INTRODUCTION
Vaginal leiomyoma is a benign tumor of the female genital tract that is extremely rare. There have only been a few cases reported. Vaginal leiomyomas are thought to develop in the vagina from vascular smooth muscle or embryonic cells. Other possibilities include smooth muscle from the vagina, rectum, bladder, or urethra [1]. Vaginal leiomyomas are most common in women between the ages of 35 and 50, and the most frequently arise in the anterior wall of the midline, with less frequently occurring in the posterior and lateral walls. Vaginal leiomyomas are typically round, well-circumscribed, whorl-like, and can be intramural or pedunculated [2].
We report a case of transvaginal treatment for vaginal leiomyoma. In addition, to assist clinicians in better diagnosing and managing this rare case, we conducted a literature review on the diagnosis and treatment of vaginal leiomyoma.
CASE REPORT
A 52-year-old gravid 8, parity 2 female was presented to the outpatient department with no complaint, but a routine transvaginal ultrasound showed a 2.2 × 1.8 cm uneven low-echogenic nodule on the left anterior wall of the vagina with a clear boundary and a few blood flow signals (Fig. 1).
On gynecological examination, a 2 cm round mass with a hard texture, good mobility, and no apparent sense of fluctuation could be touched in the middle and lower 1/3 of the left anterior wall of the vagina. The cervix was smooth; the uterus was anterior, the right lateral wall was prominent, and there was no tenderness and abnormal tactility in the bilateral adnexal area.
To protect the urethra, a 16 Foley catheter was inserted intraoperatively. Five IU oxytocin was diluted with 40 mL normal saline and injected into the tissue space between the vaginal mass and the vaginal wall to form a water pad. The vaginal tumor capsule was opened longitudinally with a cold knife, and the tumor was completely removed. The tumor fossa was intermittently closed with 2–0 absorbable sutures, and the vaginal wall at the tumor fossa was sutured with continuous hemlock (Fig. 2). Gross examination of the mass revealed a 2.5 × 2 cm white, medium-quality solid mass, weighing approximately 5 g. The cut section showed a woven appearance, and subsequent histopathological examination revealed a vaginal leiomyoma (Fig. 3).
DISCUSSION
Vaginal leiomyoma is a rare benign tumor of the female reproductive tract. The mass can appear anywhere on the vaginal wall, most commonly in the anterior and lateral walls, and is typically localized, mobile, and non-tender. Vaginal leiomyomas are usually asymptomatic, which may also cause pain or urinary tract symptoms depending on their anatomic location and size of the mass [3]. Dyspareunia occurs when a tumor blocks the vagina [4]. Leiomyoma of the anterior wall of the vagina can cause symptoms such as dysuria, urinary tract infections, and obstructive voiding [5]. When combined with infection, it can result in abnormal vaginal secretion, odor, pelvic inflammatory disease, pelvic pain, fever, and even be misdiagnosed as a malignant vaginal tumor [6].
Ultrasonography and magnetic resonance imaging (MRI) are valuable in the preoperative diagnosis of vaginal leiomyomas because they assess the morphology, location, and relationship of the mass to adjacent structures. However, histopathological confirmation is the gold standard [7]. A vaginal leiomyoma can be solid or cystic inconsistency, and it can go through the same degenerative changes as uterine fibroids, such as hyalinization, calcification, liquefaction, necrosis, and cystic degeneration [3]. It is easy to be misdiagnosed, and the diagnosis must be thoroughly evaluated using ultrasound, MRI, and clinician experience. Previous research has found that vaginal leiomyoma is frequently misdiagnosed as a paraurethral cyst, bladder leiomyoma, cervical fibroid, vaginal malignancy, and so on. Especially the leiomyomas of the anterior vaginal wall are easily confused with urinary tumors and bladder prolapse, preoperative positive pressure urethrography can be used to determine the tumor site [8].
Treatment for vaginal leiomyomas varies depending on the location and size of the leiomyoma. The preferred treatment is vaginal excision. In our case, we used oxytocin diluent injection in the tissue space to form a water pad during the operation, which can distinguish the boundary of the leiomyomas, avoid damage to surrounding tissues or organs, and reduce bleeding while removing the leiomyomas, thus making the surgical field clear. Adjuvant therapy can aid in surgical resection of large and blood-rich vaginal leiomyomas. Yinxia Liu et al. [9] reported a case in which six months of preoperative gonadotrophin releasing hormone (GnRH) analogue treatment reduced the tumor size from 5.7 × 5.2 × 6.6 cm to 4.2 × 2.3 × 3.2 cm, making surgical resection easier and safer. GnRH analogues affect the function of the hypothalamo-pituitary-gonadal axis by decreasing gonadotropin release and synthesis, particularly luteinizing hormone (LH) [10]. Menopausal symptoms are a common side effect of GnRH analogues, but hormone add-back therapy has been shown to attenuate hypoestrogenic effects [11]. Bapuraj et al. [12] reported a case in which an MRI revealed a large mass measuring 11.0 × 9.0 × 8.0 cm in the left lateral vaginal wall. Before myomectomy, a flush pelvic arteriogram was performed to locate the vascular supply branch of the mass and selectively embolize the vaginal branch of the left anterior division of the internal iliac artery. Pelvic arteriography after embolization revealed no blood supply to the tumor from the uterine or contralateral vaginal arteries. The mass was removed one week after embolization, and vaginal reconstruction was performed. Laparoscopic surgery has a clear vision to avoid damage to the bladder, ureter, rectum, and uterine artery when treating upper vaginal leiomyoma. Upper vaginal leiomyoma surgery with laparoscopy is both safe and feasible [13]. According to other studies, exposure to the surgical field is extremely difficult for tumors in the upper part of the anterior vaginal wall and obese patients with a deep vagina. Unlike traditional vaginal surgery, vaginal myomectomy via transvaginal natural orifice transluminal endoscopic surgery (vNOTES) can provide a clearer approach and a better outcome [14].
CONCLUSIONS
Transvaginal ultrasonography is the preferred examination for vaginal leiomyomas, and transvaginal myomectomy is the classic treatment method. The formation of a water pad with oxytocin dilution can effectively reduce intraoperative bleeding and shorten surgery time.
Article information and declarations
Ethical approval
All the procedures performed in this study were in accordance with the ethical standards of Ethics Committee of Fuxing Hospital, Capital Medical University and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The publication of this case report got permission of the patient.
Conflict of interest
All authors declare no conflict of interest.
