Ostwal P*, Kale K**, Chauhan AR***
(* Second Year Resident, ** Assistant Professor, *** Professor, Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India.)
Leiomyomas are common tumors of the female genital tract, more commonly arising from the uterus and the cervix. Primary vaginal wall leiomyomas are rare, with only 300 reported cases in the literature. They are more commonly located in the anterior vaginal wall and present with a variety of symptoms which leads to difficult diagnosis. Surgical excision is the treatment of choice, preferably by vaginal route. Here we report a case of primary vaginal wall leiomyoma in a 37-year-old female presenting with mass protruding out of the introitus. Vaginal excision was performed and diagnosis was confirmed on histopathology.
Vagina is a rare site for the occurrence of leiomyoma. Vaginal masses commonly include polyp, papilloma and hemangioma. Only few cases of vaginal leiomyoma have been reported in literature, of which anterior wall is the most commonly affected site. Here we discuss one such rare case of primary vaginal wall leiomyoma which posed a diagnostic challenge.
A 37-year-old parous woman with one living issue, presented to the outpatient department with something coming out per vaginum since 3 - 4 months duration associated with dyspareunia and increased frequency of urination. There were no associated menstrual complaints. Past medical and surgical history was not significant. Abdominal examination was within normal limits. Local examination of the perineal region revealed a mass protruding out of the introitus (Figure 1A), which bulged on coughing. On speculum examination, the mass was elongated, 4 x 5 cm in size, confined to the anterior vaginal wall. Cervix was seen separately below the mass (Figure 1B). On per vaginal examination, uterus was anteverted, normal in size and mobile. The mass was firm in consistency, mobile, non-tender and was felt separate from the uterus. Overlying vaginal mucosa was free and healthy. Urethral opening was seen well away from the site of the mass.
Figure 1. (A) Mass protruding out of the introitus. (B) Mass seen arising from anterior vaginal wall with cervix seen separately below the mass.
Ultrasonographic examination showed a 5 x 6 cm mass in the upper part of vagina, most probably a pedunculated cervical fibroid. However, a clinical diagnosis of primary vaginal wall fibroid seemed more likely. After complete evaluation, patient underwent vaginal excision of the mass. Consent was also taken for abdominal exploration and hysterectomy if required. Under all aseptic precautions, bladder was catheterised. Base of the mass near the cervix was infiltrated with saline-adrenaline solution. A longitudinal incision was taken at the most inferior part of the mass to avoid injury to bladder (Figure 2). Plane was identified and the mass was dissected off the anterior vaginal wall using blunt and sharp dissection (Figure 3). The mass was removed completely and there was no evidence of a connecting pedicle to the uterus. Base of the myoma was obliterated using multiple sutures in figure of eight manner with no. 1 polyglactin. The excess vaginal mucosa was cut and sutured back in two layers using no. 2-0 polyglactin sutures (Figure 4).
Figure 2. Base of the mass infiltrated and a small vertical incision taken over the vaginal mucosa.
Figure 3. Mass held with a tenaculum and dissected off the vaginal mucosa by blunt and sharp dissection.
Figure 4. Final view after closure.
Grossly, the excised mass resembled a fibroid with characteristic whorling appearance on cut section. Microscopy showed a well circumscribed leiomyoma, thus confirming the diagnosis. The postoperative period was uneventful and patient was discharged on the third postoperative day.
Leiomyomas are benign mesenchymal tumors of smooth muscle origin and are commonly found in the female genital tract, especially the uterus and the cervix. Vaginal leiomyomas are very rare and till date only 330 cases have been reported in the literature. They commonly occur in females in the late reproductive age and/or nearing menopause, although rare cases have been reported in pubertal and postmenopausal females. They are more commonly located in the anterior vaginal wall as compared to the lateral and posterior vaginal walls. Vaginal leiomyomas are usually single, well circumscribed, firm in consistency and <5 cm in size. They may be asymptomatic initially or present with symptoms such as mass protruding from the vagina, bleeding, dyspareunia and lower abdominal pain. Compression of the bladder may lead to symptoms such as urinary retention and increased frequency of micturition. Gupta et al have reported a rare case of large vaginal leiomyoma growing into the abdomen and masquerading as ovarian tumor. Gowri et al have reported vaginal leiomyoma presenting as gluteal swelling and pus discharging per vagina.
Vaginal leiomyomas present a diagnostic challenge owing to their rarity. Clinical features of the mass are such as consistency and mobility can point towards the diagnosis and were primarily relied upon in our case. Transabdominal and transvaginal ultrasonography may be useful but often leads to a misdiagnosis of cervical fibroids. MRI is a better modality with greater delineation and may be used where the diagnosis is doubtful. Histopathology is confirmatory and gold standard for diagnosis of vaginal leiomyomas.
Treatment of choice for vaginal leiomyomas is surgical excision, preferably by vaginal route. In some cases with large leiomyomas, an abdomino-perineal approach may be used. Urethral catheterisation is a must for avoiding bladder injury, which is usually rare and occurs when the myomas are large and indenting the bladder.[3, 4] Some authors have suggested hysterectomy for perimenopausal females. In our opinion, the choice and route of surgery should be based on age, clinical presentation and size and extent of the vaginal leiomyoma. Recurrence may occur rarely and hence complete excision of the tumor and regular follow up is important. Malignant change is very rare, but reported.[3, 6]
Thus vaginal leiomyoma, although rare, is an important differential diagnosis of vaginal masses and should be kept in mind by the treating clinicians.
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Ostwal P, Kale K, Chauhan AR. Anterior Vaginal Wall Leiomyoma. JPGO 2017. Volume 4 No.6. Available from: http://www.jpgo.org/2017/06/anterior-vaginal-wall-leiomyoma.html