Vaginal leiomyoma is a rare solid tumour with unknown exact etiology. These tumours by and large are symptomless and the intervention of pick is surgical deletion. The diagnosing of vaginal leiomyoma is made by histopathology. In this article, we have reported a 39-year-old adult female with a solid regular homogeneous mass mensurating about 3×4 centimeters and making to the hymenal ring in the country of the anterior wall of vesicovaginal septum.
Vaginal leiomyoma is a benign smooth musculus tumour ( 1,2,3 ) . In 1733, it was foremost reported by Denys de Leyden ( 3 ) . These tumors which are seen in adult females between the ages of 35-50 old ages are highly rare and the exact etiology is unknown ( 2,3,4,5 ) . Although rare, the vaginal leiomyoma is the most common mesenchymal tumour of the vagina ( 6,7 ) . These rare tumours can demo variable clinical symptoms such as vaginal hemorrhage, dyspareunia, bulge of mass from vagina, irregularity, trouble in micturation or abdominal hurting ( 8 ) , but are normally symptomless in the early phases.
These tumours are more often seen in the midplane anterior vaginal wall and are normally under 6 centimeter in size. But, seldom unusual presentations are reported ( 9 ) . The intervention of pick for vaginal leiomyoma is normally surgical via a transvaginal attack and the return rate after remotion is really low ( 10 ) . Sarcomatous alteration of the vaginal leiomyoma is negligible. ( 8 ) . But, careful histological scrutiny is necessary to except malignance. In diagnosing of these tumours histological scrutiny is indispensable.
In this study, our intent is to describe an unusual instance of vaginal leiomyoma.
A 39 twelvemonth old adult female gravida 2, para 2 was admitted to clinic for outpatients with a ailment of dyspareunia. Her old catamenial rhythms were regular and her last catamenial period was 13 yearss ago. There was no history of unwritten preventive usage. Her past medical history and physical scrutiny was non singular. Her critical marks were besides stable. The gynaecology speculum scrutiny showed a solid homogeneous mass in front tooth of the vaginal wall mensurating about 3×4 centimeter and making the hymenal ring ( Figure 1 ) . When the upper bound of the mass with finger scrutiny was reached, it was realised that the mass was non related to the neck or any portion of the vesica wall. On transvaginal echography scrutiny, it was shown that the patient had a big hypoechoic mass within the vagina. In add-on, the endometrial thickness was 8 millimeter and there was non such a pathological determination in the womb. All everyday preoperative research lab surveies were normal. Preoperatively, because there was concern about the hazard of urethral hurt, a urethral catheter was placed. Then, a midline perpendicular scratch with a transvaginal attack was made over the vaginal mass, it was enucleated from the paravaginal tissues by crisp and blunt dissection and was wholly removed. Per-operatively it was besides seen that the mass was a primary vaginal tumour. Surgical continuance was about 25 proceedingss, and blood loss was less than 50 milliliter. Gross scrutiny of the tumour tissue obtained showed a histologic visual aspect of leiomyoma with a 3 g weight, 3×4 centimeter ellipse lobulated nodule. On cut subdivision it was steadfast, grey-yellow coloured, and showed no countries of bleeding, mortification, or hydropic devolution ( Fig & A ; Atilde ; ?re 2 ) . The mass was reported as benign on frozen-section scrutiny. There were no intraoperative or postoperative complications. The patient was discharged 2 yearss after surgery. Six hebdomads after surgery, the patient was symptomless. Pelvic scrutiny findings were normal.
Histologic scrutiny showed that the tumour was well-circumscribed, but non encapsulated. Histology revealed a benign smooth spindle cell tumour. The tumour cells were spindle-shaped and had eosinophilic cytol. The cytoplasmatic membrane was distinguishable. Hypercellularity, mitotic activity, or atomic atypia were non present. There were islands of hyaloid devolution in the tumour where mortification was non seen. The rich collagenic matrix noted in the vaginal tumour was present. On microscopic scrutiny, the lesion appeared to dwell of subperitoneal smooth musculus proliferations. On immunohistochemical scrutiny, the tumour cells were painted as positive for desmin and smooth musculus actin ( SMA ) and as negative for musculus specific actin ( MSA ) . In the karyon of the tumour cells, Lipo-Lutin and estrogen receptors were positive.
Vaginal leiomyoma which is a benign smooth musculus tumor is a really rare tumour of the vagina. They normally have no relation with the womb. In 1733, they were foremost described by Denys de Leyden ( 3 ) . Up to now, rare instances of a few hundred have been reported in the universe ( 11 ) . Bennett and Erlich found merely nine instances in 50,000 surgical specimens ( 12 ) while in 15,000 necropsies reviewed at the Johns Hopkins Hospital was found merely one instance ( 10 ) . When we revise the instances in our infirmary, this is the first instance in the last 20 old ages.
Though leiomyoma of the vagina begins at a much earlier age, it is seen often between the ages of 35 and 50 old ages because of slow growing feature of the tumour ( 13 ) . Unlike uterine leiomyomas, vaginal leiomyoma predominates in white adult females ( 12 ) . Although it is a common status in adult females, work forces have besides been reported ( 14 ) . The tumour normally arises from the anterior vaginal wall ( 15 ) or seldom from the sidelong vaginal walls ( 9,10,16 ) . The bulk of these tumours are localized and nomadic multitudes. Besides, they are normally lone and little in size, about 3-4 centimeter in diameter ( 17 ) , but on occasion may be multiple or tremendous in size ( 10,16,18 ) . In 1965, Kettle and Loeffler reported a instance where the largest vaginal leiomyoma with a weight of 1,450 g ( 18 ) . These are non tender tumours. In our instance the leiomyoma had arisen from the anterior vaginal wall, was lone and individual, was 3-4 centimeter in diameter and there was no relationship between the womb and the vaginal leiomyoma.
Leiomyomas may be seen anyplace in the smooth musculus cells. ( 19 ) The extrauterine sites of this tumor are the unit of ammunition ligament, uterosacral ligament, ovary, inguinal canal, kidney and really seldom vagina and vulva. Symptoms vary harmonizing to the size and location of the leiomyoma. At the oncoming, the tumour is symptomless. The tumour turning over clip ( & A ; acirc ; & A ; deg ; ? 6 centimeter ) may do ailments such as hurting, bulge of the mass from vagina, dyspareunia, irregularity, leukorrhea, hemorrhage and urinary piece of land symptoms ( 8 ) . After climacteric, the tumour may regress spontaneously because it is hormon-dependent. They are frequently diagnosed by the way when they grow outside of the womb ( 20 ) . In diagnosing ultrasound and CT scan can be used. But, right diagnosing is made merely after histological scrutiny. But, early diagnosing in these tumors is good for several grounds. The most of import benefit is to forestall sarcomatous alteration of vaginal leiomyoma. Our patient was admitted to clinic for outpatients with a ailment of dyspareunia. Whereupon, vaginal leiomyoma with a hypoechoic mass within the vagina was diagnosed by the gynaecology speculum and ultrasound scrutiny.
The pathogenesis of vaginal leiomyoma is wholly unknown, but they are hormon-dependent tumors. Vaginal leiomyomas resemble typical uterine leiomyomas at both gross and microscopic degrees. But, the bulk of published studies so far suggest that vaginal leiomyomas do non arise from uterine musculus cells ( 17 ) . Vaginal leiomyomas are thought to originate from the smooth musculus of the vagina, rectum, vesica or urethra, or vascular smooth musculus, or embryonic cell remainders within the vagina ( 4,10,18,21,22 ) . There does non look to be any correlativity between the happening of leiomyoma in the vagina and any other sites ( 16 ) . Biochemical surveies and familial analysis suggest that vaginal leiomyoma arises independently from a individual smooth musculus cell ( 23 ) and there are karyotypic discordance even between multiple leiomyomas ( 24 ) . However, Meniru et Al. reported a instance of vaginal leiomyoma co-existing with multiple leiomyomas in the womb and the wide ligament ( 25 ) . In add-on, few authors have given an impulse to thought that vaginal leiomyomas develop from a breaking away group from the womb ( 21 ) . If this were true, the incidence of vaginal leiomyoma should be parallel to that of uterine leiomyomas. In malice of these, we can non except these theories in our patient wholly. For the minute this issue is still an unknown response precisely.
In the differential diagnosing, the localisation of the mass should be taken into consideration. In add-on, the variable consistence of the mass can take to preoperative misdiagnosis. When the mass is found in the anterior vaginal wall ; cystocele, urethrocele, urethral diverticulum, inclusion cysts, cervical myoma and prolapsus of the womb should be considered. If the mass is found in the posterior vaginal wall ; proctoceles, enterocele, inclusion cysts and tumors of the rectum and the rectovaginal septum should be considered. In add-on to the differential diagnosing, gartner canal cysts, inclusion cysts, paraurethral and Bartholin & A ; acirc ; ˆ™s cysts, adenomyosis and malignant tumours of the vagina should be considered ( 8 ) . Low-grade leiomyosarcoma should besides be considered in the differential diagnosing.
These tumours have to be removed instantly to forestall farther growing and sarcomatous alteration in the hereafter ( 26 ) . The intervention of the vaginal leiomyoma is surgical enucleation and the vaginal attack has become the preferable method in the bulk of instances. During surgical enucleation, it may be sometimes utile to set an urethral catheter into the urethra and a gloved finger into the rectum to forestall hurt to these constructions ( 8 ) . Vaginal leiomyomas normally can be separated easy from environing tissues. In our instance, we preoperatively put an urethral catheter to forestall the hazard of urethral hurt. Then, with a transvaginal attack, the mass was removed wholly and easy by crisp and blunt dissection following a midline perpendicular scratch. If the tumour is big or in an unaccessible localisation in the vagina, the abdominal attack should be preferred ( 3 ) . Recurrence of the tumour is much lower than the uterine leiomyomas ( 10,26 ) . The mass is wholly removed to forestall return. Despite everything, if return occurs oopherectomy should besides be done because it is an oestrogen-dependent tumour ( 10,26,27 ) .
Pathologically, vaginal leiomyomas are normally solid individual nodules and are little in size. They are good circumscribed homogeneous multitudes and resemble uterine leimyomas ( 28 ) . Macroscopically, on a cut subdivision they are steadfast, grey-yellow coloured. Microscopically, these tumours consist of unvarying smooth musculus cells with indistinct cell boundary lines and eosinophilic cytol. Cystic devolution can be seen in big tumours ( 17 ) . Unlike uterine leiomyomas, vaginal leiomyomas have a rich matrix of collagen tissue. In add-on, Lipo-Lutin and estrogen receptors are positive in these tumours such as uterine tumours. In our instance similar findings were seen.
The rate of sarcomatous alteration in this tumour is really low, but may happen ( 28 ) . & A ; Acirc ; In a series of 11 instances, the incidence of sarcoma has been reported as 9.1 % and the sarcomatous multitudes of the same series have been seen normally in the posterior vaginal wall ( 8,29 ) . Just because of this, careful histological rating is required to govern out a malignant alteration. For the differential diagnosing of leiomyoma and leiomyosarcoma multiple biopsies should be taken. In the pathological rating, as grounds of leiomyosarcoma mortification, mitosis, polymorphism, and invasion of environing tissue must be sought. In our instance, histologic scrutiny revealed a leiomyoma with benign smooth musculus cell tumour. Hypercellularity, mitotic activity, or atomic atypia in the tumour cells were non present.
As a consequence, vaginal leiomyoma is a benign tumour. The intervention is surgical enucleation. Harmonizing to province, the surgical attack is through vaginal or abdominal path. It must be removed wholly to forestall return and a careful histological scrutiny should be done to except malignance following surgery.