65

lnterlabial Masses in Little Girls: Review and Imaging

Recommendations

Anna
Robert

R. Nussbaum1
L. Lebowitz1

When an interlabial mass is seen on physical examination in a little girl, there is often confusion about its etiology, its implications, and what should be done next. Five common interlabial masses, which superficially are strikingly similar, include a prolapsed ectopic ureterocele, a prolapsed urethra, a paraurethral cyst, hydro(metro)colpos, and rhabdomyot.arcoma of the vagina (botryoid sarcoma). A prolapsed ectopic ureterocele occurs in white girls as a smooth mass which protrudes from the urethral meatus so that urine exits circumferentially. A prolapsed urethra occurs in black girls and resembles a donut with the urethral meatus in the center. A paraurethral cyst is smaller and displaces the meatus, so that the urinary stream is eccentric. Hydro(metro)colpos from hymenal imperforation presents as a smooth mass that fills the vaginal introitus, as opposed to the introital grapelike cluster of masses of botryoid sarcoma. Recommendations for efficient imaging are presented.

When

a female

infant

or

young

girl

presents

with

an

interlabial

mass,

the

etiology may not be apparent initially. The five entities that present in this manner are (I ) a prolapsed ectopic ureterocele (figs. 1 A and 1 B); (2) a prolapsed urethra (fig. 1 C); (3) a paraurethral cyst (fig. 1 D); (4) an imperforate hymen with hydro(metro)colpos (fig. 1 E); and (5) rhabdomyosarcoma of the vagina (botryoid sarcoma) (fig. 1 F). Because these quite different conditions strikingly similar masses, they are likely to be misdiagnosed lead to inappropriate or unnecessary radiologic examinations. On the literature, presumptive include not basis of a series of cases we we believe that the most efficient diagnosis only the based gross on certain appearance often clinically, present which of with may the on a but as the of this eval-

have analyzed and diagnostic approach key distinguishing mass and its route of urine of the degree that no further should

a review depends features. location,

These

of the

exact

also the position childs symptoms, presumptive uation is needed

of the urethral meatus and the race, and age. On the basis one can decide which either or, alternatively,

flow, as well of certainty radiographic be done next.

diagnosis,

examination

Prolapsed An ectopic

Ectopic

Ureterocele is a congenital anomaly that includes cystic dilatation

ureterocele

Received sion January

1

May 1 0, 1 982: 28, 1983. of Radiology,

Hospital

accepted Harvard
Medical

after

revi-

Department
Childrens

Medical
300 re-

of the terminal (intramural) part of a ureter, often associated orifice. About 90% of ectopic ureteroceles are associated with of a duplex collecting system and 1 0% with a single (nonduplex) Although most ectopic ureteroceles remain fixed in position, into or or even may through the fixed urethra causing during voiding. of The prolapse become symptoms sudden,

with a stenotic the upper moiety system [1]. some prolapse may be intermittent or chronic

School,

Center,

Longwood Ave. , Boston, MA 021 1 5. Address print requests to R. L. Lebowitz.

AJR 141:65-71,

intermittent,

July

1983
1-0065

0361

-803X/83/141

American

Roentgen

Ray Society

urinary retention [2, 3]. In boys, the ureterocele does not prolapse beyond the membranous part of the urethra [4, 5], but in girls it may appear at the urethral meatus producing an interlabial mass [2, 3, 6] (figs. 1 A, 1 B, and 2). While this is

66

NUSSBAUM

AND

LEBOWIIZ

AJR: 1 4 1 , July

1983

Fig.

1 -Five

common

interlabial

masses. A, Prolapsed ectopic ureterocele, acute. Redness of mucosal interlabial mass is sign of acute prolapse as blood supply has not been compromised (cf. fig. 1 B). Urine is exiting circumferentially around the ureterocele. B, Prolapsed ectopic ureterocele, chronic. Dark purple color means chronic prolapse and that blood supply has been compromised. Patient was in urinary retention. c, Prolapse of urethra (black child). Urethral meatus is in center of donut-shaped mucosal mass and urinary

stream
ficial

was central.
erosion.

Mucosa

has supercyst. Small was filled

D,

interlabial mass with small amount

meatus was

Paraurethral in this neonate

of milky

fluid.

Urethral

by mass. E, Imperforate hymen with hydrocolpos. Large collection of milky fluid

eccentric, displaced bulges translucent membrane. Incision

of hymen yielded large volume of fluid. Baby also had pelviabdominal mass. F, Rhabdomyosarcoma of vagina (botryoid sarcoma). Grapelike cluster of masses at introitus. One is bleeding from superficial erosion.

a relatively 65 cases Prolapse sively

uncommon presentation have been reported [4]. of an ectopic ureterocele girls, since ureteroceles

of a ureterocele, occurs almost

at least excluare al-

most unheard of in black children is helpful diagnostically since superficially similar interlabial primarily in black girls [7-11].

[1 ]. This racial predilection prolapse of the urethra, a mass (see below), occurs

in white

themselves

AJR:141,

July

1983

INTERLABIAL

MASSES

IN

LITTLE

GIRLS

67

A
Fig. 2.-Prolapsed ectopic ureterocele.

B
Anteroposterior

through meatus. be circumferential,

vaginal introitus around mass.

is normal.

Urinary

stream,

if

(A) and lateral (B) views. patient was not in urinary

Mass protrudes retention, would

Fig.

3.-Prolapsed

ectopic

ureterocele.

Patient

was being

catheterized

for voiding

cys-

tourethrogram tered ectopic

and catheter ureterocele.

inadvertently enContrast material

was
that

instilled
is, upper

into
pole

ureterocele
ureter (U)

and
of

its ureter,
this duplex

The prolapsed interlabial mass Because mucosa, be light the with pink.

ureterocele of varying surface duration with

presents as a smooth, round, size and color (figs. 1 A and 1 B). of the ureterocele of prolapse, the increasing time is mass vesical should and

collecting system. Catheter was then removed and patient voided. Ureterocele was seen to
prolapse through urethra. Ureterocele is very

outer a short However,

narrow arrows)
urethral

within

confines

of urethra
soon lower

of prolapse

but expands as meatus (below

(between as it is through
arrow). (Cour-

tesy of Dr. Ole Ekldf.)

subsequent ischemia, the mass will range from (fig. 1 A) to bluish-purple [3, 6] (fig. 1 B). Because terocele actually prolapses through the urethra distinct urethral meatus will not be identified

bright red the ure(fig. 3), a since it Voiding presence this will Direct cystography and affect should be done to determine the degree of reflux into the choice of therapy. if the upper moiety used pole of contrast any of the moieties, as Radionuclide studies worth the but saving. its contiin most into prolapsed

surrounds the mass (fig. 2A). If the urethra is not completely obstructed, urine will be seen to exit circumferentially around the ureterocele (fig. 1 A). The vaginal introitus will be

caudal to the mass but may be difficult or impossible to see when the prolapsed ureterocele is large (figs. 1 A and 1 B). Infrequently a pinpoint ureteric orifice has been identified on the surface of the mass when a tiny stream of urine, either spontaneously terocele, spurted seen this, nor have or children. urine or with external [6, 1 2-1 4]. reports pressure However, of it occurring on the urewe have not in infants

can determine

has function material to demonstrate ureter [3],

instillation

ureterocele (fig. 3) has been nuity with the dilated upper instances this is unnecessary.

we found

Urethral Prolapse

Prolapse of the urethra is a relatively uncommon lesion one

Radiology Once the interlabial ectopic ureterocele, made to relieve both mia of the ureterocele to aspirate fluid from [3, 4]. If this fluid established. However, mass is presumed to be a prolapsed a manual attempt at reduction can be the urinary obstruction and the ische[6, 1 2]. However, the mass is urine, it is often necessary reduction be firmly ureteroallow surgical in order to achieve the diagnosis will incision in the

that
in

occurs
girls

at all ages, but with two predominant peaks, younger than 1 8 and the other in postmenopausal

women infant

[1 8, 1 9]. The youngest reported was a 5-day-old [8]. This condition presents as an edematous, often mass that encircles point in differentiating the urethral meatus this from the other (fig. types of is

hemorrhagic 1 C), a key

a significant

of interlabial masses [7, 8, 1 1 , 1 8, 20, 21 ]. The the mass is the urethral mucosa which has through the meatus (fig. 4). The vaginal introitus easily varies vascular 1 8, 21

surface prolapsed usually

cele should be avoided, since this may subsequently reflux [3, 4, 1 3, 1 5] and thus limit the definitive alternatives [1]. Confirmation of the diagnosis and precise urinary tract anatomy and function is important, combination [16, system 1 7]
with

identifiable caudal to the mass from red to dark blue, depending

(fig. 4A). The on the status

mass of the

definition of and some sonography of a duplex

supply (fig. accounting

1 C). The mucosa bleeds for the usual complaints bleeding,

readily [7-1 1, of spotting,

early

menses,

vaginal

or hematuria. to

of usually

excretory shows upper

urography the typical pole.

and/or findings

Another occurrence prolapsed

helpful clue in the diagnosis is the predominant in black children [7-1 1 ] (fig. 1 C) as opposed ectopic ureterocele, which is seen almost exclu-

a dilated

68

NUSSBAUM

AND

LEBOWIIZ

AJR:141,

July

1983

Fig. 4.-Prolapse and lateral (B) views. is prolapsed urethra.

urinary stream being

of urethra. Anteropostenior (A) Donut-shaped interlabial mass This accounts for meatus and
in center of mass. Vaginal

introitus

is normal.

Fig. 5.-Paraurethral cyst. Anteropostenior (A) and lateral (B) views. Small mass displaces urethral meatus and accounts for its eccentric position. Vaginal introitus is normal.

sively racial

in white predilection

children

as noted

above.

The

reason

for this

genital

sinus

(paraurethral

glands,

Skenes

duct),

meso-

is unknown.

Radiology Urethral of the prolapse bladder or is not kidneys. associated Therefore, with any abnormality diagnosis is

nephric duct (Gartners duct), or MUllerian duct. The distinguishing feature of this condition is the displacement of the urethral meatus by the mass (fig. 5). Ihe eccentric urinary stream is different from the central stream in urethral prolapse and the circumferential one in prolapsed ectopic easily ureterocele. seen caudai The to the normal urethral vaginal meatus introitus and mass is usually (fig. 5). if the

certain on physical examination be obtained easily by passing lumen and into the bladder), needed.

(additional confirmation can a catheter through the central no radiographic evaluation is

Radiology If the separate urethral from, meatus is identified but displaced by, the as being completely mass, the diagnosis

of the

Parurethral

Cyst present as paucity of an uncomout of 11 [22-25]. cysts obstruction of the urois

paraurethral usually not

cyst should necessary,

present no problems. Confirmation, could be obtained by aspirating

A paraurethral cyst is another entity that can an interlabial mass in a neonate (fig. 1 D). The case reports in the literature suggests that this is mon or unrecognized, self-limiting lesion. Four reported cases underwent The exact pathogenesis unknown, or cystic but it is postulated degeneration spontaneous rupture of these epithelial-lined that they arise from of embryonic remnants

cyst [22-25], which would yield a small quantity of milky fluid. Injected contrast material would then show the cysts interior [22, 25] (fig. 6). This differs from a prolapsed ectopic ureterocele, the the aspirate volume which is urine, of milky it most and fluid closely aspirated and resembles, is large are from from (see usually which which below). not hydro(metro)colpos, endoscopy

Uroradiologic necessary.

examinations

AJR:141,

July

1983

INTERLABIAL

MASSES

IN LITTLE

GIRLS

69

Fig. 6.-Paraurethral cyst. Anteroposterior (A) and lateral (B) radiographs after aspiration of small amount of milky fluid from cyst and injection of contrast material. Cyst has not communicated with
any other part of urinary tract and has smooth lining.

Fig. 7.-Imperforate hymen with hydrocolpos. Anteroposterior (A) and lateral (B) views. Mass fills vaginal introitus. Urethral meatus is normal. Very large vagina accounts for pelviabdominal mass. When uterus is also dilated, condition is called hy-

drometrocolpos.

Hydro(metro)colpos Hydro(metro)colpos uterus) which occurs is distension in infancy and of the vagina (and is due to the accumuproximal to an imperseptum, or an atretic to intrauterine and

vaginal labial

atresia mass [26,

will

not

present On close

with

this

characteristic a normally

interposi-

27].)

inspection,

lation of excessive mucous secretions forate hymen, a transverse vaginal vagina. The secretions are secondary postnatal stimulation ternal estrogen [26]. puberty, the strual blood, When transverse
(figs. 1

tioned urethral meatus should be identifiable cephalad to the mass (fig. 7A). Because of the transparency of the thin hymen, the pearly gray color of the underlying mucoid material usually is visible (fig. 1 E). Hydro(metro)colpos from a simple imperforate hymen (or low membrane) is usually not associated with other congenital anomalies duplicated hydro(metro)colpos (unless system) the obstructed [28]. This from vaginal is almost congenital tracts mass, vagina is in atresia or is one-half distinction a mid or of a to high with genimass,

of uterine and cervical glands by ma(When this condition is encountered at of menlow ev-

precipitating factor is the accumulation and it is known as hematometrocolpos.) obstruction is an intact hymen vaginal septum), the accumulated producing
or high

the

(or a very secretions

transverse septum, which severe and often multiple tourinary and gastrointestinal In addition to the introital

always associated anomalies of the [26, 27]. a pelviabdominal

ert the membrane,

E and 7). (Mid

a bulging mass at the introitus transverse vaginal septa or

70

NUSSBAUM

AND

LEBOWIIZ

AJR:141,

July

1983

Fig. 8.-Rhabdomyosarcoma of vagina (botryoid sarcoma). Anteroposterior (A) and lateral (B) views. Characteristic grapelike cluster of masses protrudes from vaginal introitus. Urethral meatus is normal.

A
representing times the the bladder, distended vagina is present. Why and ureters,

B
(and uterus) and somethe uterus is not always phy is the ideal method If there to determine if there are any reis will

maining

problems.

is no hydronephrosis,

an excre-

dilated
the

is not known.
bladder

The hydro(metro)colpos
bowel, presenting and edema

may compress
and pelvic veins of unof the problems or cyanosis

adjacent

tory urogram would present, an excretory

be superfluous. If hydronephrosis urogram or radionuclide renogram

accounting for the occasional nary retention, constipation, lower extremities [29-31].

Radiology Since hydro(metro)colpos secondary to a simple imperother mem-

aid in the evaluation of renal function. Serial sonography then could be used to determine efficiently the resolution of the hydronephrosis. (Follow-up urograms performed after drainage of hydrocolpos have demonstrated that resolution can occur in 1 week or can take as long as 15 months [29, 32].)

forate hymen of a single vagina is not associated with congenital anomalies, if the characteristic bulging

of the

Vagina

(Botryoid resembling malignant in infants

Sarcoma) a bunch of tumor involvand children,

brane
nostic of the

that covers

the introitus

is identified,

no further

diag-

Botryoid
grapes), ing the

evaluation is usually needed before simple excision hymen. If needle aspiration through or incision of the membrane is performed, a large quantity of grey-white mucoid material is obtained. In the past, authors have focused on the urologic aspects of hydro(metro)colpos, specifically the symptoms and signs of urinary retention and urographic findings of bilateral hydronephrosis, anterolateral deviation of the ureters, and

sarcoma (G. botryoeides: the most common primary vagina, uterus, or bladder

usually occurs within the first 5 years of life [34-36]. Vaginal bleeding may be the presenting problem. The vaginal tumor commonly presents as a grapelike cluster of pearly gray masses that have prolapsed through the introitus (figs. 1F and 8) [34, 37]. Protrusion of a polypoid tumor of the bladder through the 38]. If the protruding may physical be difficult examination to urethral mass determine alone (fig. meatus is much less likely [35, is of sufficient size, however, it the exact site 38]. of origin on 1 F) [34,

anterosupenior

displacement

of the bladder

[29-32].

In fact,

Cook and Marshall [32] reported that 55% of 49 infants manifested urinary symptoms of acute retention, or frequent, scanty voiding from irritation or overflow. While it is impor-

tant to be cognizant obstructive uropathy,

this the is a secondary distended vagina its effect

of the potential for it is equally important

manifestation is decompressed. which will

an associated to realize that

resolve when is the

Radiology Rhabdomyosarcoma a characteristic before biopsy gross is rarely of the vagina usually presents such

Sonography

ideal
uterus)

method
and

for determining
on adjacent

the

size

of the

vagina
including

(and
the

appearance necessary.

(fig. 1 F) that imaging Sonography can provide spread occur to as

structures, previously sonography sonography

urinary tract. While vaginography to establish the diagnosis [30], this [33]. However, preoperative crucial to this hymen condition esis [28].) decompression has been Once

has been used has obviated is not usually (One exception the imperfonate genital tract, renal agen-

a baseline estimate local lymph nodes,

of the size liver, lung,

of the tumor. While and bone generally

for either diagnosis or management. is the occasional instance in which obstructs one half of a duplicated commonly associated with ipsilateral

late manifestations in children with advanced disease, a preliminary radiologic search for metastases is warranted once the diagnosis has been established [37, 39]. A vaginal

sarcoma
a and

often

will infiltrate
[34], so

the posterior
uroradiologic

wall of the bladder

and urologic

urethra

complete

examinations

are important.

Follow-up

of regression
usually

of the
can

accomplished,

sonogra-

tumor during combined chemoradiation therapy be done quickly and easily with sonography.

AJR:1 41, July 1983

INTERLABIAL

MASSES

IN

LITTLE

GIRLS

71

ACKNOWLEDGMENT

21 We thank Arnold Colodny for use of the clinical photographs.

22.
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