Case Report
A Gartner Duct Cyst Masquerading as Anterior Vaginal Prolapse Emily R. W. Davidson, MD, and Matthew D. Barber, MD, MHS BACKGROUND: Gartner duct cysts are embryologic remnants of the mesonephric ducts that may present as a vaginal mass or cyst. CASE: A patient was referred for surgical management of prolapse whose bulging anterior vagina was actually a Gartner duct cyst that required excision as a result of symptoms. Preoperative magnetic resonance imaging helped confirm the diagnosis. CONCLUSION: A Gartner duct cyst may present as a vaginal cyst that, if large, may mimic pelvic organ prolapse. The diagnosis should be considered when a patient’s individual prolapse compartments are inconsistent or when physical examination is suggestive of another process. (Obstet Gynecol 2017;0:1–3) DOI: 10.1097/AOG.0000000000002315
T
he symptom of feeling or seeing a vaginal bulge is more than 95% sensitive and 79% specific for a diagnosis of pelvic organ prolapse (POP).1 Clinical examination confirms the diagnosis. However, it is important to appreciate that there may be other conditions mimicking POP that would require different approaches in treatment. In this case, a patient was treated unsuccessfully for years with a pessary for POP. A referral for surgical repair revealed a large cystic vaginal mass necessitating a different surgical approach. A video representation of this case report is available online at http://links.lww.com/AOG/A999.
From the Cleveland Clinic, Cleveland, Ohio; and Duke University, Durham, North Carolina. Each author has indicated that he or she has met the journal’s requirements for authorship. Corresponding author: Emily R. W. Davidson, MD, 9500 Euclid Avenue, A81, Cleveland, OH 44195; email: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/17
VOL. 0, NO. 0, MONTH 2017
Teaching Points 1. Gartner duct cysts may mimic pelvic organ prolapse. 2. It is important to question the diagnosis of pelvic organ prolapse if the physical examination is atypical. 3. Pelvic magnetic resonance imaging is the imaging study of choice when evaluating for potential Gartner duct cyst.
CASE The patient is a 53-year-old postmenopausal white woman, gravida 5 para 4, without prior pelvic surgery who was referred for consultation for POP to a tertiary care urogynecology practice. The patient had symptoms of vaginal bulge for several years. This was treated with a pessary with limited success because the bulge would intermittently enlarge and expel the pessary. She was sexually active although reported some difficulty with intercourse as a result of prolapse. She was referred by her primary gynecologist for surgical management of a cystocele. During the office physical examination, the patient had protrusion of the anterior vaginal wall 4 cm beyond the hymen with straining (POP quantification points: Aa+3, Ba+4, C –6, and total vaginal length of 8 cm). On palpation, the wall felt firmer and less reducible than a typical cystocele, more consistent with a vaginal mass. The decision was made to proceed with imaging for better characterization. Selections from the patient’s magnetic resonance imaging (MRI) scan can be seen in Figure 1, which showed a 3.334.638.4–cm pedunculated, well-circumscribed cyst with smooth walls that appeared to arise lateral to the cervix with prominent T2 hyperintensity (Fig. 1). Given the location and appearance of the mass, the leading diagnosis was a Gartner duct cyst.2–4 After informed consent, the patient underwent surgical excision of the cyst. In the operating room, the large, nonreducible mass was seen lateral to the cervix, with thinned epithelium revealing dark fluid within the cyst (Fig. 2). A cephalad-to-caudad incision was made into the cyst, revealing dark, green–brown fluid with a smooth cyst wall that tracked up to the level of the cervix, approximately 8 cm. Using sharp, electrosurgical, and blunt techniques, the cyst wall was dissected away from the surrounding tissue. The entire cyst was excised in continuity. The remaining space was made hemostatic with coagulation and administration of a thrombin-based hemostatic agent. The redundant vaginal epithelium was excised, and the defect was closed with a running, locked absorbable suture. At her postoperative visit, the patient reported some urgency urinary incontinence but had no complaints. Examination revealed well-healed incisions, good apical
OBSTETRICS & GYNECOLOGY
Copyright Ó by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1
Fig. 1. Preoperative magnetic resonance imaging. Magnetic resonance imaging shows the patient’s pelvic anatomy in sagittal (A), coronal (B), and axial (C) views. The T2-hyperintense mass (arrow) is seen in its left, lateral position relative to the uterus (*) and cervix (†) and even prolapsing through the introitus in the sagittal view. Davidson. Gartner Duct Cyst Mimicking Prolapse. Obstet Gynecol 2017.
Video 1. Video case report describing a large vaginal mass presenting as prolapse. Video created by Emily RW Davidson, MD. Used with permission. and posterior support, and a moderate loss of anterior support although not reaching the hymen. Histology of the lesion revealed a cyst wall with squamous lining, chronic inflammation, giant cell reactions, granulation tissue, and ulceration, compatible with a Gartner duct (mesonephric) cyst.
DISCUSSION In a male embryo, the mesonephric or Wolffian ducts develop into the ductus deferens, ejaculatory duct, and seminal vesicles. 5 In a female embryo, the ducts are supposed to regress. Persistent intraabdominal tissue may present as adnexal masses of mesonephric origin, but a persistent portion near
Scan this image to view Video 1 on your smartphone.
2
Davidson and Barber
the vagina can present as a Gartner duct cyst.6 A differential diagnosis for vaginal masses like this patient’s includes a urethral diverticulum, enlarged Skene’s gland, enlarged Bartholin’s cyst, benign smooth tissue mass, endometriotic implant, and rarely a vaginal metastasis or primary malignancy.6 A Gartner duct cyst may be identified as a result of its location, usually arising lateral to the cervix as well as its contents demonstrating hyperintensity on T2-weighted MRI.2,4 Bartholin’s cysts arise near the posterior introitus and would involve the labia, a urethral diverticulum would arise from the urethra, and a Skene’s gland cyst occurs closer to the urethra.5,6 A vaginal myoma or malignancy could arise in any location, but the substance would generally be solid.4 In the literature, Gartner duct cysts have been reported throughout a woman’s lifetime including pregnancy. Reports describe drainage before vaginal delivery, excision, and marsupialization.2,7,8 This case underlines the importance of questioning a diagnosis when some pieces of information are unexpected or incongruous. For this patient, a wellsupported vaginal apex (C526) in the setting of advanced stage III anterior wall prolapse (Ba5+4) combined with the unusual firmness and irreducibility of the anterior wall led to the speculation that this was not routine anterior compartment prolapse.9 When the diagnosis of Gartner duct cyst is suspected, MRI may be of particular use compared with ultrasonography because many as 10% of women with Gartner duct cyst will have Müllerian or renal abnormalities including renal agenesis and ectopic ureters.10,11 In this setting, MRI is superior to computed tomography scan in its soft tissue discrimination12 and has the further advantage of avoidance of ionizing radiation. Surgical treatment after diagnosis may include drainage with marsupialization or excision. Both techniques were associated with low rates of complications and recurrence in a case series of 29 patients; only one patient had a recurrence, and
Gartner Duct Cyst Mimicking Prolapse
OBSTETRICS & GYNECOLOGY
Copyright Ó by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Fig. 2. Intraoperative photography. This series of photographs outlines the surgical progression of the cyst excision. A. Preoperatively, the large vaginal bulge is apparent past the hymen, mimicking a large cystocele. B. The large cyst is incised, revealing murky green contents (not shown). C. Using Metzenbaum scissors, the cyst wall is separated from the vaginal epithelium until only the proximal attachments of the cyst remain. D. The distal attachments are severed after ensuring that the cyst is completely removed. After trimming excess vaginal epithelium, the vaginal wall is repaired using absorbable suture. Davidson. Gartner Duct Cyst Mimicking Prolapse. Obstet Gynecol 2017.
she had undergone cyst excision.11 For the patient in this case report, drainage alone would have been inappropriate given the large amount of redundant vaginal epithelium after drainage.
6. Smith RP, Netter FH. Netter’s obstetrics & gynecology. 3rd ed. Philadelphia (PA): Elsevier; 2017.
REFERENCES
8. Inocencio G, Azevedo S, Braga A, Carinhas MJ. Large Gartner cyst. BMJ Case Rep 2013 Feb 25.
1. Barber MD, Neubauer NL, Klein-Olarte V. Can we screen for pelvic organ prolapse without a physical examination in epidemiologic studies? Am J Obstet Gynecol 2006;195:942–8. 2. Arumugam A, Kumar G, Si L, Vijayananthan A. Gartner duct cyst in pregnancy presenting as a prolapsing pelvic mass. Biomed Imaging Interv J 2007;3:e46. 3. Upasana T, Nitin R, Fnu S, Chhavi K. Gartner duct cyst: CT and MRI findings. J Obstet Gynaecol India 2014;64(suppl 1):150–1.
7. Boujenah J, Ssi-Yan-Kan G, Prevot S, Chalouhi GE, Deffieux X. A vaginal Gartner duct cyst presenting as a cystocele during pregnancy. Eur J Obstet Gynecol Reprod Biol 2014;180: 202–4.
9. Rooney K, Kenton K, Mueller ER, FitzGerald MP, Brubaker L. Advanced anterior vaginal wall prolapse is highly correlated with apical prolapse. Am J Obstet Gynecol 2006;195:1837–40. 10. Dwyer PL, Rosamilia A. Congenital urogenital anomalies that are associated with the persistence of Gartner’s duct: a review. Am J Obstet Gynecol 2006;195:354–9.
4. Elsayes KM, Narra VR, Dillman JR, Velcheti V, Hameed O, Tongdee R, et al. Vaginal masses: magnetic resonance imaging features with pathologic correlation. Acta Radiol 2007;48:921–33.
11. Cope AG, Laughlin-Tommaso S, Famuyide A, Gebhart JB, Hopkins MR, Breitkopf DM. Clinical manifestations and outcomes in surgically managed Gartner duct cysts. J Minim Invasive Gynecol 2017;24:473–77.
5. Cochard LR. Netter’s atlas of human embryology, updated edition. Philadelphia (PA): Saunders Elsevier; 2012.
12. Hagspiel KD. Giant Gartner duct cyst: magnetic resonance imaging findings. Abdom Imaging 1995;20:566–8.
VOL. 0, NO. 0, MONTH 2017
Davidson and Barber
Gartner Duct Cyst Mimicking Prolapse 3
Copyright Ó by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
A Gartner Duct Cyst Masquerading as Anterior Vaginal Prolapse Emily R. W. Davidson, MD, and Matthew D. Barber, MD, MHS BACKGROUND: Gartner duct cysts are embryologic remnants of the mesonephric ducts that may present as a vaginal mass or cyst. CASE: A patient was referred for surgical management of prolapse whose bulging anterior vagina was actually a Gartner duct cyst that required excision as a result of symptoms. Preoperative magnetic resonance imaging helped confirm the diagnosis. CONCLUSION: A Gartner duct cyst may present as a vaginal cyst that, if large, may mimic pelvic organ prolapse. The diagnosis should be considered when a patient’s individual prolapse compartments are inconsistent or when physical examination is suggestive of another process. (Obstet Gynecol 2017;0:1–3) DOI: 10.1097/AOG.0000000000002315
T
he symptom of feeling or seeing a vaginal bulge is more than 95% sensitive and 79% specific for a diagnosis of pelvic organ prolapse (POP).1 Clinical examination confirms the diagnosis. However, it is important to appreciate that there may be other conditions mimicking POP that would require different approaches in treatment. In this case, a patient was treated unsuccessfully for years with a pessary for POP. A referral for surgical repair revealed a large cystic vaginal mass necessitating a different surgical approach. A video representation of this case report is available online at http://links.lww.com/AOG/A999.
From the Cleveland Clinic, Cleveland, Ohio; and Duke University, Durham, North Carolina. Each author has indicated that he or she has met the journal’s requirements for authorship. Corresponding author: Emily R. W. Davidson, MD, 9500 Euclid Avenue, A81, Cleveland, OH 44195; email: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/17
VOL. 0, NO. 0, MONTH 2017
Teaching Points 1. Gartner duct cysts may mimic pelvic organ prolapse. 2. It is important to question the diagnosis of pelvic organ prolapse if the physical examination is atypical. 3. Pelvic magnetic resonance imaging is the imaging study of choice when evaluating for potential Gartner duct cyst.
CASE The patient is a 53-year-old postmenopausal white woman, gravida 5 para 4, without prior pelvic surgery who was referred for consultation for POP to a tertiary care urogynecology practice. The patient had symptoms of vaginal bulge for several years. This was treated with a pessary with limited success because the bulge would intermittently enlarge and expel the pessary. She was sexually active although reported some difficulty with intercourse as a result of prolapse. She was referred by her primary gynecologist for surgical management of a cystocele. During the office physical examination, the patient had protrusion of the anterior vaginal wall 4 cm beyond the hymen with straining (POP quantification points: Aa+3, Ba+4, C –6, and total vaginal length of 8 cm). On palpation, the wall felt firmer and less reducible than a typical cystocele, more consistent with a vaginal mass. The decision was made to proceed with imaging for better characterization. Selections from the patient’s magnetic resonance imaging (MRI) scan can be seen in Figure 1, which showed a 3.334.638.4–cm pedunculated, well-circumscribed cyst with smooth walls that appeared to arise lateral to the cervix with prominent T2 hyperintensity (Fig. 1). Given the location and appearance of the mass, the leading diagnosis was a Gartner duct cyst.2–4 After informed consent, the patient underwent surgical excision of the cyst. In the operating room, the large, nonreducible mass was seen lateral to the cervix, with thinned epithelium revealing dark fluid within the cyst (Fig. 2). A cephalad-to-caudad incision was made into the cyst, revealing dark, green–brown fluid with a smooth cyst wall that tracked up to the level of the cervix, approximately 8 cm. Using sharp, electrosurgical, and blunt techniques, the cyst wall was dissected away from the surrounding tissue. The entire cyst was excised in continuity. The remaining space was made hemostatic with coagulation and administration of a thrombin-based hemostatic agent. The redundant vaginal epithelium was excised, and the defect was closed with a running, locked absorbable suture. At her postoperative visit, the patient reported some urgency urinary incontinence but had no complaints. Examination revealed well-healed incisions, good apical
OBSTETRICS & GYNECOLOGY
Copyright Ó by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1
Fig. 1. Preoperative magnetic resonance imaging. Magnetic resonance imaging shows the patient’s pelvic anatomy in sagittal (A), coronal (B), and axial (C) views. The T2-hyperintense mass (arrow) is seen in its left, lateral position relative to the uterus (*) and cervix (†) and even prolapsing through the introitus in the sagittal view. Davidson. Gartner Duct Cyst Mimicking Prolapse. Obstet Gynecol 2017.
Video 1. Video case report describing a large vaginal mass presenting as prolapse. Video created by Emily RW Davidson, MD. Used with permission. and posterior support, and a moderate loss of anterior support although not reaching the hymen. Histology of the lesion revealed a cyst wall with squamous lining, chronic inflammation, giant cell reactions, granulation tissue, and ulceration, compatible with a Gartner duct (mesonephric) cyst.
DISCUSSION In a male embryo, the mesonephric or Wolffian ducts develop into the ductus deferens, ejaculatory duct, and seminal vesicles. 5 In a female embryo, the ducts are supposed to regress. Persistent intraabdominal tissue may present as adnexal masses of mesonephric origin, but a persistent portion near
Scan this image to view Video 1 on your smartphone.
2
Davidson and Barber
the vagina can present as a Gartner duct cyst.6 A differential diagnosis for vaginal masses like this patient’s includes a urethral diverticulum, enlarged Skene’s gland, enlarged Bartholin’s cyst, benign smooth tissue mass, endometriotic implant, and rarely a vaginal metastasis or primary malignancy.6 A Gartner duct cyst may be identified as a result of its location, usually arising lateral to the cervix as well as its contents demonstrating hyperintensity on T2-weighted MRI.2,4 Bartholin’s cysts arise near the posterior introitus and would involve the labia, a urethral diverticulum would arise from the urethra, and a Skene’s gland cyst occurs closer to the urethra.5,6 A vaginal myoma or malignancy could arise in any location, but the substance would generally be solid.4 In the literature, Gartner duct cysts have been reported throughout a woman’s lifetime including pregnancy. Reports describe drainage before vaginal delivery, excision, and marsupialization.2,7,8 This case underlines the importance of questioning a diagnosis when some pieces of information are unexpected or incongruous. For this patient, a wellsupported vaginal apex (C526) in the setting of advanced stage III anterior wall prolapse (Ba5+4) combined with the unusual firmness and irreducibility of the anterior wall led to the speculation that this was not routine anterior compartment prolapse.9 When the diagnosis of Gartner duct cyst is suspected, MRI may be of particular use compared with ultrasonography because many as 10% of women with Gartner duct cyst will have Müllerian or renal abnormalities including renal agenesis and ectopic ureters.10,11 In this setting, MRI is superior to computed tomography scan in its soft tissue discrimination12 and has the further advantage of avoidance of ionizing radiation. Surgical treatment after diagnosis may include drainage with marsupialization or excision. Both techniques were associated with low rates of complications and recurrence in a case series of 29 patients; only one patient had a recurrence, and
Gartner Duct Cyst Mimicking Prolapse
OBSTETRICS & GYNECOLOGY
Copyright Ó by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Fig. 2. Intraoperative photography. This series of photographs outlines the surgical progression of the cyst excision. A. Preoperatively, the large vaginal bulge is apparent past the hymen, mimicking a large cystocele. B. The large cyst is incised, revealing murky green contents (not shown). C. Using Metzenbaum scissors, the cyst wall is separated from the vaginal epithelium until only the proximal attachments of the cyst remain. D. The distal attachments are severed after ensuring that the cyst is completely removed. After trimming excess vaginal epithelium, the vaginal wall is repaired using absorbable suture. Davidson. Gartner Duct Cyst Mimicking Prolapse. Obstet Gynecol 2017.
she had undergone cyst excision.11 For the patient in this case report, drainage alone would have been inappropriate given the large amount of redundant vaginal epithelium after drainage.
6. Smith RP, Netter FH. Netter’s obstetrics & gynecology. 3rd ed. Philadelphia (PA): Elsevier; 2017.
REFERENCES
8. Inocencio G, Azevedo S, Braga A, Carinhas MJ. Large Gartner cyst. BMJ Case Rep 2013 Feb 25.
1. Barber MD, Neubauer NL, Klein-Olarte V. Can we screen for pelvic organ prolapse without a physical examination in epidemiologic studies? Am J Obstet Gynecol 2006;195:942–8. 2. Arumugam A, Kumar G, Si L, Vijayananthan A. Gartner duct cyst in pregnancy presenting as a prolapsing pelvic mass. Biomed Imaging Interv J 2007;3:e46. 3. Upasana T, Nitin R, Fnu S, Chhavi K. Gartner duct cyst: CT and MRI findings. J Obstet Gynaecol India 2014;64(suppl 1):150–1.
7. Boujenah J, Ssi-Yan-Kan G, Prevot S, Chalouhi GE, Deffieux X. A vaginal Gartner duct cyst presenting as a cystocele during pregnancy. Eur J Obstet Gynecol Reprod Biol 2014;180: 202–4.
9. Rooney K, Kenton K, Mueller ER, FitzGerald MP, Brubaker L. Advanced anterior vaginal wall prolapse is highly correlated with apical prolapse. Am J Obstet Gynecol 2006;195:1837–40. 10. Dwyer PL, Rosamilia A. Congenital urogenital anomalies that are associated with the persistence of Gartner’s duct: a review. Am J Obstet Gynecol 2006;195:354–9.
4. Elsayes KM, Narra VR, Dillman JR, Velcheti V, Hameed O, Tongdee R, et al. Vaginal masses: magnetic resonance imaging features with pathologic correlation. Acta Radiol 2007;48:921–33.
11. Cope AG, Laughlin-Tommaso S, Famuyide A, Gebhart JB, Hopkins MR, Breitkopf DM. Clinical manifestations and outcomes in surgically managed Gartner duct cysts. J Minim Invasive Gynecol 2017;24:473–77.
5. Cochard LR. Netter’s atlas of human embryology, updated edition. Philadelphia (PA): Saunders Elsevier; 2012.
12. Hagspiel KD. Giant Gartner duct cyst: magnetic resonance imaging findings. Abdom Imaging 1995;20:566–8.
VOL. 0, NO. 0, MONTH 2017
Davidson and Barber
Gartner Duct Cyst Mimicking Prolapse 3
Copyright Ó by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
