PERI-URETHRAL AND PERINEAL-VAGINAL MASSES: HOW TO DEAL WITH IT ?

Periurethral, perineal or vaginal  masses are masses or swelling around the urethral meatus, vaginal area or the perineal region. The incidence is less than 4%. The main presentation is feeling a swelling or mass around the meatus, vagina & vulva, difficulty in passing urine, urethral discharge and pain on sexual intercouse. There is limited information / literature on the exact incidence, diagnosis and management for this conditions.

periurethral mass

The differential diagnosis of suchs  massess include;

• Urethral Diverticulum ( 84%)
• Peri-urethral leiomyoma (7%)
• Periurethal vagianl cyst/ Gartner's cyst (6%) or remnant of mullerian duct cyst
• Skene's gland cyst or abcess
• Retention cyst
• Urethral Prolapse
• Urethral Caruncle
• Ectopic Ureterocele 
• Inguinal/Femoral Hernia
• Benign tumours- angiomyoblastoma, fibromas, warts
• Malignancies

The diagnosis is usually clinical, and some case we may need to do some imaging studies to see the nature & extent of the lesions. The suggested imaging studies include perineal Ultrasound, Ct Scan/ MRI, Urethroscopy/cystoscopy, micturating cystogram and double balloon urethrogram.

The management options will depends on the diagnosis. If small & asymptomatic, usually can be managed as conservatively. Aspiration of the cyst content can be done , but usually the cyst reoccurs. The suggested surgery include endoscopic re-roofing, trans-urethral incision, Marsupialization of the diverticulum or cyst, cystectomy of the cyst wall in cases of gartner's or skene gland cyst. Diverticulectomy in case of urethral diverticulum with grafting in some case. In some case excision of the lesions

Below are some of my personal collection of cases & how l managed them:

Case 1. 36 year old Para 2 with urinary incontinence & passing pus discharge urethral meatus. on examination noted tender, fluctuant mass, below urethral meatus. On pressing/milking the mass, pus & urine discharge noted coming from the urethral meatus. The diagnosis of Urethral Diverticulum was made. Marsupialization was carried out. This will create a small suburethral  fistula and allow the secretion to escape & thus facilitates the closure & healing of the fistula tract that communicates into the urethra. Based on my experience, this is very effective & simple operation.

suburethral abscess

Case 2. 32 year old patient presented with periurethral mass for 3 months. Initially the mass was small 3x 2 cm. Over few mass it become 8x8 cm. It was infected & rubbery in nature. Patient also had difficulty in passing urine. EUA & excision of the mass was carried out. The histology was consistent with para-urethral angiomyofibroblastoma. This case was published in Australia & New Zealand Continence Journal Vol 10, No 1, March 2004. The patient recovered very will with no recurrence. This condition is Benign tumour. 

Case 3. 29 year old Para1, noted cystic swelling around urethral meatus after delivery. On examination there was a cystic, transparent mass around 6 o clock below the urethral meatus. It was non tender mass. Mobile & cystic in nature. The options for such cases are neddle aspiration (but the recurrence rates are high), cystectomy, & marsupialization. In this case complete cystectomy was done. paraurethral or vaginal cyst develop as result of local irritation, inflammation or sequential blockage of vaginal or paraurethral glands. If infected the develop into abscess.

Case 4. 56 year old para 5 lady, presented with progressively enlarging mass on the left side of vagina. On examination the was 18 x 12 cm cystic mass noted. The mass was multiloculated & cystic. CT Scan showed cystic mass with no intra pelvic extension. A dignosis of  vagianl cyst/ Gartner's cyst or remnant of mullerian duct cyst was made. EUA and drainage was carried out. Serous like material removed and complete cystectomy and labioplasty was carried out. Vaginal wall cyst/ Gartner/ Mullerian remnant cyst occurs in 0.5-1% of patients. Mostly asymptomatic & unreported. An evaluation should include upper genito-urinary tract assessment to rule out any extension of the mass/cyst and other genito-urinary tract abnormalities. US/CT scan/MRI is the imaging modality of choice. If the is no concomitant abnormality of extension, than a cystectomy or marsupialization is surfice.

Case 5. 44 year old para 5 presented with recurrent left side tender vaginal mass. The mass typically present during pregnancy & subside after delivery. After the last childbirth, the mass persisted and become very tender & painful. Transabdominal ultrasound revealed a longitudinal mass from left vaginal wall extending to pouch of douglas. The mass was mixed in echogenicity. CT scan of abdomen reported as cystic mass anterior to the sacrum extending to lower part of vagina with possible differential diagnosis as (rectal duplication cyst or cystic sacrococcygeal teratoma or ischiorectal cystic lesion/abscess.). A diagnostic laparoscopy was carried out, which revealed left ischiorectal fossa abscess Therefore, 300cc of pus and caseous material drained through vagina. Pus culture and sensitivity grew B-hemolytic non A/B steptococcus. Otherwise, swab AFB, all other infective screening were negative. The fasting blood sugar was 4.8mmol/l. Sigmoidoscopy and Colonoscopy was essentially normal. This time a large marsupialization was done & the abscess was drained. Since than the mass/abscess did recurred. She remain asymptomatic until now.

Case 6. 68 year old patient postmenapausal for 20 year, presented with painful micturition and vaginal soreness. On assessment, there was a growth at the external urethral meatus. The common diagnosis for such conditions are Caruncle or urethral prolapse. In this case this patient had a urethral prolapse. Treatment for caruncle or prolapse is usually topical estrogen application. In some case caruncle/prolapse can be infected. in such cases antibiotics may be indicated. Surgical options includes cauterization for the caruncle or prolapse.  In some cases of prolapse, circumferential excision of the prolapse and approximation of the urethro-vagina margins can be carried out.

Case 7. 58 year old, presented with urinary obstruction & pv bleeding. 

On Examination, noted friable mass periurethrally. Biosy was consistent with sq cell ca stage 4. Patient was referred for radiotherapy. Malignancy at peri- urethral region is very rare. Prognosis is usually poor.

Case 8. This is a 15 year old girl, presented with continuous urine leakage from young. No proper previous evaluation. On examination, there was continuous leakage & wetness at periurethral region. CTU was carried out, revealed an ectopic ureter from right kidney extending to the periurethral region. Patient was referred to our paediatric surgeon, who subsequently ligated the ectopic ureter. Patient was symptom free after this procedure.

Case 9. A 6 year old child presented with difficulty in pass urine & para peri-urethrally. The mass was firm in consistency & non tender. It was reducible. An inguinal hernia was suspected. This patient referred to paediatric surgeons. The finding confirm reducible inguinal hernia with omentum

Case 10. A 58 year old patient presented with large mass, protruding from the vulval region. It was there for nearly 20 year. it was slow growing mass. On examination there was a firm & pedunculated mass on the left labia. It was non tender and mobile. US & CT scan did not show any extension or pelvic mass, Uterus & ovaries was normal, Labial Fibroma was diagnosed. Patient underwent excision with much problem. Histology was consistent with fibroma

Case 11. 65 year old para 5 presented with right side periurethral mass. the mas was firm & tender on pressure. Patient also had voiding difficulty. On examination there was a firm mass in the right upper labia and extending to lower abdomen. it was not reducible. A CT scan revealed a possible ovarian mass with omentum. A diagnosis of ovarian hernia was diagnosed. EUA & exploration was carried out, It turn of as ovarian fibroma prolapsing through the inguinal canal. Right Salphingo-oopherectomy & hernia repair was carried together with surgical team. Patient recovered well. Histology consistent with ovarian fibroma.

Other Mass that I have seen in my practice:

Recurrent mass at upper left labial. First excision biopsy was leiomyoma. came back again after 5 years, the second Excision Biopsy can as Leiomyosarcoma. She was subsequently referred for wider excision and chemotherapy with gynae-oncologist.

This patient presented as fungating grown & wary lesions. Biopsy & excision of the warty growth reveal Hyperkeratosis. Manged with local & systemic steroids. No under dermatology.

Hypertrophic clitoris. Patient planned for clitroplasty

 Genital Wart. Excision & cauterization of the wart carried out. Followed by application of  imiquimod cream.

Chronic Ulceration & necrotic mass. Biopsy revealed sq cell ca, Wide excision & radiotherapy carried out.

 Recurrent Paget's Disease . Now on remission & intermittent Imiquimod cream treatment.

Excessive Lichen sclerosis. Excision biopsy and local Steroid treatment given, recover very well.

 A baby with Ambiguous genitalia. given to paediatric surgeon to manage

 Case of Vulva Varicosity before & after ligation of the feeding vessels ( by Plastic Surgeon) newer modality is sclerotherapy and embolization technique by Interventional radiologist.

In Summary, In most case proper history & examination is sufficient to make a diagnosis. In some case we may want to take a biopsy before treatment or we can do an excision biopsy which is diagnostic and therapeutic, in which the lesion is removed at the same setting. We also may need some imaging modality like US/CT Scan or MRI or CTU / cystoscopy to assess the extend of peri-urethral, perineal or vaginal masses. These imaging will give us some idea about the relationship of such mass with the surrounding areas. This information is important to plan our definitive surgical plan.

All the photos were taken and displayed with patients permission.

Like to thank the owners of the drawings/ pictures as these photos were taken taken from google images. They were displayed here purely for teaching purpose only.