Large Gartner cyst of the posterior vaginal fornix

Background

‘Vaginal cyst’ is a generic medical term that encompasses many different lesions that may occur anywhere along the vaginal walls. When describing the prevalence, most of the literature cites the work of Pradhan and Tobon, who in 1986 reported a prevalence of 1 in 200. Although it is widely accepted that this number probably underestimates the actual prevalence of this anomaly, no other studies have investigated it.1 One reason could be the lack of an integrated classification that could help clinicians in their diagnostic approach. The two most important classifications of congenital anomalies of the reproductive tract, proposed by the American Society for Reproductive Medicine (formerly the American Fertility Society) and by the European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy, do not take into consideration vaginal cysts of embryological origin.2 3 A recent publication by De Bortoli et al proposed a new integrated classification that uses anatomy in conjunction with the embryological and dermatological origins, which, although interesting, is only based on a literature review, and its clinical impact has not been evaluated.4 For these reasons, clinicians who have to deal with a rare presentation of a vaginal cyst are left with only their clinical judgement when making a diagnosis and deciding which management to pursue.

This case report perfectly embodies the difficulties that one has to face when approaching such patients, and the timeline depicted in figure 1 shows the many procedures and diagnostic exams that were carried out over 3 years before a final diagnosis could be made. This case report was prepared following the CARE (CAse REports) guidelines.5

Case presentation

Investigations

Transvaginal ultrasound showed a normal-sized uterus and regular adnexa and underneath the uterus and posterior to the cervix an anechoic cystic mass, measuring 65×43×47 mm, with no vascularisation and without any endocystic papillary structures that moved concomitantly with the uterus (figure 3). The only wall of the cyst that was clearly definable was the anterior one, which gave us the idea that the mass originated from a fluid collection behind a TVS, but we could not exclude that the mass was also involving the rectum.

Subsequently, a proctosigmoidoscopy excluded a rectal pathology, as well as a possible communication between the cyst and the rectal lumen. A transrectal ultrasound ascertained that the cyst wall was independent from the anterior rectal wall and only adjacent to it. Tumour markers (Ca 125, CEA and Ca15.3) done in the past were negative and were not repeated.

Although all the aforementioned diagnostic workups the clinical dilemma remained: was the mass a vaginal cyst originating from the upper portion of the vagina or was instead a fluid accumulation behind a complete transverse cervicovaginal septum?

Differential diagnosis

As previously mentioned in the introduction, the two major classifications of congenital Mullerian anomalies do not give enough attention or do not even mention the anomalies that could involve the vagina. We investigated the literature to find any case report on pelvic–vaginal cysts that resemble our case. Unfortunately, all the published cases of vaginal cyst describe masses that originate from the anterior wall and usually protrude into the vagina but not into the pelvis. We also found a case report of a TVS, similar to our case, but which was located in the lower part of the vaginal canal and led to amenorrhoea and hematocolpos.

Treatment

On the basis of the available preoperative data, we discussed with the patient about the risks and benefits of the possible therapeutic options: cyst–septum fenestration versus total cyst removal; an ultrasound-guided tetracycline sclerotherapy was also considered but excluded because of the large size of the lesion and the lack of a definitive preoperative diagnosis.6 After obtaining the informed consent from the patient, in which she expressed her desire for the least invasive approach, we decided to treat the lesion through the vagina under spinal anaesthesia. An experienced gynaecologist performed the procedure. Collin’s vaginal speculum was inserted, and the bulging membrane was grasped with two Kelly’s clamps (figure 4). The cyst was punctured and around 30 mL of clear fluid was aspirated and stored for cytological evaluation. A small vertical incision was then performed and through it a mini-hysteroscope was inserted. When the internal of the cyst was inspected, it appeared smooth, quite hyperemic; as it was slightly inflamed and devoid of vaginal rugae, no fistula or other sort of communication with the adjacent organs were seen. A circumferential excision of the cyst’s anterior wall protruding in the vagina was made, and the bleeding edges were sutured with a continuous through and through stitches around the entire circumference using Vicryl 00 (figure 5). The patient made an uneventful recovery and was discharged the day after surgery.

Outcome and follow-up

Cytological evaluation of the intracystic fluid collection revealed an acellular fluid content and the histopathological examination reported a cyst wall lined by a single layer of simple ciliated cuboidal cells, at places de-epithelialised. The subepithelial stroma had vascular congestion and showed inflammatory infiltrate (figure 6). After discussing with the pathologist, given the non-mucinous aspect of the cells, a definitive diagnosis of Gartner’s cyst was made.

The patient, followed up biweekly for 3 months, remained asymptomatic, with normal menstrual cycle and did not report any discomfort during intercourses, which were allowed to restart 2 months after surgery.

The last clinical examination showed intact fenestration with some vaginal rugae formation beyond it and no vaginal discharge, and the transvaginal ultrasound showed a normal posterior fornix (figures 7 and 8).