A 33-year-old woman comes to the office for evaluation of a vaginal mass. The patient first noticed the mass 2 weeks ago after having pain during intercourse. She has avoided intercourse since, but the mass is still present. The patient has had no irregular menstrual bleeding or postcoital bleeding. She has had 4 sexual partners in the last year and uses combination oral contraceptives. The patient had 3 term vaginal deliveries in her 20s; her largest baby was 4.54 kg (10 lb). She had an abnormal cervical cancer screening 2 years ago but a normal follow-up colposcopy. Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 76/min. BMI is 26 kg/m². On pelvic examination, there is a 3-cm mass on the anterior aspect of the vaginal wall that does not change in size with Valsalva maneuver. The mass is tender to palpation and expresses a purulent urethral discharge. Which of the following is the most likely diagnosis in this patient?

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11ec25c8_d9e8_4f0d_bc81_3150fa6d92d7_MD0003_00 This patient's anterior vaginal wall mass is due to a urethral diverticulum, an abnormal localized outpouching of the urethral mucosa into surrounding tissues. Urethral diverticula likely arise from recurrent periurethral gland infections, which can develop into an abscess that eventually breaches the urethral mucosa. The persistent infection, inflammation, and increased tissue tension on the diverticulum causes a tender anterior vaginal wall mass that may present as dyspareunia or a palpable mass on pelvic examination. In addition, the diverticulum may collect urine and debris, resulting in a purulent discharge, dysuria, or postvoid dribbling. An MRI is used to confirm the diagnosis of urethral diverticulum; patients are treated via surgical excision. (Choice A) Bartholin gland abscesses can present as a tender vulvar mass that expresses a purulent discharge and causes dyspareunia. This diagnosis is unlikely because the Bartholin glands are located at the posterior vulvar vestibule (4 and 8 o'clock position), not along the anterior vaginal wall. Bartholin glands (Choice B) Abnormal cervical cancer screening results caused by human papillomavirus (HPV) infection are typically due to high-risk HPV subtypes. In contrast, condyloma acuminata (ie, genital warts) are caused by low-risk HPV subtypes and typically present as either asymptomatic or pruritic, cauliflower-like lesions, which are not seen in this patient. (Choice C) Symptomatic pelvic organ prolapse is common in multiparous women, particularly those who have had vaginal deliveries and fetal macrosomia, and can cause pelvic pressure and an anterior vaginal bulge (eg, cystocele). However, this diagnosis is unlikely because pelvic organ prolapse typically bulges with Valsalva maneuver and has no associated purulent discharge. cystocele (Choice E) Uterine leiomyomas create a bulky, irregular uterus that may cause bladder outlet obstruction, which can lead to overflow incontinence. Uterine leiomyomas generally do not cause dyspareunia or a purulent discharge. Educational objective: A urethral diverticulum, which is an abnormal localized outpouching of the urethral mucosa into surrounding tissues, can cause dyspareunia. Patients typically have a palpable, tender mass on the anterior vaginal wall that has an associated purulent discharge. References: Female urethral diverticula in the contemporary era: is the classic triad of the "3Ds" still relevant? (http://www.ncbi.nlm.nih.gov/pubmed/27079128) Urethral diverticulum in the female: a meta-analysis of modern series. (http://www.ncbi.nlm.nih.gov/pubmed/26545036)

A 33-Year-Old Woman Comes to the Office for Evaluation of a Vaginal