Abstract

Clitoral epidermoid inclusion cysts are rare benign lesions that may cause physical discomfort, genital disfigurement, and psychosocial distress when they become large. A 47-year-old woman presented with a rapidly enlarging clitoral mass measuring approximately 11 cm. She had no history of female genital mutilation, vulvar trauma, or vulvar surgery. Clinical, hormonal, and imaging findings did not suggest hyperandrogenism, virilization, or malignancy. Complete cyst excision, accompanied by clitoral hood plasty and labioplasty, was performed with careful preservation of the dorsal clitoral neurovascular structures. Histopathology confirmed an epidermoid inclusion cyst. The postoperative course was uneventful.

Introduction

Clitoral masses are uncommon and may affect body image, sexual well-being, urinary or mechanical comfort, and psychological health. Epidermoid inclusion cysts in the clitoral region are rare and may develop spontaneously or after genital trauma, surgery, or female genital mutilation^(1-4).

Although most reported lesions are small or slowly enlarging, large cysts may mimic clitoromegaly and require evaluation for endocrine, congenital, inflammatory, and neoplastic causes. Imaging can help define the cystic nature of the lesion and its anatomical relationships, while hormonal assessment is useful when virilization is part of the differential diagnosis^{(1, 5)}.

We report a rare case of a giant clitoral epidermoid inclusion cyst in a patient with no prior genital mutilation, vulvar trauma, or vulvar surgery. The lesion was managed by complete excision, with preservation of clitoral neurovascular structures and restoration of external genital anatomy.

Case Report

A 47-year-old gravida 2, para 2 woman presented with a progressively enlarging clitoral mass. She reported that the lesion had first become noticeable approximately three months before presentation and had rapidly increased in size. She had no history of female genital mutilation, vulvar trauma, vulvar piercing, prior vulvar surgery, or recurrent vulvar infection.

Her medical history was notable only for hypothyroidism controlled with levothyroxine. Menstrual cycles were regular. Serum total and free testosterone levels were within normal limits. There were no clinical findings suggestive of virilization or hyperandrogenism.

Physical examination revealed a large, cylindrical, fluctuant mass in the clitoral region, measuring approximately 11 cm in length, with intact overlying skin and no signs of acute inflammation. The lesion caused marked distortion of the external genital anatomy (Figure 1).

Pelvic ultrasonography and magnetic resonance imaging demonstrated a well-defined fluid-filled cystic lesion confined to the clitoral region, without deep pelvic extension or features suspicious for malignancy.

The case report was reviewed in accordance with local institutional policy. Because it involved a single anonymized case report without experimental intervention, formal ethics committee approval was not required. The case was managed in accordance with the ethical principles of the Declaration of Helsinki, as revised in 2000. The patient provided written informed consent before treatment and separate written consent for publication of anonymized clinical details and images.

Surgical excision was planned because of the size of the lesion, anatomical distortion, and patient-reported distress. An elliptical incision was made around the cystic mass (Figure 2). Careful blunt and sharp dissection was performed along the cyst wall, with care taken to preserve the dorsal clitoral neurovascular structures. The cyst was completely excised without rupture. The redundant clitoral hood and adjacent labial tissue were reconstructed to restore normal vulvar morphology. Hemostasis was achieved meticulously, and the incision was closed in layers using absorbable sutures.

The resected specimen measured 11x3 cm. On gross examination, the lesion was cystic and contained keratinous material. Microscopic examination showed a keratin-filled cyst lined by stratified squamous epithelium, consistent with an epidermoid inclusion cyst.

The postoperative course was uneventful. At three months of in-person follow-up, the patient reported satisfactory cosmetic and functional outcomes, with restoration of external genital anatomy and no clinical evidence of recurrence (Figure 3). At 12 months postoperatively, she was contacted by telephone and reported preserved clitoral sensation and sexual satisfaction comparable to her preoperative baseline.

Discussion

Epidermoid inclusion cysts are benign cystic lesions lined by squamous epithelium and filled with keratinous debris. In the clitoral region, they are rare and most often associated with prior trauma, genital surgery, or female genital mutilation; spontaneous cases have also been reported^{(1, 2, 4)}.

The present case is clinically relevant for several reasons. In a recent systematic review of 162 patients, the mean cyst size was 5.9 cm; of these, 132 cases were associated with female genital mutilation, whereas only 27 were classified as spontaneous⁽¹⁾. Female genital mutilation-associated giant lesions measuring 13 cm and 10 cm, respectively, have been reported^{(6, 7)}. Paulus et al.⁽⁸⁾ described a 2.5 cm spontaneous preputial cyst. Al-Ojaimi and Abdulla⁽⁴⁾ also described a giant 8 cm spontaneous clitoral epidermoid inclusion cyst mimicking clitoromegaly. Against this background, the present case is distinctive because an 11 cm lesion developed over a  reported interval of approximately three months in an adult without female genital mutilation, vulvar trauma, piercing, recurrent infection, or previous vulvar surgery. The lesion caused marked anatomical distortion resembling clitoromegaly, while normal androgen levels and the absence of virilization helped exclude endocrine causes. Complete excision with preservation of the dorsal clitoral neurovascular structures, combined with clitoral hood and labial reconstruction, further demonstrates a function-preserving approach for an unusually large lesion.

The preferred treatment for symptomatic clitoral epidermoid inclusion cysts is complete surgical excision^{(1, 2, 9)}. However, surgery in this region requires careful planning because of the functional importance of clitoral innervation and vascularity. Previous reports have highlighted the importance of avoiding injury to clitoral neurovascular structures; sensory mapping has been described as an additional technique in selected cases⁽⁹⁾.

In our case, complete excision was combined with reconstruction of redundant hood and labial tissues. The objective was not only the removal of the cyst but also the restoration of normal external genital anatomy. This combined approach may be particularly relevant for large lesions, in which simple cyst removal can leave redundant tissue, persistent distortion, or unsatisfactory cosmetic results.

At the 12-month telephone follow-up, the patient’s report of preserved clitoral sensation and of sexual satisfaction comparable to her preoperative baseline supports the absence of any new postoperative sensory or sexual deficits. Nevertheless, because no validated sexual-function instrument was administered, these patient-reported findings should be interpreted cautiously.

This report has inherent limitations. It describes a single patient; validated sexual-function or quality-of-life instruments were not used. Although patient-reported clitoral sensation and sexual satisfaction were obtained by telephone at 12 months, objective in-person assessment, including physical examination for recurrence, was limited to three months. Therefore, postoperative functional outcomes remain descriptive in nature, and longer clinical follow-up is needed to evaluate the durability of the anatomical result and the risk of recurrence.

Conclusion

Giant clitoral epidermoid inclusion cysts are rare, but should be considered in the differential diagnosis of non-hormonal clitoral enlargement. Preoperative imaging, hormonal evaluation when indicated, complete excision, and meticulous preservation of clitoral neurovascular structures are key elements of management.