Benign Cysts, Rests, and Adnexal Tumors of the Vulva

Background and Clinical Presentation

Cysts in the region of the Bartholin gland often involve the duct and are termed Bartholin duct cysts . The orifices of the ducts draining the Bartholin glands are typically located in the posterior introitus (5 o'clock and 7 o'clock positions in lithotomy). Bartholin duct cysts presumably follow obstruction of the duct and may be accompanied by infection and an abscess formation ( Fig. 5.1 ). Rarely these lesions may be detected on imaging.

Diagnostic Criteria

Histologically, a Bartholin duct cyst is lined by a transitional or squamous epithelium and the specimen often contains associated Bartholin gland ( Fig. 5.2 ). The diagnosis is made by identification of the transitional epithelium and gland (if obtained). Its distinction from a Skene duct cyst is based principally on its posterior rather than periurethral location ( Fig. 5.3 ). The clinical differential diagnosis also includes mucous cysts, EICs, benign adnexal tumors (hidradenoma), and soft tissue tumors, such as lipomas.

Management

Traditionally, the management of a Bartholin duct cyst/abscess consisted of insertion of a Word catheter. Another option is marsupialization for Bartholin duct cysts/abscesses. Antibiotic therapy is recommended in the setting of cellulitis. If a cyst recurs after marsupialization, removal of the entire cyst, duct, and gland (if possible) is recommended. As with all cysts, other vulvar neoplasms must be excluded, specifically carcinomas arising in the Bartholin gland or duct (see Chapter 7 ). The latter, however, are extremely rare.

Background and Clinical Presentation

The Skene glands (also known as the periurethral glands, lesser vestibular glands, or paraurethral glands ) are located on the anterior wall of the vagina, around the distal part of the urethra (see Fig. 5.3 ). They secrete a viscous lubricating fluid upon sexual arousal, which drains into the urethra and periurethral openings. Skene duct cysts are rare and may occur in newborns, where they present as discrete periurethral pea-size swellings. In adults, they are occasionally reported in association with dyspareunia.

Diagnostic Criteria

Like Bartholin duct cysts, Skene duct cysts are lined by transitional epithelium and in some cases squamous epithelium if sampled near the surface. A variable amount of chronic inflammation is typically encountered.

Differential Diagnosis

The most important distinction is a clinical one between Skene duct cysts and similar entities, such as ectopic ureterocele, urethrocele, urethral diverticula, and benign or malignant urethral and paraurethral tumors.

Management

Management consists of marsupialization or removal of the cyst.

Background and Clinical Presentation

Mucous cysts occur over a wide age range but are usually seen in multiparous women in the third and fourth decades. They present exclusively in the region of the vulvar vestibule and in the majority are solitary lesions of 1 to 2 cm in diameter. They are usually asymptomatic, but patients may complain of pain if the cysts have recently enlarged or impinge on the urethra, where they may cause dysuria.

The origin of mucous cysts has been debated in the past. Theories of origin include invagination of overlying squamous epithelium with mucinous metaplasia, para-mesonephric (müllerian) origin, and origin from urogenital sinus epithelium. The first is unlikely, because most mucous cysts do not communicate with the overlying squamous epithelium, and the squamous differentiation in these cysts is of a metaplastic nature. The paramesonephric origin has been challenged by others who emphasize that the müllerian ducts terminate in the region of the hymen and play no part in the development of the vulvar vestibule. Moreover, the most caudal extension of müllerian epithelium seen in diethylstilbestrol exposure is cephalad to the hymen. Finally, clear cell carcinoma, a tumor arising in müllerian epithelium, has not been reported in the vulvar vestibule. Urogenital sinus epithelium remains the most plausible, inasmuch as both ciliated and mucous cells have been observed in derived epithelium, including the Bartholin gland.

The development of mucous cysts appears to be hormone related in that the lesions occur most frequently in the reproductive years, including during pregnancy.

Diagnostic Criteria

Histologically, mucous cysts contain mucinous epithelium identical in appearance to that lining the endocervix or vaginal adenosis ( Fig. 5.4 ). Less commonly, they contain squamous metaplasia ( Fig. 5.5 ). Ciliated cells have been reported in some cases and may be mixed with the mucinous epithelium.

Differential Diagnosis

The differential diagnosis of mucous cysts includes mesonephric remnants (cuboidal epithelium and a fibromuscular wall) and Bartholin duct cysts (transitional epithelium). The labium minus transverses over the middle of the Bartholin cyst.

Background and Clinical Presentation

EICs occasionally occur in the vulvar region and are most commonly associated with prior trauma or circumcision. Vulvar EICs may become infected and management is similar to that of cutaneous EICs ( Fig. 5.6A ).