International Journal of Surgery Case Reports 93 (2022) 106955

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Vaginal leiomyoma mimicking a Cystocele (report case)

Ahmed Touimi Benjelloun *, Imane Ziad, Douha Elkaroini, Houssine Boufettal,
Sakher Mahdaoui, Naima Samouh
Obstetrics and Gynecology Department, University Hospital Center Ibn Rochd, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Morocco

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Leiomyoma, known as a disease of the uterus, composed of spindle-shaped smooth
Case report muscle fibers and collagenous stroma, is rarely encountered in other sites especially in the vagina.
Ectopic leiomyoma Case presentation: We report, here, an exceptional case of a vaginal leiomyoma situated in the anterior vaginal
Vaginal leiomyoma
wall suggesting in the first place a cystocele. The MRI objectified a rounded formation of the anterior wall of the
Cystocele
vagina with regular contours highly suggestive of a vaginal leimyoma. The tumor was surgically removed by the
vaginal route. The histopathologic examination confirmed the diagnosis of vaginal leiomyoma.
Clinical discussion: Vaginal leiomyomas are commonly seen in women between the ages of 35 and 50 and are
believed to be more common in Caucasian women. Although a rare tumor, vaginal leiomyomas may present with
a variety of clinical features and may be mistaken preoperatively for a cystocele, urethrocele, Skene's duct ab­
scess, Gartner's duct cysts, urethral diverticulum, vaginal cysts, cysts Bartholin's gland or a malignant vaginal
tumor. The diagnosis is based on careful examination and preoperative imaging (ultrasonography and MRI).
Removal of the tumor by vaginal route, wherever possible, with subsequent histopathological examination ap­
pears to be the optimum management plan. Although the lesion is benign, local recurrences following incomplete
resection and sarcomatous changes have been reported.
Conclusion: Vaginal leiomyoma is a rare benign tumor. The diagnosis is often made only postoperatively after
resection of the mass. The tumors may be found in any location within the vagina but are most commonly located
on an anterior wall. Imaging can confirm the vaginal origin of the lesion. Surgical excision is the treatment of
choice. The diagnosis is based on the histological study of the tumor.

1. Introduction 2. Observation

Vaginal tumors are rare and include papilloma, hemangioma, We report the case of a 65-year-old female patient, fifth gesture, fifth
mucosal polyp and rarely leiomyoma. Vaginal leiomyomas are benign pare, mother of five children delivered by vaginal route, who has been
mesenchymal tumors that are rare with their ectopic locations, only menopausal for thirteen years, with no relevant family or personal his­
about 300 cases reported since the first case detected in 1733 by Denys tory, not taking any drug, and who consulted for a vaginal swelling
de Leyden [1]. In general, the diagnosis is only made postoperatively, appeared since nine months responsible for a sensation of intra vaginal
after histological study of the nodule. These tumors most often originate ball, pelvic heaviness and dyspareunia. This mass progressively
from the anterior vaginal wall causing various clinical presentations or increased in size until it became embarrassing. There were no reported
even at the expense of neighboring organs: uterine cervix, bladder, episodes of metrorrhagia or functional urinary signs such as retention or
rectum or vulva. urinary incontinence. The general condition was preserved.
We report a case of a primary leiomyoma of the vagina originating The clinical examination revealed:
from the anterior wall and presenting with a sensation of an intra-
vaginal ball that worsens with prolonged standing and at the end of • On inspection of the perineum and vulva: visualization of a mass in the
the day. All our work has been reported in line with the SCARE criteria anterior wall of the vagina 1 cm from the urethral meatus suggestive
and guidelines [16]. of a Cystocele.

* Corresponding author.
E-mail address: [email protected] (A. Touimi Benjelloun).

https://doi.org/10.1016/j.ijscr.2022.106955
Received 8 January 2022; Received in revised form 13 March 2022; Accepted 13 March 2022
Available online 19 March 2022
2210-2612/© 2022 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
A. Touimi Benjelloun et al. International Journal of Surgery Case Reports 93 (2022) 106955

• Vaginal touching coupled with abdominal palpation: palpation of a 3 cm having the characteristics of slow growth and small size, does not pro­
cystic intra vaginal mass, painless, mobile and non reducible. It re­ duce symptoms at first and regresses spontaneously after menopause,
mains 3 cm away from the anterior cul de sac. may not manifest in a large number of patients who doesn't become
• On speculum examination: the cervix appeared normal and no aware of the disease.
bleeding was observed (Fig. 1). Vaginal leiomyomas are commonly seen in women between the ages
of 35 and 50 and are believed to be more common in Caucasian women
An endovaginal ultrasound was ordered but did not identify any [3,5].
abnormality. An additional MRI was therefore performed objectifying a They usually appear as a single, well-circumscribed mass originating
rounded formation of the anterior wall of the vagina lateralized to the from the medial anterior wall [6], as we have observed in our case, and
right measuring 3 cm in diameter with regular contours (Fig. 2). less frequently, from the posterior and side walls. They are often
Given the size of the lesion and its symptomatic nature, a surgical asymptomatic but depending on the site of onset they can be associated
excision was performed by the vaginal route by professor Mahdaoui. A with lower abdominal pain, low back pain, vaginal bleeding, dyspar­
Foley's catheter was introduced in the urethra for protecting the latter. eunia, urinary symptoms as pollakiuria, dysuria or other features of
No adhesion was found. We proceeded to the enucleation of the mass urinary obstruction [7]. The clinical diagnosis of vaginal leiomyoma
and we obliterated the dead space. The surgery took place without requires a high index of suspicion as the tumor could easily be mistaken
incident. The patient was discharged on the second postoperative day. for cystocele, urethrocele, Skene's duct abscess, Gartner's duct cysts,
She recovered uneventfully and she was able to resume to her daily urethral diverticulum, vaginal cysts, cysts Bartholin's gland or a malig­
activity within the next day. After a two-month follow-up, the vaginal nant vaginal tumor [8,9].
wound healed well and the patient reported no discomfort and was able The majority of these tumors are around 3 to 4 cm in diameter [10].
to resume her sexual activity (Fig. 3). The largest vaginal leiomyoma recorded was 20 cm in diameter. In 1933
The tumor was then sent for histopathologic examination. The Pistuddi reported a case of vaginal fibromyoma which, after removal,
macroscopic examination describes a solid mass of 2.8 × 2 × 1.8 cm weighed 1450 g [11]. Usually these tumors are single, benign and slow
with a whitish fasciculate appearance and the Microscopic examination growing, but sarcomatous transformation has been reported [12].
revealed a well-circumscribed leiomyoma underlying the squamous Imaging, ultrasound and MRI can confirm the vaginal origin of the
epithelium, consistent with the diagnosis of vaginal leiomyoma without lesion. On magnetic resonance imaging, they appear as well-demarcated
any signs of malignancy (Fig. 4). solid masses of low signal intensity on T1 and T2-weighted images, with
homogeneous contrast enhancement, while leiomyosarcomas and other
3. Discussion vaginal malignancies shows a characteristic high T2 signal intensity
with irregular and heterogeneous areas of necrosis or hemorrhage [13].
Ectopic leiomyomas are benign mesenchymal tumors that arise from The use of MRI is particularly useful when fibroids grow rapidly, have
smooth muscle components. They are rare, they can be localized in the poor delimitation on ultrasound, and when there is a high suspicion of
ovary, broad ligament, round ligament, and exceptionally in the vulva malignancy [14]. It is accurate for diagnosing a leiomyoma with a
and vagina [2]. sensitivity of 88 to 93% and a specificity of 66 to 91% [15].
Since the first case described by Denis de Leyde in 1733, around 300 Surgical removal of the mass via the vaginal route remains the
cases of vaginal fibroids have been reported worldwide [1]. Indeed, therapeutic method of choice, but the abdominoperineal route is
Bennett and Ehrlich [3] identified only 9 cases out of 50,000 samples for necessary for large tumors [5]. The diagnosis is rarely mentioned pre­
histopathological examination and 1 case out of 15,000 autopsies at operatively and only the anatomopathological examination makes it
Johns Hopkins University. However, Liu [4] argues that the tumor possible to retain it. Although the lesion is benign, local recurrences
following incomplete resection and sarcomatous changes have been
reported [13].

4. Conclusion

Vaginal leiomyoma is a benign mesenchymal tumor whose location

is rare. This localization is usually asymptomatic, discovered inciden­
tally during a clinical examination or by discomfort or a sensation of
intravaginal lump. Vaginal myoma appears as a firm, painless lump,
especially on the anterior wall of the vagina. Imaging can confirm the
vaginal origin of the lesion. Surgical excision is the treatment of choice.
The diagnosis is based on the histological study of the tumor, which can
confirm the diagnosis and rule out a malignant component.

Consent

Written informed consent was obtained from the patient for publi­
cation of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Ethical approval

Fig. 1. Appearance of vaginal swelling (arrow). I declare on my honor that the ethical approval has been exempted

2
A. Touimi Benjelloun et al. International Journal of Surgery Case Reports 93 (2022) 106955

Fig. 2. MRI appearance of the intra-vaginal mass.

Fig. 4. Macroscopic appearance of the lesion.

Guarantor

Dr. Touimi Benjelloun Ahmed.

Research registration number

None.

CRediT authorship contribution statement

Fig. 3. Surgical excision of the lesion.
Touimi Benjelloun Ahmed: the main doctor conceived the original
idea, revised manuscript.
by my establishment. Ziad Imane: followed up, summed up, revised manuscript.
Elkaroini Doha: followed up, wrote manuscript.
Funding
All authors contributed to the interpretation of the results, discussed.
None.

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A. Touimi Benjelloun et al. International Journal of Surgery Case Reports 93 (2022) 106955

Declaration of competing interest [8] C.H. Sim, J.H. Lee, J.S. Kwak, S.H. Song, Necrotizing ruptured vaginal leiomyoma
mimicking a malignant neoplasm, Obstet. Gynecol. Sci. 57 (6) (20 nov 2014)
560–563.
There are no conflicts of interest. [9] Y. Wu, W. Wang, X. Sheng, L. Kong, J. Qi, A misdiagnosed vaginal leiomyoma: case
report, Urol. Case Rep. 3 (3) (1 mai 2015) 82–83.
References [10] C.P. Nel, A.J. Tiltman, Leiomyoma of the vagina, SA Med. J. 54 (1978) 816–817.
[11] S. Sayammagaru, P. Livanos, T.G. Maulik, Vaginal leiomyoma, J. Obstet. Gynaecol.
26 (5) (janv 2006) 485–486.
[1] S.B. Young, P.G. Rose, K.L. Reuter, Vaginal fibromyomata: two cases with [12] Ö. Çobanoğlu, C.G. Zorlu, Y. Ergun, L. Kutluay, Leiomyosarcoma of the vagina,
preoperative assessment, resection, and reconstruction, Obstet. Gynecol. 78 (5 Pt Eur. J. Obstet. Gynecol. Reprod. Biol. 70 (2) (déc 1996) 205–207.
2) (Nov 1991) 972–974. [13] Bae Jeong Hoon, Choi Sae Kyung, Kim Jin Woo, Case reports : vaginal leiomyoma:
[2] J. Drissi, A. Zazi, J. Kouach, D.-R. Moussaoui, M. Dehayni, Léiomyome vaginal : à a case report and review of the Literature, J. Womens Med. 1 (2) (2008) 92–94.
propos d’un cas, Int. J. Innov. Appl. Stud. 10 (2) (févr 2015) 506–508. [14] H. Chin, X. Ong, P. Yam, B. Chern, Extrauterine fibroids: a diagnostic challenge and
[3] H.G. Bennett, M.M. Ehrlich, Myoma of the vagina, Am. J. Obstet. Gynecol. 42 (2) a long-term battle | BMJ case reports (2014:bcr2014204928). Disponible sur: BMJ
(1941) 314–320, août. Case Rep. (2014) https://casereports.bmj.com/content/2014/bcr-2014-204928.sh
[4] M.-M. Liu, Fibromyoma of the vagina, Eur. J. Obstet. Gynecol. Reprod. Biol. 29 (4) ort.
(déc 1988) 321–328. [15] A.T. Khan, M. Shehmar, J.K. Gupta, Uterinefibroids:current perspectives, Int. J.
[5] I. Chakrabarti, A. De, S. Pati, Vaginal leiomyoma, J. Life Health 2 (1) (2011) 42–43. Womens Health 6 (29 janv 2014) 95–114.
[6] K. Shimada, I. Ohashi, H. Shibuya, F. Tanabe, T. Akashi, MR Imaging of an atypical [16] R.A. Agha, T. Franchi, C. Sohrabi, G. Mathew, for the SCARE Group, The SCARE
vaginal leiomyoma, Am. J. Roentgenol. 178 (3) (mars 2002) 752–754. 2020 guideline: updating consensus Surgical CAse REport (SCARE) guidelines, Int.
[7] M. Asnani, K. Srivastava, H.P. Gupta, S. Kunwar, A.N. Srivastava, A rare case of J. Surg. 84 (2020) 226–230.
giant vaginal fibromyoma, Intractable Rare Dis. Res. 5 (1) (2015) 44–46.