Diagnosis and management of periurethral cysts

Large Cyst of Skene Gland: A Rare Perineum Mass

Objective  In this report we present a rare case of a large cyst of Skene gland in a female patient with a palpable vaginal mass persisting for at least 2 years. Case Report  A 67-year-old female admitted to the department of urology due to the presence of "a vaginal mass" for the past 2 years. A cyst of Skene's duct was suspected based on clinical manifestation and findings of magnetic resonance imaging showing an extensive cyst formation in the upper vaginal area and anterior to the urethra. Based on these findings, a decision for surgical removement of the cyst was made. The cyst was incised, drained, and marsupialized. The postoperative recovery was uneventful, and the patient was discharged on the second postoperative day. Conclusion  High clinical suspicion is important to reach this rare diagnosis. Partial excision and marsupialization of the cyst is a simple procedure with low morbidity, without recurrence, and excellent results.

A diagnostic conundrum: Is it a periurethral diverticulum/cyst or a bulking agent (Bulkamid)?

INTRODUCTION

Urethral bulking agents are commonly used to manage female stress urinary incontinence (SUI) as they have been suggested to be safe, efficacious, and a minimally invasive surgical option. Bulkamid is a newer bulking agent that has been introduced and promoted in the market for use. It is non-particulate in nature with high tissue biocompatibility, and consequently, it is difficult to differentiate between Bulkamid and a periurethral cyst on magnetic resonance imaging (MRI). This, therefore, presents a diagnostic dilemma.

METHODS AND MATERIALS

Here we describe two cases with previous injections of Bulkamid referred to our Centre for management of a presumed periurethral diverticulum based on MRI findings. Both patients were reviewed and examined in outpatient clinics with MRI findings discussed at MDT, further imaging was required.

RESULTS

We found that a limited noncontrast computed tomography (CT) pelvis, followed by a voiding cystometrogram (VCMG), and then a repeat limited noncontrast CT pelvis effectively differentiated between Bulkamid and these presumed periurethral diverticulae. The theory behind this was that during micturition, the contrast would pass through to the urethral diverticulum and appear as high-density (bright) material within the periurethral region (the pre-VCMG was required to prove that any high-density material was due to the contrast and not pre-existing high-contrast material).

CONCLUSION

A CT scan done in conjunction with a VCMG is likely to be more effective in differentiating between Bulkamid and a true periurethral diverticulum than an MRI scan. Appropriate diagnostic evaluation of periurethral lesions can lead to time-saving and cost-effective patient management as this will bypass the need for unnecessary investigations and possible unwarranted surgical intervention.

Skene's glands abscess an overlooked diagnosis in acute lower urinary symptoms

Skenitis refers to the infection of the Skene's glands. Skene's glands are paraurethral glands localized on the upper wall of the vagina. The diagnosis of Skene's glands abscess or infection is usually made based on the history and physical examination, but half of women with para-urethral gland symptoms present with non-palpable lesions and necessitate further evaluation with imaging. Patients may present with chronic urethral pain, recurrent urinary tract infections, unexplained dyspareunia, and dysuria. At imaging Skene's glands are typically located on the anterior vaginal wall, at symphysis level and paramedian to urethra. Clinicians should consider Skenitis in the differential diagnosis of lower urinary tract symptoms. We report a case of a 48-year-old woman with acute lower urinary tract symptoms with a final diagnosis of Skene's glands abscess.

Adult-onset Skene's gland cyst following a history of multiple gynecological treatment interventions

Skene's gland cysts are rare and the cause of adult-onset is still unclear. We report the case of a 34-year-old woman developing a Skene's gland cyst following a history of various gynecological treatment interventions. She finally underwent surgical excision of the cyst and no recurrence has been observed 1 year after the surgery.

Surgical excision of paraurethral cyst

Purpose

Patients with paraurethral cyst may be asymptomatic or bothered by sensation of a mass, pain, distorted urinary outflow, dyspareunia, and dysuria (1). Differential diagnosis includes ectopic ureterocele, pelvic organ prolapse, and urethral diverticulum. At present, the management of paraurethral cysts is unclear, but surgical excision appears as the best treatment option (1-3). Alternative methods include waiting for spontaneous rupture, needle aspiration and marsupialization (4). The aim of the video-tutorial is to provide anatomic views and surgical steps necessary to achieve a successful complete excision of a paraurethral cyst.

Materials and methods

A 54-year-old woman with a 2cm paraurethral cyst bothered by intermittent sensation of an introital mass, dyspareunia, and dysuria was admitted to surgical excision according to the described technique. Urethrocystoscopy and ultrasonography were preoperatively performed to confirm the diagnosis and rule out an urethral diverticulum. Surgical steps included: cyst exposure; vaginal mucosa incision; adequate dissection (needle injection of saline solution inside the cyst can be performed to inflate the cyst) with scissors and swab, isolation and excision of paraurethral cyst, layered reconstruction with avoidance of suture layers overlapping.

Results

Surgical procedure was successfully achieved without complications. The postoperative course was uneventful. No recurrence was observed and the patient reported complete resolution of her symptoms.

Conclusions

The featured video showed complete excision of a paraurethral cyst successfully achieved without complications. Surgical excision represents a safe and effective procedure to manage paraurethral cysts. This step-by-step video-tutorial may represent an important tool to improve surgical know-how.

Can magnetic resonance imaging differentiate among transurethral bulking agent, urethral diverticulum, and periurethral cyst?

PURPOSE

To evaluate magnetic resonance imaging findings that differentiate among periurethral bulking agents (primarily collagen), urethral diverticulum, and periurethral cyst.

METHODS

We searched our radiologic database retrospectively from 2001 to 2017 for periurethral cystic lesions, identifying a total of 50 patients with 68 lesions. Final diagnoses in 68 lesions were bulking agents (27), urethral diverticula (29), and periurethral cysts (12). Two abdominal radiologists, blinded to clinical history, independently evaluated T1, T2, and post-contrast images. The readers assessed number, morphological features, location, connection to urethra and mass effect, signal intensity, and enhancement for each lesion. Fisher exact test and logistic regression analysis were performed for each univariate significant feature. The operative and pathologic reports were the reference standard.

RESULTS

Magnetic resonance imaging features found more often in bulking agents versus urethral diverticulum were multiple lesions (P = 0.011), upper or upper-mid-urethral location (P ≤ 0.0001), lack of internal fluid/fluid level (P = 0.002), no urethral connection (P = 0.005), T1 isointensity, and T2 mild hyperintensity compared to muscles but lower T2 signal than urine (P < 0.0001). Most cases of urethral diverticula and periurethral cysts were detected at mid- and lower urethra. Urethral diverticula were larger than bulking agents and periurethral cysts (P = 0.005 and P = 0.023) (mean diameter = 24, 16, 15 mm, respectively). Most bulking agents (93%) and urethral diverticula (90%) showed mass effect on urethra, while periurethral cysts (75%) did not (P < 0.0001).

CONCLUSION

Signal intensity and lesion characterization on magnetic resonance imaging can significantly differentiate bulking agent from urethral diverticulum and periurethral cyst. Radiologists should consider differential diagnosis of a bulking agent, especially when distinguishing characteristics described here are present to prevent incorrect diagnosis and ultimately unnecessary surgical intervention.

Skene's gland cyst: a simple marsupialization technique

INTRODUCTION AND HYPOTHESIS

We present a simple approach to the marsupialization of a Skene's gland cyst.

METHODS

Our technique facilitates suture placement to exteriorize the cyst wall to efficiently treat a distal Skene's gland cyst and reduce the risk of recurrence.

CONCLUSION

Marsupialization is an accepted option for the surgical management of Skene's gland cyst. This technique is an effective and streamlined approach to Skene's gland marsupialization.

Female paraurethral leiomyoma: treatment and long-term follow-up

INTRODUCTION

We describe our experience with evaluating the ideal management of female paraurethral leiomyomas from imaging to surgery and follow-up.

METHODS

Between January 2009 and January 2012, we treated six women (age range 32-49 years) affected by paraurethral leiomyoma of different sizes.

RESULTS

All the six patients underwent transvaginal excision of the mass. They are free of recurrence at follow-up (range 32-72 months). Two patients developed stress urinary incontinence after the excision: in both cases, incontinence was corrected by a tension-free vaginal tape-obturator (TVT-O) placement. In one patient, a fascial sling was necessary to repair a urethral lesion that developed during surgical excision of the mass.

CONCLUSION

A well-defined protocol for diagnosing and managing a paraurethral mass had not been established as yet due the rarity of the mass. We suggest performing pelvic magnetic resonance imaging (MRI) as a primary examination, followed by lesion biopsy. Complete surgical resection performed transvaginally should be the treatment of choice. As paraurethral leiomyomas does not originate from intraurethral smooth-muscle component, urethral lesion is rare. Excision of female urethral leiomyoma transvaginally is safe, and postoperative urinary incontinence, if any, can be easily corrected with minimally invasive tecniques.

Experiences with the management of paraurethral cysts in adult women

INTRODUCTION

Paraurethral cysts may be acquired or congenital pathology, and are rarely encountered in urogynecologic practice. Therefore, no consensus on management of paraurethral cyst could be reached. We aimed to report our experience on the management of paraurethral cysts in adult women.

MATERIAL AND METHODS

A retrospective chart review was conducted on adult women diagnosed with paraurethral cysts between 2011 and 2012. Patients' complaints, parity, physical signs, diagnostic tests and the obtained findings, surgical intervention, duration of follow-up period, complications, recurrence and histologic examination of the cysts wall were evaluated in the patients included.

RESULTS

Ten adult women, aged 23-48 years (mean: 41 years) with paraurethral cysts between 2011 and 2012 were identified. All patients were multiparous. The patients' complaints included palpable mass, dyspareunia, and dysuria. All patients underwent preoperative urethrocystoscopy. All the cysts were solitary and in dimension of 1 to 3.5 cm and localized in the distal urethra. All patients underwent surgical excision. The mean follow-up period was 8 months (range: 6-12 months). Neither complications nor recurrences were observed. Histopathological examination showed that 5 cysts were lined with squamous epithelium, 2 were lined with transitional epithelium, and 3 were lined with both types of epithelium.

CONCLUSIONS

Paraurethral cysts may be symptomatic and routine urological examinations are sufficient for diagnosis without using advanced imaging technique. In such symptomatic adult patients, partial surgical resection combined with fulguration can be performed effectively without complications. This treatment modality seems exceptional according to the literature.

A leiomyoma presenting as an exophytic periurethral mass: a case report and review of the literature

Periurethral masses in females are rarely observed, although they can occur anywhere along the genitourinary tract. They may be detected on physical examination or present with symptoms such as vaginal swelling, bladder outlet obstruction, vaginal bleeding, hematuria, or urinary tract infection. We report a sexually inactive, 27-year-old woman with an exophytic, fimbria-like periurethral mass. The benign nature of the lesion was suspected on the basis of the findings of magnetic resonance imaging. Surgical enucleation was performed. The microscopic examination revealed a urethral leiomyoma. Immunohistochemical study confirmed a leiomyoma with positive staining for smooth muscle actin and negative staining for S-100.

Benign masses of the female periurethral tissues and anterior vaginal wall

Due to their rarity, benign masses of the periurethral tissues and anterior vaginal wall are poorly understood. Arriving at the proper evaluation and treatment is challenging because many of these masses have similar presenting signs and symptoms, as well as overlapping differential diagnoses. The literature regarding these lesions mainly consists of level III evidence, mostly involving case reports and series. Clinical management has traditionally been based on established surgical principles and expert opinion. This review presents the pertinent embryologic and anatomic background for these benign masses, as well as other pertinent etiological processes. Furthermore, the most current evidence is reviewed regarding the differential diagnosis, evaluation, and treatment for each mass.