Vaginal mass

A vaginal mass is a lump, swelling or protrusion felt or visible in the vagina or bulging through the introitus. Most are benign cysts or prolapse of the bladder, rectum or uterus, but a solid, fixed, ulcerated or bleeding mass needs biopsy to exclude vaginal cancer or metastasis. The main clinical point is to locate the mass by compartment and consistency (cystic, solid, reducible) and to decide on imaging or biopsy before any drainage or excision.

Clinical relevance. Suburethral masses may be urethral diverticula, and incision without imaging risks a urethrovaginal fistula. Cancer is uncommon but easily missed when a lesion is attributed to a cyst or prolapse.

Anatomy. The anterior wall lies against the urethra and bladder, the posterior wall against the rectum and pouch of Douglas, and the lateral walls carry remnants of the Wolffian (Gartner) duct. The apex is the cervix or the vault after hysterectomy. The introitus contains the hymen, vestibule and openings of the Bartholin and Skene glands.

Mechanisms. Cysts arise from embryonic duct remnants, trapped epithelium after trauma or childbirth, and blocked glands. Prolapse results from weakened support. Solid masses are polyps, fibroids, warts, granulation tissue, endometriosis, infection or neoplasia.

Classification. By site: anterior, posterior, lateral, apical, introital. By consistency: cystic, solid, reducible. By origin: congenital, acquired benign, infective, neoplastic, foreign body or iatrogenic.

Key distinctions. A mass that bulges on straining and reduces on lying down is prolapse. A tender anterior cyst with post micturition dribble, dyspareunia and recurrent urinary infection suggests urethral diverticulum. A lateral anterior cyst, non tender and fluctuant, is usually a Gartner duct cyst. A hard, ulcerated or friable mass is malignant until proved otherwise.

History

• Onset, duration, change in size, relation to straining, standing and the end of the day.
• Pressure, dragging, bulge, difficulty inserting tampons, dyspareunia, apareunia.
• Urinary: stress or urgency incontinence, post micturition dribble, hesitancy, incomplete emptying, recurrent infection, haematuria, dysuria.
• Bowel: constipation, splinting, digital evacuation, rectal bleeding.
• Bleeding, postcoital bleeding, discharge (offensive, blood stained), fever, pain.
• Parity, mode of delivery, episiotomy or tears, forceps, hysterectomy, vaginal or pelvic surgery, mesh or sling placement, pessary use.
• Menopausal status and use of vaginal oestrogen.
• Cervical screening and HPV vaccination history, previous abnormal results, in utero exposure to diethylstilbestrol, immunosuppression, HIV.
• Retained foreign body: tampon, condom, device, sexual aid.
• Weight loss, cough, haemoptysis, pelvic or back pain, leg oedema (advanced malignancy).
• Family history of gynaecological or colorectal cancer.

Examination

• Vital signs, BMI, abdomen for mass, inguinal lymph nodes.
• Inspect the vulva and introitus at rest and on straining, standing and supine.
• Speculum examination with a half speculum or Sims speculum to inspect each wall separately, the vault and the cervix.
• Palpate the mass: size, position (anterior, posterior, lateral), consistency, tenderness, mobility, fixation, reducibility, pulsation, discharge on pressing the urethra (urethral diverticulum).
• Bimanual and rectovaginal examination: uterine size and mobility, adnexal mass, rectovaginal septum nodularity, parametrial extension.
• Cough stress test with the prolapse reduced.
• Assess oestrogenisation, ulceration, bleeding, warts, and signs of infection.
• Examination under anaesthesia for children, severe pain, or inability to tolerate examination.

Red flags

• Hard, irregular, ulcerated or friable mass, or contact bleeding.
• Postmenopausal bleeding or bloodstained discharge.
• Fixed mass, rectovaginal or parametrial infiltration, inguinal lymphadenopathy.
• Mass in a girl or adolescent with bleeding or a grape like appearance (sarcoma botryoides).
• Fever with a tender fluctuant mass (abscess) or foul discharge with a retained foreign body (toxic shock risk).
• Acute urinary retention or severe hydronephrosis with advanced prolapse.
• Prolapsed mass with necrosis, ulceration or haemorrhage.
• Acute inversion of the uterus after delivery (shock, bleeding).

Special groups. Children: congenital anomalies and rhabdomyosarcoma. Postmenopausal women: prolapse, atrophy related erosion and malignancy. Postpartum women: haematoma, inversion, retained products and fistula. Women with a pessary: erosion and impaction.

Organised by site and nature. Each cause is common unless marked serious or uncommon. Cystic masses

• Epithelial inclusion cyst (posterior or lower third, after childbirth, episiotomy or surgery).
• Gartner duct cyst (anterolateral wall, from the Wolffian duct remnant).
• Müllerian cyst (anterior or lateral, mucin filled).
• Urethral diverticulum (anterior, suburethral, tender, post micturition dribble, dyspareunia, recurrent urinary infection, with possible stone or carcinoma inside).
• Skene gland cyst or abscess (periurethral).
• Bartholin cyst or abscess (introital, posterolateral).
• Endometriotic cyst or nodule (posterior fornix, rectovaginal septum).
• Vaginal haematoma (after delivery, surgery, trauma or intercourse).
• Hydrocolpos and haematocolpos from imperforate hymen or transverse vaginal septum (bulging bluish membrane).
• Vaginal adenosis (with in utero diethylstilbestrol exposure).

Reducible or protruding masses

• Cystocele, urethrocele, rectocele, enterocele.
• Uterine prolapse, vault prolapse after hysterectomy.
• Rectal prolapse (full thickness folds) appearing at the anal verge.
• Prolapsed cervical or endometrial polyp.
• Prolapsed submucous fibroid.
• Inverted uterus (puerperal or tumour related).
• Urethral prolapse or urethral caruncle (meatal, not vaginal).
• Prolapsed ureterocele (girls).

Solid benign masses

• Genital warts (condylomata acuminata) and molluscum contagiosum.
• Vaginal polyp, fibroepithelial polyp, granulation tissue at the vault.
• Mesh erosion or exposure, suture granuloma, retained foreign body, pessary erosion.
• Fibroma, leiomyoma, lipoma, rhabdomyoma.
• Leiomyoma of the vagina and vaginal wall endometriosis.
• Vaginal tuberculosis or schistosomal granuloma (uncommon, endemic regions).
• Lymphogranuloma venereum and donovanosis (uncommon).

Malignant masses

• Serious: vaginal squamous cell carcinoma (the commonest primary vaginal cancer).
• Serious: clear cell adenocarcinoma (in utero diethylstilbestrol exposure), vaginal melanoma, vaginal sarcoma.
• Serious: metastasis from cervix, vulva, endometrium, ovary, colorectum, bladder or choriocarcinoma (cannonball vaginal nodules, high beta hCG).
• Serious: sarcoma botryoides (embryonal rhabdomyosarcoma) in girls under 5 years.
• Serious: endodermal sinus (yolk sac) tumour in infants.
• Serious: vaginal intraepithelial neoplasia (flat or raised lesion).
• Serious: cervical cancer extending to the vagina.

Infection

• Vaginal wall abscess, infected cyst, infected retained foreign body.
• Pelvic abscess pointing into the vault.

Special groups. Infants and girls: hydrocolpos, prolapsed ureterocele, urethral prolapse, haemangioma, sarcoma botryoides and yolk sac tumour. Postmenopausal women: prolapse, polyp, atrophy with granulation tissue and cancer.

Stepwise reasoning

1. Locate the mass (compartment) and decide whether it is cystic, solid or reducible.
2. Test for pregnancy and infection, and ask about retained foreign bodies.
3. Image cystic masses on the anterior wall and any complex mass before any drainage or excision.
4. Biopsy any solid, ulcerated, friable or persistent mass, and any mass in a postmenopausal woman with bleeding.
5. Stage promptly when cancer is found.

First line tests

• Urine pregnancy test; urine dipstick, microscopy and culture.
• Vaginal swab for pH, microscopy and culture; nucleic acid amplification tests for chlamydia, gonorrhoea, Trichomonas vaginalis and Mycoplasma genitalium; herpes simplex virus swab for ulcers.
• Cervical screening and HPV testing if due (a normal result does not exclude cancer).
• Post void residual by bladder scan for a mass with urinary symptoms (over 100 mL suggests incomplete emptying).
• Full blood count and C reactive protein for suspected infection.

Imaging

• Translabial or transperineal ultrasound and transvaginal ultrasound: cyst or solid, relation to the urethra, bladder and rectum, levator integrity, haematocolpos, endometrioma, uterine and adnexal masses.
• MRI pelvis with T2 weighted sequences: urethral diverticulum (periurethral fluid collection, often partly circumferential), Gartner and Müllerian cysts, deep endometriosis, vaginal tumour extent, nodes. Prefer MRI for any anterior cyst before drainage.
• Renal tract ultrasound for advanced prolapse, urethral diverticulum or Müllerian anomaly (hydronephrosis, absent kidney).
• CT chest, abdomen and pelvis, and PET CT, for staging a confirmed malignancy.

Targeted tests and procedures

• Punch biopsy under local anaesthetic (lidocaine 1% 2 to 5 mL infiltrated, maximum 200 mg of plain lidocaine, 3 mg/kg) of any solid, ulcerated, pigmented or persistent lesion; excisional biopsy of a small lesion.
• Colposcopy with biopsy for suspected vaginal intraepithelial neoplasia or warts.
• Cystourethroscopy: ostium of the diverticulum in the mid urethra; excludes carcinoma and stone.
• Beta hCG for suspected choriocarcinoma or pregnancy related mass; squamous cell carcinoma antigen and CA 125 only to follow established disease.
• Proctoscopy or sigmoidoscopy for a posterior mass with bowel symptoms.
• Examination under anaesthesia with vaginoscopy in children, with biopsy of any mass.
• Cytology or Gram stain and culture of aspirated fluid only after imaging has excluded a diverticulum.

Limitations. Small posterior or lateral cysts may be felt only on bimanual examination. Imaging may fail to separate a diverticulum from a cyst without MRI. A biopsy of a necrotic tumour can show only inflammation, so repeat biopsy at the edge of a suspicious lesion. Ultrasound cannot stage vaginal cancer.

Immediate steps. Control haemorrhage, remove a retained foreign body, drain a vaginal abscess, replace an inverted uterus, relieve urinary retention with a catheter, and refer suspected cancer within 2 weeks. Reassure the woman that most masses are benign, and plan investigation of the rest.

Analgesia. Paracetamol 1 g orally every 4 to 6 hours, maximum 4 g daily (3 g daily with chronic alcohol use, malnutrition or hepatic impairment; 15 mg/kg each dose under 50 kg). Ibuprofen 400 mg orally every 6 to 8 hours with food, maximum 2.4 g daily; avoid in peptic ulcer, renal impairment, heart failure and NSAID sensitive asthma.

Epithelial inclusion cyst, Gartner duct cyst, Müllerian cyst. Observe when asymptomatic and confirmed on imaging. Symptomatic cysts: excision, or marsupialisation for larger cysts. Care is needed with a lateral cyst because the ureter lies close.

Urethral diverticulum. Treat infection first with culture directed antibiotics. Empirical cover for lower tract infection: nitrofurantoin modified release 100 mg orally twice daily for 3 days with food (avoid when eGFR is under 45 mL/min/1.73 m2 and near term in pregnancy). Definitive treatment is diverticulectomy with layered closure and an interposed flap in a urology or urogynaecology unit; conservative management is acceptable for small, mildly symptomatic diverticula. Carcinoma inside a diverticulum needs oncology management.

Skene and Bartholin abscess. Incision and drainage with a catheter (inflatable tip catheter left in place for 4 to 6 weeks) or marsupialisation.

Antibiotics are used for cellulitis or systemic illness: co-amoxiclav 625 mg orally three times daily for 5 days (625 mg twice daily when creatinine clearance is under 30 mL/min).

Penicillin allergy: doxycycline 100 mg orally twice daily plus metronidazole 400 mg orally twice daily for 5 to 7 days (avoid doxycycline in pregnancy; use clindamycin 300 mg orally four times daily). Biopsy persistent or recurrent lesions in women over 40.

Vaginal haematoma. Small and stable: ice, analgesia and observation. Expanding or with falling haemoglobin: surgical evacuation and ligation of the bleeding point, with packing and catheterisation, blood transfusion if needed and antibiotics.

Genital warts of the vagina. Cryotherapy or trichloroacetic acid 80 to 90% applied weekly by a clinician to dry lesions, repeated for up to 6 weeks; do not use podophyllotoxin or imiquimod inside the vagina. Test for other sexually transmitted infections, check cervical screening and offer HPV vaccination.

Foreign body and mesh or pessary erosion. Remove the foreign body, irrigate, and give co-amoxiclav 625 mg orally three times daily for 5 days for infection (625 mg twice daily when creatinine clearance is under 30 mL/min).

For pessary erosion, remove the pessary and apply vaginal oestrogen: oestradiol 10 microgram vaginal tablet nightly for 2 weeks, then twice weekly (contraindicated with undiagnosed vaginal bleeding, active venous thromboembolism and active liver disease), then review in 2 to 4 weeks before refitting.

Mesh exposure: oestrogen cream first, then excision of exposed mesh.

Prolapsed polyp or fibroid. Hysteroscopic or vaginal removal with histology; infected or necrotic submucous fibroid needs antibiotics (co-amoxiclav 625 mg orally three times daily for 5 days) and removal.

Prolapse. Pelvic floor muscle training, weight loss, treatment of constipation and cough, vaginal oestrogen for atrophy (oestradiol 10 microgram vaginal tablet nightly for 2 weeks, then twice weekly), a ring pessary, or surgery. Strangulated or incarcerated prolapse is reduced under analgesia after lubrication.

Puerperal uterine inversion. Call for help, give fluids and blood, and replace the uterus immediately by pushing the fundus through the cervix with the palm. If a cervical ring prevents this, give uterine relaxant (glyceryl trinitrate 50 microgram intravenously, repeated to a total of 200 microgram if needed, or terbutaline 0.25 mg subcutaneously), and give oxytocin only after replacement.

Laparotomy for failure.

Haematocolpos, imperforate hymen, transverse septum. Surgical incision or excision by a gynaecologist, with the hymen cruciate incision for imperforate hymen; reassess for associated renal anomaly.

Endometriosis. Excision and hormonal suppression (combined oral contraceptive, dienogest 2 mg orally once daily continuously, or norethisterone acetate 5 mg orally once daily increased by 2.5 mg every 2 weeks to a maximum of 15 mg daily).

Vaginal cancer and vaginal intraepithelial neoplasia. Multidisciplinary oncology care. Intraepithelial neoplasia: excision, laser ablation, or topical therapy.

Invasive disease: radiotherapy with concurrent cisplatin 40 mg/m2 intravenously once weekly during treatment (check renal function, full blood count, hearing and electrolytes; reduce or stop for creatinine clearance under 60 mL/min) for most stages, surgery for selected small upper vaginal tumours, and chemotherapy for metastasis.

Sarcoma botryoides: combination chemotherapy (vincristine, actinomycin D, cyclophosphamide) with conservative surgery by paediatric oncology.

Metastatic and choriocarcinoma masses. Treatment of the primary tumour; gestational choriocarcinoma needs specialist chemotherapy with methotrexate or actinomycin D by a trophoblastic disease centre.

Special groups. Pregnancy: avoid podophyllotoxin and doxycycline; Bartholin abscess is drained; prolapse is managed with a pessary; vaginal delivery is usually possible. Children: examination under anaesthesia with vaginoscopy and paediatric gynaecology or surgery referral. Postmenopausal women: low threshold for biopsy.

Monitoring. Review at 4 to 6 weeks after drainage or excision. Follow up biopsy results within 2 weeks. After malignancy, follow up by oncology with examination every 3 to 6 months for 2 years. Referral and escalation. Refer urgently within 2 weeks to gynaecological oncology for any suspicious mass. Refer to urogynaecology or urology for urethral diverticulum, fistula, mesh complications and complex prolapse. Refer to paediatric gynaecology for any mass in a girl. Refer to the on call team for haemorrhage, abscess with sepsis, inversion or retention.

Admission criteria. Haemodynamic instability, expanding haematoma, abscess with sepsis, acute retention, inversion, strangulated prolapse, and suspected cancer with bleeding or obstruction. Discharge and follow up. Most women are managed as outpatients with a named contact and result review within 2 weeks. Give written advice on pessary care and wound care.

Safety netting. Return for heavy bleeding, fever, offensive discharge, inability to pass urine, severe pain or enlargement of the mass.