Nonpainful vulvar mass in a 42-year-old woman

Presentation

A 42 y.o. woman presents for her annual gynecologic exam and complains of a non-painful mass on her right vulva. On examination, there is a 6-cm right-sided, mobile, non-tender mass just lateral to her right labium majus. It is bothersome when sitting and she cannot comfortably ride her bicycle. On physical examination, the mass is not compressible.

Correct Answers

Your most likely diagnosis is: B. lipoma

Your treatment plan is: C. Wide local excision

Discussion

Lipomas are benign masses that may occur on the vulva. Those that are asymptomatic and not enlarging can be monitored. Treatment for tumors that become bothersome or interfere with movement or enlarge significantly consists of a simple wide local excision. Liposuction is another option if the lipoma is soft and has a small connective tissue component. The procedure typically results in less scarring but with large lipomas, it may fail to remove the entire tumor, which can lead to regrowth.

Liposarcomas are found in 1% of lipomas and are mostly well-differentiated. Other cell types that can be found include dedifferentiated, myxoid, round, and pleomorphic. Lipoblastomas have also been reported in the literature but they are very rare.

Vulvar lipomas can be confused with hernias, but unlike hernias, they cannot be compressed. A cyst of the Canal of Nuck can sometimes mimic an inguinal hernia. At times, it can be difficult to distinguish a lipoma from a hernia. Radiologic studies such as magnetic resonance imaging or ultrasound may be helpful in these situations. Fibromas can also occur on the vulva and are usually easily excised.

In this case, a vulvar abscess is unlikely due to lack of pain, erythema, or fluctuance of the mass. The patient’s history does not seem to point in thatdirection. However, surgical management would elucidate the diagnosis.

A Bartholin duct cyst is located more medially on the vulva than is seen in this patient. The labium minus is located in the middle of the Bartholin duct cyst. Patients with this diagnosis complain of discomfort with sitting, inserting tampons, and intercourse. The bottom line is that if a patient is symptomatic and there is uncertainty as to the exact diagnosis, then once a hernia is ruled out, biopsy and/or excision is warranted and will guide any further management.