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Clinical case: Müllerian cyst
In this article, we describe a case of a woman who developed a Müllerian Cyst. We will explore its diagnosis, signs, symptoms, and management, together with some anatomical explanations that will help you understand the topic as much as possible!
| Cystocele |
- a collapsed urinary bladder caused by a degradation of the fascia between the bladder and vagina, usually occurring in postmenopausal women. Manifestation - urinary incontinence Causes - Lack of estrogen |
| Rectocele |
- a bulging of the rectum into the vagina caused by a degradation of the septum on the posterior side of the vagina Manifestations - rectal pain, constipation, difficulties during sexual intercourse Causes - hysterectomy, childbirth |
| Enterocele |
- a prolapse of the small bowel into the pelvis, resulting in a bulge of the vaginal wall Causes - pregnancy, childbirth, aging |
| Urethrocele | - a collapsed urinary bladder caused by a degradation of the fascia between the bladder and vagina, usually occurring in postmenopausal women. |
| 'Para 2' | Para (parity) represents the number of times a female is or has carried a pregnancy to term, so 'para 2' refers to two pregnancies carried to term |
| Origins of cysts |
Mesonephric duct cyst - non-malignant cyst that develops from the vestigial remnant of the mesonephric ducts Inclusion cysts - develop from an abnormal proliferation of epidermal cells within a specific area in the dermis Skene’s glands - their ducts that drain into the distal urethra may become infected and swell, producing cysts Bartholin’s glands - their ducts that drain into the vagina can become obstructed and distended |
| Vaginal fornices | Superior recesses of the vagina formed due to the protrusion of the cervix into the upper portion of the vagina |
| Anesthesia |
Spinal - anesthetic is injected inside the subarachnoid space within the lumbar cistern, impairing movement and numbing Epidural - anesthetic is injected inside the epidural space surrounding the inferior part of the dural sac, causing only loss of sensation while preserving motor control. |
After reviewing this case you should be able to describe the following:
- What is meant by a cystocele and what are the typical causes of this condition. What is meant by a rectocele and what are its causes. And the same for an enterocele.
- What is meant by “para 2.” What is the associated term is and what it means.
- The origin (briefly) of: inclusion, mesonephric (Gartner’s), Skene’s and Bartholin’s gland cysts; also the basis of a urethrocele, and urethral diverticulum.
- What is meant by the vaginal fornices.
- What is spinal anesthesia? How it differs from epidural anesthesia.
This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.
It has been modified and reviewed by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.
Case description
History and clinical examination
A 42-year-old woman, para 2, was referred to the gynecology clinic after an initial incorrect diagnosis of having a cystocele. Upon physical examination she was found to have a very large (8 cm) nontender mass protruding from the anterior wall of her vagina (Figure 1).
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The asymptomatic mass had been apparent for about six months. The patient’s medical history was unremarkable. The mass was soft and could be readily compressed by manual pressure.
Imaging
Perineal ultrasonography and cystoscopy showed that the cyst was not related to the lower urinary tract; thus, the mass was likely a singular entity (Figure 2).
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This conclusion was further supported when the patient was evaluated after bladder emptying and the cyst did not change in size. Abdominal and vaginal ultrasonography failed to reveal any renal or associated internal genital pathology.
Management and evolution
Surgical extirpation was performed and the mass was removed via a vaginal approach, under spinal anesthesia.
There were no postoperative complications, and at the 4-week follow-up visit, the patient was in good clinical condition. Pathology confirmed a benign Müllerian cyst lined with mucinous and squamous epithelium (Figure 3).
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Anatomical and surgical considerations
The female reproductive system develops from two components: the urogenital sinus and the paramesonephric ducts. The two are conjoined at the sinus tubercle (Müllerian eminence). Paramesonephric ducts degenerate in males, but the adjoining mesonephric ducts (Wolffian) develop into male reproductive organs. This sex based differences in the contributions of the paramesonephric ducts to reproductive organs is dependent on the production, and degree of presence, of Müllerian Inhibiting Factor.
Vaginal cysts are relatively rare and tend to be small (less than 2 cm), to present in the third or fourth decade of life, and most are Müllerian, as in this case. The differential diagnoses of a cyst in the lower female genital tract include:
- Müllerian, inclusion, mesonephric (Gartner’s), Skene’s and Bartholin’s gland cysts;
- pelvic organ prolapse,
- hematocolpos, and
- a myxomatous tumor.
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Simple mesonephric (Gartner’s) or paramesonephric (Müllerian) cysts are prevalent near the fornices. But the most common location for Müllerian cysts, as here, is along the anterolateral aspect of the vagina. The great majority of vaginal cysts are asymptomatic and require no treatment. However, as in this case, a Müllerian cyst may become sufficiently large to become problematic and require excision. When cysts are symptomatic, patients may complain of:
- vaginal discomfort,
- vaginal pressure,
- vaginal mass,
- dyspareunia,
- vaginal bleeding,
- or urinary symptoms.
Müllerian cysts are benign. The patient in this case had an usual cyst in that it grew in size, was mistakenly diagnosed as a cystocele, and became symptomatic.
Objective explanations
Objectives
- What is meant by a cystocele and what are the typical causes of this condition. What is meant by a rectocele and what are its causes. And the same for an enterocele.
- What is meant by “para 2.” What is the associated term is and what it means.
- The origin (briefly) of: inclusion, mesonephric (Gartner’s), Skene’s and Bartholin’s gland cysts; also the basis of a urethrocele, and urethral diverticulum.
- What is meant by the vaginal fornices.
- What is spinal anesthesia? How it differs from epidural anesthesia.
Definition and causes of a cystocele, rectocele, & enterocele
A cystocele (Figure 5+6) occurs when the tough fascial septum between a woman's bladder and vagina degrades. Because estrogen helps maintain the elastic tissues around the vagina, cystoceles are typically found in postmenopausal women. With the degradation of the septum, the bladder collapses into the vagina. The woman may then experience urinary incontinence and incomplete emptying of the bladder. Figure 5 clearly shows why the original diagnosing physician had mistaken the cyst for a cystocele.
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A rectocele occurs when the septum on the posterior side of the vagina degrades, allowing the rectum to budge in the vagina. There are two main causes of a rectocele: childbirth, and hysterectomy. Rectoceles may be associated with rectal pain, constipation and difficulties during sexual intercourse.
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An enterocele (small bowel prolapse) occurs when the small bowel descends into the pelvis and causes the vaginal wall to bulge. Pregnancy and childbirth, and aging may put pressure on the pelvic floor musculature allowing an enterocele to occur. The bowel prolapse occurs at the rectouterine pouch, so from the lithotomy position an enterocele will look similar to a rectocele.
Meaning of 'para 2'
Parity (para) and gravidity (grad) are the number of times a female is or has carried a pregnancy to term (parity) and number of times a woman has been pregnant (gravidity).
Origin of various Cysts and the basis of urethrocele and urethral diverticulum
A mesonephric duct (Gartner’s duct) cyst is a non-malignant cyst that develops from the vestigial remnant of the mesonephric ducts. These cysts are typically small asymptomatic cysts that are located along the anterolateral walls of the vagina.
Inclusion cysts are the most common vulvar cysts and they may also occur in the vagina. They result from the abnormal proliferation of epidermal cells within a specific area in the dermis. This may be caused by trauma (e.g., laceration, episiotomy repair) that entraps viable epithelial tissue below the skin surface, or they may develop without a known cause.
Skene’s (lesser vestibular, paraurethral) glands are located on the anterior wall of the vagina. These glands have ducts that drain into the distal urethra. These ducts may become infected and swell producing cysts that cause pain and difficulty with urination and/or pain during intercourse.
Bartholin’s (greater vestibular) glands are located deep to the bulbospongiosus muscle. They secrete mucus that lubricates the vagina. The mucous reaches the vagina via two ducts. These ducts may become obstructed and distended producing discomfort, especially if they become large, and also during sexual intercourse.
A urethrocele is similar to a cystocele (see Explanation 1) but the urethra rather than the bladder herniates into the vagina. A urethral diverticulum is a pouch that forms along the urethra. The pouch is continuous with the urethral lumen and thus it can fill with urine. A urethral diverticulum may result in a painful vaginal mass, pelvic pain, and urinary tract infections.
Vaginal fornices
The fornices of the vagina (fornix is singular) are the superior recesses of the vagina (Figure 7). They are formed because the cervix protrudes into the upper portion of the vagina. The posterior fornix is larger than the anterior fornix. There are also two lateral fornices. The fornices are often perforated during attempted self-induced abortions.
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Spinal anesthesia
In spinal anesthesia, a small needle is used to inject the anesthetic directly into the subarachnoid space within the lumbar cistern. Spinal anesthesia numbs the body below and sometimes above the site of the injection and impairs movement.
In epidural anesthesia, a needle or catheter is injected into the epidural space surrounding the inferior part of the dural sac. The anesthetic generally results in a decrease or loss in lower body sensation while preserving motor control. The mechanism of exactly why this occurs is not known. Regardless, epidural anesthetics are often the anesthesia of choice during labor and delivery.
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