{"paper_id":"cfb174b9-e405-4510-a22b-5a68d7e12980","body_text":"Female Genital Tract Cysts\nAbstract\nCystic diseases in the female pelvis are common. Cysts of the female \ngenital tract comprise a large number of physiologic and pathologic \ncysts. The majority of cystic pelvic masses originate in the ovary, and \nthey can range from simple, functional cysts to malignant ovarian \ntumors. Non-ovarian cysts of female genital system are appeared at \nleast as often as ovarian cysts. In this review, we aimed to discuss the \nmost common cystic lesions the female genital system.\nKey words: Female, genital tract, cyst\nKadın Genital Sistem Kistleri\nÖzet\nKadınlarda pelvik kistik hastalıklar sık gözlenmektedir. Kadın genital \nsistem kistleri çok sayıda patolojik ve fizyolojik kistten oluşmaktadır. \nPelvik kistlerin büyük çoğunluğu over kaynaklı olup, basit ve fonksi-\nyonel kistten malign over tumörlerine kadar değişebilmektedir. Over \nkaynaklı olmayan genital sistem kistleri ise en az over kistleri kadar sık \nkarşımıza çıkmaktadır. Biz bu derlememizde, kadın genital sisteminde \nen sık karşılaşabileceğimiz kistik lezyonları tartışmayı amaçladık.\nAnahtar kelimeler: Kadın, genital sistem, kist\nKonya University, Meram Medical Faculty, \nDepartment of Obstetric and Gynacology, \nKonya, Turkey \nEur J Gen Med 2012;9 (Suppl 1):21-26\nReceived: 27.12.2011\nAccepted: 12.01.2012\nCorrespondence: Dr. Harun Toy\nHarun Toy, MD, Konya University, Meram \nMedical Faculty, Department of Obstetric \nand Gynacology, 42060 Konya, Turkey.\nTel:+903322237863\nE-mail:haruntoy@hotmail.com\nHarun Toy, Fatma Yazıcı\nEuropean Journal of General Medicine\nReview Article\n\nEur J Gen Med 2012;9(Suppl 1):21-26\nFemale genital tract cysts\n22\nFEMALE GENITAL TRACT CYSTS\nLesions of the female reproductive system comprise a \nlarge number of physiologic and pathologic cysts (Table \n1). In order to avoid unnecessary therapy or treatment \ndelay, in most cases, it originates in the ovary.\nI.UTERUS\nA. Congenital Mullerian (paramesonephric) duct \nanomalies\nIf the uterine horn becomes obstructed, it may become \ndilated and filled with fluid or blood products and thus \nmimic a cystic pelvic mass such as a non-communicating \nrudimentary horn with uterus unicornis (1).\nB. Congenital uterine cysts such as Wolffian duct (me-\nsonephric) cysts \nC. Mullerian duct cysts\nD. Adenomyosis\nAdenomyosis is a common, nonneoplastic condi¬tion \nthat affects menstruating women, particu¬larly those \nwho are multiparous. In cystic adeno¬myosis, lesion size \nvaries, and lesions may occur anywhere within the myo-\nmetrium (1).\nE. Cystic degeneration of intrauterine leiomyoma\nAn exophytic or pedunculated leiomyoma also may \nmimic a cystic adnexal mass if cystic degeneration is \npresent.\nF. Cystic adenomatoid tumor\nCystic changes of adenomatoid tumors are extremely \nrare, and this tumor is found subserosally in the pos-\nterior fundus or near the cornua. The wall of the cystic \nadenomatoid tumor is lined with flattened cuboidal epi-\nthelium, and this epithelial cells show immunopositivity \nfor cytokeratin and calretinin (2).\nG. Adenocystic tumor\nH. Intramyometrial hydrosalpinges\nI. Parasitic cysts such as echinococcal cyst\nJ. Cystic endometrial atrophy: a cystic gland dilata-\ntion combined with endometrial atrophy.\nK. Cystic endometrial hyperplasia: is characterized by \nsimilar small endometrial cysts in an evenly thickened \nendometrium of over 5 to 6 mm.\nII. CERVIX UTERI\nA. Benign Diseases\n1. Cervical Nabothian Cysts: A nabothian cyst is a \ncommon incidental finding that is usually located in \nthe uterine cervix where one would find endocervical \nglands. Submucosal layer of the cervix is the most com-\nmon location of these cysts, rarely they are seen deeply \ninto the cervical wall. Nabothian cysts may occur by the \ninflammation and reparative processes of chronic cer-\nvicitis, following minor trauma or childbirth. Anechoic \ncystic structures are the ultrasonographic apperances of \nthese cysts. Adenoma malignum (minimal deviation ad-\nenocarcinoma of mucinous type) or other glandular ma-\nlignant cervical lesions can mimic nabothian cysts, but \nthe latter are usually located deeper in the cervix (3,4). \nGenerally, nabothian cysts do not require any therapy. \nIf the lesion character is not clear and malignancy can -\nnot be ruled out and if the patient relief from pain or \na bothersome feeling of fullness in the vagina, surgical \nintervention is needed (3-5).\n2. Tunnel Cluster: A specific type of nabothian cyst. \nCharacterized by complex multicystic dilatation of en -\ndocervical glands (3).\n3. Uterine Cervicitis: Uterine cervicitis is one of the \nmost common gynecologic diseases. Symptoms or signs \nof acute cervicitis are a tenacious jellylike, yellow, or \nturbid discharge and a sensation of pelvic pressure or \ndiscomfort (3).\n4. Endocervical Hyperplasia: Located in the endocervix \nand superficial layer of the cervical wall. Frequently \nseen in women who use oral contraceptive agents and \nwomen who are pregnant or postpartum (3).\n5. Endometrioma: Endometriosis of the uterine cervix \nis estimated at 0.1– 2.4% of all endometriotic localiza-\ntions. This rare localization may be totally asymptom -\natic or associated with nonspecific findings like postco-\nital or intermenstrual bleeding. The classic strategies \nof diagnosis and management involve colposcopy and \nexcision (6).\nB. Malign Diseases\n1. Adenocarsinoma \n2. \nAdenoma malignum: Adenoma malignum, which is also \ncalled ‘‘minimal deviation adenocarcinoma’’, is known \nto be a rare variant of well-differentiated mucinous ad-\nenocarcinoma of the uterine cervix, which is character-\nized by multilocular cystic lesions extending from the \nendocervical glands to the deep cervical stroma (7).\n\nToy and Yazıcı\nEur J Gen Med 2012;9(Suppl 1):21-26\n 23\nIII. VAGINA AND VULVA\nBenign vaginal cysts are in the majority of cases asymp-\ntomatic and are often incidentally discovered during \ngynecological examination for other purposes (8). True \ncystic lesions of the vagina originate from vaginal tissues \nbut lesions arising from the urethra and surrounding tis-\nsues can present as cystic lesions in the vagina as well \n(9). The incidences of cyst types in decreasing order are \nas follows: mullerian cysts (44%), epidermal inclusion \ncysts (23%), Gartner’s duct cysts (11%), Bartholin’s gland \ncysts (7%) and endometriotic type (7%). Vaginal cysts are \nmost common in the third and fourth decades (9,10). \nThrough physical examination the lesion should be as-\nsessed for location, mobility, tenderness, definition \n(smooth versus irregular) and consistency (cystic versus \nsolid) (9). Imaging by means of ultrasound, voiding cys-\ntourethrogram (VCUG), computerized tomography (CT) \nor magnetic resonance imaging (MRI) may be required to \ncharacterize the lesion further (9). \nA. CYSTS OF EMBRYONIC ORIGIN\n1. Mullerian Cysts\nMullerian duct cysts (MDCs) are uncommon pelvic cystic \nlesions, with the peak clinical incidence between the \nthird and fourth decades of life. They usually present as \nsmall, midline, cystic masses with no symptoms and re-\nquire no treatment. Occasionally, a mullerian cyst may \nbecome large enough that symptoms will warrant exci -\nsion (11).\n2. Gartner’s Duct Cysts\nGartner's duct cysts are cystically dilated wolffian duct \nremnants and these cysts are usually located along the \nanterolateral vaginal wall. Gartner’s duct cysts can also \nbe associated with abnormalities of the metanephric \nurinary system (9).\n3. Skene’s Duct Cysts\nSkene’s (paraurethral) glands are bilateral, prostatic \nhomologues located in the floor of the distal urethra. \nObstruction of the ducts, presumed secondary to ske -\nnitis (most commonly gonorrhea), causes formation of \ncysts (9). Benign, asymptomatic; if large, may cause \nurethral obstruction and urinary retention (3).\n4. Bartholin’s Duct Cysts\nBartholin’s glands are located bilaterally at the base of \nthe labia minora and drain through 2- to 2.5-cm–long \nducts that empty into the vestibule at about the 4 \no’clock and 8 o’clock positions. Bartholin’s duct cysts, \nthe most common cystic growths in the vulva, occur \nin the labia majora. Two percent of women develop a \nBartholin’s duct cyst or gland abscess at some time in \nlife (12,13). These benign cysts usually occur in women \nwho are in reproductive years (12). Obstruction of the \ndistal Bartholin’s duct may result in the retention of se-\ncretions, with resultant dilation of the duct and forma -\nTable 1. Cystic lesions of the female reproductive sys-\ntem.\nUterus\n  Congenital Mullerian (paramesonephric) duct anomalies\n  Congenital uterine cysts such as Wolffian duct (mesonephric) cysts \n  Mullerian duct cysts\n  Adenomyosis\n  Cystic degeneration of intrauterine leiomyoma\n  Cystic adenomatoid tumor\n  Adenocystic tumor\n  Intramyometrial hydrosalpinges\n  Parasitic cysts such as echinococcal cyst\n  Cystic endometrial atrophy\n  Cystic endometrial hyperplasia\nCervix uteri \n   Benign diseases\n       Cervical Nabothian Cysts \n       Tunnel cluster \n       Uterine cervicitis \n       Endocervical hyperplasia \n       Endometrioma\n  Malign Diseases\n       Adenocarsinoma \n       Adenoma malignum\nVagina and vulva \n  Cysts of embryonic origin \n     Mullerian cysts\n     Gartner’s duct cysts \n     Skene’s duct cysts \n     Bartholin’s duct cysts \n     Vaginal adenosis\n     Cysts of the canal of nuck (Hydrocele)\n  Cysts of urethral origin \n     Urethral caruncle \n     Urethral diverticulum\n  Epidermal cysts\n  Endometriosis\n  Ectopic ureterocele \n  Rare vaginal cystic lesions\nFallopian tubes\n  Hydrosalpinx \n  Hematosalpinx \n  Pyosalpinx\n  Inclusion cyst\nParaovarian cysts \n  Mesonephric cysts\n  Paramesonephric cysts\nOvarian cysts\n  Benign ovarian cyst\n  Bordeline ovarian cyst\n  Malign ovarian cyst\n\nEur J Gen Med 2012;9(Suppl 1):21-26\n24\nFemale genital tract cysts\ntion of a cyst. The cyst may become infected, and an \nabscess may develop in the gland. If the cyst becomes \ninfected, induration usually is present around the gland, \nand walking, sitting, or sexual intercourse may result \nin vulvar pain. Treatment is by incision and drainage. \nInsertion of a Word catheter, gauze wick or rubber drain \nmay also effect good drainage (12).\n5. Vaginal adenosis\n6. Cysts of the Canal of Nuck (Hydrocele): The proces-\nsus vaginalis, also referred to as the canal of Nuck, is a \nrudimentary peritoneal sac that accompanies the round \nligament through the inguinal canal into the labia ma-\njora. Cysts of the canal of Nuck are found in the superior \naspect of the labia majora or inguinal canal (9).\nB. CYSTS OF URETHRAL ORIGIN\n1. Urethral caruncle: Urethral caruncles present as lo -\ncalized, red, friable lesions at the urethal meatus. They \nare generally seen in the postmenopausal women, and \nthey most likely represent ectropion of the urethral wall \nsecondary to postmenopausal regression of the vaginal \nmucosa (9).\n2. Urethral diverticulum: A urethral diverticulum likely \nforms as a consequence of infected periurethral glands \nor cysts rupturing into the urethral lumen. Urethral di-\nverticula are usually found on the anterior vaginal wall \nalong the distal two-thirds of the urethra (9).\nC. EPIDERMAL CYSTS\nEpidermal inclusion cysts secondary to buried epithelial \nfragments following episiotomy or other surgical proce-\ndures are the most common nonembryological type of \nvaginal cysts. These are localized, painless, and easily \nconfused with sebaceous cysts. Most of these cysts are \nasymptomatic, treatment is by simple excision  (9).\nD. ENDOMETRIOSIS\nEndometriotic cysts of the vagina and vulva are rare. \nUsually they mimic other, more frequently encountered \nlesions. Not always they have the typical symptoms of \nendometriosis and there diagnosis is rare determined \nbefore the surgical procedure and hystopathological \nexamination. A detailed anamnesis, thorough clini -\ncal examination and additional methods (cystoscopic. \nimaging, sonographic) are needed for the diagnosis. \nManagement consists of a surgical removal of the le-\nsions, hormonal suppression of the ovarian function and, \nby all means, following up the patients for appearance \nof a recurrence or of a lesion de novo (14).\nE. ECTOPIC URETEROCELE \nA ureterocele is a cystic dilatation of the distal ureter. If \npresent with an ectopic ureter, may present as a cystic \nvaginal mass.\nF. RARE VAGINAL CYSTIC LESIONS\n1. Vaginitis Emphysematosa\n2. Hidradenoma\n3. Dermoid cyst\nIV. FALLOPIAN TUBES \nA. Hydrosalpinx: Hydrosalpinx is a common adnexal le-\nsion that may occur either in isolation or as a compo-\nnent of a complex pathologic process (eg, pelvic inflam-\nmatory disease, endometriosis, fallopian tube tumor, or \ntubal pregnancy) that leads to distal tubal occlusion. \nThe most common causes of hydrosalpinx are pelvic in -\nflammatory disease and endometriosis; among women \nwith these condi¬tions, 8% develop hydrosalpinx (1).\nB. Hematosalpinx: Hematosalpinx results from obstruc-\ntion and dilatation of the fallopian tubes by blood prod-\nucts. It most commonly occurs in the context of endo -\nmetriosis, although a tubal ectopic pregnancy, pelvic \ninflammatory disease, adnexal torsion, malignancy, and \ntrauma also may cause tubal bleeding (1,15).\nC. Pyosalpinx: Pyosalpinx is more likely to be bilateral, \nwith fal¬lopian tube wall thickening, thickened utero -\nsacral ligaments, edema of the presacral fat, and small-\nbowel ileus. Pelvic inflammatory disease is one of the \nmost common causes of acute pelvic pain; it is impor-\ntant to differentiate pelvic inflammatory disease from \novarian malignancy, adnexal torsion, and acute appen -\ndicitis (1).\nD. Inclusion Cyst: Peritoneal inclusion cyst are seen in \nthe serosa of the tube anda re related to the frequent \nirritations that plague the area.\nV. PARAOVARIAN CYSTS\nParaovarian cysts account for 10%–20% of all ad¬nexal \nmasses. They arise from the mesosalpinx—the superior , \nfree border of the broad ligament—which invests the \nfallopian tube. they are most common in women in the \n3rd and 4th decades of life (1). Two types of paraovar-\nian cyst\nA. Mesonephric cysts\nB. Paramesonephric cysts\n\nToy and Yazıcı\nEur J Gen Med 2012;9(Suppl 1):21-26\n 25\n1. Hydatid cyst of morgagni: These are a common find-\ning at laparatomy. They are paramesonephric in origin. \nThey are usually small and under rare circumstances \nmay undergo torsion.\nVI. OVARIAN CYSTS\nThe rapid development of ultrasound technology and its \nroutine application during gynecological examinations \nhas led to the more frequent detection of ovarian cysts. \nSuch cysts can be diagnosed at any age or stage of a \nwoman's life, and detected as early as the fetal stage or \nas late as the postmenopause. Large cysts, multiloculi, \nsepta, papillae and increased blood flow are all suspect-\ned signs of neoplasia. \nA. Benign Ovarian Cysts\n1. Follicle Cyst: Follicle cyst is found at mid cycle and \nits size ranges up to 25 mm. \n2. Corpus Luteum Cyst:\n3.Theca-Lutein Cyst: Theca lutein cysts or hyperstimu -\nlation cysts are associated with abnormal high levels of \nbHCG (human chorionic gonadotropine) as in multiple \ngestations, trophoblastic disease and most commonly \ndue to pharmacologic hyperstimulation (16).\nB. Borderline Ovarian Cysts\n1. Serous\n2. Mucinous\nC. Malign Ovarian Cysts\nCystic ovarian tumors are classified on the basis of tu -\nmor origin as epithelial germ cell sex cord stromal tu -\nmors, unclassified and metastatic tumors (Table 2). The \nsubtypes of epithelial tumors include serous, mucinous, \nendometrioid and clear cell tumors. They represent 60% \nof all ovarian and 85% of malignant ovarian neoplasms \nand their prevalence increases with age, peaking in the \nsixth and seventh decade of life (16).\nREFERENCES\n1. Moyle PL, Kataoka MY , Nakai A, Takahata A, Reinhold \nC, Sala E. Nonovarian cystic lesions of the pelvis. \nRadiographics 2010;30(4):921-38.\n2. Kim NR, Cho HY , Ha SY . Intramyometrial uterine cysts \nwith special reference to ultrastructural findings: report \nof two cases. J Obstet Gynaecol Res 2011;37(3):259-63.\n3. Bin Park S, Lee JH, Lee YH, Song MJ, Choi HJ. Multilocular \ncystic lesions in the uterine cervix: broad spectrum of \nimaging features and pathologic correlation. AJR Am J \nRoentgenol 2010;195(2):517-23.\n4. Yıldız Ç, Özsoy ZA, Bahçe S, Sümer D, Çetin A. Multiple \nand large nabothian cysts: a case report. Cumhuriyet Med \nJ 2009;31:456-45.\n5. Yamashita Y , Takahashi M. Adenoma malignum: MR ap-\npearances mimicking nabothian cyst. AJR 1994;162:649–\n50. \n6. Coccia ME, Rizzello F , Castellacci E, Cammilli F . \nSonographic diagnosis of a large and deep endometrioma \nof the uterine cervix. J Clin Ultrasound 2010;38(4):209-\n11.\n7. Sugiyama K, Takehara Y . MR findings of pseudoneoplastic \nlesions in the uterine cervix mimicking adenoma malig-\nnum. Br J Radiol 2007;80(959):878-83.\n8. Kondi-Pafiti A, Grapsa D, Papakonstantinou K, Kairi-\nVassilatou E, Xasiakos D. Vaginal cysts: a common \npathologic entity revisited. Clin Exp Obstet Gynecol \n2008;35(1):41-4.\n9. Eilber KS, Raz S. Benign cystic lesions of the vagina: a \nliterature review. J Urol 2003;170(3):717-22.\nTable 2. Classification according to the origin due to \novarian tumors\n1. Epithelial ovarian tumors\n   a. Serous\n   b. Mucinous\n   c. Emdometrioid\n   d. Clear cell\n   e. Transitional cell\n2. Germ cell tumors\n   a. Dysgerminoma \n   b. Endodermal sinus tumor\n   c. Polyembryoma\n   d. Choriocarcinoma\n   e. Teratoma\n3. Sex Cord-stromal tumors\n   a. Granulosa-stromal cell\n     i. Granulosa cell\n     ii. Thecoma-fibromas\n   b. Sertoli-Leydig cell \n   c. Sex cord tumor\n   d. Gynandroblastoma\n   e. Sex cord tumor with annular tubules\n4. Unclassified and metastatic\n\nEur J Gen Med 2012;9(Suppl 1):21-26\nFemale genital tract cysts\n26\n10. Pradhan, S. and Tobon, H.: Vaginal cysts: a clinicopatho-\nlogical study of 41 cases. Int J Gynecol Pathol 1986;5:35.\n11. Li CC, Ko SF , Ng SH, Huang CC, Wan YL, Lee TY . Symptomatic \ngiant Müllerian duct cyst in an infant: radiographic and \nCT findings. Abdom Imaging 2004;29(4):525-7.\n12. Omole F , Simmons BJ, Hacker Y . Management of \nBartholin's duct cyst and gland abscess. Am Fam Physician \n2003;68(1):135-40.\n13. Kaufman RH. Benign diseases of the vulva and vagina. 4th \ned. St Louis: Mosby, 1994:168-248.\n14. Tiufekchieva E, Borisov S. Endometrial cysts of the va-\ngina and the vulva (case reports and a literature review). \nAkush Ginekol (Sofiia) 2006;45(7):55-8.\n15. Atri M, Ascher SM. Fallopian tubes: hematosalpinx. In: \nHricak H, Akin O, Sala E, et al, eds. Diagnostic imaging: \ngynecology. Salt Lake City, Utah: Amirsys-Elsivier, 2006; \n50–55.\n16. Dujardin M, Schiettecatte A, Verdries D, de Mey J. Cystic \nlesions of the female reproductive system: a review. JBR-\nBTR 2010;93(2):56-61.","source_license":"CC0","license_restricted":false}