Review Article Female Genital Tract Cysts Harun Toy, Fatma Yazıcı Konya University, Meram Medical Faculty, Abstract Department of Obstetric and Gynacology, Konya, Turkey Cystic diseases in the female pelvis are common. Cysts of the female genital tract comprise a large number of physiologic and pathologic Eur J Gen Med 2012;9 (Suppl 1):21-26 cysts. The majority of cystic pelvic masses originate in the ovary, and Received: 27.12.2011 they can range from simple, functional cysts to malignant ovarian tumors. Non-ovarian cysts of female genital system are appeared at Accepted: 12.01.2012 least as often as ovarian cysts. In this review, we aimed to discuss the most common cystic lesions the female genital system. Key words: Female, genital tract, cyst Kadın Genital Sistem Kistleri Özet Kadınlarda pelvik kistik hastalıklar sık gözlenmektedir. Kadın genital sistem kistleri çok sayıda patolojik ve fizyolojik kistten oluşmaktadır. Pelvik kistlerin büyük çoğunluğu over kaynaklı olup, basit ve fonksi- yonel kistten malign over tumörlerine kadar değişebilmektedir. Over kaynaklı olmayan genital sistem kistleri ise en az over kistleri kadar sık karşımıza çıkmaktadır. Biz bu derlememizde, kadın genital sisteminde en sık karşılaşabileceğimiz kistik lezyonları tartışmayı amaçladık. Anahtar kelimeler: Kadın, genital sistem, kist Correspondence: Dr. Harun Toy Harun Toy, MD, Konya University, Meram Medical Faculty, Department of Obstetric and Gynacology, 42060 Konya, Turkey. Tel:+903322237863 E-mail:[email protected] European Journal of General Medicine Female genital tract cysts FEMALE GENITAL TRACT CYSTS II. CERVIX UTERI Lesions of the female reproductive system comprise a A. Benign Diseases large number of physiologic and pathologic cysts (Table 1. Cervical Nabothian Cysts: A nabothian cyst is a 1). In order to avoid unnecessary therapy or treatment common incidental finding that is usually located in delay, in most cases, it originates in the ovary. the uterine cervix where one would find endocervical I.UTERUS glands. Submucosal layer of the cervix is the most com- mon location of these cysts, rarely they are seen deeply A. Congenital Mullerian (paramesonephric) duct into the cervical wall. Nabothian cysts may occur by the anomalies inflammation and reparative processes of chronic cer- If the uterine horn becomes obstructed, it may become vicitis, following minor trauma or childbirth. Anechoic dilated and filled with fluid or blood products and thus cystic structures are the ultrasonographic apperances of mimic a cystic pelvic mass such as a non-communicating these cysts. Adenoma malignum (minimal deviation ad- rudimentary horn with uterus unicornis (1). enocarcinoma of mucinous type) or other glandular ma- lignant cervical lesions can mimic nabothian cysts, but B. Congenital uterine cysts such as Wolffian duct (me- the latter are usually located deeper in the cervix (3,4). sonephric) cysts Generally, nabothian cysts do not require any therapy. C. Mullerian duct cysts If the lesion character is not clear and malignancy can- not be ruled out and if the patient relief from pain or D. Adenomyosis a bothersome feeling of fullness in the vagina, surgical Adenomyosis is a common, nonneoplastic condi¬tion intervention is needed (3-5). that affects menstruating women, particu¬larly those who are multiparous. In cystic adeno¬myosis, lesion size 2. Tunnel Cluster: A specific type of nabothian cyst. varies, and lesions may occur anywhere within the myo- Characterized by complex multicystic dilatation of en- metrium (1). docervical glands (3). Uterine Cervicitis: Uterine cervicitis is one of the E. Cystic degeneration of intrauterine leiomyoma 3. most common gynecologic diseases. Symptoms or signs An exophytic or pedunculated leiomyoma also may of acute cervicitis are a tenacious jellylike, yellow, or mimic a cystic adnexal mass if cystic degeneration is turbid discharge and a sensation of pelvic pressure or present. discomfort (3). F. Cystic adenomatoid tumor 4. Endocervical Hyperplasia: Located in the endocervix Cystic changes of adenomatoid tumors are extremely and superficial layer of the cervical wall. Frequently rare, and this tumor is found subserosally in the pos- seen in women who use oral contraceptive agents and terior fundus or near the cornua. The wall of the cystic women who are pregnant or postpartum (3). adenomatoid tumor is lined with flattened cuboidal epi- 5. Endometrioma: Endometriosis of the uterine cervix thelium, and this epithelial cells show immunopositivity is estimated at 0.1– 2.4% of all endometriotic localiza- for cytokeratin and calretinin (2). tions. This rare localization may be totally asymptom- G. Adenocystic tumor atic or associated with nonspecific findings like postco- ital or intermenstrual bleeding. The classic strategies H. Intramyometrial hydrosalpinges of diagnosis and management involve colposcopy and I. Parasitic cysts such as echinococcal cyst excision (6). J. Cystic endometrial atrophy: a cystic gland dilata- B. Malign Diseases tion combined with endometrial atrophy. 1. Adenocarsinoma K. Cystic endometrial hyperplasia: is characterized by 2. Adenoma malignum: Adenoma malignum, which is also similar small endometrial cysts in an evenly thickened called ‘‘minimal deviation adenocarcinoma’’, is known endometrium of over 5 to 6 mm. to be a rare variant of well-differentiated mucinous ad- enocarcinoma of the uterine cervix, which is character- ized by multilocular cystic lesions extending from the endocervical glands to the deep cervical stroma (7). 22 Eur J Gen Med 2012;9(Suppl 1):21-26 Toy and Yazıcı Table 1. Cystic lesions of the female reproductive sys- sues can present as cystic lesions in the vagina as well tem. (9). The incidences of cyst types in decreasing order are Uterus as follows: mullerian cysts (44%), epidermal inclusion Congenital Mullerian (paramesonephric) duct anomalies cysts (23%), Gartner’s duct cysts (11%), Bartholin’s gland Congenital uterine cysts such as Wolffian duct (mesonephric) cysts cysts (7%) and endometriotic type (7%). Vaginal cysts are Mullerian duct cysts most common in the third and fourth decades (9,10). Adenomyosis Cystic degeneration of intrauterine leiomyoma Through physical examination the lesion should be as- Cystic adenomatoid tumor sessed for location, mobility, tenderness, definition Adenocystic tumor (smooth versus irregular) and consistency (cystic versus Intramyometrial hydrosalpinges solid) (9). Imaging by means of ultrasound, voiding cys- Parasitic cysts such as echinococcal cyst Cystic endometrial atrophy tourethrogram (VCUG), computerized tomography (CT) Cystic endometrial hyperplasia or magnetic resonance imaging (MRI) may be required to Cervix uteri characterize the lesion further (9). Benign diseases Cervical Nabothian Cysts A. CYSTS OF EMBRYONIC ORIGIN Tunnel cluster Uterine cervicitis 1. Mullerian Cysts Endocervical hyperplasia Endometrioma Mullerian duct cysts (MDCs) are uncommon pelvic cystic Malign Diseases lesions, with the peak clinical incidence between the Adenocarsinoma third and fourth decades of life. They usually present as Adenoma malignum small, midline, cystic masses with no symptoms and re- Vagina and vulva Cysts of embryonic origin quire no treatment. Occasionally, a mullerian cyst may Mullerian cysts become large enough that symptoms will warrant exci- Gartner’s duct cysts sion (11). Skene’s duct cysts Bartholin’s duct cysts 2. Gartner’s Duct Cysts Vaginal adenosis Cysts of the canal of nuck (Hydrocele) Gartner's duct cysts are cystically dilated wolffian duct Cysts of urethral origin remnants and these cysts are usually located along the Urethral caruncle anterolateral vaginal wall. Gartner’s duct cysts can also Urethral diverticulum Epidermal cysts be associated with abnormalities of the metanephric Endometriosis urinary system (9). Ectopic ureterocele Rare vaginal cystic lesions 3. Skene’s Duct Cysts Fallopian tubes Skene’s (paraurethral) glands are bilateral, prostatic Hydrosalpinx Hematosalpinx homologues located in the floor of the distal urethra. Pyosalpinx Obstruction of the ducts, presumed secondary to ske- Inclusion cyst nitis (most commonly gonorrhea), causes formation of Paraovarian cysts cysts (9). Benign, asymptomatic; if large, may cause Mesonephric cysts Paramesonephric cysts urethral obstruction and urinary retention (3). Ovarian cysts Benign ovarian cyst 4. Bartholin’s Duct Cysts Bordeline ovarian cyst Bartholin’s glands are located bilaterally at the base of Malign ovarian cyst the labia minora and drain through 2- to 2.5-cm–long ducts that empty into the vestibule at about the 4 o’clock and 8 o’clock positions. Bartholin’s duct cysts, the most common cystic growths in the vulva, occur III. VAGINA AND VULVA in the labia majora. Two percent of women develop a Bartholin’s duct cyst or gland abscess at some time in Benign vaginal cysts are in the majority of cases asymp- life (12,13). These benign cysts usually occur in women tomatic and are often incidentally discovered during who are in reproductive years (12). Obstruction of the gynecological examination for other purposes (8). True distal Bartholin’s duct may result in the retention of se- cystic lesions of the vagina originate from vaginal tissues cretions, with resultant dilation of the duct and forma- but lesions arising from the urethra and surrounding tis- Eur J Gen Med 2012;9(Suppl 1):21-26 23 Female genital tract cysts tion of a cyst. The cyst may become infected, and an E. ECTOPIC URETEROCELE abscess may develop in the gland. If the cyst becomes A ureterocele