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J Indian Assoc Pediatr Surg. 2010 Jan-Mar; 15(1): 23–24.
PMCID: PMC2998664

Epidermoid cyst of clitoris mimicking clitoromegaly

Abstract

Clitoromegaly in pediatric and adolescent age group is usually indicative of a disorder of sexual differentiation. We report a girl child presenting with clitoral enlargement due to an epidermoid cyst. The cyst was excised with complete cosmetic recovery.

Keywords: Clitoral cysts, clitoromegaly, epidermoid cysts

INTRODUCTION

Clitoromegaly (or macroclitoris) due to nonendocrinal causes is rare and rarer still is clitoral enlargement due to some underlying mass lesion, such as a pilonidal cyst, epidermoid cyst, or an abscess. A good clinical examination can spare the child from extensive investigations and associated emotional disturbances in such cases.

CASE REPORT

A 5-year-old girl presented with progressive clitoral enlargement of 1 year. There was no urinary complaint, history of trauma, or hormonal treatment. There were no systemic complaints. General physical and abdominal examination was unremarkable. External genitalia were female type with clitoral enlargement. A cystic mass 4 × 3 cm was noted over the clitoris [Figure [Figure1a1a and andb].Theb].The labia minora on right were splayed over the cyst. Urethral and vaginal openings were separate. There was no hyperpigmentation. Ultrasound revealed normal urinary tract and internal genitalia. The cyst was excised under general anesthesia [Figure 2]. The histopathology revealed it to be a keratinous epidermoid cyst. The child recovered uneventfully. Normal cosmetic appearance of the external genitalia was restored [Figure 3]. There is no recurrence at 30-month follow-up.

Figure 1
(a) Clinical photo showing clitoromegaly; and (b) extent of the cyst
Figure 2
Surgical excision of the cyst
Figure 3
Postoperative appearance 4 months after surgery

DISCUSSION

Female external genitalia may have multitude of cysts. Merlob et al gave an incidence of 0.6% in infancy.[1] Such cysts may be vaginal (hymenal), paraurethral, or clitoral. Clitoral cysts are most infrequent among these.

Clitoral cysts present clinically as swelling on clitoris. The literature is replete with instances when such a cyst has been diagnosed clinically as clitoromegaly with differential diagnosis of true hermaphroditism, adrenal hyperplasia, clitoral, ovarian, and adrenal neoplasms, stromal hyperthecosis, polycystic ovarian syndrome, and exogenous androgen exposure.[2] Such errors in diagnosis mandate many laboratory investigations, such as serum levels of free testosterone, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, total testosterone, androstenedione, deoxycorticosterone, 11-deoxycortisol, karyotype, an intravenous pyelogram, and pelvic ultrasound. This is time consuming and expensive. A simple clinical examination should be sufficient for differentiating clitoral cyst from the hormonal causes of clitoromegaly.[3]

Epidermoid cysts of the clitoris are seen commonly after type I female genital mutilation/female circumcision done in some ethnic communities in Africa and West Asia.[4,5] A few cases of such cysts in infancy have also been reported.[1,3,6] A simple enucleation of the cyst with reconstruction of external genitalia is the preferred mode of treatment.

A good clinical examination should be the first investigation in clitoromegaly. Clitorial enlargement due to hormonal causes or disorders of sexual differentiation is symmetrical and uniform, which it is not in this case. Clitoral cysts or other local lesions need to be considered, which may avoid unnecessary investigations.

Footnotes

Source of Support: Nil

Conflict of Interest: None declared

REFERENCES

1. Merlob P, Bahari C, Liban E, Reisner SH. Cysts of the female external genitalia in the newborn infant. Am J Obstet Gynecol. 1978;132:607–10. [PubMed]
2. Linck D, Hayes MF. Clitoral cyst as a cause of ambiguous genitalia. Obstet Gynecol. 2002;99:963–6. [PubMed]
3. Abudaia J, Habib Z, Ahmed S. Dermoid cyst: A rare cause of clitoromegaly. Pediatr Surg Int. 1999;15:521–2. [PubMed]
4. Rouzi AA, Sindi O, Radhan B, Ba’aqeel H. Epidermal clitoral inclusion cyst after type I female genital mutilation. th Am J Obstet Gynecol. 2001;185:569–71. [PubMed]
5. Adekunle AO, Fakokunde FA, Odukogbe AA, Fawole AO. Female genital mutilation-postcircumcision vulval complications in Nigerians. J Obstet Gynaecol. 1999;19:632–5. [PubMed]
6. Teague JL, Anglo L. Clitoral cyst: An unusual cause of clitoromegaly. J Urol. 1996;156:2057. [PubMed]

Articles from Journal of Indian Association of Pediatric Surgeons are provided here courtesy of Medknow Publications