Conservative treatment and follow-up of vaginal Gartner’s duct cysts: a case series

The internal urogenital tract is derived from two sets of ducts: the Wolffian ducts (mesonephric) and the Müllerian ducts (paramesonephric). These ducts are present in both sexes. In women, during the eighth week of embryologic development, the paired Müllerian (paramesonephric) ducts fuse distally and develop into the uterus, cervix, and upper vagina. In addition, the Wolffian ducts regress. If the ducts persist in a vestigial form, they can form Gartner’s cysts. These cysts are mainly located in the right anterolateral wall of the vagina and less commonly in the lateral walls of the uterus [1, 2]. The imperfect development of Wolffian ducts can also result in urogenital abnormalities, such as changes in the metanephric urinary system [1, 3]. Cases of ectopic ureter, unilateral renal dysgenesis, and renal hypoplasia have also been reported in association with Gartner’s cysts [1, 4]. Most of these lesions are asymptomatic, but they may be accompanied by infections, bladder dysfunction, abdominal pain, vaginal discharge, and urinary incontinence due to extrinsic compression of the bladder neck [3]. True Gartner’s duct cysts are typically located along the anterolateral wall of the proximal third of the vagina. In contrast, Bartholin’s cysts are typically located in the posterolateral wall of the lower third of the vagina and are associated with the labia majora [1, 5]. The differential diagnosis might include Bartholin’s gland cyst, uterine prolapse, cystocele, rectocele, enterocele, urethral diverticulum, endometriosis, and malignant growth, among others [6]. Although vaginal cysts are found in approximately 1 to 2 % of women and Gartner’s duct cysts comprise approximately 10 % of vaginal benign cysts [1, 7], there is still some controversy regarding which course of action should be taken. This is the first study reporting long-term clinical observation of these lesions.

This is one of the few studies of Gartner’s cysts with a series of consecutive cases followed over a long period of time who were exclusively subject to clinical observation. Most of the case series presented in the literature typically present patients who were treated surgically [8]. The follow-up of these patients ranged from 2 to 17 years. In these four cases the location of the cysts was the right wall of the vagina. Gartner’s cysts are typically small with an average diameter of 2 cm. However, these cysts can increase in size and be confused with other structures, such as cystocele and uterine prolapse [6]. In fact, in this series, the size ranged from 1.5 to 4.2 cm. In all cases, the diagnosis was made incidentally during routine pelvic examination and most lesions were asymptomatic. Only one of the four women had urethral stricture with a history of recurrent UTI, but this condition did not have any relation with the presence of the cyst (Case 3). Transvaginal ultrasound was the test of choice for diagnostic confirmation (Fig. 3b). The investigation of the characteristics of these lesions can be made with urinary tract imaging tests, such as ultrasound and MRI. Intravenous pyelography and computed tomography are additional examinations that may be requested [1]. Treatment depends on the symptoms and desire of the patient. In the cases presented in this study, the women were asymptomatic and chose to be observed clinically. In this situation, surgery is not typically performed because this type of surgery can be complex and is not recommended unless the patient has severe symptoms [9]. When a patient is symptomatic, the initial procedure can involve cyst drainage, injection, or aspiration, and intra-cystic tetracycline [10]. In large and symptomatic or recurrent cysts, excision or marsupialization is indicated [4]. Cyst marsupialization is a simple minimally invasive procedure, which creates minimal surgical scarring and results in the pathological diagnosis of a Gartner duct cyst. Long-term follow-up after such a procedure has proven its efficacy with no demonstrated side effects or recurrence [11]. The management strategies for multiloculated recurrences include periodic surveillance, sclerotherapy, and marsupialization [12]. In older patients, a mass wall biopsy is recommended to exclude neoplasia; however, malignant transformation of Gartner’s cysts is exceedingly rare [13].

Despite the small number of cases of Gartner’s cysts, this study shows that conservative treatment can be a safe option for asymptomatic patients. However, further studies with a larger number of women in older age groups are needed for a better definition of conduct for these patients.