(Professor and Head of Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
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.
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. 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.
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.
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. 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. 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. Vaginal endometriotic cysts are found along the posterior vaginal fornix, or in areas of trauma. 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.
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. 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.
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.
I thank Dr Manjarekar V for taking the two photographs included in the case report.
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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