A Mirror of Hospital Practice

VAGINAL Case record The patient, aged 22, para I, admitted with By N. C. m.b. (Cal.), d.g.o. (Dub.), f.r.c.s. (Edin.) SEN, of 10 duration Obstetrician and Gynecologist, Sanctoria Hospital, painless vaginal bleeding days' with no of amenorrhce?L Disergarh P. O., Dist. Burdwan, West Bengal previous history History of difficulty during coitus was elicited Benign tumours of the are rare. Of only on asking. General condition was fair. these, the cystic tumours are commoner than Vaginal examination revealed an anteverted, the solid. Cystic tumours of the vagina may firm, regular, normal-sized with normal have various points of origin. According to adnexa. A sessile smooth swelling was felt high Taussig (1922), they may arise from (i) the up in the vagina on its anterolateral wall remnants of the Wolffian ?it being the on the left side. Speculum examination revealed commonest source, (ii) from an accessory a glistening white, thin-walled, smooth, tense cyst ureter as a soft sac-like mass in the lateral with a broad base, about 1^ inches by 2 inches, anterovaginal wall, (in) from epithelial inclu- projecting from the anterolateral wall on the sions produced at the time of vaginal or left. There was a bad erosion on either lips of perineal repairs and rarely (iv) from remnants the . The bleeding was uterine and fairly of true vaginal glands. Whitehouse (1935) active. Dilatation of the cervix and curettage cites other sources, viz, of endometrio- was done and the cyst removed. arise in matous nature which the rectovaginal The cyst, on puncture, produced clear, watery septum from endometriomatous growth and pro- fluid. Its wall was thin and the inside smooth. ject from the upper part of the posterior examination revealed the follow- wall of the vagina. He records "two such Histological ing features (see figures 1 and 2, plate XLIX) : cases. Very rarely, there may be multilocular (1) The cyst wall was lined incompletely with in the Occasionally cystadenomata vagina. a of cubical . dilated resemble small thin, single layer also, lymphatics may There were a few villous projections inside the with an endothelial under cysts lining. Again, cyst cavity (A), also lined incompletely with of cells down the influence inflammation, grow a layer of cubical epithelium. The walls as from the basal layer of vaginal stratified well as the core of the villi were made of soft epithelium in the form of solid processes, from fibrous tissue showing some amount of which glandular tubules may ultimately develop. degeneration in the villi (A). Situated in the From these pseudoglands small cysts arise, wall of the cyst were seen narrow linear spaces, which may be so numerous as to be studded all lined with cylindrical epithelium (B). No over the vaginal surface. The condition in this cilia were visible on the cylindrical cells extreme degree is very rare, and has been although no special staining was done with described by Bonney and Glendinning (White- this purpose. These spaces were evidently the remnants of the Wolffian Towards the house, 1935) as adenomatosis vaginse. In fewer system. side of the wall were seen long numbers, or as isolated examples, such cysts are vaginal cyst narrow lined with stratified not uncommon. They are usually found in the spaces epithelium, at continuous with that the vagina third of the and are places lining upper vagina, generally and at to be isolated (D) associated with chronic inflammation of the (C) others, appeared There were some round cell infiltra- cervix uteri. completely. tion round these s|paces, and also under tihe The case recorded here is that of a cyst of vaginal mucosa. The wall of the^ cyst also Wolffian duct origin. contained blood vessels and lymphatic spaces. 456 THE INDIAN MEDICAL GAZETTE [Oct., 1950

Comments layer of stratified squamous epithelium is seen in of the wall. The same The Miillerian and Wolffian ducts grow, during part cyst cyst may show the embryonic period, in close neighbourhood. In different types of epithelium in different the female, Miillerian system predominates parts of its wall. When the cyst is large, the be so flattened out and develops into various system. epithelium may by pressure The Wolffian system atrophies and its vestiges atrophy as to be almost unrecognizable. In remain in the neighbourhood of the female sex some cases, it is completely atrophied and duct called the wall becomes denuded of its organs. The main the Gartner's ' epithelial Remnants .of the Wolffian duct courses in the , then extends layer (Novak, 1947). are visible in the downwards along the lateral margin of the , system usually neighbourhood uterus (occasionally included in the uterine of the cyst. In the present case, the epithelial musculature itself) and then along the antero- layer consisted almost entirely of cuboidal lateral wall of the vagina to its lowermost epithelium and was denuded at places. The portion. Usually its lumen is obliterated but spaces lined with stratified epithelium and often it is incomplete. Cystic dilatation of surrounded by a round cell infiltration (C and D imperfectly obliterated portion of the duct in photomicrograph) are probably inclusions of the mucosa in its wall due to chronic may result in cyst in various portions of its vaginal infective in the and are course. While in the upper part of its course process neighbourhood of it may give rise to various types of broad probably potentially capable producing cyst cysts, in the lower part it gives rise to as described by Bonney and Glendinning. as is recorded here. Symptoms and signs Character of cyst Vaginal cysts give rise only to symptoms of mechanical at the While usually small and single, protruding origin; they may protrude causing discomfort and bearing down into the vagina, it may be segmented and , pain due to pressure on the pelvic floor muscles. multiple and may attain a large size. When may cause in coitus. the cyst may burrow under the anterior They occasionally difficulty large, In the the was moderate in wall and inside the lumen of present case, cyst vaginal project size and as the the vagina and even show at the vaginal produced slight dyspareunia introitus to simulate very closely, and only symptom. it may also be associated with it. Again, it may also proceed deeply into the pelvic cellular tissue. Treatment these are sessile but be Usually, cysts may When small and symptomless the cyst does in occasional cases. The wall is thin polypoid not require any treatment but' when there is and translucent and the content is usually watery symptom it should be treated with surgical and colourless although it may be blood-stained excision. in some cases.

REFERENCES Situation Novak, E. (1947) .. Gynaecological and Obstet- Due to the situation of the Gartner's duct in rical Pathology. W. B. the anterolateral wall of the vagina, the cyst Saunders Co., Philadelphia. arising from it also has this peculiar site. This Taussig, F. J. (1022) .. Nelson's Loose Leaf Sur- contrasts well with the more common variety gery, 7, 653. Thomas of the viz inclusion The Nelson and Sons, New vaginal cyst, cysts. York. latter, usually small, are situated in the lower part of the vagina in its posterior wall and only Whitehouse, H. B. Eden and Lockyer's Gyncc- in its lateral and anterior walls. (1935). cology. J. and A. Churchill occasionally London. This peculiar distribution of the inclusion Ltd., cysts is easily explainable by their aetiology, i.e. by inclusion of vaginal mucosa beneath its surface either after irregular lacerations of the vagina^ after childbirth or after the operation of perineorrhaphy, both by burial of mucous membrane tags when the wound is sutured.

Microscopic features 1 The wall of the Gartner's duct cysts is lined by an epithelial layer, often of undulating outline. The lining cells present many varia- tions. Usually there is a single layer of cubical or cylindrical cells, not infrequently showing cilia. Often, however, a flattened Plate XLIX VAGINAL CYST : N. C. SEN. (M. H. P.) PAGE 455

ili

Fig. i.1. A = A villus projecting into the cyst cavity and lined by cuboidal cells and showing some degeneration. B =?Remnants Remnants of Wolffian system, a linear, narrow space lined by cylindrical epithelium.

2. Fig. _ C = Linear space lined by stratified epithelium and continuous with that lining the vaginal mucosa. D = Narrow space lined by stratified epithelium appearing to be completely isolated from (E).