Vaginal leiomyoma in a perimenopausal woman: A rare case report and review of the literature

We present a rare case of a 50-year-old woman who visited the outpatient department with complaints of abnormal uterine bleeding and heaviness in the abdomen for 1 year. She also reported a protruding mass outside the introitus during coughing and straining, accompanied by dyspareunia and occasional difficulty in urination. Upon local examination, a mass measuring 5*6 cm was observed protruding through the anterior vaginal wall posterior to the urethra on straining and on pervaginum examination cervix was normal and uterus measuring the size of 12 weeks [ Figure 1 ]. Ultrasonography indicated adenomyosis of the uterus, with a suspected mass protruding through the posterior bladder or anterior vaginal wall. To confirm the diagnosis, magnetic resonance imaging (MRI) imaging was conducted and it showed adenomyoma in the fundus of the uterus with a pedunculated submucosal uterine fibroid. Another large polypoidal mass lesion is seen within the vaginal cavity, hypointense on T1 and isointense on T2, and it shows homogenous post-contrast enhancement. It has two asymmetrical round ends. A larger one measures 4 * 4.4 cm, and the smaller end measures 2.8 * 1.5 cm. The vaginal mass is causing deformity of the posterior urinary bladder wall and proximal urethra [ Figure 2 ]. Image of the vaginal mass MRI pelvis image shows: vaginal mass with uterus showing submucosal leiomyoma The diagnosis of vaginal leiomyoma along with pedunculated submucosal leiomyoma with adenomyosis of the uterus was made. The patient planned for a hysterectomy for submucosal leiomyoma with adenomyosis and excision of the vaginal mass via vaginal route. The patient underwent hysterectomy, and in the same setting as the location of the mass near the posterior part of a urethra, with the help of a urologist, an incision was given over the mucosa of the vagina, extended, and the mass was enucleated. The size of the vaginal mass was around 4 * 5 cm size enucleated, the redundant vaginal wall was excised, and the same was sent for histopathology examination [ Figure 3 ]. The cut section of the mass showed a whorled appearance. The histopathology of the vaginal mass showed vaginal leiomyoma. (a) Operative image excision of vaginal mass. (b) Submucosal leiomyoma of uterus After excision of redundant vaginal wall, normal anatomy restored described in post operative image [ Figure 4 ]. Post operative image after excision of vaginal mass restoration of normal anatomy The post-operative period was uneventful. The patient had no complaint of difficulty urinating and had symptomatically improved.

Vaginal leiomyomas, originating from the anterior vaginal wall, are exceedingly uncommon, with only around 300 reported cases documented in the literature to date.[ 1 ] These fibromyomas can lead to diverse clinical manifestations, including dyspareunia, pain or dysuria, depending on their size and location. We report a case of a 50-year-old woman, who presented with heaviness in the abdomen, dyspareunia with abnormal uterine bleeding and mass protrusion outside the introitus. The case is unique as its location of mass and proximity to the urethra make the diagnosis difficult.

Leiomyomas are commonly observed in the female reproductive tract, with the uterus being the most prevalent location, followed by the cervix, round ligament, uterosacral ligament, ovary and inguinal canal.[ 2 ] This site of occurrence and proximity to the urethra and bladder make our case particularly unique. Vaginal leiomyomas are benign tumours originating from the smooth muscle elements of the vaginal wall. They are relatively uncommon, accounting for approximately 5% of periurethral masses in a recent series involving 79 patients. These masses can manifest anywhere within the vagina, ranging in diameter from 0.5 to 15 cm. These tumours are frequently found on the anterior vaginal wall and can be either related or unrelated to leiomyomas in other parts of the body.[ 3 ] Typically, they present as a smooth, firm, round mass located on the anterior vaginal wall, occasionally leading to misdiagnosis as a urethral diverticulum or paraurethral cyst, which resembles our case scenario. Generally, vaginal leiomyomas develop in women aged between 35 and 50. Most cases involve a single tumour that is small and slow-growing. However, these lesions are often influenced by oestrogen levels, leading to rapid growth during pregnancy or regression after menopause. The presence of symptoms largely depends on the size and location of the tumour, including mass effects, obstruction, pain and dyspareunia. Recently, like in our case 48-year-old multipara presented to the outpatient department with an ultrasonographic report showing multiple uterine fibroids with a vaginal mass diagnosed on ultrasonography and MRI, and the mass was enucleated. Histopathology revealed a vaginal leiomyoma.[ 1 ] Ultrasound and MRI can aid in assessing the extent, characteristics and involvement of the mass before surgical intervention. Excision or enucleation through a vaginal approach is usually curative and recommended to confirm the diagnosis, rule out malignancy and alleviate symptoms. In cases of larger tumours, an abdominal–perineal approach is typically preferred. The initial diagnostic method of choice for evaluating vaginal leiomyomas is trans-perineal ultrasonography, which offers advantages, such as affordability, accessibility and reliable accuracy in establishing a diagnosis.[ 4 ] However, the challenge lies in distinguishing between benign and malignant lesions. MRI is sparingly employed to assess tumour extent and differentiate between benign and malignant lesions. Malignant growths typically exhibit a low-intensity signal on T2-weighted scans, unlike normal smooth muscle cells.[ 5 ] Nevertheless, histopathological analysis of the surgical specimen remains the gold standard for the definitive diagnosis and exclusion of malignancy. In rare instances, leiomyomas of the vagina can undergo malignant transformation, giving rise to borderline malignancy or leiomyosarcoma. A rare case reported of a 38 year old women who experienced symptoms of foul vaginal discharge and dyspareunia for 2 months. Upon undergoing total excision of the tumour, the diagnosis was confirmed as leiomyosarcoma.[ 6 ] Smooth muscle tumours of the vagina are classified into three types: leiomyomas, atypical leiomyomas and leiomyosarcomas. Tavassoli and Norris proposed criteria to differentiate leiomyosarcoma from atypical and benign tumours, including tumour size larger than 5 cm, infiltrative margins and more than five mitotic figures per ten high-power fields. Nielsen et al . added a fourth criterion of moderate-to-severe cytological atypia. According to their criteria, if three or all of these features are present, the neoplasm is classified as a sarcoma. Atypical benign leiomyomas satisfy two characteristics, while benign leiomyomas exhibit only one or none of these traits. In our case, none of these attributes were observed, indicating a diagnosis of a benign tumour.[ 7 ] The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Nil. There are no conflicts of interest.