Vaginal Bulge is Not Always Prolapse.

Objective: The objective of this video is to review a case of a patient that presented to urogynecology clinic for prolapse, but was noted to have anterior vaginal cyst. In this video we review differential diagnosis, embryologic origin of vaginal cyst, excision procedure, imaging and pathology of the vaginal cyst.

Setting: Urogynecology clinic/operating room PARTICIPANT: Patient who presented with anterior vaginal cyst INTERVENTION: 34yo G0 referred to Urogynecology for a vaginal bulge. On exam she had a 4 cm anterior vaginal cystic mass. The differential diagnosis for benign vaginal cysts is broad including Müllerian or Gartner's (mesonephric) ducts, Skene duct, Bartholin gland, epidermal inclusion, or endometriotic cysts, adenosis, or urethral diverticulum (1,2). Most are secondary to embryological remnants or trauma (3). Müllerian ducts form the fallopian tubes, broad ligament, uterus, cervix and upper part of the vagina. Müllerian epithelium is replaced with squamous epithelium of the urogenital sinus; however, Müllerian epithelium can persist anywhere along the vaginal wall. Thus, Müllerian cysts can be found at any location in the vagina (4). During vaginal cyst work-up, imaging can be helpful to further differentiate the cyst and aid in surgical planning. Our patient had an in-office translabial ultrasound that revealed a fluid filled vaginal cyst that had possible bladder connection. Pelvic MRI showed a 4 cm non-communicating fluid-filled cyst that was abutting the bladder in its entirety. We present imaging and a surgical excision video demonstrating the importance of meticulous dissection directly on the bladder wall. The video also presents histopathology slides with bland, endocervical-type columnar epithelium, leading to the final diagnosis of a Müllerian duct cyst.

Conclusion: Vaginal cysts require careful examination and imaging. Understanding their location is crucial for surgical planning, counseling, and successful patient outcomes.