Gartner duct cyst in pregnancy presenting as a prolapsing pelvic mass
1 Department of Biomedical Imaging, Faculty of
Medicine, University of Malaya, Kuala Lumpur, Malaysia
2 Department of Obstetrics and Gynaecology,
Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
Gartner duct cysts are the remnants of the Wolffian duct
and they are rarely seen in adulthood. We present a case of a pregnant patient
with a prolapsing vaginal mass. A diagnosis of Gartner duct cyst was made after
MRI was performed. The Gartner duct cyst was drained when the patient went into
labour allowing vaginal delivery to be performed. � 2007 Biomedical
Imaging and Intervention Journal. All rights reserved.
Keywords: Gartners duct cysts; Wolffian duct; magnetic
A 30-year-old primigravida was seen at 27 weeks of
pregnancy for a routine check up. Antenatal ultrasound showed a single intra
uterine pregnancy and a cystic structure in the pelvis, which was diagnosed as
an ovarian cyst in pregnancy. A repeat ultrasound at the authors� hospital
confirmed a single viable foetus in cephalic presentation. There was a cystic
mass measuring 7.8 cm x 7.4 cm x 5.9 cm in the left adnexa, which was diagnosed
to be an ovarian cyst. During the 36th week of pregnancy, the patient felt a
mass descending from her vagina on straining at micturition and defecation.
A digital and speculum examination of the vagina revealed
a cystic swelling measuring 7 cm in size that had a stalk attached to the left
vaginal wall, displacing the cervix to the right side. Magnetic resonance
imaging (MRI) of the pelvis was performed and revealed a mass in the left
lateral vaginal fornix. This mass was homogenous and returned low signal on
T1-weighted and high signal on T2- weighted images, consistent with a cyst. The
mass extended into the pelvis and measured 8 cm x 3.6 cm x 6.2 cm. The gravid
uterus and cervix were displaced superiorly (Figures 1 to 3). No other pelvic
masses were seen.
In view of the imaging and clinical findings, a diagnosis
of Gartner duct cyst in pregnancy was made.
At 39 weeks of pregnancy, the patient went into labour and
under epidural anaesthesia, aspiration of the Gartner duct cyst produced 60 ml
of clear fluid. Delivery was then induced. The baby was delivered with vacuum
assistance due to poor maternal effort. The cyst fluid was sent for cytology
examination where smear microscopy showed degenerating red blood cells, a few
lymphocytes and polymorphs with squamous cells. Mother and baby were
subsequently discharged well.
The differential diagnoses of a cyst in the lateral
aspects of the female genital tract include ovarian cysts, broad ligament
cysts, nabothian cysts, Bartholin cysts and Gartner duct cyst.
During the eighth week of embryologic development, the
paired M�llerian (paramesonephric) ducts fuse distally and develop into the
uterus, cervix and upper vagina, which are lined by a pseudostratified columnar
(glandular) epithelium. Wolffian (mesonephric) ducts normally regress in the
female, and their remnants include Gartner duct, epo�phoron and paro�phoron.
Beginning at week 12 of intrauterine development, a squamous epithelial plate
derived from the urogenital sinus begins to grow upward and replace the
original pseudostratified columnar epithelium with squamous mucosa . The
Gartner duct is the remnant of the vaginal portion of the Wolffian duct.
Secretion by persistent glandular epithelium causes cystic dilatation, giving
rise to Gartner duct cysts.
M�llerian and Wolffian derivatives can be found at almost
any location within the vaginal walls. Clinically, the distinction between
M�llerian and Gartner�s duct cysts is of little importance .
True Gartner�s duct cysts are usually located along the
anterolateral wall of the proximal third of the vagina. In contrast, Bartholin
cysts are usually located in the posterolateral wall of the inferior third of
the vagina associated with the labia majora [1, 2]. Typically, Gartner�s duct
cysts are small and asymptomatic, with an average diameter of 2 cm. When the
cysts enlarge they may be mistaken for other structures, such as a cystocele or
urethral diverticulum. The largest Gartner duct cyst reported measured 16 cm x
15 cm x 8 cm . The larger cysts can also cause dyspareunia or interfere with
normal vaginal delivery .
Gartner duct cysts can also be associated with
abnormalities of the metanephric urinary system. Although such abnormalities
usually present in childhood, awareness of this association should prompt the
clinician to image the urinary tract in these patients. Ectopic ureters,
besides having direct communications with the vagina and introitus, have been
reported to communicate with Gartner duct cysts and cause urinary incontinence
. The Gartner duct cyst may also represent an ipsilateral blind vagina, thus
lending support to the hypothesis that the distal segment of the Wolffian duct
contributes to the formation of the vagina.
MRI is the imaging modality of choice for characterising
the cyst . These cysts have been observed in 1%-2% of female pelvic MR
imaging examinations . They are typically located in the anterolateral
aspect of the proximal third of the vagina. They exhibit low signal intensity
on T1-weighted images and high signal intensity on T2-weighted images when they
are simple cysts. When there is intracystic protein, mucin, or hemorrhage, they
exhibit intermediate to high signal intensity on T1-weighted images. Neither
the cyst nor its wall enhances after intravenous contrast injection . Most
of these lesions are confined to the vaginal walls, but the larger cysts can
extend into the ischiorectal fossa.
Other cysts that can arise in the vagina and cause
considerable diagnostic confusion are Bartholin cysts. They arise from the duct
system of Bartholin glands. Most cysts involve the main duct only and thus are
unilocular. Bartholin cysts are usually unilateral, non tender, tense, palpable
masses 1-4 cm in diameter. Most contain sterile fluid and are located in the
posterior part of the labia majora. The cysts are often asymptomatic unless
they become enlarged or infected, whereby contrast administration demonstrates
pericystic enhancement on computed tomography (CT) and MR .
Nabothian cysts are retention cysts of the cervical
glands. They are caused by chronic inflammation with scarring of the cervix,
which leads to occlusion of the lumen of the cervical glands. They appear as
single or multiple well-circumscribed cystic lesions in the cervical fibrous
stroma and can grow considerably large. Cystic accumulation of mucus within the
dilated glands accounts for the MR appearance . Most of them show high
signal intensity on T2-weighted images. On T1 -weighted images, most were
isointense with urine or muscle .
Paratubal (paraovarian) cysts develop within the broad
ligament. They arise most commonly from either the mesothelial epithelium of
peritoneal inclusions or vestiges of the paramesonephric ducts and rarely from
remnants of the mesonephric ducts . Many Gartner duct cysts drain
spontaneously or are aspirated, as in this case. If surgical treatment is
indicated, marsupialisation or simple transvaginal excision is usually adequate
In conclusion, the differential diagnosis of a cystic
lesion found in the lateral aspect of the female genital tract should include
Gartner duct cysts. MRI is the imaging modality of choice in confirming the
Figure 1 Sagittal T2-weighted MR image of the pelvis shows a cystic mass (arrows) lying posterior to the urinary bladder and inferior to the gravid uterus.
Figure 2 Axial STIR MR image shows a well-defined cystic mass (thin arrows) lying posterior to the gravid uterus (thick arrows).
Figure 3 Coronal T2-weighted image shows the cyst (black arrows) lying lateral to the cervical os (block arrow). The fetal brain (asterisk) is seen within the uterus.
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|Received 12 May 2007; received in revised form 15 August
2007; accepted 28 August 2007
Correspondence: Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Tel.: +603-79502069; Fax: +603-79581973; E-mail: email@example.com (Anushya Vijayananthan).
Please cite as: Arumugam AV, Kumar G, Si LK, Vijayananthan A,
Gartner duct cyst in pregnancy presenting as a prolapsing pelvic mass, Biomed Imaging Interv J 2007; 3(4):e46
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