Vaginal Epidermal Cyst In Pregnancy

Author Information

Madhva Prasad S*, Mhaske N**, Kharat D***, Fonseca MN****.
(* Senior Resident, ** Second Year Resident, *** Assistant Professor, **** Additional Professor. Department of Obstetrics/Gynecology, LTMMC and LTMGH, Mumbai, India.)

Abstract

A 22 year old with 32 weeks gestation presented with sudden onset, gradually progressing cystic swelling from vagina. Successful surgical resection was done. Histopathological examination confirmed it as epidermal cyst.

Introduction:

Cystic lesions of vagina are uncommon and are usually incidental findings. A rare presentation in pregnancy is reported here.

Case Report

A 22 year old primigravida was on regular antenatal follow up. At 32 weeks of gestation, she complained of mass per vaginum. She reported discomfort with walking and increased vaginal pressure. Symptoms were present since 2 weeks and were gradual in progression. There was no history of fever, cough or pain in abdomen.
She was afebrile, and systemic examination was unremarkable. Obstetric examination revealed a live intrauterine gestation of around 32 weeks.
On local examination, a single, smooth, fluctuant 4x4 cm cystic swelling was seen arising from the right postero-lateral wall of vagina, distending the introitus. There was minimal tenderness, but no redness or discharge.  HIV/HBsAg/HCV were negative. Blood sugars were normal. Complete blood counts including white blood cell counts were within normal limits. Tablet cefixime 250 mg twice a day for one week. Persistence of the cyst and increase in symptoms, necessitated surgical removal. Cyst removal was done under intravenous sedation. Patient was taken in lithotomy position (figure 1) and bladder emptied. Base of the cyst was identified around 4 cm above the introitus, which was clamped and cut. The stump was ligated with delayed absorbable sutures of polygalactin no 1. Cyst fluid was aspirated and sent for microscopy and culture. Cyst wall sent for histopathological examination Patient was discharged on postoperative day 4.
Cyst fluid microscopy showed no malignant cells and culture was negative. Histopathological examination revealed epidermal cyst (figure 2).
On follow up after 2 weeks, the sutures were intact and no recurrence or induration was felt at the surgical site.  Patient went into spontaneous labor. In the second stage of labor, upon crowning, left mediolateral episiotomy was given, with no difficulty. She delivered a healthy male child of 2700 grams. There was no perineal tear. Day 1 post delivery examination photograph is shown. (figure 3) Patient was followed up 1 month post delivery. The episiotomy site and the surgical site had healed well.


Figure 1: Arrow showing vaginal cyst distending introitus (72 dpi resolution).


Figure 2: (96 dpi resolution) A: Stratified squamous epithelium; B: Fibro-muscular cyst wall; C: Focal inflammatory infiltrate.

Discussion

Benign cystic lesions of the vagina present a spectrum, from small asymptomatic lesions to large ones. These may be of embryological origin, ectopic tissue or urological abnormalities.[1]
While most are asymptomatic, many are incidentally discovered during gynecological examination.  Histologically, they can be Mullerian cysts (30%), Bartholin's duct cysts (27.5%), epidermal cysts (25%), Gartner's duct cysts(12.5%) and endometrioid cysts (2.5%) [2] While the occurrence of vaginal cystic lesions, in general, has been described as rare, [3, 4] a literature search reveals that the number of cases reported in pregnancy are few. While conservative management can be done, such a method of management entitles close follow up, to ensure that the cyst is managed appropriately by drainage during early labour.[5,6] When drainage is done during antenatal period, [7] the patient should be followed up regularly due to the possibility of recurrence. Persistent symptoms may necessitate excision during pregnancy, [8] as in the case reported here. Vaginal fibrosis and difficulty during episiotomy are potential problems, which were not encountered in this patient.  Surgical management may be deferred to the puerperal period when the size of the cyst is relatively constant and is only minimally symptomatic [9] It is important not to overlook these cysts since the rare possibilities of malignancy [10,11,12] of  and  rectovaginal fistulae exist. [13] This case is being reported for its rarity and to add to the knowledge about this entity.

References
  1. Eilber KS, Raz S. Benign cystic lesions of the vagina: a literature review. J Urol . 2003 Sep; 170(3):717–22
  2. Kondi-Pafiti A, Grapsa D, Papakonstantinou K, Kairi-Vassilatou E, Xasiakos D. Vaginal cysts: A common pathological entity revisited. Clin Exp Obstet Gynecol 2008 Jan; 35(1): 41–4 .
  3. Jayaprakash S, Lakshmidevi M, Kumar SG. A rare case of posterior vaginal wall cyst. BMJ Case Rep [Internet]. 2011; Published online 2011 Jul4.  doi:  10.1136/bcr.02.2011.3804.
  4. Rao A, Rao B, Kurian MJ, Pai RR. Two rare presentations of epidermal cyst. J Clin Diagn Res. 2014 Oct; 8(10): OD 1–3.
  5. Arumugam A, Kumar G, Si L, Vijayananthan A. Gartner duct cyst in pregnancy presenting as a prolapsing pelvic mass. Biomed Imaging Interv J [Internet]. 2007 Oct;3(4):e46. PMID: 3097688
  6. Lallar M, Nandal R, Sharma D, Shastri S. Large posterior vaginal cyst in pregnancy. BMJ Case Rep [Internet]. 2015 Jan ;2015; Published online 2015 Jan 20. doi: 10.1136/bcr-2014-208874. 
  7. Hasbargen U, Hillemanns P, Scheidler J, Kimmig R, Hepp H. [Paravaginal abscess in pregnancy]. Zentralbl Gynakol [Internet]. 2001 Oct [ cited 2015Mar 18] ;123 (10):595–8. [ Article in German] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11753817 
  8. Pereira N, Guilfoil DS. Excision of an enlarging vaginal epidermal inclusion cyst during pregnancy: a case report. J Low Genit Tract Dis. 2012 Jul; 16(3):322–4.
  9. Goldberg Y, Lavie O, Mandel R, Auslender R. Imaging of an atypical large perineal cyst diagnosed during pregnancy. Ultrasound Obstet Gynecol . 2012 Dec; 40(6):721–3.
  10. Němejcová K, Dundr P, Povýšil C, Sláma J. Primary vaginal squamous cell carcinoma arising in a squamous inclusion cyst: Case report. Cesk Patol [Internet]. 2012 Jan [cited 2015 Mar 18];48(3):153–5. [ Article in Czech] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23057430
  11. Zhao J, Xiang Y, Zhao D, Ren T, Feng F, Wan X. Isolated epithelioid trophoblastic tumor of the vagina: a case report and review of the literature. Onco Targets Ther. 2013 Jan ;6:1523–6.
  12. Dahiya K, Jain S, Duhan N, Nanda S, Kundu P. Aggressive angiomyxoma of vulva and vagina: a series of three cases and review of literature. Arch Gynecol Obstet. 2011 May; 283(5):1145–8.
  13. Nasser HA, Mendes VM, Zein F, Tanios BY, Berjaoui T. Complicated rectovaginal fistula secondary to Bartholin’s cyst infection. J Obstet Gynaecol Res. 2014 Apr ;40(4):1141–4.
Citation

Vaginal Epidermal Cyst In Pregnancy. Madhva Prasad S, Mhaske N, Kharat D, Fonseca MN. JPGO 2015. Volume 2 No. 5. Available from: http://www.jpgo.org/2015/05/vaginal-epidermal-cyst-in-pregnancy.html