NASPAG 24 th Annual Clinical Meeting, Issues and Answers in Pediatric and Adolescent Gynecology, April 15-17, 2010, Las Vegas, Nevada Oral Abstracts Large Epidermal Cyst of the Clitoris: A Novel Diagnostic Approach to Assist in Surgical Removal Eduardo Lara-Torre, MD, Amanda B. Murchison, MD, Steven Lewis, MD, and Evelyn Garcia, MD Department of Obstetrics and Gynecology and Department of Radiology, Virginia Tech-Carilion School of Medicine/ Carilion Clinic. Roanoke, VA Background: Epidermal cysts of the clitoris are un- common especially without a history of trauma or sur- gery to the area. Surgical removal has been the preferred approach. The importance of preserving the sensation and vascular supply to the clitoris; there- fore retaining sexual health, requires meticulous dis- section and careful removal of the mass. The poor resolution of the external genitalia seen on imaging via utilization of the traditional pelvic coil during Magnetic Resonance (MR) makes the identification of these structures difficult. The following case illus- trates a novel use of an alternative coil during MR to better evaluate clitoral lesions which in turn impacts the surgical management and outcomes. Case: A 15 year old non-sexually active adolescent presented complaining of a 2 year history of clitoral en- largement. The physical exam showed a 4Â5 cm clito- ral mass arising from the superior aspect of the glans and covered by the clitoral hood. The lesion appeared to arise from the surface of the clitoris but the glans was normal (Figure 1). There were no virilizing signs and a complete hormonal evaluation showed no endo- crinopathy. Initial imaging using MR with a pelvic coil showed a periclitoral cyst filled with homogeneous material and normal appearance of the other genital anatomy but poor resolution of the neurovascular supply. The patient desired surgical intervention as the mass distorted her anatomy and caused her social anx- iety with her peers. Given the location of the cyst and the blood supply to the clitoris, further evaluation was necessary to preserve the neurovascular bundle during the resection. MR imaging of the perineum was performed with a superconducting 1.5-T MR system (Magnetom Sonata, Maestro Class, Syngo MR 2004A version; Siemens Medical Solutions, Erlangen, Germany) with a small CP Flex coil, 17 Â 36 cm (commonly used to image the wrist). The patient was placed in a modified lithotomy position with the coil wrapped from back to front on the perineum (like a sanitary napkin). The clitoral cyst demonstrated homogeneous signal intensity of proteinatious fluid without septations or mural nodules (Figure 2). The corpora cavernosa had a normal course to the clitoris which was displaced posteroinferiorly by the cyst interposed between the clitoral hood and the clitoris. Post gadolinium T1- weighted fat saturated spoiled gradient echo images show normal enhancement of the vascular structures and corpora with absence of cyst enhancement. Fig. 1. Mass appearance on physical exam. (H) Clitoral Hood, (CL) Clitoris, (C) Clitoral cyst. Ó 2010 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc. 1083-3188/10/$36.00 J Pediatr Adolesc Gynecol (2010) 23:e61ee72