Prolapsing vaginal fibroepithelial polyp

Background

Although the most common cause of prolapsing tissue from the vagina is pelvic organ prolapse, in young nulliparous reproductive aged patients special consideration must be taken for a thorough differential diagnosis and search for other aetiologies.1 2 Fibroepithelial polyps are benign growths typically limited to 1–2 cm; however, they can rarely grow larger.3 Although uncommon, fibroepithelial polyps in the vagina can result in protrusion of tissue through the introitus, causing discomfort, ulcerations, bleeding and anxiety in patients.4 Surgical excision of the polyps can provide a minimally invasive solution and is often curative. Despite excision, fibroepithelial polyps can recur and require postoperative follow-up with a gynaecologist.4 We present a case of a vaginal fibroepithelial polyp presenting as a protruding vaginal mass in a nulliparous female in late adolescence. A signed consent was obtained from the patient for publication of this case and associated deidentified photographs.

Case presentation

An adolescent nulliparous female was referred for evaluation of prolapsing vaginal tissue. For the past 5 years, she had noticed a bulge protruding outside of the vagina that was not worse with exertion or increased abdominal pressure. She denied symptoms of stress or urge urinary incontinence, constipation or faecal incontinence. Otherwise healthy, she endorsed regular normal periods, denied tobacco use or prior sexual activity and had no other medical or surgical history.

Investigations

Physical exam revealed an adolescent female in no distress with a body mass index of 19.2. Pelvic exam demonstrated a normal appearing external genitalia with redundant prolapsing vaginal tissue originating from the distal posterior wall and protruding beyond the hymen to approximately 5 cm outside of the vagina. The tissue was covered with thick, rugated vaginal epithelium, not involving the rectovaginal septum or rectal mucosa. Cervix was visualised and appeared normal. There was a normal bimanual exam with an anteverted, small, mobile uterus and no adnexal masses were appreciated. No rectocele was noted on rectovaginal exam (figure 1A). MRI was performed which demonstrated a redundant large fibroepithelial polyp of the distal posterior vaginal wall, consistent with exam (figure 2).

Differential diagnosis

When vaginal masses are evaluated in the clinical setting, further evaluation into the diagnosis includes both benign and malignant masses. Initial clinical evaluation includes information on the onset, duration, location of the mass, as well as associated symptoms such as vaginal pruritus, bleeding and discharge. Most solid vulvar tumours are benign and arise from local tissue; however, malignant lesions are possible.3

Fibroepithelial polyps, also referred to as acrochordons (most commonly known as skin tags) are benign, fibroepithelial lesions that are typically soft, skin-coloured polypoid masses, devoid of hair.3 4 These polyps often demonstrate as a solitary, slow-growing, painless growth.3 They generally measure 1–6 mm in diameter but can grow larger and can arise from a stalk protruding from the vaginal epithelium.3 4

Pelvic organ prolapse is a common condition involving descent of the anterior vaginal wall, posterior vaginal wall, uterus and cervix, vaginal apex or the perineum. Anterior or posterior vaginal wall prolapse appears as a bulging vaginal wall. Prolapse is a dynamic condition that typically worsens throughout the day and with Valsalva.3 Fibroepithelial polyps are not dynamic like pelvic organ prolapse and are constant protrusions without weakening of the vaginal wall, descent of the bladder or rectum into the vagina, or associated urinary or faecal symptoms.

Cystic tumours may present as a complaint of a vaginal protrusion. Bartholin gland cysts are usually unilateral and are found on the inner inferior aspect of the vulva at the vulvovaginal junction. They are usually asymptomatic unless infected when they then can be very painful.3 In contrast, Gartners’s duct cysts usually arise from the anterolateral upper vagina, are painless, fluid filled and typically small, but can enlarge to protrude outside the introitus.3 Skene’s cysts which are found in the periurethral tissue, and urethral diverticuli, usually found in the suburethral area, are also most commonly benign cystic masses. Comparatively, a fibroepithelial polyp can be larger, with a stalk or less defined boundary as it arises from the epithelial tissue of the vulva or vagina. In this case, the vaginal mass was posterior and midline without the smooth characteristic of a cystic mass and was not fluid filled.

Sarcomas develop as isolated masses on the labia majora, clitoris or Bartholin gland, are larger than 5 cm in diameter, and have infiltrating margins with extensive necrosis.3 In younger women, the most common malignancy of the vagina is a sarcoma botryoides subtype of an embryonal rhabdomyosarcoma, which typically develops in girls younger than 5y.3 Sarcoma botryoides appears as multiple polyp-like structures or as a nodular, cystic or pedunculated growth.3 Biopsy is one of the most reliable methods to identify a sarcoma or malignancy of the vulva or vagina and differentiate these masses from a benign fibroepithelial polyp.

Treatment

The patient was counselled on the alternatives, risks and benefits of surgical excision of the polyp. Intraoperatively, the 5×4 cm fibroepithelial polyp and hypertrophic vaginal epithelium extended superiorly to the mid-vagina with a broad stalk. A transperineal approach was undertaken to dissect around the base of the polyp, extending superiorly in an elliptical fashion. The vaginal polyp and hypertrophic tissue adjacent and superior to it were dissected from the vaginal epithelium with Metzenbaum scissors. Haemostasis was secured with cautery and the vaginal epithelium was reapproximated using running 2–0-Vicryl. The small perineal defect was repaired horizontally to prevent stenosis.

Outcome and follow-up

Final pathology was consistent with a benign appearing vaginal fibroepithelial polyp measuring 5.5×4.8 × 1.2 cm with no discrete lesion or mass identified. At postoperative visits in 1 and 6 weeks, she was recovering well with resolution of the polyp, good approximation and elasticity of the tissue and no evidence of stenosis (figure 1B).