In the last few decades, gynecological visits for vulvar conditions have increased, often for symptoms of vulvar itching and burning. Although benign vulvar tumors are an uncommon condition of the lower genital tract, it is important to consider these tumors in the differential diagnosis of vulvar complaints. To date, there is no accepted classification for benign tumors. However, these tumors can be differentiated by clinical criteria, such as benign cystic and solid tumors. Common benign tumors of the vulva include the Bartholin gland cyst or abscess, epidermoid inclusion cysts, and angiomas. Many benign vulvar tumors are asymptomatic and are found only on self-examination. Depending on the type of lesion, most do not require excisional treatment. It is important for the gynecologist to differentiate between benign and malignant lesions as malignant tumors require proper treatment.
Introduction
Benign vulvar tumors are uncommon in the lower genital tract, but are frequently a reason for a gynecologic consultation. Although most tumors do not require treatment, it is necessary to consider a differential diagnosis that includes infectious lesions, skin cancers, and pre- and malignant tumors. Currently, there is no accepted classification of benign vulvar tumors. In 2006 and 2011, the International Society for the Study of Vulvovaginal Disease (ISSVD) published nomenclature and classification of vulvar dermatologic disorders that can be used as a helpful diagnostic tool for vulvar lesions. Clinically, however, vulvar tumors can be simply divided into two major groups: cystic and solid tumors ( Table 1 ).
Mucosal cystic tumors
Within this group is the Bartholin cyst or abscess, epidermoid inclusion cyst, canal of Nuck cyst, Skene (paraurethral) cyst, and vestibular mucous cyst.
Bartholin gland cyst or abscess
The Bartholin glands are paired glands that lie deep to the mucous membrane of the vulvar vestibule. The ducts of the glands exit at 4 and 8 o’clock at the level of the vestibule (outside the hymenal ring) and are notable by pinpoint ostia. Histopathologically, they are covered with cuboidal epithelium that is mucin secreting. The ducts are either squamous-columnar or transitional epithelium. These paired glands secrete a mucin-like substance during sexual stimulation that contributes to the lubrication women note at the vaginal introitus. These glands are approximately 0.5–1 cm in size, and are not typically palpable except when they are fluid filled .
Cysts and abscess of the Bartholin’s gland are the most common disorders of the Bartholin glands and are usually present in a woman’s reproductive period. When the ostia or ducts become obstructed, mucous or pus accumulates leading to dilation and enlargement of the gland. A Bartholin cyst is associated with a viscous syrupy fluid that fills the gland. They are typically 1–3 cm in size but can measure up to 5 cm. In smaller cysts, symptoms may be absent. Larger cysts may cause pressure and pain. The diagnosis is clinical and often incidental. These can be observed in most cases. Some women will require treatment. Techniques are similar to Bartholin abscess (see below). In postmenopausal women with a Bartholin cyst, some experts advise a biopsy of the gland to rule out a rare adenocarcinoma of the gland.
A Bartholin abscess occurs when the fluid-filled cyst becomes infected with bacteria and the gland distends with pus. Traditionally, the inciting organism was believed to be Neisseria gonorrhoeae or Chlamydia trachomatis but rates of infection with these organisms have declined markedly. Recent studies show the presence of opportunistic organisms, as either single agents ( Escherichia coli (E. coli) ) or polymicrobial infections . The diagnosis is clinical and most women experience exquisite pain with great difficulty with sitting or walking. Women present acutely to the office or emergency room. Physical examination reveals a tense, tender, fluctuant mass distorting the vulvar anatomy that often fools the inexperienced practitioner into believing this is a labia majora abscess. Treatment is necessary and immediate relief occurs when the pus is drained. This can be accomplished by a number of techniques: a) incision and drainage of the abscess, b) incision and drainage followed by insertion of a Word Catheter, c) marsupialization, and d) gland excision .
- 1.1a
Incision and drainage of the abscess is the simplest technique leading to decompression of the Bartholin cavity and rapidly alleviates symptoms of pain. This technique consists of making an incision over the area of greatest tension of the abscess. Incision should be performed close to the Bartholin duct meatus in the vulvar vestibule. Although this is symptomatically effective, it has a high rate of recurrence if it is not coupled with another treatment (see below).
- 1.1b
The placement of a Word catheter is a technique that often accompanies incision and drainage. The Word catheter is a small latex catheter with a terminal balloon that is easily inflated with 3–5 mL of sterile saline or sterile water. Balloon expansion occurs once the catheter has been placed through the gland incision. A Word catheter allows the enlarged (and infected) gland to stay open as it creates a tract by fistulization. Typically, these catheters are left in place for 4–6 weeks. After placement, the catheter tail is tucked into the vagina for patient comfort .
- 1.1c
Marsupialization is an effective procedure that was originally described in 1950. This technique includes creating a “pouch” after making a 2–2.5-cm incision along the long axis of the abscess and suturing the cyst wall to the vestibular mucosa. This allows the abscess cavity to remain open as infection clears.
- 1.1d
Gland removal: Ultimately, if these measures are not successful, gland removal in the operating suite is definitive treatment.
Recurrence is always a consideration for a Bartholin gland cyst or abscess. Marsupialization is associated with the lowest rate of recurrence (besides gland excision) and can be performed in an outpatient office setting ( Fig. 1 ).
Epidermoid inclusion cyst
Epidermoid inclusion cysts, also called epidermal cysts, occur at any age, even in newborns, and mainly affect the labia majora. These common cysts are mistakenly called sebaceous cysts and arise from hair follicles that are obstructed with keratin leading to a characteristic yellow-white papule . These cysts may be single or multiple, and sometimes look like milla. They typically measure 2–5 mm. Most epidermal inclusion cysts are not symptomatic but can require incision and drainage when symptoms lead to irritation. Inflammation and secondary infection can occur with scratching or rubbing .
Skene’s (paraurethral) gland cysts
Skene’s glands are bilateral paraurethral glands located to the right and left of the urethral meatus. These glands are analogous to the prostate gland in men and secrete a small amount of mucoid material that contributes to lubrication during sexual activity. When there is obstruction of the Skene’s duct, a cyst may form. Differential diagnosis should include a urethral diverticulum as treatment is markedly different between the two conditions. Urethral diverticulum is in direct communication with the urethra thus incision and draining leads to direct injury to the urethra. Urethrocystoscopy and magnetic resonance imaging (MRI) can differentiate a urethral diverticulum from a Skene’s gland cyst .
Canal of Nuck cyst
Canal of Nuck cyst is a peritoneal sac cyst located in the upper and lateral regions of the labia majora. Anatomically, this herniating sac may accompany the round ligament through the inguinal canal into the labia majora. This rudimentary peritoneal sac is normally obliterated during embryonic life or early childhood . Canal of Nuck cysts are also called hydroceles (analogous finding in males). A third of these cysts are associated with an inguinal hernia, but they usually do not contain omentum or bowel loops. These cysts can exceed 5 cm, are typically soft, malleable, and elastic. They can wax and wane in size, indicative of the movement of peritoneal fluid through this canal. Most canal of Nuck cysts are painless. The differential diagnosis can be difficult, and must be distinguished from inguinal hernias, lymphadenopathy, and soft tissue tumors such as lipomas, leiomyomas, and endometriosis of the round ligament.
The most common method for diagnosis is by clinical examination; however, ultrasound can help distinguish a cystic and solid mass. MRI can be useful in difficult cases .
Treatment consists of observation to surgical excision. Small cysts can be followed expectantly. Large canal of Nuck cysts require excision with careful surgical dissection of the inguinal region and potential plastic surgery closure. Employment of a general surgeon can be useful if the inguinal canal is involved as most gynecologists do not operate in this region of the body.
Vestibular mucous cysts
Mucous cysts generally come from the minor vestibular glands that are located within the vestibule of the vulva (adjacent to the hymen). These simple cysts are typically symptomatic and are generally discovered on physical examination. They range in size from several millimeters to several centimeters. Confusion with a Skene’s gland cyst is common, especially when the vestibular mucous cyst is located in the anterior vestibule. These simple cysts are covered by mucous secreting columnar epithelium and are sometimes accompanied with squamous metaplasia. They are characterized by being sessile, unique, spherical or ovoid cysts, with liquid consistency . As most are asymptomatic, they may not require treatment. Occasionally, surgical excision of these tumors is necessary if symptoms of pressure, pain, cosmesis, or dyspareunia appear.
Mucosal cystic tumors
Within this group is the Bartholin cyst or abscess, epidermoid inclusion cyst, canal of Nuck cyst, Skene (paraurethral) cyst, and vestibular mucous cyst.
Bartholin gland cyst or abscess
The Bartholin glands are paired glands that lie deep to the mucous membrane of the vulvar vestibule. The ducts of the glands exit at 4 and 8 o’clock at the level of the vestibule (outside the hymenal ring) and are notable by pinpoint ostia. Histopathologically, they are covered with cuboidal epithelium that is mucin secreting. The ducts are either squamous-columnar or transitional epithelium. These paired glands secrete a mucin-like substance during sexual stimulation that contributes to the lubrication women note at the vaginal introitus. These glands are approximately 0.5–1 cm in size, and are not typically palpable except when they are fluid filled .
Cysts and abscess of the Bartholin’s gland are the most common disorders of the Bartholin glands and are usually present in a woman’s reproductive period. When the ostia or ducts become obstructed, mucous or pus accumulates leading to dilation and enlargement of the gland. A Bartholin cyst is associated with a viscous syrupy fluid that fills the gland. They are typically 1–3 cm in size but can measure up to 5 cm. In smaller cysts, symptoms may be absent. Larger cysts may cause pressure and pain. The diagnosis is clinical and often incidental. These can be observed in most cases. Some women will require treatment. Techniques are similar to Bartholin abscess (see below). In postmenopausal women with a Bartholin cyst, some experts advise a biopsy of the gland to rule out a rare adenocarcinoma of the gland.
A Bartholin abscess occurs when the fluid-filled cyst becomes infected with bacteria and the gland distends with pus. Traditionally, the inciting organism was believed to be Neisseria gonorrhoeae or Chlamydia trachomatis but rates of infection with these organisms have declined markedly. Recent studies show the presence of opportunistic organisms, as either single agents ( Escherichia coli (E. coli) ) or polymicrobial infections . The diagnosis is clinical and most women experience exquisite pain with great difficulty with sitting or walking. Women present acutely to the office or emergency room. Physical examination reveals a tense, tender, fluctuant mass distorting the vulvar anatomy that often fools the inexperienced practitioner into believing this is a labia majora abscess. Treatment is necessary and immediate relief occurs when the pus is drained. This can be accomplished by a number of techniques: a) incision and drainage of the abscess, b) incision and drainage followed by insertion of a Word Catheter, c) marsupialization, and d) gland excision .
- 1.1a
Incision and drainage of the abscess is the simplest technique leading to decompression of the Bartholin cavity and rapidly alleviates symptoms of pain. This technique consists of making an incision over the area of greatest tension of the abscess. Incision should be performed close to the Bartholin duct meatus in the vulvar vestibule. Although this is symptomatically effective, it has a high rate of recurrence if it is not coupled with another treatment (see below).
- 1.1b
The placement of a Word catheter is a technique that often accompanies incision and drainage. The Word catheter is a small latex catheter with a terminal balloon that is easily inflated with 3–5 mL of sterile saline or sterile water. Balloon expansion occurs once the catheter has been placed through the gland incision. A Word catheter allows the enlarged (and infected) gland to stay open as it creates a tract by fistulization. Typically, these catheters are left in place for 4–6 weeks. After placement, the catheter tail is tucked into the vagina for patient comfort .
- 1.1c
Marsupialization is an effective procedure that was originally described in 1950. This technique includes creating a “pouch” after making a 2–2.5-cm incision along the long axis of the abscess and suturing the cyst wall to the vestibular mucosa. This allows the abscess cavity to remain open as infection clears.
- 1.1d
Gland removal: Ultimately, if these measures are not successful, gland removal in the operating suite is definitive treatment.
Recurrence is always a consideration for a Bartholin gland cyst or abscess. Marsupialization is associated with the lowest rate of recurrence (besides gland excision) and can be performed in an outpatient office setting ( Fig. 1 ).
