Giant fibroepithelial vulvar polyp in a pregnant woman

Background

Fibroepithelial stromal polyps of the vulvovaginal region are uncommon hormone-sensitive lesions that occur especially in women of reproductive age.1 They usually appear in the vagina, and rarely in the vulva or cervix.2 These lesions have a wide range of morphological appearances and tend to grow up to 5 cm, but can rarely reach up to 20 cm.3 4 Despite being usually asymptomatic, they can cause discharge, bleeding or general discomfort with the sensation of heaviness. The pathogenesis of these polyps is still not well known, but there is evidence suggesting a hormonal influence such as the association with pregnancy and hormone therapy, and the presence of oestrogen and progesterone receptors in fibroepithelial stromal cells.5–7 Although benign, they have numerous morphological appearances and therefore can be confused with some malignant tumours. The treatment is local excision and the diagnosis is confirmed with histopathological studies2.

Case presentation

A 22-year-old woman at 29 weeks’ gestation (gravida 1, para 0) presented to the obstetrics emergency department with spontaneous bleeding from a mass on the right side of the vulva. On examination of the external genitalia, there was a very large pedunculated mass with multiple finger-like projections.

The patient described having a small vulvar mass since she was 11 years old that had grown with the pregnancy (figure 1A), causing a sensation of heaviness in her pelvis without pain. She had been too embarrassed to seek medical help before, but she reported that she had never bled from the mass. Until then, the pregnancy had been uneventful, besides a urinary tract infection with Escherichia coli at 25weeks, which was successfully treated with antibiotics.

The bleeding had no haemodynamic repercussion and was controlled with some simple sutures (figure 1B). The patient was followed through the rest of the pregnancy in the hospital. Coming to term, the vulvar mass grew larger to a maximum of 15.5 cm and she had one more episode of small bleeding that was easily controlled with compression.

Investigations

To better characterise the mass, a Doppler ultrasound was performed which showed a hypoechogenic oval mass with hypervascularisation around it (figure 2).

Treatment

Taking into consideration the size of the lesion and its risk of bleeding, we decided to perform an elective caesarean section. At 39 weeks of pregnancy, a female baby was born with an Apgar score of 9−10−10 and a birth weight of 2990 g. In the same procedure, we also performed the excision of the vulvar mass without any complications (figures 3 and 4).

Outcome and follow-up

The histopathological study revealed a giant fibroepithelial polyp of 15.5×11.5×4 cm and weighing 282 g (figure 5). Microscopically, it showed keratinised squamous epithelium covering stromal tissue with myxoid areas and fibrovascular support. The stalk of the polyp presented medium diameter thin-walled vessels. The results of immunohistochemistry staining were positive for oestrogen and progesterone receptors, and negative for CD34 (figure 6).

There were no complications during the immediate follow-up and the patient was discharged from the hospital 3 days after the surgery. One week later, she had a small dehiscence of the vulvar suture (figure 7) which was re-sutured.

At 5 weeks follow-up, the patient presented with favourable overall outcomes and very satisfying aesthetical and functional results (figure 8).

One year after the procedure the patient has no signs of recurrence.