Vaginal Inclusion Cyst

A vaginal inclusion cyst is a keratin-filled cyst lined by squamous epithelium. It forms when vaginal epithelium is buried in the submucosa after childbirth, episiotomy repair, vaginal surgery or other trauma.

• It is a common cystic vaginal lesion in women who have delivered vaginally.
• It sits mostly in the posterior or lower third of the vagina near an old scar.
• It is benign and often needs no treatment.

A firm, smooth, round nodule 0.5 to 3 cm, white or yellow beneath the mucosa, painless in most women.

• Dyspareunia, vaginal discomfort or a lump felt by the woman or a partner.
• Differential diagnosis: Gartner duct cyst, Müllerian cyst, Bartholin cyst, urethral diverticulum, endometriotic nodule, vaginal tumour, rectocele.
• Complications: infection, abscess, rupture, recurrence, dyspareunia.

Diagnosis is clinical, by examination and the history of delivery or surgery.

• Speculum and bimanual examination, with the history of delivery or surgery.
• Ultrasound or MRI when the cyst is deep, large or unclear in relation to the urethra or rectum.
• Histology of the excised wall.
• Biopsy for any solid, ulcerated or growing lesion.

Observe asymptomatic cysts and excise symptomatic ones with the wall intact.

• Supportive: reassure; warm sitz baths 10 to 15 minutes, 3 times daily for discomfort; avoid squeezing the cyst.
• Pharmacological: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours). Infected cyst: amoxicillin-clavulanate 625 mg oral 8-hourly for 5 to 7 days, or clindamycin 300 mg oral 8-hourly for 5 to 7 days in penicillin allergy.
• Procedures: observation for asymptomatic cysts. Symptomatic cysts: excision with the intact cyst wall under 1 percent lignocaine (maximum 3 mg/kg, absolute maximum 200 mg plain) or regional anaesthesia, with closure of the dead space with absorbable 3-0 sutures. Incision and drainage for an abscess, with excision after 4 to 6 weeks.
• Special groups: in pregnancy defer elective excision until after delivery.
• Red flags: rapid growth, hardness, bleeding, ulceration, fever with severe pain.
• Follow-up: review at 2 weeks after excision and at 3 months for recurrence.