Keywords : vaginal fibroid
Although uterine fibroids are common, vaginal fibroids are
very rare. We report a case of large vaginal fibroid which
could not be diagnosed before surgery.
A 55 years old para 2 belonging to upper middle socioeconomic status came complaining of pain in abdomen off and on since 1 month. Pain was tolerable and did not radiate anywhere. It increased on exertion and became less after rest. Both her deliveries were by cesarean section, the last being 29 years back. She had tubal ligation done. She attained menopause 12 years back. There was history of laparotomy 15 years back for some tumor, probably uterine or ovarian. Operation record was not available. She was obese and also a known case of hypertension and coronary heart disease taking regular treatment. Her mother had died of hypertension and heart disease. On abdominal examination, a midline infraumbilical scar was seen. A suprapubic lump was felt reaching upto the umbilicus. It was irregular in shape, having variable consistency and had restricted mobility. On vaginal examination, the cervix was high up and flushed with vagina. The same lump was felt and could not be made out separately from the uterus and ovaries. Her hemoglobin was 14.4 dL, lucocyte count 7.290/m3 , differential count – P-64 L-33 E-03, ESR 12 mm first /hour, blood group O Rh +ve, random blood sugar 82 mg/dL, serum creatinine 0.8 mg/dL, blood urea 8 mg/ dL, bleeding time 2 minutes 40 seconds, clotting time 4 minutes 10 seconds, serum sodium 137 mEq /dL, and serum potassium 4.09 mmol/L. Mantoux test was 22x25 mm, Elisa for tuberculosis was negative and CA 125 was 7.69 IU/mL. Her ECG showed normal sinus rhythm with T wave abnormalities and chest x-ray revealed cardiomegaly. Echocardiography showed concentric left ventricular hypertrophy, and mild anterior region hypokinetic and diastolic dysfunction. Sonogrpahy revealed a large predominantly hypoechoic mass in the pelvis measuring 13.8 x 11.9 x 9.4 cm extending upto the umbilicus but more towards right side and anterior to iliac vessels. Uterus and ovaries could not be defined separately. Besides, sonography also revealed cholelithiasis. MRI of pelvis was suggestive of a 17.8 x 17.4 x 8.8 cm solid mass in relation to posterior wall of the uterus. It had cystic area with hypokinetic contents suggestive of blood. Since ovaries could not be visualized, it was difficult even on MRI to ascertain whether the mass was arising from the ovaries or the uterus.
Abdomen was opened by midline incision through the previous scar. The incision was extended above the umbilicus to facilitate removal of the gall bladder. A mass with soft consistency was seen arising from the posterior vaginal wall and going upwards. There were no adhesions between the mass and the posterior surface of the uterus. The uterus and both the ovaries were normal in appearance, (Figure 1). There were adhesions between the mass and the rectum and the great vessels of the pelvis. The adhesions were carefully separated. Adhesions between the uterus and the bladder were separated. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and removal of the vaginal cuff with the mass were done. This was followed by cholecystectomy. Total operative time was 2 hours and 30 minutes. Blood loss was minimal.
The patient stood the procedure well and her postoperative period was uneventful Alternate stitches were removed on 9 th and 10th postoperative day and she was discharged in good condition. Histopathological examination of the specimen revealed chronic cervicitis, and leiomyoma with secondary changes arising from posterior part of the vagina (Figure 2). Endometrium, ovaries, and tubes were unremarkable. Gall bladder showed chornic cholecystitis and cholelithiasis.
This case is interesting because of the many risk factors she had, both surgical and medical. Presentation was like an ovarian tumor. But at laparotomy and after histopathological examination, it was found to be a vaginal fibroid which itself is rarely seen in this manner and age group.
Uterine leiomyomata are common benign pelvic tumors
occurring in at least 20% of women aged 30 years 1
. The
majority of myomas arise in the uterus but they may also
arise from the round ligament, uteroovarian and uterosacral
ligaments, the vagina, and the vulva. In only 1-4% cases,
the myoma grows primarily in the cervix 2
. Primary vaginal
fibroids are even rarer. The earliest reference made of such
a tumor is attributed to De Leyden in 1773, and the first
review of literature concerning such tumors was published
in 18823
. Approximately 330 vaginal leiomyomas have been
reported in the world literature. In the initial stages, the
vaginal leiomyomas may be asymptomatic 4
. Symptoms
arise with the growth of the tumor mainly due to
compression. There may be variable clinical presentation
and a broad differential diagnosis that can lead to preoperative misdiagnosis 5
. Leron and Stanton 5
reported a
case of vaginal leiomyoma with a symptom complex of
prolapse with urinary urgency and urge incontinence. Gowri
et al 6
reported a case of leiomyoma arising from the lateral
vaginal wall presenting as a gluteal swelling with pus
discharging vaginally, creating clinical dilemma in
diagnosis 6
. Treatment is always surgical. Enucleation and
excision is the treatment of choice in young patients. The
obvious problem is the most effective approach. This is
either by the abdominal or vaginal route, depending on the
location of the tumour 7
. In perimenopausal age group,
hysterectomy should be done as was done in our case.
