Author
Information
Parulekar
SV
(Professor
and Head of Department of Obstetrics and Gynecology, Seth G.S.
Medical College and K.E.M Hospital, Mumbai, India.)
Abstract
Vaginal
wall cyst is a not very common condition. It may be developmental (of
mullerian or wolffian duct origin), dermoid, or due to inclusion, as
after an episiotomy or perineal tear. A 69 year old menopausal woman,
presented with a complaint of intermittent mucoid vaginal discharge
for one year. She gave a history of a cystic swelling in the vagina
in the past. She had four normal vaginal deliveries. She was found to
have a 2 mm diameter opening in the center of the posterior vagina,
which was continuous with a 3x3x2 cm cavity under the mucosa. A
diagnosis of a sinus due to spontaneous rupture of a posterior
vaginal wall cyst was made. Ultrasonograpy (USG) revealed a smooth
walled cavity under the posterior vaginal mucosa, with no solid
component. The patient opted not to have surgical excision of the
lesion. This is the first case of a vaginal sinus due to spontaneous
rupture of a vaginal wall cyst in the world literature.
Introduction
Vaginal
wall cyst is a not very common condition. It is usually diagnosed
incidentally while the woman is examined for some other condition.
Large cysts located in the lower vagina may present with a complaint
of something coming out per vaginaum. Vaginal cysts may be
developmental, as from mullerian duct or wolffian duct remnants. A
dermoid cyst (mature cystic teratoma may be found in the midline
posteriorly.[1] An inclusion cyst may develop due to trauma like an
episiotomy or a perineal tear. The cysts are benign, and need removal
when large or symptomatic. Spontaneous rupture of a cyst and
formation of a sinus is so far unknown. We present the first case of
a vaginal sinus due to spontaneous rupture of a vaginal wall cyst in
the world literature.
Case
Report
A 69
year old woman presented with a complaint of intermittent mucoid
vaginal discharge for one year, occurring at intervals of 1 to 2
months. The discharge would be copious and would last for a few hours
every time. She had a history of a swelling in the vagina a few years
ago, which ceased to be symptomatic about one year ago. She was
postmenopausal for twenty years. She had four normal deliveries. She
had an episiotomy during her first delivery There was no history of
any dyspareunia. She had undergone puerperal sterilization operation
after her last delivery 39 years ago. She was under treatment for
hypertension for 15 years. She had undergone some abdominal operation
in childhood, the details of which were not known to her. She also
had undergone surgical treatment for a cervical rib many years ago.
Her general and systemic examination showed no abnormality. A
speculum examination showed a 2 mm diameter opening in the center of
the posterior vagina, which was continuous with a cavity under the
mucosa. Palpation of the posterior vaginal wall around the opening
between a finger in the vagina and another in the rectum showed
thickening in that area and sliding movement between the two fingers,
suggesting the presence of smooth walled and lubricated opposing
walls between them. A hemostat was passed through the opening. It
passed into a space measuring 3x3x2 cm, suggesting the presence of a
cavity of that size (figure 1). A diagnosis of a vaginal wall sinus
following spontaneous rupture of a posterior vaginal wall cyst was
made. Ultrasonograpy (USG) revealed a smooth walled cavity under the
posterior vaginal mucosa, with no solid component. The patient opted
not to have surgical excision of the lesion, in view of her age, four
deliveries and three operations in the past, and chronic
hypertension.
Figure 1. Posterior vaginal wall cyst with an opening into the vagina (arrow).
Figure 2. Posterior vagina showing an opening, through which a hemostat has been passed and its blades have been opened to demonstrate the extent of the underlying space.
Discussion
A
mucous cyst is variously located in the vagina.[2,3,4] It is
unilocular and measures 0.5 to 7 cm in diameter. It is lined by a
single layer of columnar mucous cells, though ciliated cells and
squamous metaplasia may be seen focally.[2] A Gartner duct
(mesonephric) cyst is small, single, and found along the lateral or
anterolateral vaginal wall. It is lined by a single layer of cuboid,
nonmucinous cells. A basement membrane and smooth muscle fibers in
the surrounding stroma are not always present.[2] An epidermal
inclusion cyst is small, located in the anterior or posterior vaginal
wall. Vaginal adenosis is seen as multiple small cysts. An ectopic
ureter may drain into a Gartner duct cyst, producing a large cyst.[5] Vaginal endometriotic cysts are found along the posterior vaginal
fornix, or in areas of trauma.[6] They produce tender, small to
medium sized lesions with fibrosis around them. A dermoid cyst is low
down under the posterior vagina. It is small to medium sized. Its
contents are sebaceous, though derivatives of all the germ layers can
be found in it.[7]
Vaginal
wall cysts should not be mistaken for vaginal wall prolapse. Vaginal
wall prolapse shows an expansile impulse on Valsalva's maneuver,
while a cyst does not do so.
The
cyst in the case presented was a mucous cyst. These cysts often have
very thin walls which appear to be likely to rupture any time. They
often rupture during surgical dissection. However spontaneous rupture
of a vaginal wall cyst has not been reported in the world literature
so far. The site of rupture is usually small. If it does not heal, it
would result in formation of a small permanent opening. The size of
the cyst is much larger than the opening, and hence a chronically
discharging sinus would form. After collection of mucus in it over a
period of some time (dependent onthe initial size of the cyst), the
contents would empty into the vagina, only to fill again. This is
what happened in our patient. She had undergone four deliveries and
three operations in the past, was elderly and had chronic
hypertension. In view of all this, the benign nature of the lesion,
and her age, she opted not to undergo any operative treatment. If an
operative treatment is required for a ruptured vaginal wall cyst, it
would be best to wait until it fills again, and then excise it.[8] Marsupialization of the cyst is another therapeutic option. The
opening created is quite large and the contents drain out readily.
After some time, the lining epithelium undergoes metaplasia and
assumes characteristics of adult vaginal epithelium.[8]
Conclusion
Spontaneous
rupture of a vaginal wall cyst is a possibility. If it occurs, one
should wait for it to fill up again before attempting to operate on
it.
Acknowledgment
I
thank Dr Manjarekar V for taking the two photographs included in the case
report.
References
-
Kurman RJ, Prabha AC. Thyroid and parathyroid glands in the vaginal wall: report of a case. Am J Clin Pathol 1973;59:503-507.
-
Deppisch LM. Cysts of the vagina. Classification and clinical correlations. Obstet Gynecol 1975;45:632-637.
-
Pradhan S, Tobon H. Vaginal cysts: a clinicopathological study of 41 cases. Int J Gynecol Pathol 1986;5:35-46.
-
Sahnidt WN. Pathology of the vagina – Vaginal cysts. In: Fox H, Wella M, editors. , eds. Haines and Taylor Obstetrical and Gynecological Pathology. Vol. 1, Fifth edition New York, NY: Churchill Livingstone; 2003:180–3.
-
Kjaeldgaard A, Fianu S. Classification and embryological aspects of ectopic ureters communicating with Gartner's cysts. Diagn Gynecol Obstet 1982;4:269-273.
-
Gardner HL. Cervical and vaginal endometriosis. Clin Obstet Gynecol 1966;9:358-372.
-
Kondi-Pafiti A, Grapsa D, Papakonstantinou K, et al. Vaginal cysts: A common pathological entity revisited. Clin Exp Obstet Gynecol 2008;35:41–4.
-
Parulekar SV. Practical Gynecology and Obstetrics. 5th ed. Mumbai: Vora Medical Publications; 2011.
Citation
Parulekar
SV. Vaginal Sinus Due To Rupture Of Posterior Vaginal Wall Cyst. JPGO
2015 Volume 2 Number 6. Available from: http://www.jpgo.org/2015/06/vaginal-sinus-due-to-rupture-of.html