Half Dumbbell-shaped Gartner’s Cyst Presenting As Paraurethral Cyst

Author Information

Parulekar SV* Fernandes GC**.

(*Professor and Head, Department of Obstetrics and Gynecology, ** Associate Professor, Department of Pathology, Seth G S Medical College & KEM Hospital, Mumbai, India.)

Abstract

A Gartner’s duct cyst develops from residual parts of a wolffian duct. Though it most commonly develops under the anterolateral aspect of the upper vagina, it can develop anywhere from lateral aspect of the uterus along the lateral aspect of the vagina up to the introitus. Paraurethral area is an unusual location for such cysts. Such a case is presented here.

Introduction

Gartner’s ducts are found in about 25% of women. About 1% of these develop Gartner’s duct cysts.[1] Other cystic lesions under the vagina include mullerian cysts (30%), Bartholin duct cysts (27.5%), epidermal inclusion cysts (25%), endometroid cysts (7%) and others.[2,3] Usually a Gartner’s duct cyst is found anywhere from lateral aspect of the uterus along the lateral aspect of the vagina up to the introitus. Paraurethral area is an unusual location for such cysts. A large Gartner’s duct cyst presenting as a paraurethral cyst is presented here.

Case Report

A 26 year old woman, married for 8 months, presented with a complaint of dyspareunia for 4 months. It was superficial dyspareunia, experienced mainly during penetration, and the pain was local, lasting for prolonged periods after coitus. Her menstrual cycles were every 28-30 days, the bleeding being moderate and painless, lasting for 3-4 days. She had a spontaneous abortion at 1.5 months of amenorrhea 3 months ago, for which a blunt curettage had been done. That procedure had been uneventful and her recovery had been complete. Her medical and surgical history was not contributory.  There was no leucorrhea, urinary disturbance, vulvar pruritus or pain. Her general, systemic and abdominal examination revealed no abnormality. Local examination of the vulva showed a right paraurethral cyst measuring about 2 cm in diameter in its projecting part (figure 1). It was soft and nontender. The size of its deeper part could not be ascertained, though no large mass was felt in that area. A speculum examination showed normal vagina and cervix. There was no mass palpable lateral to the right wall of the vagina. The urethra was normal. A bimanual pelvic examination showed a retroverted, normal sized, mobile uterus and no pelvic masses. A diagnosis of right paraurethral cyst was made. Excision of the cyst was advised in view of the woman’s severe symptoms. Ultrasonography showed normal kidneys and ureters. A 5 cm diameter cyst with no loculi and clear fluid was found lateral to the right vaginal wall. The results of her investigations for fitness for anesthesia were normal. Excision of the cyst was carried out under general anesthesia. After incision on the medical aspect of the cyst away from the urethra and during dissection of the cyst from the surrounding tissue, it was found that the cyst extended for 7-8 cm along the lateral aspect of the vagina. It was dissected carefully avoiding injury to the urethra and urinary bladder. No tubular structure like urethra was found entering the upper end of the cyst. Hemostasis was achieved in the bed of the cyst, which was then occluded by a series of purse-string sutures of No. 1-0 polyglactin from its deepest part to the superficial part. The introital epithelial incision was closed with interrupted sutures of No. 1-0 polyglactin. The patient made an uneventful recovery. The cyst contained thick yellowish creamy fluid. Histopathological examination showed lining of squamous epithelium, columnar epithelium in some parts and no epithelium is some parts. There was smooth muscle in its walls and skeletal muscle in a finger-like projection into the lumen of the cyst. A diagnosis of Gartner’s duct cyst was made.

Figure 1. Clinical appearance of the cyst.

Figure 2. Dissection of the cyst.

Figure 3.  Cyst wall lined partly by squamous epithelium and partly by columnar with smooth muscle in the wall (squamous epithelium-1 arrow, columnar epithelium-2 arrows). [H&E x 100].

Figure 4.  Finger- like projection of the cyst wall lined by columnar epithelium, inner smooth muscle and outer skeletal muscle (smooth muscle -1 arrow, skeletal muscle-2 arrows). [H&E x 100].

Figure 5. High power view highlighting the smooth muscle and skeletal muscle. (smooth muscle -1 arrow, skeletal muscle-2 arrows) [H&E x 400].

Figure 6. Another area of the cyst wall with squamous epithelial lining and a thick layer of smooth muscle. [H&E x 100].

Figure 7. Cyst wall highlighting both smooth muscle and skeletal muscle. (smooth muscle -1 arrow, skeletal muscle-2 arrows) [H&E x 100].

Discussion

Various cysts or cystic structures found in relation to the vagina include mullerian cysts, Gartner’s duct cysts, Bartholin’s duct cysts, Skene’s duct cysts, cysts of the canal of Nuck, endometriotic cysts, ectopic ureterocele and urethral diverticulum.[2,4-8] A Gartner’s duct cyst develops from residual parts of a wolffian duct. After completion of the development of the mullerian ducts, the wolffian ducts regress and may remain vestigial in females.[9] Gartner’s ducts are found in about 25% of women. About 1% of these develop Gartner’s duct cysts. They comprise about 10 % of vaginal benign cysts.[7] A Gartner’s duct cyst is usually single, measuring up to 2 cm in diameter.[10] Usually these cysts are asymptomatic. Sometimes they are associated with local pain, swelling, dyspareunia, urinary bladder dysfunction including urinary incontinence.[11] A Gartner’s duct cyst is usually situated along the anterolateral wall of the proximal third of the vagina, above the level of the lower border of the pubic symphysis.[7,12-15] But it can be located anywhere along the lateral aspect of the uterus and vagina, up to the level of the introitus. The location of the cyst in the case presented was paraurethral, which was extremely unusual. Malignant change in a Gartner’s duct cyst is very rare.[16] Another unusual feature in this case was the presence of a skeletal muscle projection into the lumen of the cyst from one side. It can be explained by the compression of the cyst by the levatore ani muscle from the lateral aspect, making it into the shape of a half dumbbell. This was not appreciated during the dissection of the cyst, because the cyst was large and dissection had to be done at a depth, which limited vision. The cyst must have been adherent to the levatore ani muscle on its lateral aspect, due to which some fibers of the muscle got cut and remained with the surgical specimen. Sometimes these cysts are associated with renal abnormalities like ipsilateral agenesis, dysplasia or crossed fused kidney or an aberrant ureter opening into the cyst. The cyst may be a part of Herlyn-Werner-Wunderlich syndrome.[17-21] There may association with a bicornuate uterus, hemi outflow tract obstruction to menstrual flow, or diverticula of the fallopian tubes.[22] 

Mullerian duct cysts have a lining of secretory epithelium as in the endocervix or fallopian tube. Inclusion cysts of the vagina contain keratin and squamous debris and have inflammation and foreign-body reaction around it. Endometriotic cysts show endometrial type glands and stroma and evidence of chronic hemorrhage in the form of hemosiderin laden macrophages. Bartholin’s cysts show squamous and urothelial epithelium with inflammatory infiltrate, residual mucinous glands with nonsulfated sialomucin and sometimes calcifications like malakoplakia. The histological appearance in the case presented was typical of a Gartner’s duct cyst, except the presence of skeletal muscle on the outside of one wall. It was due to some fibers of the levator ani running along the lateral aspect of the vagina getting separated during the dissection of the cyst.

A Gartner’s duct cyst may be managed by just observation and prolonged follow-up if it is small and asymptomatic. If it is of moderate size, sympttomatic and situated near the vaginal fornix, it is best treated by marsupialization, which avoids inadvertent injury the ureter. A very large cyst is managed by marsupialization or excision. Great care must be taken to rule out an aberrant ureter opening into the cyst, or a ureterovaginal fistula forms.

Conslusion

A Gartner’s duct cyst can have varied presentations, different locations, varying size and may be a associated with many anomalies. Great care needs to be taken to exclude such anomalies, and avoid complications like ureteric injury during its surgical treatment.

Acknowledgments

I thank Dr Sreshthha Mahanti for taking the operative photographs.

References

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Citation

Parulekar SV, Fernandes GC. Half Dumbbell-shaped Gartner’s Cyst Presenting As Paraurethral Cyst. JPGO 2018. Volume 5 No.1. Available from: http://www.jpgo.org/2018/02/half-dumbbell-shaped-gartners-cyst.html