The Case Files

Abstract

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.