A 26-year-old woman comes to the emergency department due to a bump on her vaginal introitus. The patient first noticed the mass 2 days ago, but it has increased in size and now causes discomfort when she walks or exercises. She had unprotected sex with a new partner 6 weeks ago and has had 10 lifetime partners. The patient had an abnormal Pap test last year but had a normal colposcopy. She smokes a half pack of cigarettes daily but does not use alcohol or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, and pulse is 80/min. On pelvic examination, the pubic hair is shaved. There is a 4-cm, mobile, soft, nontender cystic mass behind the right posterior labium majus that extends into the vagina. The remainder of the examination is normal. Which of the following is the most likely diagnosis in this patient?
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This patient has a Bartholin duct cyst, which occurs due to blockage of the Bartholin gland duct. The Bartholin glands are located bilaterally at the posterior vaginal introitus and have ducts that drain into the vulvar vestibule at the 4 and 8 o'clock positions to provide vulvovaginal lubrication. The Bartholin glands are not palpable unless ductal blockage occurs, resulting in mucoid fluid buildup and cyst formation.
Women with small Bartholin duct cysts are often asymptomatic and may be diagnosed incidentally on routine examination. In contrast, larger cysts (as seen in this patient) cause increased tissue tension and friction, resulting in vaginal pressure and discomfort with sexual activity, walking, or sitting (all of which apply direct pressure on the vulva and cyst). On pelvic examination, a soft, mobile, nontender, cystic mass is palpated behind the posterior labium majus with possible extension into the vagina. Asymptomatic cysts can be managed expectantly; symptomatic cysts require incision and drainage with possible Word catheter placement.
(Choice B) A Bartholin gland abscess can develop from an infected cyst; however, patients have additional findings of localized erythema and induration and a tender, fluctuant mass (not seen in this patient).
(Choice C) Condylomata acuminata appear as groups of smooth papules or sessile, verrucous growths typically caused by human papillomavirus types 6 and 11.
(Choice D) Condylomata lata—a feature of secondary syphilis—are gray-white, raised lesions affecting mucous membranes (eg, mouth, perineum); there is no associated cyst formation.
(Choice E) Epidermal inclusion cysts appear as raised, mobile, flesh-colored nodules sometimes associated with a central punctum.
(Choice F) Hidradenitis suppurativa creates inflamed, purulent nodules in intertriginous areas (eg, axilla, inguinal region) that cause draining sinuses and scarring; disease is typically multifocal and painful.
(Choice G) Lymphogranuloma venereum presents as small, painless papules or pustules that ulcerate. Advanced stages develop painful, swollen lymph nodes that coalesce to form buboes, which may rupture.
Educational objective:
Large, symptomatic Bartholin duct cysts can present with vaginal discomfort and pressure with sexual activity, walking, or sitting. Physical examination reveals a soft, mobile, nontender mass located behind the posterior labium majus with possible extension into the vagina. Treatment of symptomatic Bartholin duct cysts is with incision and drainage.