Day: September 3, 2012

What Causes Vulvar Masses?

Patient Presentation
A 21-year-old female came to clinic because of a mass on her left labia majora. She said she had noticed it two days ago after a long bike ride. It was slightly painful since then, especially with walking. She had tried soaking in a bathtub with some relief. She denied any overt trauma, vaginal discharge, dysmenorrhea, abdominal or pelvic pain or fever. Her last sexual encounter was 6 months previously and she had used condoms and foam for sexually transmitted infections and pregnancy prevention. The past medical history showed an ankle sprain and head injury because of athletics. The pertinent physical exam showed a healthy female with normal vital signs. Genitourinary examination found a 3 mm red/yellow knobbly lesion at 3 o’clock on the labia majora. It did not extend to the labia minora. There was no punctum seen. The surrounding skin was mildly erythematous and was very mildly painful with palpation. There was no streaking of the erythema. Individual hair follicles appeared normal in the area. No vaginal discharge was seen and the rest of the tissue appeared healthy.

The diagnosis of epidermal inclusion cyst was made. The patient was counseled that this was a common problem and usually resolved. The lesion probably had been there but was not noticed until the surrounding skin became irritated after the long bike ride. The patient was instructed to wear loose clothing until the erythema resolved, along with sitz baths. The physician also commended using an anti-chaffing product for biking and similar activities with strict perineal hygiene after exercise. The patient was to followup if the pain did not resolve or increased, the lesion became larger or other symptoms developed.

Discussion
Vulvar disease in children and adolescents often involves the skin structures with contact dermatitis, vaginal/perianal streptococcus infection, folliculitis, herpes labialis and similar problems causing much of the complaints. Trauma from straddle injuries and sexual abuse also are part of the differential diagnosis. Vulvar masses do occur but are somewhat less common in the pediatric population. Usually the vulvar mass diagnosis is made clinically by history, location and appearance, and most vulvar masses are benign. Treatment for vulvar masses may be necessary because of location and pain/irritation secondary to size and movement.

Learning Point
Common vulvar masses includes:

  • Bartholin gland cyst
    • Location: 4 and 8 o’clock of the labia majora, classically crosses the labia minora
    • Appearance: cystic, usually painless but may be painful
    • Other: may become infected and rarely is malignant
  • Epidermal inclusion cysts
    • Location: labia majora
    • Appearance: small, can be grouped, may be yellowish
    • Firm, nodular with palpation, often asymptomatic
  • Mucous cysts of vestibule
    • Location: vestibule
    • Appearance: superficial, smooth, < 2 cm usually
  • Vulvar fibroma
    • Location: labia majora, perineal body, introitus
    • Appearance: firm, asymptomatic, not cystic
  • Vulvar lipoma
    • Location: labia majora, may be associated with other lipomas on abdomen or thighs
    • Appearance: subcutaneous, soft, fatty lesion, not cystic, usually asymptomatic, may be slow growing
  • Canal of Nuck cyst
    • Location: inguinal crease or anterior labia majora. Does not cross the labia minora
    • Appearance: cystic swelling. Can occur anywhere along inguinal canal or in labia majora
    • Other: remnant of peritoneum
  • Vulvar hematoma
    • Location: anywhere within the vulva
    • Appearance: tense swelling of tissue that appears red and/or bruised, very painful
    • Other: usually has history of trauma
  • Sebaceous gland cysts
    • Location: may occur anywhere as may be ectopic
    • Appearance: firm, small lesions with punctum
  • Inguinal hernia
    • Location: Internal inguinal ring to vulva
    • Appearance: cystic mass which may be reducible
  • Other Vulvar Masses
    • Adenocarcinoma
    • Angiokeratoma
    • Dysontogenetic cyst
    • Endometriosis
    • Gartner duct cyst
    • Hemangioma
    • Hidradenoma – accessory breast tissue
    • Leimyoma
    • Myoblastoma
    • Pyogenic granuloma
    • Skene duct cyst
    • Syringoma
    • Rhabdomyosarcoma
    • Vaginal inclusion cyst

    Questions for Further Discussion
    1. What are indications to consider sexual abuse in a patient presenting with vulvar disease?
    2. What are indications for referral to a gynecologist for vulvar disease?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Vulvar Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Hill DA, Lense JJ. Office management of Bartholin gland cysts and abscesses. Am Fam Physician. 1998 Apr 1;57(7):1611-6, 1619-20.

    Pundir J, Auld BJ. A review of the management of diseases of the Bartholin’s gland. J Obstet Gynaecol. 2008 Feb;28(2):161-5.

    McWilliams GD, Hill MJ, Dietrich CS 3rd. Gynecologic emergencies. Surg Clin North Am. 2008 Apr;88(2):265-83, vi.

    Micali G, et. al. Benign Vulvar Lesions. Medscape.
    Available from the Internet at http://emedicine.medscape.com/article/264648-overview (rev. 9/29/11, cited 5/7/12).

    Stockdale CK, Boardman RA. Bartholin Cyst. ePocrates.
    Available from the Internet at https://online.epocrates.com/u/29351060/Bartholin+cyst/Diagnosis/Differential (rev. 6/24/11, cited 5/7/12).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital