Excision Of Collapsed Vaginal Wall Cyst With Old Rupture: Innovative Approach

Innovation
Author Information

Parulekar SV.
(Professor and Head, Obstetrics and Gynecology, Seth G S Medical College & K E M Hospital, Mumbai, India.)

Abstract

A vaginal wall cyst sometimes ruptures spontaneously and may form a chronic discharging sinus. Excision of such a collapsed vaginal wall cyst is difficult as it is often empty and collapsed. An innovative method of excising such a cyst is presented.

Introduction

Vaginal wall cysts are not very uncommon in a busy gynecological practice. Many of them are diagnosed incidentally while the patient presents for some other condition. Large cysts may present with dyspareunia or symptoms of genital prolapse. Spontaneous rupture of a cyst and formation of a sinus has been reported only once in the world literature.[1] That patient refused surgical treatment. This is the second such case in the world literature. An innovative method was used to excise the cyst.

Case Report

A 34 year old woman presented with a complaint of chronic intermittent vaginal discharge of mucus, dating from spontaneous rupture of a swelling in her vagina 3 months ago. Turbid looking fluid had been discharged at that time. She had two normal deliveries in the past, the youngest child being 6 years old. Her menstrual history was normal. Her medical and surgical history was not contributory. Her general and systemic examination revealed no abnormality. A speculum examinaion of the vagina showed a bulging of the anterior vagina, which was folded up like a collpased structure. There was no expansion of the vagina on coughing, ruling out a cystocele. Pressure on the collapsed wall produced a drop of mucus from a very small opening in the posterior aspect.The remaining vagina was normal. The uterus was of normal size and shape. There were no pelvic lumps. A diagnosis of spontaneously ruptured anterior vaginal wall cyst which had led to formation of a chronic discharging sinus was made. Her investigations for fitness for anesthesia were normal. A cystoscopy was performed. It showed no abnormality, ruling out any connection between the cyst and the urinary bladder or the urethra.

The patient was placed in lithotomy position under spinal anesthesia. Aseptic and antiseptic technique was used. A size 14 Foley's catheter was passed into the urinary bladder. The opening of the sinus was identified by pressure on the collapsed cyst, which caused escape of a drop of mucus through the opening. The vaginal wall was held near the opening and then the opening was enlarged by serial passage of the tip of a small curved hemostat followed by Hegar's dilators from size 3/6 to 5/8. Then a No. 14 Foley's catheter was passed into the cyst through the dilated sinus track. Its balloon was inflated with normal saline until the cyst distended (about 10 ml). Then a circumferential incision was made in the vaginal mucosa around the opening of the cyst, and the incision was extended cranially and caudally for 1 cm each. The vaginal wall was dissected off the cyst wall, and then the cyst wall was dissected off the surrounding structures, like the urinary bladder posteriorly and the ischiocavernosus laterally on the right side. The opening through which the Foley's catheter had been passed expanded sopntaneously during dissection when the vagina was released on all sides around it. Finayy the cather balloon came out. A finger was passed into the cyst to define its limit. The cyst was found to be 5-6 cm in diameter. After removal of the cyst, hemostasis was achieved in its bed. Excess of vagina was excised and vaginal edges were sutured with interrupted sutures of No. 1-0 polyglactin. The patient made an uneventful recovery. Histopahology showed the cyst to be a benigh mucus secreting cyst.


Figure 1. Collpased anterior vaginal wall cyst. Opening of the cyst is seen (arrow).


Figure 2. Tip of a small curved hemostat is passed into the opening of the cyst.


Figure 3. The opening is dilated with passage of a Hegar's dilator.



Figure 4. A Foley's catheter is passed into the cyst through its opening.

Figure 5. The anterior vagina is dissected partly off the cyst wall. A part of the balloon of the Foley's catheter is seen through the enlarged opening of the cyst (arrow).


Figure 6. The anterior vagina has been dissected partly off the cyst wall. The edges of the vagina are shown by black arrows, and the limits of the cyst are shown by green arrows.



Figure 7. The balloon of the Foley's catheter is seen being expressed through the enlarged opening in the cyst.

Figure 8. A finger is passed into the cyst through the opening in its wall.


Figure 9. The cyst has been separated almost completely. The edges of the vagina are shown by black arrows, and those of the cyst are shown by green arrows.
Discussion

The cyst in this case was a mucous cyst. Such a cyst is often very thin walled and is more likely to rupture than other cysts of the vagina.[2,3] In case of a spontaneous rupture of the cyst, if the site of rupture heals, the cyst fills up again over a period of time. But if the epithelium lining the cyst heals with the vaginal epithelium over the edges of the opening caused by the rupture, a discharging sinus forms, which periodically empties its contents into the vagina. Surgical excision of such a cyst is difficult when it is collpapsed. If it is filled to some extent, dissection becomes easier because the cyst can be seen well and risk of accidental injury to adjacent structures like the urinary bladder and rectum is reduced. The cyst was never filled to adequately in the case presented, and only a few drops of mucus could be expressed at any time. In order to delineate its limits during surgery, it was necessary to fill it up. Distending it with saline was not an option, because its opening could not be closed and the saline would leak out during dissection. Then the cyst would collapse again. Filling it with a viscous liquid like lubricant or lignocaine gel would also not work out for the same reason, and operative field would become messy too. Hence an innovative idea was used. After dilating the opening of the cyst, a Foley's catheter was passed into it and its balloon was inflated so as to distend the cyst. Subsequent operative steps were as for excision of an anterior vaginal wall cyst. This maneuver reduced the risk of intraoperative injury to the urinary bladder and urethra, since the cyst wall was well defined and dissection was easier.

Conclusion

Distension of a collapsed vaginal wall cyst due to chronic rupture and sinus formation can be achieved with a balloon catheter. This makes dissection of the cyst easier and significantly reduces the risk of injury to adjacent structures.

References
  1. 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
  2. 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.
  3. Pradhan S, Tobon H. Vaginal cysts: a clinicopathological study of 41 cases. Int J Gynecol Pathol 1986;5:35-46.
Citation

Swaminathan G, Parulekar SV. Bilateral Gonadectomy In A Case Of Complete Androgen Insensitivity Syndrome. JPGO. 2018 Vol 5 No. 8. Available from: http://www.jpgo.org/2018/08/excision-of-collapsed-vaginal-wall-cyst.html