presents to the emergency department stating that she noticed a growth protruding from her vagina. It has been painless except during intercourse and constant in all characterizations since detection three days earlier. She denies vaginal bleeding, urinary retention, incontinence, fever, injury, and back, abdominal, and pelvic pain. Her vital signs are normal, but her physical examination was significant for a 2.5 cm x 4 cm stalk-like, pedunculated, fluctuant, nontender, mobile, cystic-appearing mass protruding from the right anterolateral vaginal wall. The rest of the genitourinary and abdominal systems were without notable abnormalities and pathology. A blood sample sent to the lab failed to note leukocystosis, and urinalysis and pregnancy tests were negative. After a supporting ultrasound was obtained, a Gartner's duct cyst was diagnosed, and a gynecological follow-up was made for marsupialization to prevent a recurrence. Gartner's ducts are identified in approximately 25 percent of all adult women, and nearly one percent evolve into Gartner's duct cysts. During embryological development, the mesonephric (Wolffian) ducts develop, form their predetermined structures, and later regress. Remnants often remain, however, until they develop a secretory mechanism, cause dilation of surrounding cells, and thus yield a Gartner's duct cyst, most often during and after late adolescence. Classically, the cysts are solitary, unilateral, less than 2 cm in diameter, and are located in the anterolateral vaginal wall of the proximal a third of the vagina. (J Gynecol Surg 2009;24:75; J Pelvic Med Surg 2007;13:141.) Gartner's duct cysts are generally asymptomatic, and most commonly diagnosed upon routine gynecologic examination, but patient complaints can include that of skin tag, dysuria, pressure, itching, dyspareunia, pelvic pain, or protrusion from the vagina if it enlarges to a detectable size, making it a candidate for surgical removal. (J Diagn Med Sonog 2008;24:344; J Pelvic Med Surg 2007;13:141; J Am Osteopath Assoc Dermatol 2007;8:40.) If large enough to cause obstetrical complications, the cyst can be drained to facilitate delivery. To define the course of the Gartner's duct cyst and differentiate it from other pathologic considerations and structures, MRI can be a useful tool. Histologic examination may be employed to correctly identify the cellular remnants composed of non-mucin secreting low columnar or cuboidal epithelium, but in clinical practice, it is not necessary. (J Diagn Med Sonog 2008;24:344.) The differential diagnosis can include but is not limited to Bartholin's gland cyst or abscess, prolapsed urethra, prolapsed uterus, vaginal wall inclusion cyst, endometriosis, leiomyoma, sarcoma botryoides, malignant mass, Skeene's gland cyst, or abscess and ureterocele. (J Am Osteopath Assoc Dermatol 2007;8:40.) Only in exceptionally rare and isolated cases has there been a malignant transformation identified. (Int J Gynecol Cancer 2009;19[9]:1655.) Patients may be discharged safely from the emergency department with gynecologic follow-up for definitive treatment. Dr. Letiziais the director of operations and an emergency physician at Trinitas Regional Medical Center in Elizabeth, NJ.Mr. Kellyis a fourth-year medical student at Spartan Health Sciences University in St. Lucia.

Mayer-Rokitansky-Küster-Hauser syndrome associated with fused renal ectopia and hydroureter

DIAGNOSING THE COMBINATION OF RENAL DYSGENESIS, GARTNER'S DUCT CYST AND IPSILATERAL MULLERIAN DUCT OBSTRUCTION

Doxycycline Sclerotherapy of a Symptomatic Paravaginal Mesonephric Duct Remnant

A cyst is a blind pouch of tissue, which may be containing air, fluid, pus or any other substance. Vaginal wall cysts are located on or under the vaginal wall lining, are usually asymptomatic and may present as a small lump felt in the vagina or protruding from the vagina. These cysts can be of varying sizes, ranging from the size of a pea to that of an orange. These may get infected and present with inflammatory signs and symptoms.We report here a case of a 38-year-old female who presented with complaints of something coming out of her vagina, initially mistaken to be uterovaginal prolapse, which, on detailed clinical examination, was diagnosed to be a posterior vaginal wall cyst. The cyst was managed surgically by excision, and on histopathological examination, it was later confirmed to be a Gartner's duct cyst over the posterior vaginal wall, rare in its location.

Genital anomalies associated with unilateral renal agenesis are generally due to agenesis or hypoplasia of the entire urogenital ridge or distal mesonephric aberrations. However, renal adysplasia could also occur in association with anomalies of the ventral urogenital sinus. The patient presented didelphys uterus in the superior uterine segment, a septate cervix, and a simple vagina. After transvaginal puncture and injection of a contrast agent into the bulge observed in the right vaginal wall, a filled sac or cavity was detected, possibly a hemibladder. This structure continued upward with a possible dilated tortuous ureter that filled retrogradely. Magnetic resonance imaging also showed the presence of the right blind paravaginal sac. Right hemitrigone and ureteral orifice were absent in the cystourethroscopy. No right kidney was found, despite the use of multiple imaging techniques. Blind hemibladder, ectopic ureterocele, and Gartner's duct cyst seem to be a possible diagnosis associated to Müllerian malformations and supposed unilateral renal agenesis. Therefore, Müllerian anomalies without combined mesonephric alteration could be associated with conditions of the ventral urogenital sinus, including blind hemibladder or ectopic ureterocele with secondary renal dysplasia.

Mayer-Rokitansky-Küster-Hauser syndrome with rare findings of inferior crossed-fused renal ectopia and Gartner's duct cyst: a video case report

Gartner's duct cyst and ipsilateral renal agenesis

Gartner's duct cysts develop from cystic dilatation of remnants of the embryonic mesonephros. A case in which an asymptomatic Gartner's duct cyst was detected incidentally using endovaginal ultrasound is described.

Two cases of Gartner's duct cyst with vaginal ectopic ureter and associated renal anomalies are reported. This unusual wolffian duct anomaly may be more common than previously suspected, especially in Asian patients. The radiologist and ultrasonographer should be aware of this anomaly and should perform a pelvic sonogram in any patient in whom there appears to be an absent or dysplastic kidney. Care should be taken to try and identify the Gartner's duct cyst extending caudally posterior to the base of the urinary bladder.

Local recurrent rectal cancer may present with extraluminal lesions. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is good for diagnosis of such an extraluminal lesion. A 51-year-old Asian female was diagnosed with uT3N0M0 rectal adenocarcinoma 31 months ago. She had undergone chemotherapy, radiotherapy and abdominoperineal resection (APR). Eight months ago, colonoscopy and computed tomography (CT) were unremarkable. Carcinoembryonic antigen was 1.1 ng/ml. Pelvic examination revealed a 3 x 2 cm firm soft-tissue mass palpable through the left vaginal wall. EUS revealed a mass in the left lateral vaginal wall measuring up to 21 x 27 mm in cross section without invasion of adjacent pelvic structures. Transvaginal EUS-FNA was performed with a 22-gauge needle. Final cytology confirmed recurrent rectal adenocarcinoma. Subsequent surgery also confirmed a 2.3 cm grade II adenocarcinoma. The tumor focally extended to the inked margin. The uterus and ovary specimen were negative for disease. We herein report a successful role of transvaginal EUS-FNA for early detection of recurrent rectal cancer at the vaginal wall after abdominoperineal resection (APR).