1 Mucinous Cysts of the Vestibule and Medial Labia Minora

These are common, usually asymptomatic subepithelial cysts occurring in the vestibule [1].

They are of variable sizes and usually solitary lesions that are skin colored, red, and yellow or occasionally have a bluish tinge.

The cysts are lined histologically by mucinous epithelium and are of interest as they are derived from the urogenital sinus embryologically [2] (Fig. 13.1).

Fig. 13.1
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Mucinous cyst of the vestibule. Courtesy of Professor Jacob Bornstein

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No treatment is needed, and patients can be reassured, unless they become big or located in the clitoris area (Figs. 13.2, 13.3, 13.4, and 13.5).

Fig. 13.2
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Mucinous cyst in the clitorial area. Courtesy of Professor Jacob Bornstein

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Fig. 13.3
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Excision of the clitorial cyst. Courtesy of Professor Jacob Bornstein

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Fig. 13.4
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Excision of the clitorial cyst. Courtesy of Professor Jacob Bornstein

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Fig. 13.5
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The cyst enucleated from the clitoris. Courtesy of Professor Jacob Bornstein

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2 Epidermal Cyst (Epidermoid Cyst; Epithelial Cyst)

These are the commonest skin cysts occurring on vulva and usually develop in hair-bearing areas (Figs. 13.6, 13.7, 13.8, and 13.9).

Fig. 13.6
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Epidermal cysts: skin colored nodules. Courtesy of Professor Jacob Bornstein

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Fig. 13.7
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Epidermal cysts: skin colored nodules. Courtesy of Professor Jacob Bornstein

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Fig. 13.8
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Epidermal cysts: skin colored nodules. Courtesy of Professor Jacob Bornstein

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Fig. 13.9
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Epidermal cysts: skin colored nodules. Courtesy of Professor Jacob Bornstein

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The cause is unknown but may be iatrogenic following surgery or blockage of the pilosebaceous unit. Histologically, epidermoid cysts are lined by stratified squamous epithelium and are filled with keratin to produce lesions that clinically contain a white content.

They are usually asymptomatic, but some patients may complain that they are unsightly or irritating. Some reported cases have involved the clitoral hood to give the impression of clitoromegaly [3]. Infected cysts are painful and can discharge pus.

They can vary in size from 1–2 mm (often called milia) to several cm and also color (skin colored to clinically obvious yellow nodules).

A biopsy is not usually necessary, and management depends on symptoms. Asymptomatic lesions can be managed expectantly, while other lesions can be locally excised.

3 Bartholin Gland Cyst, Abscess, and Tumor

There are two Bartholin glands situated within the labia majora on both sides, with their ducts open to the vestibule at 4 and 8 o’clock. They have the function of producing mucous for lubrication during intercourse. They are unusual in that they have a long duct from the main body of the gland which may become blocked to produce a deep-seated cystic swelling region of the gland that histologically is lined by mucinous epithelium.

Bartholin gland cyst is diagnosed clinically. Small cysts are often asymptomatic and can be managed conservatively. A few become infected and form an abscess. Some patients may complain of the feeling of a lump or pain during intercourse. Traditionally, symptomatic cysts are managed surgically with marsupialization during which the cyst wall is incised and the edge sutured so there is a continuous surface from the interior to the exterior enabling the interior to drain. This procedure has a high cure rate (Fig. 13.10). Another option which involves inserting a Word catheter into the cyst has been advocated and can be carried out in the outpatient setting [4]: Under local anesthesia, a small balloon with an inflatable distal end is inserted into the cyst cavity. The aim of the balloon catheter insertion is to create an epithelialized fistula or sinus tract to allow drainage. The catheter has a stem (3 cm long) and an inflatable balloon tip to hold saline, which allows the catheter to remain in the cyst cavity. There is no good clinical evidence to support either technique. Other techniques that have been suggested include the use of silver nitrate gland ablation, sclerotherapy, and CO2 ablation; however, a systematic review of the different clinical practices failed to show any one as a superior treatment [5].

Fig. 13.10
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Bartholin cyst. On the left, the cyst presents as a bulge in the right vestibule; top, enucleation of the cyst; bottom, incision and drainage of the cyst. Courtesy of Professor Jacob Bornstein

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Cysts may become infected, creating a Bartholin gland abscess with Escherichia coli being the single most common pathogen [6]. The management of Bartholin gland abscess is incision and drainage of the abscess usually with an incision on the inner side of the vestibule. The use of the Word catheter is an alternative. If an abscess spontaneously discharges, then there is less value in incision and drainage, and the abscess should slowly resolve. Routine antibiotics are not usually necessary.

Bartholin’s gland carcinoma is a rare tumor, and it is often initially misdiagnosed as Bartholin’s gland cyst. Many cases present as a cyst that, however, when the latter does not respond to standard conservative therapy [7]. The malignant tumor is often long-standing and presents with a painless vulvar mass [8]. Most tumors are squamous cell carcinomas or adenocarcinomas. The current evidence base is insufficient to suggest different management from vulvar squamous cell carcinoma [9]. The lesions are often deep-seated or likely to be associated with metastatic disease. The proximity to the anal sphincter may necessitate partial resection with reconstruction. In a case series of 36 patients, the 5-year survival rate was 84% [10]. It is estimated that patients with lymph node metastases have an overall survival of 40–50% which is lowered to 18% if 2 or more nodes are involved [11].

Epidermal Cyst: Breaking the Myths

  • Of all vulvar cysts, epidermal cysts are the commonest.

  • Biopsy is not usually necessary for this cyst.