Recurrent and rapidly growing vaginal wall leiomyoma during pregnancy: a case description

Introduction

Vaginal leiomyoma is a rare smooth muscle tumor that typically develops in the anterior wall but can also occur in the lateral and posterior walls, although much less frequently (1). To date, approximately 300 cases of vaginal leiomyoma have been reported since Denys de Leyden documented the first case in 1733 (2,3). Leiomyoma of the vaginal wall during pregnancy is exceptionally uncommon, with only approximately 10 cases being reported thus far (4,5). The clinical manifestations are not specific and can include asymptomatic presentation, a prolapsed vaginal mass, vaginal bleeding, and urinary obstruction, among others.

Given the rarity of this condition and its nonspecific clinical presentation, diagnosis and treatment can be challenging. There is also a lack of evidence to guide diagnosis, treatment, and prognosis for vaginal leiomyoma during pregnancy. In this case report, we present a rare occurrence of a recurrent vaginal leiomyoma that had previously been treated with transvaginal vaginal leiomyoma excision 10 years prior. Subsequently, during this pregnancy, the tumor rapidly increased in size, posing a unique medical challenge. We also conducted a literature analysis, in the hope that our treatment experience, combined with insights from the literature, can provide valuable guidance for managing this rare pregnancy-associated condition.

Case presentation

A 32-year-old pregnant woman was admitted to West China Second University Hospital due to a vaginal mass. The patient had a resection of a vaginal mass 10 years previously, which was pathologically diagnosed as a highly cellular leiomyoma. She had no recurrence during the 10 years of follow-up. Fourteen weeks previously, she became pregnant and noticed a gradually developing mass on the same side of the vagina. Physical examination revealed a mass measuring 6 cm × 6 cm × 5 cm in size at the vaginal orifice, originating from the left vaginal wall (Figure 1A,1B). Ultrasound imaging suggested an intrauterine pregnancy and a vaginal mass approximately 5 cm in size (Figure 2A,2B). There was no leiomyoma in the uterus. Surgical intervention was indicated due to a progressively growing vaginal mass of undetermined nature during pregnancy, which was obstructing the vaginal orifice, potentially impeding the birth canal and affecting labor progression. A resection of the vaginal mass was performed under general anesthesia. The mass was located beneath the left vaginal mucosa near the orifice, with a clear boundary suggestive of a leiomyoma. The procedure began with an incision in the vaginal mucosa (Figure 3A). Scissors were then used to carefully separate the mass from the vaginal wall (Figure 3B). An ultrasound knife was employed to cut the vessels supplying the mass. (Figure 3C,3D). The mass was completely resected, and the wound surface showed no obvious bleeding (Figure 3E). Finally, the vaginal mucosa was sutured with absorbable stitches (Figure 3F). The appearance of the vaginal area returned to normal (Figure 4A), and the mass had a smooth surface resembling a leiomyoma (Figure 4B,4C). Pathological results confirmed the diagnosis of leiomyoma with degeneration. After the operation, the patient recovered well and showed no signs of impending abortion. She successfully gave birth to a healthy baby girl vaginally at 38+4 gestational weeks. The patient showed no signs of recurrence during the 24-month follow-up period. A detailed timeline outlining the patient’s clinical course is presented in Figure 5. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s), and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 A vaginal mass located on the left vaginal wall, positioned beneath the mucosa near the vaginal orifice (A,B).

Figure 2 Ultrasound imaging indicated a vaginal mass measuring approximately 5 cm (A) and an intrauterine pregnancy (B).

Figure 3 The steps of the operation. (A) The procedure began with an incision in the vaginal mucosa. (B) Scissors were used to carefully separate the mass from the vaginal wall. (C,D) An ultrasound knife was employed to cut the vessels supplying the mass. (E) The mass was completely resected, and the wound surface showed no obvious bleeding. (F) The vaginal mucosa was sutured with absorbable stitches.

Figure 4 The appearance of the wound after the operation (A) and the size of the mass (B,C).

Figure 5 A timeline summarizing the patient’s clinical course.

Discussion

Vaginal leiomyoma is a nonmalignant tumor that originates from smooth muscle cells located in the vasculature, embryonic tissue, or other smooth muscle tissues within the vagina, rectum, bladder, or urethra (6-8). Due to their rarity, there is currently no standardized diagnostic or treatment protocol for this condition.

Clinical implications

The incidence of vaginal leiomyoma tends to be highest in women of reproductive age, specifically those 40–44 years old (9). The clinical symptoms of vaginal leiomyoma vary depending on the location and size of the tumor (7,10). In the majority of cases, vaginal leiomyoma is revealed as a mass on the vaginal wall via incidental examination. When a vaginal leiomyoma is located on the anterior vaginal wall, the most common site, dysuria may occur. If the tumor grows too large, it can protrude from the vaginal wall and obstruct the vagina, causing dyspareunia during nonpregnancy periods and potentially impacting delivery during pregnancy. Additionally, in some cases, patients may experience pain, which can be compounded by infection. The diagnostic imaging methods employed in our case were ultrasound and magnetic resonance imaging. Imaging examinations generally only provide information on the location, size, and relationship with surrounding tissues. Determining the specific pathological type still requires postoperative pathological examination, and preoperative differential diagnosis with other diseases such as pelvic organ prolapse, cystocele, and vaginal cysts, is also necessary (4). The patient in our case had undergone a resection surgery for vaginal leiomyoma 10 years earlier; however, no leiomyoma was detected before the onset of her pregnancy. During pregnancy, the leiomyoma grew rapidly and ultimately resulted in blockage of the vaginal canal. Given the distinct medical history, our diagnosis was heavily dependent on the patient’s medical background, history, and the appearance of the mass, both of which indicated a strong possibility of vaginal leiomyoma.

Review of the literature

In the management of vaginal leiomyoma, complete vaginal resection through dissection and identification of the pseudocapsule can lead to a significantly low recurrence rate during a nonpregnancy period (11). We conducted a systematic review of published literature on vaginal leiomyoma. The inclusion criteria included (I) English-language publications; (II) original reports of vaginal leiomyoma cases; and (III) availability of clinical management details. A comprehensive systematic literature search was performed. PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), and Clinical Trials.gov were searched from database inception to December 1, 2024. The reference lists of the published reviews and retrieved articles were checked for additional sources. The search terms were as follows: “leiomyomas”, “fibroid”, “fibroid tumor”, “uterine fibroid”, “uterine fibroma”, and “vaginal”. Thus far, only six cases of vaginal leiomyoma have been managed through vaginal resection during pregnancy (4,5,12-14) (Table 1). In another case, cesarean section was performed with removal of the vaginal leiomyoma through vaginal incision 3 weeks postpartum (15). Only two cases have been reported in which the vaginal leiomyoma recurred and rapidly enlarged during pregnancy, suggesting a possible hormonal association (12,14). The details of these cases were in line with those of our patient. There was no recurrence after surgery, and the vaginal leiomyoma grew rapidly during pregnancy. Rywlin et al. suggested that the characteristics of uterine leiomyoma recurrence during pregnancy, as well as the histological changes observed in uterine leiomyoma associated with pregnancy, indicate a hormone-related mechanism (14). Leiomyomas often exhibit changes in size and cellular structure during pregnancy due to the fluctuations in hormone levels. These hormones can stimulate the growth of leiomyoma, leading to enlargement during pregnancy, or in some cases, regression after delivery. Molecular factors may be involved in the development of myomas; for instance, there may be a relationship between phosphorylation and leiomyoma progression (16). However, their involvement in the growth of myomas during pregnancy remains unclear due to the rarity of the related cases, and thus, further research is needed. Based on our analysis, performing vaginal resection of leiomyoma during pregnancy is safe, and delaying the surgery can lead to unnecessary indications for cesarean section during delivery and potentially serious consequences such as uterine rupture.

Surgical management

With the advancement of surgical instruments and techniques, our team has gained valuable insights into surgeries for vaginal leiomyoma in pregnant patients. First, the case presented here was a recurrent vaginal leiomyoma, for which we advocate a clear definition of the surgical boundaries, with the use of energy-generating tools such as an ultrasound scalpel to effectively reduce intraoperative bleeding. Second, we approach the surgical wound closure meticulously to minimize the occurrence of hematoma and infections caused due to incomplete closure. Finally, in order to minimize the requirement for suture removal and simplify postoperative care, we advise absorbable suturing whenever possible. Our experience with these surgical techniques has resulted in favorable outcomes. However, continued research and studies are required to improve these techniques for optimal outcomes in such cases.

Conclusions

Vaginal leiomyoma resection during pregnancy is safe, with key surgical measures including clearly defining the surgical boundaries, using energy-generating surgical instruments to reduce intraoperative bleeding, and ensuring successful closure of the surgical wound to minimize postoperative complications such as bleeding and infection. Overall, performing vaginal resection for leiomyoma during pregnancy is a viable option with favorable outcomes if the aforementioned surgical principles are attentively observed.

Acknowledgments

None.

Footnote

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-678/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s), and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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