Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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Bartholin Cyst TERMINOLOGY Definitions • Bartholin glands (or greater vestibular glands) are mucussecreting glands located in vulvar vestibule, just lateral and inferior to vaginal introitus • Drain via narrow duct 2.5 cm in length • Cystic dilatation of Bartholin gland occurs secondary to duct obstruction IMAGING General Features • Best diagnostic clue ○ Palpable, and sometimes visible mass lateral and inferior to vaginal introitus ○ Most common vulvar cystic mass ○ Size ranges 1-4 cm • Location ○ Posterolateral distal vaginal wall, medial to labia minora, and at level of introitus Ultrasonographic Findings • Grayscale ultrasound ○ Cystic structure: Anechoic to mixed echogenicity if complicated by hemorrhage or infection; may contain septations ○ Thick walled if infected • Power Doppler ○ No internal vascularity, may see reactive hyperemia around Bartholin abscess MR Findings • T1WI ○ Low signal fluid if uncomplicated, signal may ↑ with infection or hemorrhage • T2WI ○ High signal fluid if uncomplicated, proteinaceous fluid may be lower signal than simple fluid Imaging Recommendations • Protocol advice ○ Clinical diagnosis: Imaging generally not required unless complications suspected CT Findings • Hypo- to hyperdense cystic lesion near vaginal introitus ○ Any solid component within should raise concern for malignancy DIFFERENTIAL DIAGNOSIS Other Labial Masses • Sebaceous cyst: Epidermal inclusion cysts, may become infected, respond well to incision and drainage • Thrombophlebitis or other infections • Hematoma: Straddle injury, abuse • Tumors: Rare, usually clinically obvious • Endometriosis/endometrioma Vulval Varices • Associated with pelvic congestion syndrome • Throughout vulva, not limited to vestibule Gartner Duct Cyst • Similar in appearance but in anterolateral wall of proximal vagina Skene Gland Cyst • Periurethral in origin and separate from vaginal wall PATHOLOGY General Features • Etiology ○ Obstruction of normal Bartholin gland duct Microscopic Features • Body of gland contains mucinous acini, duct has mixed squamous, mucinous, and transitional epithelial cells, and duct orifice is mostly squamous cells CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Usually asymptomatic ○ 1-4 cm, but can increase in size with repeated sexual stimulation ○ Can result in dyspareunia ○ Can become painful due to infection Demographics • Epidemiology ○ Approximately 2% of women ○ Can typically become symptomatic in 2nd to 3rd decade of life, but seen in all ages Natural History & Prognosis • Most are uncomplicated • If infected → Bartholin abscess ○ Perineal pain, tender labial mass ○ Multimicrobial or related to gonorrhea/chlamydia ○ Increased size of preexisting mass • Carcinomas are rare (1% of all gynecologic malignancies and 0.1-0.5% of vulvar carcinomas) ○ 80% are either squamous or adenocarcinoma Treatment • Abscess ○ Incision/drainage ± silver nitrate cautery ○ Marsupialization or excision for recurrent cases – Broad-spectrum antibiotics after surgical drainage ○ Placement of Word catheter – Outpatient or ER treatment – Limited by tendency to dislodge SELECTED REFERENCES 1. Hosseinzadeh K et al: Imaging of the female perineum in adults. Radiographics. 32(4):E129-68, 2012 2. Kushnir VA et al: Novel technique for management of Bartholin gland cysts and abscesses. J Emerg Med. 36(4):388-90, 2009 3. Ergeneli MH: Silver nitrate for Bartholin gland cysts. Eur J Obstet Gynecol Reprod Biol. 82(2):231-2, 1999 4. Hill DA et al: Office management of Bartholin gland cysts and abscesses. Am Fam Physician. 57(7):1611-6, 1619-20, 1998 5. Yuce K et al: Outpatient management of Bartholin gland abscesses and cysts with silver nitrate. Aust N Z J Obstet Gynaecol. 34(1):93-6, 1994 Diagnoses: Female Pelvis 845

Gartner Duct Cyst Diagnoses: Female Pelvis TERMINOLOGY • Gartner duct cyst (GDC) is an embryonic remnant of wolffian (mesonephric) duct, lined with nonmucinous low columnar cells ○ Associated with renal/ureteral/müllerian anomalies ○ Located in anterolateral vaginal wall IMAGING • Ultrasound is 1st modality of choice ○ Cyst with thin walls, separate from cervix – May contain echogenic material and septations • MR provides better resolution and spatial differentiation from other organs ○ Usually low T1 signal intensity and high T2 signal intensity – Hemorrhage or proteinaceous debris results in high T1 and T2 signal intensity KEY FACTS TOP DIFFERENTIAL DIAGNOSES • Nabothian cysts • Vaginal inclusion cysts • Endometriosis • Urethral diverticulum • Ectopic ureterocele • If solid appearing, consider vaginal tumors or cervical/vaginal polyp DIAGNOSTIC CHECKLIST • Cystic lesion in anterolateral vaginal wall, distinct from cervix and no internal flow on Doppler • In females with ipsilateral renal dysgenesis, a ureterocelelike "cyst" without associated ureteric dilatation is highly suspicious for GDC (Left) Longitudinal transabdominal ultrasound shows an ovoid cyst ſt inferior to the cervix st. The endometrium is normal in this retroverted uterus. (Right) Coronal transvaginal ultrasound in the same patient shows 2 ovoid cysts ſt in the upper vagina, consistent with Gartner duct cysts. (Left) Sagittal T2 TSE MR, in the same patient, confirms the location of the Gartner duct cysts ſt, inferior to the cervix st, which contains a nabothian follicle . (Right) Transverse transabdominal ultrasound shows a Gartner duct cyst ſt inferior and posterior to the bladder st. 846

Gartner Duct Cyst<br />

Diagnoses: Female <strong>Pelvis</strong><br />

TERMINOLOGY<br />

• Gartner duct cyst (GDC) is an embryonic remnant of<br />

wolffian (mesonephric) duct, lined with nonmucinous low<br />

columnar cells<br />

○ Associated with renal/ureteral/müllerian anomalies<br />

○ Located in anterolateral vaginal wall<br />

IMAGING<br />

• <strong>Ultrasound</strong> is 1st modality of choice<br />

○ Cyst with thin walls, separate from cervix<br />

– May contain echogenic material <strong>and</strong> septations<br />

• MR provides better resolution <strong>and</strong> spatial differentiation<br />

from other organs<br />

○ Usually low T1 signal intensity <strong>and</strong> high T2 signal<br />

intensity<br />

– Hemorrhage or proteinaceous debris results in high<br />

T1 <strong>and</strong> T2 signal intensity<br />

KEY FACTS<br />

TOP DIFFERENTIAL DIAGNOSES<br />

• Nabothian cysts<br />

• Vaginal inclusion cysts<br />

• Endometriosis<br />

• Urethral diverticulum<br />

• Ectopic ureterocele<br />

• If solid appearing, consider vaginal tumors or<br />

cervical/vaginal polyp<br />

DIAGNOSTIC CHECKLIST<br />

• Cystic lesion in anterolateral vaginal wall, distinct from<br />

cervix <strong>and</strong> no internal flow on Doppler<br />

• In females with ipsilateral renal dysgenesis, a ureterocelelike<br />

"cyst" without associated ureteric dilatation is highly<br />

suspicious for GDC<br />

(Left) Longitudinal<br />

transabdominal ultrasound<br />

shows an ovoid cyst ſt<br />

inferior to the cervix st. The<br />

endometrium is normal in<br />

this retroverted uterus. (Right)<br />

Coronal transvaginal<br />

ultrasound in the same patient<br />

shows 2 ovoid cysts ſt in the<br />

upper vagina, consistent with<br />

Gartner duct cysts.<br />

(Left) Sagittal T2 TSE MR, in<br />

the same patient, confirms the<br />

location of the Gartner duct<br />

cysts ſt, inferior to the cervix<br />

st, which contains a<br />

nabothian follicle . (Right)<br />

Transverse transabdominal<br />

ultrasound shows a Gartner<br />

duct cyst ſt inferior <strong>and</strong><br />

posterior to the bladder st.<br />

846

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