Letizia, Matthew J. DO; Kelly, Joseph V.M.
A 19-year-old woman with no past medical or surgical history presents to the emergency department stating that she noticed a growth protruding from her vagina. It has been painless except during intercourse and constant in all characterizations since detection three days earlier. She denies vaginal bleeding, urinary retention, incontinence, fever, injury, and back, abdominal, and pelvic pain.
Her vital signs are normal, but her physical examination was significant for a 2.5 cm x 4 cm stalk-like, pedunculated, fluctuant, nontender, mobile, cystic-appearing mass protruding from the right anterolateral vaginal wall. The rest of the genitourinary and abdominal systems were without notable abnormalities and pathology. A blood sample sent to the lab failed to note leukocystosis, and urinalysis and pregnancy tests were negative. After a supporting ultrasound was obtained, a Gartner's duct cyst was diagnosed, and a gynecological follow-up was made for marsupialization to prevent a recurrence.
Gartner's ducts are identified in approximately 25 percent of all adult women, and nearly one percent evolve into Gartner's duct cysts. During embryological development, the mesonephric (Wolffian) ducts develop, form their predetermined structures, and later regress. Remnants often remain, however, until they develop a secretory mechanism, cause dilation of surrounding cells, and thus yield a Gartner's duct cyst, most often during and after late adolescence.
Classically, the cysts are solitary, unilateral, less than 2 cm in diameter, and are located in the anterolateral vaginal wall of the proximal a third of the vagina. (J Gynecol Surg 2009;24:75; J Pelvic Med Surg 2007;13:141.) Gartner's duct cysts are generally asymptomatic, and most commonly diagnosed upon routine gynecologic examination, but patient complaints can include that of skin tag, dysuria, pressure, itching, dyspareunia, pelvic pain, or protrusion from the vagina if it enlarges to a detectable size, making it a candidate for surgical removal. (J Diagn Med Sonog 2008;24:344; J Pelvic Med Surg 2007;13:141; J Am Osteopath Assoc Dermatol 2007;8:40.) If large enough to cause obstetrical complications, the cyst can be drained to facilitate delivery.
To define the course of the Gartner's duct cyst and differentiate it from other pathologic considerations and structures, MRI can be a useful tool. Histologic examination may be employed to correctly identify the cellular remnants composed of non-mucin secreting low columnar or cuboidal epithelium, but in clinical practice, it is not necessary. (J Diagn Med Sonog 2008;24:344.) The differential diagnosis can include but is not limited to Bartholin's gland cyst or abscess, prolapsed urethra, prolapsed uterus, vaginal wall inclusion cyst, endometriosis, leiomyoma, sarcoma botryoides, malignant mass, Skeene's gland cyst, or abscess and ureterocele. (J Am Osteopath Assoc Dermatol 2007;8:40.) Only in exceptionally rare and isolated cases has there been a malignant transformation identified. (Int J Gynecol Cancer 2009;19:1655.) Patients may be discharged safely from the emergency department with gynecologic follow-up for definitive treatment.
Dr. Letizia is the director of operations and an emergency physician at Trinitas Regional Medical Center in Elizabeth, NJ. Mr. Kelly is a fourth-year medical student at Spartan Health Sciences University in St. Lucia.
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