International Urology and Nephrology 27 (6), pp. 775- 778 (1995)

Skene's Duct Cyst in Adult Women: Report of Two Cases

M. ISHIGOOKA, S. HAYAMI, T. HASH/MOTO, M. TOMARU, H. YAGUCI-N, I. SASAOAWA, T. NAKADA

Department of Urology, Yamagata University, School of Medicine,Yamagata, Japan

(Accepted January 7, 1995)

Skene's duct cysts in the adult are uncommon lesions. Complete urologic ex- aminations are necessary because these lesions simulate other clinically important lesions. Herein we report two cases of Skene's duct cyst in adult women. In these cases we could make differential diagnosis by physical, radiological and endoscopic examinations.

Introduction

Cysts of the ducts of Skene are uncommon ailments [1-5]. The present- ing symptoms of the paraurethral cysts include a local mass [1, 2, 4, 5], pain [1], dyspareunia [1, 2, 4], dysuria [6], distorted voiding stream [5] and vaginal discharge [1]. In some cases, these lesions may be asymptomatic [1, 4]. Com- plete urological evaluations are necessary to differentiate this benign lesion from other clinically important lesions, such as urethral diverticulum, ectopic ureterocele and paraurethral tumours.

In the present paper we describe two cases of Skene's duct cyst in adult women. The methods for differential diagnosis of this lesion are discussed.

Case reports

Case 1. A 20-year-old woman was referred to us because of spraying of the urinary stream during voiding. Examination of the external genitalia re, vealed a nontender 3 cm cystic mass on the left posterior lateral aspect of the urethral orifice (Fig. 1). This mass was displacing the orifice up and to the right side. Laboratory test values were all within normal limits. Urine culture was negative. Drip infusion pyelography revealed normal kidneys. The bladder and the urethra appeared to be normal on cystourethroscopy. Voiding and post- voiding films revealed no evidence of a urethral diverticulum. Opacification of the cyst with contrast medium showed no communication between the cyst and the urethra (Fig. 2). Then we diagnosed this patient as having paraurethral cyst. The cyst was resected under lumbar anaesthesia. Histologically, the cyst was lined by transitional cell epithelium.

VSP, Utrecht Akad~miai Kiad6, Budapest

776 Ishigooka et al.: Skene's duct cysts

Fig. 1. Gross appearance of the paraurethral cyst in Case 1

Fig. 2. Injection of contrast medium into the cyst showed no communication with the urethra (cystography was simultaneously performed).

Arrow indicates the paraurethral cyst

Case 2. A 33-year-old woman complained of a palpable mass in the paraurethral region. On physical examination a fluctuant left paraurethral mass, 2 cm in diameter, was noted. Urine culture was negative for bacterial growth. Serum electrolytes, creatinines and blood cell counts were all within normal limits. Excretory urography, voiding cystourethrography, ultrasonography of the kidney and cystourethroscopy showed no abnormal findings. Injection of contrast media into the cyst indicated that the cyst had no communication

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Ishigooka et al.: Skene 's duct cysts 777

Fig. 3. Microscopic appearance of the cyst wall in Case 2. The cyst was lined by stratified squamous epithelium

(H&E, reduced from x400)

with the urethra. Then the cystic lesion was diagnosed as paraurethral cyst. The cyst was excised under lumbar anaesthesia. Histologically, the cyst wall was lined by stratified squamous epithelium (Fig. 3).

Discussion

Paraurethral cysts in women are classified primarily according to their acquired or congenital aetiology [4]. Acquired inclusion cysts are thought to be secondary to the trauma of childbirth and are usually lined by stratified squa- mous epithelium [1, 4]. This lesion may contain caseous or purulent material [4]. Congenital cysts arise from the various embryologic components and vesti- gial remnants [4, 7, 8], Congenital cysts are derived from three embryologic components: (1) the miillerian duct system, (2) the mesonephric duct system (Gartner's duc0 and (3) the urogenital sinus derivatives (Skene's ducts and other paraurethrai glands). Their origin usually could be identified by the histo- logic appearance of the lining epithelium, unless there is gross distortion by infection [1, 4, 7].

Skene's duct cysts are rare, especially in the adult [2, 4]. Differential diag- nosis from other types of paraurethral cysts is usually made by demonstration of a transitional epithelium or a stratified squamous epithelium in the whole or in part of the cyst wall [1, 5, 9]. Clinically, this lesion should be differentiated from ectopic ureterocele [6, 10], urethral diverticulum [6], urethrocele and peri- urethral connective tissue neoplasms. For the diagnosis of paraurethral cysts

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778 Ishigooka et al.: Skene's duct cysts

close physical examinations, radiological studies and endoscopic findings seem mandatory. On physical examination, the ectopic ureterocele commonly presents in the proximal urethra and the urethral diverticulum usually presents as a suburethral mass, while the paraurethral cyst occurs lateral to the distal urethra [6]. Paraurethral tumours usually present as a solid mass, while para- urethral cyst may be palpated as a cystic mass. Excretory urography, voiding cystography, ultrasonography and cystourethroscopy are necessary for differen- tial diagnosis. Injection of contrast medium into the cyst appears to be useful to exclude ectopic ureterocele and urethral diverticulum, since such lesions may indicate direct or indirect communication with the urethra. Differential diagno- sis of the paraurethral cyst can be made by findings in such examinations.

In the neonate, paraurethral cysts often rupture, with spontaneous cure. Treatment of this lesion consists of partial excision with marsupialization of the cyst wall [8]. In contrast, spontaneous rupture is rare in the adult. Total excision of the cyst appears to be a treatment of choice for the adult [4], since this lesion is often accompanied by chronic inflammation.

References

1. Deppisch, L. M.: Cysts of the vagina: Classification and clinical correlations. Obstet. Gynecol., 45, 632 (1975).

2. James, S. T.: A large cyst of Skene's duct - a rare cause of superficial dyspareunia. Aust. NZ J. Obstet. Gynaecol., 19, 61 (1979).

3. Gottesman, J. E., Sparkuhl, A.: Bilateral Skene duct cysts. J. Pediatr., 94, 945 (1979). 4. Das, S. P.: Paraurethral cysts in women. J. Urol., 126, 41 (1981). 5. Miller, E. V.: Skene's duct cyst. J. Urol., 131, 966 (1981). 6. Stovall, T. G., Muram, D., Long, D. M.: Paraurethral cyst as an unusual cause of acute

urinary retention. J. Rep. Med., 34, 423 (1989). 7. Bergner, D. M.: Paraurethral cysts in the newborn. South. Med. J., 78, 749 (1985). 8. Blaivas, J. G., Pais, V. M, Retik, A. B.: Paraurethral cysts in female neo-nate. Urology,

7, 504 (1976). 9. Kimbrough, H. M., Vaughan, E. D.: Skene's duct cyst in newborn: Case report and re-

view of the literature. J. Urol., 117, 387 (1977). 10. Kjaeldgaard, A., Fianau, S., Thorgeirsson, T., Ekman, P.: Single bifid ectopic ureter

presenting clinically as a vaginal cyst. Diag. Gynecol. Obstet., 3, 321 (1981).

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