- Email: [email protected]
Clitoral epidermal inclusion cyst leading to anorgasmia: A case report and literature review
Journal Pre-proof Clitoral epidermal inclusion cyst leading to anorgasmia: A case report and literature review A.M. DiCarlo-Meacham, MD, K.L. Dengler, MD, A.N. Snitchler, DO, D.D. Gruber, MS, MD PII:
S1083-3188(20)30151-0
DOI:
https://doi.org/10.1016/j.jpag.2020.01.150
Reference:
PEDADO 2446
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 4 December 2019 Revised Date:
18 January 2020
Accepted Date: 24 January 2020
Please cite this article as: DiCarlo-Meacham AM, Dengler KL, Snitchler AN, Gruber DD, Clitoral epidermal inclusion cyst leading to anorgasmia: A case report and literature review, Journal of Pediatric and Adolescent Gynecology (2020), doi: https://doi.org/10.1016/j.jpag.2020.01.150. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc. on behalf of North American Society for Pediatric and Adolescent Gynecology.
1
Title: Clitoral epidermal inclusion cyst leading to anorgasmia: A case report and literature review
2
A.M. DiCarlo-Meacham, MD, Department of Obstetrics and Gynecology, Walter Reed National
3
Military Medical Center, Bethesda, MD
4
K.L. Dengler, MD, Department of Obstetrics and Gynecology, Walter Reed National Military
5
Medical Center, Bethesda, MD
6
A.N. Snitchler, DO, Department of Pathology, Walter Reed National Military Medical Center,
7
Bethesda, MD
8
D.D. Gruber, MS, MD, Department of Obstetrics and Gynecology, Walter Reed National Military
9
Medical Center, Bethesda, MD
10
Declaration of interests: None
11
Eposter presentation at the 2019 American Urogynecologic Society/International
12
Urogynecologic Association Joint Scientific Meeting in Nashville, TN Sept. 24-28, 2019.
13
Corresponding author: Angela DiCarlo-Meacham, MD
14
Walter Reed National Military Medical Center, Department of Obstetrics and Gynecology
15
Address: 8901 Wisconsin Ave, Bethesda, MD 20889
16
Phone: 636-288-2955; Email: [email protected]
17
Word Counts: Abstract 120, Manuscript 923
18
Disclaimer: The views expressed in this article are those of the authors and do not reflect the
19
official polices of the Departments of the Army, Air Force or Navy, the Department of Defense or
20
the U.S. Government. 1
21 22 23
Abstract
24
Background: Clitoral epidermal inclusions cysts are most frequently seen following trauma,
25
especially female genital mutilation. Spontaneous clitoral epidermal inclusion cysts are rare with
26
an unclear etiology and their impact on later sexual function has not been described.
27
Case: A 15 year-old spontaneously developed a clitoral mass that progressively enlarged over
28
seven years, ultimately leading to secondary anorgasmia. Surgical removal resulted in
29
restoration of normal anatomy and complete return of clitoral function. Final pathology revealed
30
the mass to be an epidermal inclusion cyst.
31
Summary and Conclusion: Clitoral epidermal inclusion cysts typically present in childhood or
32
early adolescence and can lead to sexual dysfunction if left untreated. Physicians must consider
33
the potential sequelae of these cysts when counseling and managing these patients.
34
Key Words
35
Anorgasmia; Clitoral cyst; epidermal inclusion cyst; sexual dysfunction
2
36
Introduction
37
Epidermal inclusion cysts are commonly found on the face, neck and torso, but are less
38
commonly reported on the vulva. They are characterized by a cyst wall of stratified squamous
39
epithelium containing keratinous debris. Clitoral epidermal inclusion cysts are rare and can be
40
spontaneous or a result of implantation of follicular epithelium into the dermis following trauma,
41
particularly female genital mutilation.1 Spontaneous cysts can be present at birth or develop
42
later in life and can present a diagnostic challenge for clinicians.
43
The differential diagnosis of a clitoral cyst is broad and includes congenital, hormonal,
44
neoplastic, infectious or structural etiologies which can lead to a costly and timely workup for the
45
patient. Diagnosis of an epidermal inclusion cyst is typically made clinically based on the
46
appearance of a discrete cyst that is freely mobile and radiologic imaging can help confirm the
47
diagnosis.2 On pelvic ultrasound they appear as simple hypoechoic cystic structures and on
48
magnetic resonance imaging (MRI) they have high signal intensity on diffusion weighted
49
images. Surgical management poses its own challenges as surgeons are tasked with removing
50
the cyst while preserving the neurovascular structures vital for normal clitoral function.
51
Because spontaneous clitoral epidermal inclusion cysts are rare, no previous descriptions of
52
their presentation or growth pattern has been published and their etiology remains unclear.
53
Additionally, the impact they can have on sexual function has not been described.2-16 We
54
present a case of a large clitoral epidermal inclusion cyst that led to secondary anorgasmia and
55
review the growth, development, and sequelae of other reported clitoral epidermal inclusion
56
cysts.
57
Case
3
58
A 15 year-old developed a spontaneous vulvar mass that progressively grew over seven years.
59
She had presented to a gynecologist during that time frame due to bothersome skin splitting and
60
irritation from and the cyst rubbing on her clothing. The cyst was drained but later recurred. At
61
age 22 she presented to the Urogynecology clinic due to loss of clitoral sensation and the
62
development of anorgasmia over the previous year. She had no history of trauma or surgery to
63
her vulva and no medical problems. On physical exam, she had hypoestrogenic appearing
64
vulvar epithelium and a four centimeter mass located superior to the urethra with inability to
65
retract the clitoral hood to visualize the clitoris (Figure 1).
66
Pelvic MRI was done to further characterize the mass and showed a 3.9x4.0x1.8cm area of high
67
signal intensity on T2 images with minimal peripheral enhancement overlying the clitoris. There
68
was no communication with the peritoneal cavity or urethral involvement. She was taken to the
69
operating room for surgical excision.
70
A transverse incision was made at the inferior aspect of the cyst. This minimized risk of injury to
71
the neurovascular structures of the clitoris and maximized epithelium for reconstruction of the
72
labia minora and clitoral hood. A clear cyst wall was identified and easily separated from the
73
surrounding structures with blunt and sharp dissection. As the base of the cyst was reached, the
74
clitoral glans became visible and a clear separation between the cyst and the clitoris was seen.
75
The clitoris and its neurovascular structures remained intact. The cyst was found to be an
76
epidermal inclusion cyst on pathologic evaluation (Figure 2).
77
After removal of the cyst, distended vulvar epithelium was available for reconstruction of the
78
labia minora and clitoral hood. The tissue was reapproximated in the midline in a cephalad-
79
caudad manner and the labia minora and clitoral hood were reconstructed with a series of
80
interrupted delayed absorbable stitches placed bilaterally. A small amount of tissue was
4
81
trimmed to ensure symmetry but excess tissue was intentionally left to allow for tissue
82
retraction. Vaginal premarin cream was given post-operatively to assist in wound healing.
83
Immediately following surgery, the patient had partial return of sensation to the clitoris. At her six
84
week post-operative visit she had an excellent cosmetic result but still had decreased sensation
85
to the clitoris from her baseline. By seven months postoperatively she had regained sensation to
86
her clitoris and could again achieve an orgasm (Figure 3).
87
Summary and Conclusion
88
With the addition of our case, sixteen cases of spontaneous clitoral epidermal inclusion cysts
89
exist in the literature.2-16 Of these, all required surgical removal aside from one which regressed
90
in infancy.3 Nearly all cases were diagnosed prior to adulthood with seven cases (43.8%) being
91
diagnosed in early childhood3-5,10,12-13,16 and seven (43.8%) being first noted in early
92
adolescence, likely around the time of puberty.2, 7-9, 14-15 An additional case first presented during
93
pregnancy, regressed following delivery and then grew again with a subsequent pregnancy,
94
ultimately requiring excision.6 These patterns of growth suggest that estrogen may play a key
95
role in their development or growth.
96
Van der Putte et al demonstrated variation in the embryonic development of the clitoral prepuce.
97
In one variant of prepuce development, they found cornified cavities within the lamellae
98
separating the prepuce from the glans.17 Spontaneous dilation of these cornified cavities may
99
lead to cyst formation and could explain cysts that present in infancy or early childhood.
100
Estrogen stimulation of the epithelium within those cavities leading to increased desquamation
101
of skin cells could explain why a significant percentage of patients noted cyst formation during
102
times of increased estrogen levels. Figure 2 illustrates the desquamation of skin cells found
103
within the cyst in our patient. A similar pattern of growth has been seen in patients with clitoral
104
epidermal inclusion cysts following female genital mutilation with the theory that implanted 5
105
epidermis from the procedure proliferates with estrogen stimulation leading to cyst
106
development.18
107
Two important sequelae highlighted in this review are psychological distress and sexual
108
dysfunction. Of the ten patients that were peri-pubertal or older in the cases reported, 70%
109
experienced psychological distress from the anomaly, 50% experienced pain, and 90%
110
experienced distress and/or pain.2-16 Furthermore, in the case described above, one patient
111
experienced anorgasmia, which has not been previously described as a sequela of a clitoral
112
epidermal inclusion cyst. Surgical removal was necessary in all patients with symptomatic cysts.
113
In the five women who the authors stated were sexually active at the time of removal, all
114
reportedly maintained or regained sexual function. Patients diagnosed and treated early in
115
childhood or in early adolescence may have been spared the psychological distress that
116
patients who presented at older ages experienced. The potential impact of these cysts on
117
current or future female self-image and sexual function is compelling and referral for surgical
118
removal should be considered once the diagnosis is made by clinical exam and/or diagnostic
119
imaging.
120
This case demonstrates the potential significant impact untreated clitoral epidermal inclusion
121
cysts can have on sexual function. Because these cysts most often require surgery to resolve,
122
the potential impact of clitoral cysts on sexual function should be considered even when
123
evaluating patients who are not yet sexually active. Because most spontaneous clitoral
124
epidermal inclusion cysts seem to present during the pediatric or adolescent time frames based
125
on this literature review, pediatricians and pediatric and adolescent gynecologists should be
126
aware of the potential sequelae of these cysts so that patients and parents can be counseled
127
appropriately and make the most informed decisions regarding cyst management.
128
Disclosures
6
129
All authors have no disclosures or conflicts of interest to declare.
130
131 132 133 134
References 1. Rouzi AA: Epidermal clitoral inclusion cysts: not a rare complication of female genital mutilation. Hum Reprod 2010; 7:1672-4 2. Johnson LT, Lara-Torre E, Murchison A, et al: Large epidermal cyst of the clitoris: a
135
novel diagnostic approach to assist in surgical removal. J Pediatr Adolesc Gynecol 2013;
136
2:e33-5
137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152
3. Beltrao LA, Correia EPE, da Rosa EB, et al: Clitoris cyst mimicking ambiguous genitalia and presenting spontaneous regression. Pediatr Int 2019; 1:113-4 4. Schober MS, Hendrickson BW, Alpert SA: Spontaneous clitoral hood epidermal inclusion cyst mimicking clitoromegaly in a pediatric patient. Urology 2014; 1:206-8 5. Saha M: Epidermoid cyst of the clitoris: a rare cause of clitoromegaly. APSP J Case Rep 2013; 3:51 6. Hughes JW, Guess MK, Hittelman A, et al: Clitoral epidermoid cyst presenting as pseudoclitoromegaly of pregnancy. AJP Rep 2013; 1:57-62 7. Al-Ojaimi EH, Abdulla MM: Giant epidermoid inclusion cyst of the clitoris mimicking clitoromegaly. J Low Genit Tract Dis 2013; 1:58-60 8. Beurdeley M, Cellier C, Lemoine F, et al: Imaging of a primitive clitoral epidermoid cyst. Pediatr Radiol 2012; 6:764-7. 9. Lambert B: Epidermoid cyst of the clitoris: a case report. J Low Genit Tract Dis 2011; 2:161-2 10. Aggarwal SK, Manchanda V, Pant N: Epidermoid cyst of clitoris mimicking clitoromegaly. J Indian Assoc Pediatr Surg 2010; 1:23-4
7
153 154 155
11. Paulus YM, Wong AE, Chen B, et al: Preputial epidermoid cyst: an atypical case of acquired pseudoclitoromegaly. J Low Genit Tract Dis 2010; 4:382-6 12. Anderson-Mueller BE, Laudenschlager MD, Hansen KA: Epidermoid cyst of the clitoris:
156
an unusual cause of clitoromegaly in a patient without history of previous female
157
circumcision. J Pediatr Adolesc Gynecol 2009; 50: e130-2
158 159 160 161 162 163
13. Cetinkursun S, Narci A, Sahin O, et al: Epidermoid cyst causing clitoromegaly in a child. Int J Gynaecol Obstet 2009; 1:64 14. Linck D, Hayes MF: Clitoral cyst as a cause of ambiguous genitalia. Obstet Gynecol 2002; 5 pt 2:963-6 15. Schmidt A, Lang U, Kiess W: Epidermal cyst of the clitoris: a rare cause of clitorimegaly. Eur J Obstet Gynecol Reprod Biol 1999; 2:163-5
164
16. Teague JL, Anglo L. Clitoral cyst: an unusual cause of clitorimegaly. J Urol 1996; 6:1057
165
17. Van der Putte SC, Sie-Go DM: Development and structure of the glandopreputial sulcus
166
of the human clitoris with a special reference to glandopreputial glands. Anat Rec
167
(Hoboken) 2011; 1:156-64
168 169
18. Asante A, Omurtag K, Roberts C: Epidermal inclusion cyst of the clitoris 30 years after female genital mutilation. Fertil Steril 2010; 3:1097
170
8
171
Figure Legends
172
Figure 1. Large cyst of the clitoral hood obscuring the clitoris.
173
Figure 2. Pathologic (H&E stain at 40x magnification) image of the cyst composed of a thin layer
174
of stratified squamous epithelium with keratin debris flaking off into the cyst lumen (arrow),
175
consistent with epidermal cyst.
176
Figure 3. Post-operative exam at 11 months. The patient had regained complete return of
177
clitoral function by that point.
178
9
S1083-3188(20)30151-0
DOI:
https://doi.org/10.1016/j.jpag.2020.01.150
Reference:
PEDADO 2446
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 4 December 2019 Revised Date:
18 January 2020
Accepted Date: 24 January 2020
Please cite this article as: DiCarlo-Meacham AM, Dengler KL, Snitchler AN, Gruber DD, Clitoral epidermal inclusion cyst leading to anorgasmia: A case report and literature review, Journal of Pediatric and Adolescent Gynecology (2020), doi: https://doi.org/10.1016/j.jpag.2020.01.150. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc. on behalf of North American Society for Pediatric and Adolescent Gynecology.
1
Title: Clitoral epidermal inclusion cyst leading to anorgasmia: A case report and literature review
2
A.M. DiCarlo-Meacham, MD, Department of Obstetrics and Gynecology, Walter Reed National
3
Military Medical Center, Bethesda, MD
4
K.L. Dengler, MD, Department of Obstetrics and Gynecology, Walter Reed National Military
5
Medical Center, Bethesda, MD
6
A.N. Snitchler, DO, Department of Pathology, Walter Reed National Military Medical Center,
7
Bethesda, MD
8
D.D. Gruber, MS, MD, Department of Obstetrics and Gynecology, Walter Reed National Military
9
Medical Center, Bethesda, MD
10
Declaration of interests: None
11
Eposter presentation at the 2019 American Urogynecologic Society/International
12
Urogynecologic Association Joint Scientific Meeting in Nashville, TN Sept. 24-28, 2019.
13
Corresponding author: Angela DiCarlo-Meacham, MD
14
Walter Reed National Military Medical Center, Department of Obstetrics and Gynecology
15
Address: 8901 Wisconsin Ave, Bethesda, MD 20889
16
Phone: 636-288-2955; Email: [email protected]
17
Word Counts: Abstract 120, Manuscript 923
18
Disclaimer: The views expressed in this article are those of the authors and do not reflect the
19
official polices of the Departments of the Army, Air Force or Navy, the Department of Defense or
20
the U.S. Government. 1
21 22 23
Abstract
24
Background: Clitoral epidermal inclusions cysts are most frequently seen following trauma,
25
especially female genital mutilation. Spontaneous clitoral epidermal inclusion cysts are rare with
26
an unclear etiology and their impact on later sexual function has not been described.
27
Case: A 15 year-old spontaneously developed a clitoral mass that progressively enlarged over
28
seven years, ultimately leading to secondary anorgasmia. Surgical removal resulted in
29
restoration of normal anatomy and complete return of clitoral function. Final pathology revealed
30
the mass to be an epidermal inclusion cyst.
31
Summary and Conclusion: Clitoral epidermal inclusion cysts typically present in childhood or
32
early adolescence and can lead to sexual dysfunction if left untreated. Physicians must consider
33
the potential sequelae of these cysts when counseling and managing these patients.
34
Key Words
35
Anorgasmia; Clitoral cyst; epidermal inclusion cyst; sexual dysfunction
2
36
Introduction
37
Epidermal inclusion cysts are commonly found on the face, neck and torso, but are less
38
commonly reported on the vulva. They are characterized by a cyst wall of stratified squamous
39
epithelium containing keratinous debris. Clitoral epidermal inclusion cysts are rare and can be
40
spontaneous or a result of implantation of follicular epithelium into the dermis following trauma,
41
particularly female genital mutilation.1 Spontaneous cysts can be present at birth or develop
42
later in life and can present a diagnostic challenge for clinicians.
43
The differential diagnosis of a clitoral cyst is broad and includes congenital, hormonal,
44
neoplastic, infectious or structural etiologies which can lead to a costly and timely workup for the
45
patient. Diagnosis of an epidermal inclusion cyst is typically made clinically based on the
46
appearance of a discrete cyst that is freely mobile and radiologic imaging can help confirm the
47
diagnosis.2 On pelvic ultrasound they appear as simple hypoechoic cystic structures and on
48
magnetic resonance imaging (MRI) they have high signal intensity on diffusion weighted
49
images. Surgical management poses its own challenges as surgeons are tasked with removing
50
the cyst while preserving the neurovascular structures vital for normal clitoral function.
51
Because spontaneous clitoral epidermal inclusion cysts are rare, no previous descriptions of
52
their presentation or growth pattern has been published and their etiology remains unclear.
53
Additionally, the impact they can have on sexual function has not been described.2-16 We
54
present a case of a large clitoral epidermal inclusion cyst that led to secondary anorgasmia and
55
review the growth, development, and sequelae of other reported clitoral epidermal inclusion
56
cysts.
57
Case
3
58
A 15 year-old developed a spontaneous vulvar mass that progressively grew over seven years.
59
She had presented to a gynecologist during that time frame due to bothersome skin splitting and
60
irritation from and the cyst rubbing on her clothing. The cyst was drained but later recurred. At
61
age 22 she presented to the Urogynecology clinic due to loss of clitoral sensation and the
62
development of anorgasmia over the previous year. She had no history of trauma or surgery to
63
her vulva and no medical problems. On physical exam, she had hypoestrogenic appearing
64
vulvar epithelium and a four centimeter mass located superior to the urethra with inability to
65
retract the clitoral hood to visualize the clitoris (Figure 1).
66
Pelvic MRI was done to further characterize the mass and showed a 3.9x4.0x1.8cm area of high
67
signal intensity on T2 images with minimal peripheral enhancement overlying the clitoris. There
68
was no communication with the peritoneal cavity or urethral involvement. She was taken to the
69
operating room for surgical excision.
70
A transverse incision was made at the inferior aspect of the cyst. This minimized risk of injury to
71
the neurovascular structures of the clitoris and maximized epithelium for reconstruction of the
72
labia minora and clitoral hood. A clear cyst wall was identified and easily separated from the
73
surrounding structures with blunt and sharp dissection. As the base of the cyst was reached, the
74
clitoral glans became visible and a clear separation between the cyst and the clitoris was seen.
75
The clitoris and its neurovascular structures remained intact. The cyst was found to be an
76
epidermal inclusion cyst on pathologic evaluation (Figure 2).
77
After removal of the cyst, distended vulvar epithelium was available for reconstruction of the
78
labia minora and clitoral hood. The tissue was reapproximated in the midline in a cephalad-
79
caudad manner and the labia minora and clitoral hood were reconstructed with a series of
80
interrupted delayed absorbable stitches placed bilaterally. A small amount of tissue was
4
81
trimmed to ensure symmetry but excess tissue was intentionally left to allow for tissue
82
retraction. Vaginal premarin cream was given post-operatively to assist in wound healing.
83
Immediately following surgery, the patient had partial return of sensation to the clitoris. At her six
84
week post-operative visit she had an excellent cosmetic result but still had decreased sensation
85
to the clitoris from her baseline. By seven months postoperatively she had regained sensation to
86
her clitoris and could again achieve an orgasm (Figure 3).
87
Summary and Conclusion
88
With the addition of our case, sixteen cases of spontaneous clitoral epidermal inclusion cysts
89
exist in the literature.2-16 Of these, all required surgical removal aside from one which regressed
90
in infancy.3 Nearly all cases were diagnosed prior to adulthood with seven cases (43.8%) being
91
diagnosed in early childhood3-5,10,12-13,16 and seven (43.8%) being first noted in early
92
adolescence, likely around the time of puberty.2, 7-9, 14-15 An additional case first presented during
93
pregnancy, regressed following delivery and then grew again with a subsequent pregnancy,
94
ultimately requiring excision.6 These patterns of growth suggest that estrogen may play a key
95
role in their development or growth.
96
Van der Putte et al demonstrated variation in the embryonic development of the clitoral prepuce.
97
In one variant of prepuce development, they found cornified cavities within the lamellae
98
separating the prepuce from the glans.17 Spontaneous dilation of these cornified cavities may
99
lead to cyst formation and could explain cysts that present in infancy or early childhood.
100
Estrogen stimulation of the epithelium within those cavities leading to increased desquamation
101
of skin cells could explain why a significant percentage of patients noted cyst formation during
102
times of increased estrogen levels. Figure 2 illustrates the desquamation of skin cells found
103
within the cyst in our patient. A similar pattern of growth has been seen in patients with clitoral
104
epidermal inclusion cysts following female genital mutilation with the theory that implanted 5
105
epidermis from the procedure proliferates with estrogen stimulation leading to cyst
106
development.18
107
Two important sequelae highlighted in this review are psychological distress and sexual
108
dysfunction. Of the ten patients that were peri-pubertal or older in the cases reported, 70%
109
experienced psychological distress from the anomaly, 50% experienced pain, and 90%
110
experienced distress and/or pain.2-16 Furthermore, in the case described above, one patient
111
experienced anorgasmia, which has not been previously described as a sequela of a clitoral
112
epidermal inclusion cyst. Surgical removal was necessary in all patients with symptomatic cysts.
113
In the five women who the authors stated were sexually active at the time of removal, all
114
reportedly maintained or regained sexual function. Patients diagnosed and treated early in
115
childhood or in early adolescence may have been spared the psychological distress that
116
patients who presented at older ages experienced. The potential impact of these cysts on
117
current or future female self-image and sexual function is compelling and referral for surgical
118
removal should be considered once the diagnosis is made by clinical exam and/or diagnostic
119
imaging.
120
This case demonstrates the potential significant impact untreated clitoral epidermal inclusion
121
cysts can have on sexual function. Because these cysts most often require surgery to resolve,
122
the potential impact of clitoral cysts on sexual function should be considered even when
123
evaluating patients who are not yet sexually active. Because most spontaneous clitoral
124
epidermal inclusion cysts seem to present during the pediatric or adolescent time frames based
125
on this literature review, pediatricians and pediatric and adolescent gynecologists should be
126
aware of the potential sequelae of these cysts so that patients and parents can be counseled
127
appropriately and make the most informed decisions regarding cyst management.
128
Disclosures
6
129
All authors have no disclosures or conflicts of interest to declare.
130
131 132 133 134
References 1. Rouzi AA: Epidermal clitoral inclusion cysts: not a rare complication of female genital mutilation. Hum Reprod 2010; 7:1672-4 2. Johnson LT, Lara-Torre E, Murchison A, et al: Large epidermal cyst of the clitoris: a
135
novel diagnostic approach to assist in surgical removal. J Pediatr Adolesc Gynecol 2013;
136
2:e33-5
137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152
3. Beltrao LA, Correia EPE, da Rosa EB, et al: Clitoris cyst mimicking ambiguous genitalia and presenting spontaneous regression. Pediatr Int 2019; 1:113-4 4. Schober MS, Hendrickson BW, Alpert SA: Spontaneous clitoral hood epidermal inclusion cyst mimicking clitoromegaly in a pediatric patient. Urology 2014; 1:206-8 5. Saha M: Epidermoid cyst of the clitoris: a rare cause of clitoromegaly. APSP J Case Rep 2013; 3:51 6. Hughes JW, Guess MK, Hittelman A, et al: Clitoral epidermoid cyst presenting as pseudoclitoromegaly of pregnancy. AJP Rep 2013; 1:57-62 7. Al-Ojaimi EH, Abdulla MM: Giant epidermoid inclusion cyst of the clitoris mimicking clitoromegaly. J Low Genit Tract Dis 2013; 1:58-60 8. Beurdeley M, Cellier C, Lemoine F, et al: Imaging of a primitive clitoral epidermoid cyst. Pediatr Radiol 2012; 6:764-7. 9. Lambert B: Epidermoid cyst of the clitoris: a case report. J Low Genit Tract Dis 2011; 2:161-2 10. Aggarwal SK, Manchanda V, Pant N: Epidermoid cyst of clitoris mimicking clitoromegaly. J Indian Assoc Pediatr Surg 2010; 1:23-4
7
153 154 155
11. Paulus YM, Wong AE, Chen B, et al: Preputial epidermoid cyst: an atypical case of acquired pseudoclitoromegaly. J Low Genit Tract Dis 2010; 4:382-6 12. Anderson-Mueller BE, Laudenschlager MD, Hansen KA: Epidermoid cyst of the clitoris:
156
an unusual cause of clitoromegaly in a patient without history of previous female
157
circumcision. J Pediatr Adolesc Gynecol 2009; 50: e130-2
158 159 160 161 162 163
13. Cetinkursun S, Narci A, Sahin O, et al: Epidermoid cyst causing clitoromegaly in a child. Int J Gynaecol Obstet 2009; 1:64 14. Linck D, Hayes MF: Clitoral cyst as a cause of ambiguous genitalia. Obstet Gynecol 2002; 5 pt 2:963-6 15. Schmidt A, Lang U, Kiess W: Epidermal cyst of the clitoris: a rare cause of clitorimegaly. Eur J Obstet Gynecol Reprod Biol 1999; 2:163-5
164
16. Teague JL, Anglo L. Clitoral cyst: an unusual cause of clitorimegaly. J Urol 1996; 6:1057
165
17. Van der Putte SC, Sie-Go DM: Development and structure of the glandopreputial sulcus
166
of the human clitoris with a special reference to glandopreputial glands. Anat Rec
167
(Hoboken) 2011; 1:156-64
168 169
18. Asante A, Omurtag K, Roberts C: Epidermal inclusion cyst of the clitoris 30 years after female genital mutilation. Fertil Steril 2010; 3:1097
170
8
171
Figure Legends
172
Figure 1. Large cyst of the clitoral hood obscuring the clitoris.
173
Figure 2. Pathologic (H&E stain at 40x magnification) image of the cyst composed of a thin layer
174
of stratified squamous epithelium with keratin debris flaking off into the cyst lumen (arrow),
175
consistent with epidermal cyst.
176
Figure 3. Post-operative exam at 11 months. The patient had regained complete return of
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clitoral function by that point.
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