A periurethral mass in a 25-year-old woman

History of present illness: A 25-year-old gravida 3, para 1 woman presents to the office complaining of a 1-year history of a vaginal bulge, dyspareunia, and intermittent urinary incontinence. She can feel pressure in the vagina but cannot see a bulge protruding from the introitus. She admits to dyspareunia with both initial insertion and deep penetration. She denies incontinence of urine with coughing, laughing, sneezing, or urgency. However, she experiences post-void dribbling. The feels as if she never completely empties her bladder as she constantly feels the urge to void. She has had three urinary tract infections in the past year, but denies a history of pyelonephritis, nephrolithiasis, hematuria, or urinary hesitancy. She is in a stable relationship with one sexual partner in the past year. She has a remote history of trichomoniasis. Otherwise her medical and surgical histories are negative. Physical examination General appearance: Well-nourished woman in no acute distress Vital signs: Temperature: 37.2°C Pulse: 68 beats/min Blood pressure: 128/70 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 99% on room air Abdomen: Soft, nontender, nondistended, obese, no organosplenomegaly External genitalia: Unremarkable Bladder: Nontender, no palpable masses Urethra: Meatus midline, suburethral fullness and tenderness. No discharge from the meatus with compression of the midurethra Vagina: Loss of epithelial rugations in the midurethral area, otherwise no lesions; scant clear discharge; Bartholin’s and Skene’s glands are unremarkable Cervix: Parous, no mucopurulent discharge, no lesions Uterus: Small, anteverted, nontender, mobile Adnexa: Nontender, no masses Laboratory studies: Urine dipstick: Moderate leukocyte estrace, negative nitrites, pH 6.0, trace blood, specific gravity 1.015, negative ketones, negative glucose, negative bilirubin Urine culture: Negative Cystourethroscopy was performed in the office with a rigid 30° cystourethroscope after application of 2% lidocaine gel to the urethra Imaging: MRI was ordered.