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An unusual case of vaginal myoma presenting with postmenopausal bleeding.

Vaginal leiomyomas are uncommon benign tumour with variable clinical presentation. These tumours arise most commonly from anterior vaginal wall. We report a case of 50-year old postmenopausal woman who presented with urinary retention, profuse vaginal bleeding and mass protruding into vagina. Local examination revealed a pedunculated mass attached to the posterior vaginal wall with vascular stalk one cm below the cervix. Mass was hanging outside vulva and vascular pedicle was profusely bleeding. The pedicle was ligated and tumour was excised. Subsequent histopathology revealed a vaginal myoma.


Introduction 1
Vaginal leiomyoma is a rare entity and may present with varied clinical features mimicking prolapse, urinary obstruction, vaginal bleeding, pain abdomen etc. These tumours most commonly arise from anterior vaginal wall and less commonly from posterior and lateral wall (1,2). We report an unusual case of post menopausal woman with leiomyoma of vagina arising from posterior vaginal wall and presenting with urinary retention and heavy postmenopausal bleeding.

Case Report
A 50-year-old postmenopausal woman presented to our department with complaint of postmenopausal bleeding of two months duration, retention urine of 15 days duration for which she was catheterised from a private clinician. When she was on the way to the hospital suddenly she noticed something coming out of the vagina. On arrival to the hospital she was profusely bleeding and was in shock. She was resuscitated and immediately shifted to the operating room. On examination patient was severely anaemic and her vitals showed tachycardia and hypotension (pulse rate 110/min, BP 80/50 mm of Hg). Local examination revealed a 10 ×10cm pedunculated mass hanging outside the vulval outlet (Fig. 1). The mass was attached to the posterior vaginal wall with vascular stalk. The vascular stalk was profusely bleeding as it was sheared off because of the traction created by hanging mass. Per speculum and per vaginum examination revealed normal cervix and uterus. The pedicle was clamped and mass was excised. With the clinical diagnosis of vaginal myoma, tumour was sent for histopathological diagnosis. Gross examination revealed a 10× 8 cm mass with whorled appearance on cut section. Microscopic examination revealed well circumscribed leiomyoma (Fig. 2). Follow up at six month showed no recurrence.

Discussion
Leiomyomas are common tumours of female genital tract but occurrence in vagina is very rare. Vaginal leiomyomas usually arise from anterior vaginal wall as a single solid mass. Occurrence in the posterior vaginal wall is very rare (2). Presentation can have varying symptoms including urinary obstruction, dysuria, dyspareunia, lower abdominal pain, vaginal bleeding etc. Rarely, they may be asymptomatic. These tumours are usually regarded as benign but sarcomatous changes have been reported (3). Preoperative diagnosis can be made by ultrasonography but usually it is better delineated with magnetic resonance imaging (MRI). In MRI they appear as homogenous lesion with signal similar to that of myometrium (4). In the index case diagnosis was evident clinically as tumour pedicle was arising from the the posterior vaginal wall and mass was hanging outside the vulval introitus Surgical removal is the treatment of choice. Vaginal approach is usually feasible but at times abdominoperineal approach may be required to complete the excision in large tumours (5).
Leiomyoma of vagina are thought to be estrogen dependent as they rapidly grow during pregnancy and regress after menopause. Recurrence is uncommon, but it has been suggested that if recurrence occurs in premenopausal patient, ovaries should be removed. But our patient was postmenopausal, so role of estrogen in vaginal myoma and oophrectomy in recurrent case cannot be over emphasized.
This case was unusual for one, it occurred in postmenopausal women where it is thought to regress, second it presented with profuse vaginal bleeding which is uncommon , third it was arising from posterior vaginal wall and attached to it with vascular stalk.