A 33-year-old woman comes to the office for evaluation of a vaginal mass. The patient first noticed the mass 2 weeks ago after having pain during intercourse. She has avoided intercourse since, but the mass is still present. The patient has had no irregular menstrual or postcoital bleeding. She has had 4 sexual partners in the past year and uses combination oral contraceptive pills. The patient had 3 term vaginal deliveries in her 20s; the largest baby was 4.54 kg (10 lb). Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, and pulse is 76/min. BMI is 26 kg/m2. On bimanual pelvic examination, there is a 2-cm mass on the anterior vaginal wall. The mass is tender to palpation and expresses a purulent discharge from the urethra. Which of the following is the most likely diagnosis in this patient?
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This patient's anterior vaginal wall mass is most likely a urethral diverticulum, an abnormal localized outpouching of the urethral mucosa into surrounding tissues. A urethral diverticulum typically arises from recurrent periurethral gland infections, which can develop into an abscess that can eventually breach the urethral mucosa. The persistent infection, inflammation, and increased tissue tension in the area causes a tender anterior vaginal wall mass that may present as dyspareunia or a palpable mass on pelvic examination. In addition, the diverticulum may collect urine and debris, resulting in a purulent discharge, dysuria, or postvoid dribbling. MRI is used to confirm the diagnosis of a urethral diverticulum; patients are treated via surgical excision.
(Choice A) A Bartholin gland abscess can cause dyspareunia and a tender vulvar mass that expresses purulent discharge. This diagnosis is unlikely because the Bartholin glands are located at the posterior vulvar vestibule (4 and 8 o'clock positions), not along the anterior vaginal wall.
(Choice B) Abnormal cervical cancer screening results are typically due to chronic human papillomavirus (HPV) infection with high-risk subtypes (eg, HPV 16 and 18). In contrast, condyloma acuminata (ie, genital warts) are caused by low-risk subtypes (eg, HPV 6 or 11) and typically present as either asymptomatic or pruritic, cauliflower-like lesions, which are not seen in this patient.
(Choice C) Symptomatic pelvic organ prolapse can cause pelvic pressure and an anterior vaginal bulge (eg, cystocele); this condition is common in multiparous women, particularly those who have had vaginal deliveries and fetal macrosomia, such as this patient. However, pelvic organ prolapse typically causes a nontender vaginal bulge and is not associated with purulent discharge.
(Choice E) A uterine leiomyoma is a slow-growing uterine tumor that typically causes a bulky, irregular uterus and heavy menstrual bleeding. Although patients may have bulk symptoms (eg, pelvic pressure, constipation), they typically do not have dyspareunia, and there is no association with a vaginal mass or purulent discharge.
Educational objective:
A urethral diverticulum, which is an abnormal localized outpouching of the urethral mucosa into surrounding tissues, can cause dyspareunia. Patients typically have a palpable, tender mass on the anterior vaginal wall with an associated purulent discharge.