Case Report Giant Leiomyomatous of in a Young Unmarried Girl To cite: Pati B, Makhija A, Upreti P, Paul S, Agarwal P. 1 2 3 4 Giant Leiomyomatous Polyp of Banishree Pati, Amrita Makhija, Purnima Upreti, Sayanti Paul, Cervix in a Young Unmarried 5Pooja Agarwal Girl. Pan Asian J Obs Gyn 2021;4(1):43-46. 2,4Assistant Professor, 1,3Associate Professor, 5Jr. Resident Received on: 1-5Department of Obstetrics and Gynecology, Himalayan Institute of Medical Sciences, 08-09-2020 Dehradun, Uttarakhand, India Accepted on: 11-01-2021

ABSTRACT Cervical leiomyomas account for 1 to 2% of all uterine fibroids. Fibroids, commonly present in the reproductive age group women, are rare in the early decades of life. The evaluation and classification of abnormal uterine bleeding (AUB) has been standardized by FIGO. This standard is useful in parous women, but its utility is unclear about AUB in young unmarried population. Here, the authors present a case of a young, unmarried patient with AUB and a large fibroid polyp arising from the anterior aspect of the endocervix. The case is reported due to its rarity and the diagnostic and management difficulties associated with it. Keywords: Giant cervical polyp, cervical fibroid, leiomyomatous polyp, endocervical polyp, vaginal myomectomy.

INTRODUCTION for 6 months and since 2 months. She had at 13 years of age and her Cervical leiomyoma is a benign tumor of the smooth previous menstrual cycles were regular with average muscles of the cervix and accounts for 1 to 2% of all flow. However, for the last few months, her menstrual uterine fibroids. Heavy menstrual bleeding, varying cycles, although, occurring at regular intervals, were degrees of pressure symptoms, abnormal vaginal progressively becoming heavy with flow lasting 6-7 discharge and mass per vaginum are common days. She also reported passage of large clots. There presenting symptoms. Cases of fibroid are mostly was no . She informed about infrequent seen in reproductive age women and are rare in the early sexually activity and use of barrier contraceptive. decades of life. International Federation of She had never used hormonal therapy and had no and Obstetrics ( FIGO) in 2011, described a uniform and significant medical or surgical history. standardized method of evaluation and classification Her pulse rate was 108 beats per minute and the of abnormal uterine bleeding (AUB). This standard is body mass index was 23.8 kg/m2. The general physical very useful in parous women, but it is unclear about examination revealed severe pallor. The systemic AUB in young unmarried population. Here, the authors and abdominal examination was unremarkable. Due present a case of a young, unmarried patient with a to her unmarried status, the patient denied pelvic large fibroid polyp arising from the anterior aspect of examination in favor of radiological evaluation of the the endocervix. The diagnosis and management were pelvic organs. challenging because of her younger age, unmarried status and rarity of the condition.

Address for Correspondence CASE REPORT Amrita Makhija Assistant Professor A 21-year-old nulligravida, unmarried lady presented Department of Obstetrics and Gynecology Himalayan Institute of Medical Sciences in the gynecology out-patient department with the Dehradun, Uttarakhand, India complaints of foul-smelling discharge per vaginum [email protected]

Pan Asian Journal of Obstetrics & Gynecology, January-April 2021;4(1):43-46 43 Banishree Pati et al.

Her hemoglobin was 5.23 g/dL. The general blood pre-anesthetic clearance, the patient was planned picture showed severe microcytic hypochromic for polypectomy by vaginal route. Under general anemia. Serum beta-human chorionic gonadotropin anesthesia, the patient was re-examined. The mass hormone was not raised. Routine biochemical and was a sessile polyp arising from the anterior aspect of urine examination were unremarkable. The ultrasound the endocervix (Fig. 2A). It was held with vulsellum and examination of the abdomen and pelvis revealed a well traction applied to reach for its base. However, the base defined mass of 10 cm size in the . could not be visualized. Difficulty was encountered due With the consent of the patient, speculum to the large size and sessile nature of the polyp, origin examination was done. It revealed a grayish-white, from the anterior lip of cervix and due to the narrow fleshy mass in the vagina. The mass was well defined, vagina. Thus, the polyp was planned to be removed globular and bled on touch. It showed no change piecemeal. However, during manipulation for the same, with Valsalva maneuver. The vagina was normal. The the polyp started giving way and with some effort, it was cervical lips were not visualized. Bimanual examination removed in its entirety (Fig. 2B). The base of the polyp revealed the smooth and firm mass occupying the was cauterized to achieve hemostasis and to prevent whole of the vagina. The cervical lips were felt around recurrence. the mass higher up. However, the pedicle or the site of The patient made an uneventful recovery and was origin could not be made out. The uterus was normal in discharged on the second postoperative day. The size and both the fornices were free. Rectal examination histopathological examination findings were typical was unremarkable. of leiomyoma with presence of cervical tissue adjacent The patient was referred for a contrast-enhanced computerized tomography scan, which revealed a well-defined, heterogeneously enhancing, soft tissue- density mass measuring 8 × 10 cm, in the cervical region extending into the vaginal canal (Fig. 1). The lesion was causing mass effect on urinary bladder and rectum, but the fat planes were maintained. The uterus and bilateral adnexa were unremarkable. The endometrial thickness was not elevated. There was no lymphadenopathy or any pathology elsewhere in the abdomen. The provisional diagnosis of a benign polypoidal mass arising from the endocervix was made. The patient was transfused 2 units of packed red blood cells. After A

B

Fig. 1: Contrast-enhanced CT scan image (saggital section) Figs. 2A and B: (a) Clinical picture of the cervical fibroid revealing a large cervical fibroid polyp occupying polyp; (b) Specimen after polypectomy

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abdominal mass. Most cases of cervical fibroids are described during pregnancy, causing obstructed labor.2 Cervical fibroids have caused incarcerated procidentia,3 and have been interpreted as chronic uterine inversion or malignant growths. They cause menstrual abnormalities like or heavy menstrual bleeding, which was observed in our patient. Clinical examination in an unmarried woman is difficult in out-patient settings. Investigations of abnormal uterine bleeding in young women are directed towards causes like pelvic inflammatory disease or hormonal issues. Cervical fibroid polyps have not been reported at this age. All previous cases Fig. 3: Histopathological image typical of leiomyoma report them in multiparous women of perimenopausal with adjacent cervical tissue age. Besides, younger age with mass in vagina raises the suspicion of malignancy like rhabdomyosarcoma. Thus, to it (Fig. 3). The patient is followed-up at 6 months arriving at a diagnosis was a challenge. Examination post-surgery and is symptom free with no evidence of under anesthesia should be done wherever diagnostic recurrence. difficulty is anticipated. Advanced imaging modalities like magnetic resonance imaging (MRI) should be DISCUSSION utilized. Role of MRI in diagnosis and treatment Leiomyomas or fibroids are benign smooth muscle of uterine fibroids has been well established. Its tumors of the female genital tract. Smooth muscles in accuracy in diagnosing cervical fibroids has also been the cervical stroma are sparse and thus leiomyomas highlighted.4 In the present case, due to non-availability in the cervix is rare accounting for 1-2% of all fibroids. of MRI, contrast-enhanced computerized tomography Cervical fibroids are usually single, arising mainly from was done. the supravaginal portion. They may be interstitial, Most authors have reported doing hysterectomy subserous or rarely submucous. The submucous straight away or following myomectomy in such cases. fibroids infrequently grow like polyps. Commonly they In our case vaginal myomectomy was done, due to the arise from the posterior lip and ectocervix. However, in young age of the patient. Surgery posed difficulties due literature a case reports a cervical fibroid to be arising to narrow space in the vagina, origin from the anterior from the endocervix and causing complete cervical lip and large and sessile nature of the fibroid polyp. inversion.1 The present case also reports the fibroid Rate of malignant transformation is 1.7%. No polyp to be arising from the endocervix of the anterior recurrences have been documented in literature till cervical lip. now. Most fibroid polyps occupying the vagina are submucous polyps arising in the uterine body. Although CONCLUSION small cervical polyps are the commonest incidental The case is reported due to its rarity and the diagnostic finding on speculum examination, giant cervical polyps and management difficulties associated with it. It is (more than 4 cm in size) are rare and only about 23 imperative to be aware of this rare entity in younger such cases have been reported till date. Most giant population. Thorough preoperative evaluation is cervical polyps are benign mucosal polyps containing needed to avoid misdiagnosis and mismanagement. fibromuscular stroma. Cervical fibroid may lead to pressure symptoms on the bladder or bowel, , postcoital Source of Support bleeding, abnormal , introital or Nil

Pan Asian Journal of Obstetrics & Gynecology, January-April 2021;4(1):43-46 45 Banishree Pati et al.

Conflict of Interest simulating chronic non-puerperal uterine inversion. Int J Surg Case Rep. 2014;5(8):513-5. None to declare. 2. Keriakos R, Maher M. Management of cervical fibroid during the reproductive period. Case Rep Obstet Gynecol. 2013;984030. Financial Disclosure 3. Suneja A, Taneja A, Guleria K, et al. Incarcerated Nil procidentia due to cervical fibroid: an unusual presentation. Aus New Zeal J Obstet Gynaecol. 2003;43(3):252-3. Acknowledgment 4. Gupta A, Gupta P, Manaktala U, et al. Varied Clinical Presentations, the Role of Magnetic Resonance Imaging Nil in the Diagnosis, and Successful Management of Cervical Leiomyomas: A Case-Series and Review of Literature. Cureus. 2018;10(5):2653. REFERENCES 1. Turhan N, Simavli S, Kaygusuz I, et al. Totally inverted cervix due to a huge prolapsed cervical myoma

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