INTRODUCTION

Vaginal leiomyomas are uncommon. They arise from vaginal mesenchymal tissue. About 330 cases have been reported since the first detected case back in 1733 by Denys de Leyden.¹ We hereby, present a case of vaginal leiomyoma presenting as polymenorrhea and something coming out of vagina since 5 months.

CASE REPORT

A 44-year-old lady presented in the gynecology outpatient department with polymenorrhea and something coming out per vaginum since 5 months. She was para II, with both deliveries by cesarean section.

On examination, her general condition was good and abdomen was soft. On local examination, vulva was normal. Per speculum examination, cervix was not visualized; a mass in vagina was seen. On per vaginum examination, mass was felt 1 cm from the introitus, firm in consistency, smooth surfaced, nontender, nonreducible, nonfriable, and size approximately 6 × 5 cm (Fig. 1). Cervix was felt separately on left side, uterus was normal size and fornices were free. On ultrasound (USG), she was diagnosed as leiomyoma of cervix.

After investigations, patient was taken up for surgical removal of the mass. The mass was found to be attached to the posterolateral vaginal wall and not cervix. A vertical incision of about 3 cm was made on the capsule of the leiomyoma. The flaps were dissected and myoma enucleated (Fig. 2). The excess flaps were excised, hemostasis was achieved and vaginal walls were repaired. Endometrial curettage was done to rule out intrauterine pathology.

She was discharged on day 3 in good condition. Histopathology confirmed the diagnosis of a leiomyoma (Fig. 3).

Cut section showed smooth, whorled pattern with no necrosis and hemorrhage. Microscopic examination revealed the tumor to be composed of interlacing bundles of smooth muscle cells separated by vascularized connective tissue. No atypia, mitosis or necrosis was seen.

DISCUSSION

Vaginal leiomyomas are rare. Only about 330 cases have been reported since the first detected case back in 1733 by Denys de Leyden.¹ Among 50,000 surgical specimens, Bennett and Erlich² found only 9 cases and only 1 case in 15,000 autopsies. It is more common among Caucasians.² It may or may not be associated with leiomyomas elsewhere in the body. It is found to be hormone dependent. It arises from vaginal smooth muscle or local arterial musculature or smooth muscle of the bladder or urethra. It is the commonest mesenchymal tumor of vagina. Usually, it is a single, well-circumscribed mass arising from the midline anteriorly,^3-14 less commonly from the posterior walls.^15,16 In our case, the origin was from right posterolateral wall, an unusual site for vaginal myoma.

Fig.1

Vaginal leiomyoma

Fig. 2

After removal

Fig. 3

Histopathology (high power × 10)

Literature is scarce regarding vaginal leiomyomas and is limited to few case reports only. A review of literature of the last 15 years has been attempted (Table 1). Though the common age group involved is 35 to 50 years, it has been reported in women as young as 22 years⁵ and even in postmenopausal age group.^17,18 Clinical presentations were variable depending on the size and location. The commonest clinical presentation was some mass coming out of vagina.^{3,6,7,9,10,13-15,19,20} However, in some, it was pain in abdomen,^3,16 vaginal discharge,^4,12 dyspareunia,^5,21-23 infertility,⁵ urinary frequency,¹⁰ retention urine,⁹ recurrent urinary tract infection (UTI),¹¹ dysuria,²⁰ incomplete voiding,²⁰ dysmenorrhea,²¹ dysfunctional uterine bleeding,^24,25 menometrorrhagia,²⁶ gluteal swelling,²⁷ pain in right iliac fossa,¹⁷ etc. Asymptomatic vaginal fibroid²⁸ was reported at the time of diagnosis and it has been detected at the time of routine cancer screening.²⁹ Size of the vaginal tumor has varied from as small as 2 cm¹⁸ to reaching upto umbilicus.¹⁶ It can get infected and necrosed to mimic a vaginal malignancy.³⁰ Rapid enlargement mimicking a vaginal malignancy has also been reported by Sim et al.³⁰

Diagnosis is usually difficult preoperatively as it can mimic cystocele or cervical fibroid but USG and magnetic resonance imaging (MRI) usually clinch the diagnosis.³¹ Translabial sonography should be considered as an adjunct to transabdominal and transvaginal sonography for patients with suspected vaginal fibroids.³²

The MRI shows well-demarcated solid masses of intermediate signal intensity in T1- and T2-weighted images with homogeneous contrast enhancement, while leiomyosarcomas and other vaginal malignancies show high T2 signal intensity with irregular and heterogeneous areas of necrosis or hemorrhage.^33,34 Degenerated leiomyomas can also show foci of high signal intensity that correspond to a combination of edematous swelling of myoma cells from ischemia, cystic change and/or myxoid degeneration.³⁵ In our case, MRI was not done. Though USG and MRI are helpful in diagnosing, yet in few cases fine-needle aspiration cytology (FNAC)/biopsy was done for diagnosis.^12,15

Management requires surgical vaginal enucleation in most of the cases; however, abdominopelvic approach was used because of its size²⁷ and abdominal route was used by some, as it was high up in vagina and upper margin was not approachable by vaginal route.^4,24,26 In these cases, the diagnosis was made intraoperatively during abdominal hysterectomy. In some, the diagnosis was made after the histopathology report.⁶ Pre-op embolization can be done to reduce vascularity in hypervascular tumor before surgical removal.³⁶ Injury to bladder has been reported while enucleation.^11,37

Histopathological confirmation is the gold standard of diagnosis. Vaginal leiomyomas are composed of spindle-shaped cells with elongated and oval nuclei and little or no mitotic activity. The diagnosis of vaginal leiomyomas is to be reserved for those with <5 mitoses/high-power field. Increased mitotic activity in absence of aggressive behavior may be present in vaginal leiomyoma with pregnancy.³⁸ Sarcomatous transformation can occur and a histopathologic study confirms the correct diagnosis. So, atypism, hypercelullarity and mitotic figures need to be evaluated in histopathology to rule out malignancy.

Patients should be followed up for recurrence.