
==== Front
Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01007-1
10.1016/j.ijscr.2024.110226
110226
Case Report
Vulvar epidermal cyst in a 54-year-old virgin female: A very rare case report
Al-Jawad Mohammad mhammadjawad877@gmail.com
⁎
Barakat Mona
Dahoud Safinaz
Lbabidi Nour Abdulazize
Kawas Abdulmonem
Fattal Farah
University of Aleppo, Faculty of Medicine, Aleppo, Syria
⁎ Corresponding author. mhammadjawad877@gmail.com
29 8 2024
10 2024
29 8 2024
123 1102261 8 2024
21 8 2024
27 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Epidermal cysts are intradermal or subcutaneous tumors that can develop as a result of female genital mutilation (FGM) procedures or other traumatic events. The differential diagnosis of epidermal cysts in the vulvar or clitoral region depends on the age of presentation, with non-hormonal conditions like neurofibromatosis and nevus lipomatous cutaneous superficiality being considered in pediatric patients.

Case presentation

A 54-year-old female presented with urinary retention and a large vulvar mass. Imaging confirmed an epidermal cyst, which was surgically excised with successful resolution of the patient's symptoms and normal cosmetic appearance.

Discussion

Epidermoid cysts are common benign lesions that can rarely occur on the vulva, including the labia minora. These cysts may be congenital or acquired and can cause discomfort or urinary obstruction when large. Thorough clinical evaluation and imaging are crucial for accurate diagnosis and surgical planning. Excision is often recommended, especially for large, symptomatic cysts, to manage the condition and obtain a definitive diagnosis.

Conclusion

Vulvar epidermoid cysts, though rare, can occur on the labia minora. Differentiating these from other vulvar lesions and managing large, symptomatic cysts is challenging due to limited literature. This case highlights the need for comprehensive clinical evaluation, including history, exam, and imaging, to accurately diagnose and manage these rare cysts. Surgical excision is often recommended, considering potential complications. Further documentation is needed to improve the diagnosis and management of vulvar epidermoid cysts.

Highlights

• A 54-year-old virgin female had a large vulvar epidermal cyst causing urinary issues

• successfully managed via surgical excision.

Keywords

Epidermal cysts
Female genital mutilation
Vulvar
Labia minora
Case report
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pmc1 Introduction

Benign tumors of the vulva are very rarely seen. Epidermal cysts are intradermal or subcutaneous tumors that are enclosed within the epidermis [1].

Epidermal cysts can occur as a result of female genital mutilation (FGM) procedures, where the squamous epithelium becomes displaced and trapped under the skin. Over time, this leads to the accumulation of epidermal desquamations, secretions, and other cellular debris within the encapsulated space, ultimately forming the epidermal cyst [2].

The development of epidermal cysts in the genital area is often associated with prior trauma or surgical procedures, particularly those related to female genital mutilation. Alternatively, these cysts can occur spontaneously, either present at birth or developing later in life. Additionally, they may arise secondary to surgical interventions or traumatic events [3].

The differential diagnosis of epidermal cysts in the vulvar or clitoral region depends on the age of presentation. When these cysts occur in children, they can mimic clitoromegaly and be confused with virilization due to hyperandrogenic states. The non-hormonal differential diagnoses in pediatric patients include neurofibromatosis (NF) and nevus lipomatous cutaneous superficial, as these conditions can also manifest with cystic growths in the genital area that may resemble epidermal cysts [4].

It is important to highlight that in our case, we present a 54-year-old adult female with epidermal cysts of the vulva, and we highlight the challenges encountered in managing this unique case as per the SCARE checklist [5].

2 Case presentation

A 54-year-old virgin female patient presented to the gynecological clinic with urinary retention and dysuria. The patient had previously visited the urology clinic with the same complaint and was diagnosed with a severe urinary tract infection, which was treated with antibiotics. The patient has a history of meningitis at the age of 4 and secondary hypothyroidism diagnosed at the age of 20, for which she is treated with levothyroxine 100 μg. She also has a mild degree of intellectual disability. In the family history, the patient mentioned a history of hypothyroidism in her mother. There is no history of surgeries.

On physical examination, a large mass was found in the vulvar area, covering the labia without the patient's awareness. The urethral opening was small, about the size of a pinhead (Fig. 1). She had not undergone any form of trauma to the clitoral area, such as female genital mutilation (FGM) previously.Fig. 1 A large cystic mass along the midline in front and above the vulvar.

Fig. 1

An ultrasound Doppler was performed, which revealed a well-defined cystic mass with no clear vascularity or apparent relationship with the urethra or vagina.

A CT scan of the chest, abdomen, and pelvis with contrast was performed, showing the presence of a formation with a liquid density and superficially placed on the midline in front of and above the vulva, measuring 54 × 40 mm, isolated from adjacent structures (Fig. 2).Fig. 2 The section shows a formation with a superficial fluid density located on the midline, with dimensions of 4 × 5.4 cm.

Fig. 2

Surgical excision of the mass was performed (Fig. 3).Fig. 3 The appearance after surgical repair shows no injuries to the vagina or urethra.

Fig. 3

Macroscopic examination of the excised mass revealed a cystic structure measuring 70 × 50 × 33 mm, filled with keratin, without evidence of hair shafts, covered by cutaneous tissue measuring 70 × 60 mm (Fig. 4).Fig. 4 The appearance of the cyst post-excision measures 70 × 50 × 33 mm, covered with cutaneous tissue.

Fig. 4

Microscopic examination showed that the cyst was filled with keratin and lined by mature squamous epithelium with a granulosa layer. No evidence for appendages in the wall, but in the surface cutaneous. The diagnosis was an epidermal cyst at the expense of the vulva. The patient was discharged without any complications from the surgery, with noticeable improvement.

She had a normal cosmetic appearance of the external genitalia, with a complete disappearance of genital and urinary complaints. Further follow-ups will continue at the gynecological clinic.

3 Discussion

Epidermoid cysts are common benign, slow-growing cystic lesions that occur in the mid/lower dermis or subcutaneous tissue. They can be found anywhere but are commonly located on the scalp, face, neck, trunk, and extremities, and rarely on the male and female external genitalia, palm, sole, fingers, and breast [6].

Epidermoid cysts of the vulva are often localized on the clitoral region and labia majora, and very rarely on the labia minora, and are frequently multiple [6].

The rare vulvar cysts may be congenital or acquired, occurring post-traumatically or following episiotomy or as a secondary effect of female circumcision. In a few cases, they can be spontaneous [1,7].

Our patient had a solitary vulvar epidermal cyst on the labia minora without any previous exposure to trauma or surgical intervention.

Vulvar cysts can vary in size and may reach up to 5 cm in diameter before their growth stops and are often present in perimenarcheal women [2,6].

Although epidermoid cysts usually remain asymptomatic, they may cause difficulty in walking and become a painful mass. Rarely, they grow large enough to completely obstruct the urethral meatus [1,7].

In this case, the patient presented with a complaint of dysuria, and the mass could be classified as a large mass obstructing the introitus with a 7-cm diameter. The fact that our patient presented late despite having such a very big vulvar swelling was due to mental retardation resulting from her medical history.

The differential diagnosis of benign vulvar tumors includes Bartholin cysts, epidermoid cysts, Gartner's cysts, cysts of the canal of Nuck, lipomas, endometriomas, posttraumatic hematomas, and inguinal hernias, and although rare malignant tumors of the vulva such as liposarcomas should also be considered in the differential diagnosis [1,2].

In the preoperative diagnosis of vulvar lesions, detailed history taking and thorough physical examination are crucial. Diagnostic imaging is also very important. US is valuable in distinguishing cystic masses and their relationships with adjacent structures such as the clitoris and urinary tract, but sometimes their appearance is nonspecific, necessitating further imaging. Both CT and MRI are essential for diagnosing epidermoid cysts and planning surgical excision. CT is particularly useful for confirming the diagnosis of large epidermoid cysts and it is a fast and cost-effective option compared to contrast-enhanced MRI [1,2,8].

Surgical excision is often recommended for vulvar epidermal cysts, especially in cases where the cysts are large and causing discomfort. Some authors suggest monitoring asymptomatic cases with clinical and radiological methods. However, surgery has been successfully used in many reported cases to treat vulvar masses [1].

Managing large dermoid cysts presents challenges due to potential perioperative complications. If the cysts extend to the clitoris or deep into the perineal membrane, there is a risk of heavy bleeding [2].

In addition, complete surgical removal is the most suitable approach for obtaining a conclusive histopathological diagnosis and preventing potential complications such as cyst rupture, hematoma, infection, and in rare cases, carcinoma development [1].

In our case, the surgical removal of the mass solved the patient's symptoms, as well as improved her quality of life without any complications.

It is important to note that, according to the existing medical literature, this case represents the second documented instance of an exceptionally rare presentation of a large epidermoid cyst localized to the labia minora of a postmenopausal female patient, who had no prior history of trauma or any surgical interventions in the affected region.

4 Conclusion

Vulvar epidermoid cysts are frequently found in the clitoral region and labia majora, and they can also occur on the labia minora, although this is extremely rare. They usually present post-trauma, as in female genital mutilation, and may occur spontaneously.

Classifying and differentiating vulvar cysts from each other and selecting appropriate management, especially in large and symptomatic cysts, can be challenging for clinicians. However, there is currently no unified classification and management system, and there is limited literature that provides a comprehensive overview of the clinical approach to this condition. The diagnosis and surgical management of this large vulvar epidermoid cyst posed a challenge.

The diagnosis and management of vulvar cysts require a comprehensive approach, including detailed history taking, physical examination, and diagnostic imaging. Surgical excision is often recommended for large and symptomatic cysts, with careful consideration given to potential perioperative complications. Further documentation and study of such cases are essential to enhance our early diagnosis and management of this rare case without complications.

Informed consent

Unnecessary, information taken from the patient's file.

Consent for publication

All authors provide consent for publication.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Ethical approval

This case report does not require ethical approval as it involves a single patient case that is anonymized and does not include any identifiable personal information. The patient provided informed consent for the publication of this report.

Funding

N/A.

Author contribution

The work's conception and design: all authors.

paper writing, and article revision: all authors.

Final revision and approval: all authors.

Guarantor

Farah Fattal

Research registration number

Our research study does not involve human subjects.

Conflict of interest statement

N/A.
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