Vaginal Fibroma: An Unusual Vaginal Tumor

Introduction

Fibroid tumors of the female genital tract are common benign tumors in the uterus and, to some extent, in the cervix, followed occurrences in the round ligament, the uterosacral ligament, ovaries, and inguinal canal. ¹ As far back as 1941, the National Institutes of Health (NIH) noted that ∼70%–80% of women have fibroid growths by age 50. ² Myomas of the vagina are very rare tumors. They usually occur as single solid nodules localized in the vaginal wall and are encountered more commonly in women between the ages 35 and 50. ³ A vaginal fibroma is clinically a firm, benign, mesenchymal, monoclonal noninfiltrating growth. These tumors originate from smooth-muscle cells, and have diverse and nonspecific clinical features. ⁴ Vaginal fibromas usually occur arising from the midline anterior wall and, less commonly, from the posterior and lateral walls. ⁵ The tumors can be asymptomatic but, depending on the size and location of occurrences, can cause various symptoms, including abdominal pain, vaginal bleeding, dyspareunia, or dysuria. ⁶ These tumors can be intramural or pedunculated and solid as well as cystic. ⁷

Case

A 42-year-old patient presented with a history of dyspareunia, consistent vaginal pain during intercourse. She was para 1, having had a normal vaginal delivery 6 years prior. A physical examination revealed the presence of a firm tumor that was palpable in the right lateral fornix. Since there was clinical suspicion of a vaginal tumor, magnetic resonance imaging (MRI) and transvaginal ultrasound were the recommended imaging modalities to clarify the tumor's origin and relationship to the uterus, the uterine vessels, and the ureters. Ultrasonography showed a well-distinguished mass on the right side of the vaginal wall. An MRI examination was performed and showed a 22 × 20 × 25–mm, iso-intense solid tumor in the fornix (the right side of the cranial part of the vagina) clearly dissociated from the surrounding tissues (Figs. 1a,b).

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FIG. 1.

(a) Preoperative coronal T2-weighted magnetic resonance imaging (MRI) shows the contour of the 22 × 25–mm myoma. (b) Preoperative sagittal T2-weighted MRI scan of the myoma. (c and d) Intraoperative views of enucleation of the vaginal myoma (black arrows). (e) The removed myoma.

Surgical evaluation was recommended. The vaginal route is considered to be the classical approach in gynecologic surgery. Based on the literature, in comparison with uterine myomas, ⁸ the approach to a vaginal fibroid tumor needs to be well-planned, as there is risk of injuring vital neighboring structures in the pelvic cavity, including the bladder, the ureters, or the rectum. Surgical difficulties are associated with poor access to the operative field, difficulty with suturing, and the risk of increased blood loss. In this case, surgical enucleation was performed with the patient under spinal anesthesia. The tumor was completely enucleated and exteriorized via a lateral vaginal colpotomy. The incision was sutured with Vicryl® 0, the operation time was 20 minutes, and blood loss was evaluated as being minimal. The removed tissue was a sharply circumscribed, round, firm, 2 × 2 cm, gray-white tumor (Figs. 1c–e). Histopathology testing of the specimen showed that it was a leiomyoma of the vagina.

Results

The patient had an uneventful postoperative recovery. Her hospital stay was 24 hours. A clinical examination at a follow-up consultation, after 6 weeks, showed that her vagina was normal. A postoperative examination revealed complete vaginal healing.

Discussion

Leiomyomas are the most common benign tumors of the uterus. However, fibroid tumors of the vagina are very rare; since the first described case in 1733 by Denys de Leyden, until 2011, only ∼300 cases have been reported. ² Vaginal leiomyomas are commonly seen in women who are ages 35–50, with occurrences reported to be more common among Caucasian women. ¹ Vaginal fibroids are single, benign, and slow-growing tumors but sarcomatous transformation has also been reported in the literature. ⁷ Differential diagnosis by ultrasonography and physical examination can be difficult, but MRI usually confirms the diagnosis. In MRI, vaginal leiomyomas appear as well-demarcated solid masses of low signal intensity in T1- and T2-weighted images, with homogenous contrast enhancement. Leiomyosarcomas show characteristically high T2-signal intensity with heterogeneous areas of hemorrhage or necrosis. ⁹ This current case involved a 42-year-old woman who presented with dyspareunia. A physical examination, ultrasonography, and MRI were performed, and a diagnosis of a vaginal fibroid was made. Vaginal removal of the tumor in this case was performed and histopathologic testing confirmed that the patient had a vaginal leiomyoma.

Conclusions

Histopathologic confirmation is the “gold standard” of diagnosis of fibroid tumors, as it is the only way to exclude malignancy with certainty. Removal of such tumors by the vaginal route, wherever possible, appears to be the optimum solution.