11 Benign Vaginal Wall Masses and Paraurethral Lesions
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This chapter discusses benign lesions and masses of the vagina and urethra (excluding urethral diverticula). Although the exact prevalence of these conditions is unknown, they seem to be relatively common and can present with symptoms that are quite distressing to the patient.
The Skene glands, or paraurethral glands, are found on both sides of the urethra. They are the female homologues of the prostate in the male and arise from the urogenital sinus. Ailments of the Skene glands are relatively rare but include infection or abscess, cyst, and neoplasm. The exact incidence of these conditions is unknown. Cysts or abscesses of the Skene glands most commonly present in the third to fourth decades. However, Skene gland cysts have been reported in neonates, and recently a Skene gland abscess has been reported in a prepubertal girl. The incidence of Skene gland abscess in neonates was reported to be 1 in 2074 in one study.
The differential diagnosis of any anterior vaginal wall mass includes urethrocele, cystocele, urethral diverticulum, ectopic ureterocele, urethral prolapse, malignancy, Skene gland abscess or infection, Skene gland cyst, Bartholin gland cyst or infection, and Gartner duct cyst or infection. Presenting symptoms of Skene gland abscess, infection, or cyst include urethral pain, dysuria, dyspareunia, presence of an asymptomatic mass, recurrent urinary tract infections (UTIs), urethral drainage, and voiding symptoms. Clues that point to Skene gland involvement are a mass located distally and lateral along the urethra, point tenderness along the lateral and distal aspect of the urethra, and expression of pus. In our practice we consider the diagnosis of Skene gland abscess or infection not only in patients with a palpable anterior vaginal wall lesion but also in patients with chronic urethral pain, recurrent UTIs, or unexplained dyspareunia and an otherwise unremarkable workup. The diagnosis of Skene gland abscess, infection, or cyst can generally be made by history and physical examination. When the diagnosis is in doubt, further workup with magnetic resonance imaging (MRI), voiding cystourethrography, transvaginal ultrasonography, or cystourethroscopy may be warranted. A combination of the symptoms described earlier and physical examination findings demonstrating reproducible point tenderness (re-creating the patient’s complaints) distally and laterally along the urethra, palpable cystic mass, or purulent discharge on aggressive milking of the urethra is usually required to diagnose a Skene gland abscess or infection. In the absence of these symptoms or physical findings, imaging results consistent with the diagnosis are required before any treatment is offered.
Skene gland infections may present in several ways. In some cases, the duct is visible and may appear inflamed or express a purulent discharge when palpated, but there is no discrete mass (Fig. 11-1). More commonly, there is an associated cystic mass caused by a relative closure of the duct and collection of fluid. These cysts can become quite large and displace the urethral meatus (Fig. 11-2). They may drain spontaneously through the duct or rupture into the anterior vaginal wall.
Because of the relatively infrequent occurrence of Skene gland abscess or infection, very little information has been published regarding its management. Conservative management may include providing antibiotic therapy or waiting for spontaneous rupture. No guidance is available in the literature regarding the length of time for which conservative management should be tried. We usually treat patients initially with a 2-week course of antibiotics (culture specific if possible). It is felt that the initiation, progression, and propagation of urethral diverticula is secondary to an infection of the periurethral glands. Bacteria associated with a Skene duct abscess include Escherichia coli, other coliform bacteria, Neisseria gonorrhoeae, and vaginal flora. If culture results are not available, antibiotic therapy is aimed at covering these common pathogens. If there is no response, then surgical therapy is offered. If a response is seen to antibiotic therapy but symptoms recur, then a repeat course is given. In an era of increasing antibiotic resistance and other complications associated with prolonged antibiotic therapy, it is reasonable to consider surgical intervention after a failure or recurrence of symptoms following one or two courses of antibiotics if the patient is symptomatic and appropriately counseled.
There is a paucity of literature regarding the surgical management of Skene gland abscess or infection. A few small series examining the surgical management of paraurethral gland cysts may have included some infected cysts or abscesses, but no studies have looked specifically at noncystic lesions. Surgical excision, marsupialization, and simple needle aspiration have all been described for the surgical management of Skene gland or paraurethral cysts. An argument for surgical excision rather than marsupialization or needle aspiration is the fact that malignancy has been reported to occur in paraurethral cysts, and so pathological examination of these lesions seems most prudent. For this reason we prefer surgical excision whenever possible.
Before excision, cystourethroscopy is performed on all patients in the operative theater. In cases in which there is no obvious mass, every attempt is made to cannulate the opening of the duct with a lacrimal probe or similar tool if possible (see Fig. 11-1). We use two different surgical techniques based on the size of the lesion.