Presentation
Ongoing pelvic pain, dysmenorrhea and dyspareunia. Transvaginal ultrasound identified a low-lying vaginal cyst.
Patient Data
There is a solitary cyst at the symphysis pubis level and right anterolateral vaginal wall, corresponding to the cyst identified on transvaginal ultrasound.It measured 35.6 x 23.3 x 19.9 mm (CC X W X AP) in size. There is proteinaceous fluid within the cyst and consequent increased T1 signal intensity and mildly increased T2 signal intensity. (Differential diagnosis: bloody contents)
There are multiple simple nabothian cysts within the endocervical canal. These are of varying sizes. The largest individual cyst measures 13.9 mm in maximum diameter. There are clusters of smaller cysts, the largest clusters measuring at least 19.4 x 24.7 and 15.0 x 22.9 mm in maximum diameter.
The uterus is anteverted. There is mild inhomogeneous signal intensity. There are no uterine mass lesions. The endometrial cavity is normal.
The ovaries appear of normal size and volume. They have a normal follicular appearance.
There is a small hemorrhagic left ovarian cyst measuring approximately 9 mm in maximum diameter with an increased T1 signal consequently (differential diagnosis: a small left ovarian endometrioma). There are no suspicious solid or cystic ovarian mass lesions.
There is minimal physiological simple adnexal fluid. There are no features to suggest extra ovarian endometriosis (the patient had no prior history additionally). The bladder is underfilled, and normal in position and shape. There are no intracystic abnormalities. There is no urethral diverticulum or a Skene duct cyst.
The visualized intrapelvic bowel loops appear normal.
The bony pelvis is further normal.
Case Discussion
In this case, it was difficult to decide between a Gartner duct cyst and a Bartholin gland cyst, however, due to the superior extension of this cyst and anatomical position at and above the symphysis pubis, it was decided to represent a Gartner duct cyst. These typically arise above the level of the most inferior aspect of the symphysis pubis and are often located in the anterolateral wall of the superior vagina. A Bartholin gland cyst usually arises at or below the level of the symphysis pubis and arises from the posterolateral wall of the vagina.
The multiple clustered nabothian cysts were simple in nature and the differential diagnosis included a type B endocervical tunnel cluster. Adenoma malignum was considered less likely due to the simple nature and absence of solid components with negative diffusion additionally.
In view of the Gartner duct cyst, previous CT confirmed the presence of bilateral and normal kidneys and no renal tract abnormality in view of the association with urinary tract anomalies. (The abdomen was not imaged on the current MRI).
A urethral diverticulum and/or a paraurethral duct cyst (Skene duct cyst) was excluded on the MRI appearance with a normal urethra.