Gartner’s duct cyst is an embryonic benign non–tumor formation, more often localized in the anterolateral wall of the vagina. It usually proceeds asymptomatically, is detected randomly in the form of single or multiple nodes of 2-3 cm in size (less often – 6 cm or more). The presence of large cysts can be accompanied by discomfort during urination, dyspareunia, and be an obstacle to childbirth through natural pathways. To establish the diagnosis, an examination in a gynecological chair, ultrasonography is used. Uncomplicated asymptomatic disease does not require treatment. In other cases, surgical operation is indicated – excision of the cyst.
Q50.5 Embryonic cyst of the broad ligament
Gartner’s duct cyst (mesonephral cyst of the vagina), named after the Danish anatomist Gartner, who described it at the beginning of the XIX century, is a cavity formed by rudimentary remnants of the mesonephral (Wolf’s) duct and filled with serous-mucous fluid. Single-chamber, rarely multi-chamber cysts are located under the epithelium of the vaginal wall. Their growth has no proliferative nature and is caused only by the accumulation of fluid. Malignancy is extremely rare. The Gartner canal is present in a quarter of women, mesonephral cysts form in 1% at any age, are more often detected in 20-40 years.
The etiology of the disease has been little studied. Gartner’s duct cyst are dysontogenetic, originating from an embryonic canal that has not undergone reduction. In itself, the non-contamination of the residual wolf duct is not considered a pathology and serves only as a background for the development of a cyst. It may be due to hereditary predisposition, spontaneous mutations, the effect of teratogenic factors (ionizing radiation, taking medications) on the mother’s body during pregnancy.
Even in the presence of a rudimentary duct, the cyst is not always present, the accumulation of fluid in the lumen of the canal leads to pathology. In most cases, it is not possible to identify any prerequisites. In 10% of women, the disease is of a family nature. One of the main causes of volumetric formation is considered to be trauma to the vaginal walls due to vaginal childbirth, surgical operations on the vagina, colposcopy. Since the development of mesonephros is closely related to the process of nephrogenesis, Gartner’s duct cyst is often combined with congenital defects of the urinary system – ectopia of the ureter, hypoplasia of the kidney.
Embryonic remnants of Gartner’s passages are formed in the antenatal period during the formation of the fetal genitourinary system from the Wolf duct. This duct is the excretory canal of the primary kidney – the primary ureter. As the embryo develops, the mesonephral canal loses its original function, passing in the male embryo into the canal of the epididymis, the ejaculatory and ejaculatory ducts. In a female embryo, the wolf duct undergoes reduction, only its rudimentary remains in the form of appendages of the ovary – epoophoron and paraophoron are preserved.
A quarter of newborn girls also retain the distal part of the mesonephral duct – Gartner’s passages, which are segments of the channel passing through the parametrium along the ribs of the uterus, penetrating into its tissues at the level of the internal pharynx, stretching longitudinally through the cervix and the anterolateral walls of the vagina to its vestibule. It is assumed that the cystic transformation of these ducts is due to increased secretion of their epithelium.
In some patients, cysts are congenital, formed before birth, in others, fluid accumulates in the Gartner passages at any stage (more often in the reproductive age) of the postnatal period. Usually, the formations are localized along the walls of the vagina, occasionally they can be found in the parametric region. The growth of Gartner cysts occurs mainly towards the vaginal lumen, without disturbing the topography of neighboring anatomical structures, but the presence of large formations can lead to a displacement of the urethra.
In three quarters of patients, the disease is asymptomatic. In such cases, a small, soft- or tight-elastic oval formation or a series of them, located along a vertical line on the side wall of the vagina, are detected by the woman herself or become an accidental finding of a doctor during a gynecological examination. Subjective signs begin to appear with a sufficiently large cyst size or its inflammation.
Volumetric cysts of the Gartner duct are accompanied by difficulty and painful sensations during sexual intercourse, discomfort during physical exertion, walking, sitting. Cysts located in the lower parts of the vagina can bulge out through the genital slit. If the formation is localized near the urethra, there is pain in urination, frequent urges, a feeling of incomplete emptying of the bladder. When the integrity of the cystic wall is violated, a light yellow viscous liquid is poured out of the vagina.
The main complication of a mesonephral cyst is its suppuration, usually caused by trauma (including iatrogenic) of the wall, the presence of infections of the genitourinary sphere. When the surrounding tissues are involved in the purulent inflammatory process, parametritis, pelvioperitonitis, sepsis can develop – conditions that pose a threat to life, often leading to the formation of adhesions in the pelvis, secondary infertility.
The most severe consequences of the disease include a genitourinary fistula, which arose as a result of purulent melting of the urethral wall or its injury during surgical excision of a cystic formation. In isolated cases, the Gartner duct epithelium becomes a source of mesonephral adenocarcinoma of the vagina and cervix, often affecting not only adult women, but also girls of pre-puberty age (3-12 years).
Diagnosis of Gartner cysts is carried out by a gynecologist. The establishment of the primary diagnosis is not particularly difficult due to the manual and visual accessibility of the pathological focus. Mandatory diagnostic measures include clinical examination, ultrasonography. Morphological verification of the diagnosis is usually performed after surgical treatment.
- Clinical examination. A finger vaginal examination is performed, an examination in mirrors (for adequate visualization of the middle and lower thirds of the vagina, Sims or Otto mirrors are used). Gartner’s duct cyst are usually found along the side walls of the vagina in the projection of the same-named passages. The benign nature of the formation is evidenced by its mobility, a clear separation from the surrounding tissues.
- Ultrasound examination. Transvaginal ultrasound is optimal in terms of accuracy, reliability and accessibility among instrumental methods of diagnosing volumetric formations. Ultrasound signs of a cyst include clear contours, homogeneous hypoechoic contents of the cavity, lack of communication with the urethra.
Mesonephral cyst should be differentiated with urethral diverticulum, primary and metastatic malignant neoplasms of the vagina, vaginal endometriosis. Large cysts prolapsing into the genital cleft can simulate genital prolapse. Differential diagnosis with other cystic formations (paramesonephral, skinnian cysts) is of little practical value.
Treatment of cysts is usually carried out on an outpatient basis. With small formations without signs of infection that do not bother the patient, they are limited to wait-and-see tactics. Therapeutic measures are immediately started in the case of voluminous cysts accompanied by painful symptoms, or with suppuration of formations of any size. In the presence of urogenital infections, a course of antibiotic therapy, local treatment with antiseptics is pre-indicated.
There are no effective methods of treating the disease. If previously the method of sclerosing of the cystic cavity was widely used, consisting in emptying it with a puncture and introducing a sclerosing solution, then in modern gynecology, conservative treatment is practically not resorted to due to the high probability of relapses, purulent complications, the complexity of performing subsequent surgery if necessary.
The main method of treatment of Gartner cysts is surgical intervention. The peeling of the cystic formation is performed together with the capsule. The operation is performed by a gynecologist, most often under local anesthesia. Usually the patient is discharged home on the same day. In difficult cases, with a close relationship of the cyst with the urinary tract, a urologist or urogynecologist is involved in treatment. The removed material is transferred for histological examination in order to exclude malignant neoplasia.
Prognosis and prevention
The prognosis is usually favorable. In 75% of patients, pathology without treatment does not affect the quality of life and the realization of reproductive function. After radical surgery, relapses are observed only in three to five patients out of a hundred. In order to avoid complications, patients with formations of insignificant size are shown the supervision of a gynecologist. Large cysts are subject to timely surgical treatment with preliminary thorough sanitation of the vagina, accurate determination of the relationship of the cystic cavity with neighboring anatomical structures by means of radiation imaging.