Leiomyoma is a benign mesenchymal tumor; it most commonly occurs in the uterus in woman's genital system [1]. It can be also observed in the locations out of the uterus such as fallopian tubes, cervix, round ligament, vagina and urethra [2] [3]. Vagina is a location in which leiomyoma is rarely encountered, and this location was first defined in 1733 [4]. Vaginal leiomyoma is generally located in the middle line of anterior vaginal wall, and it rarely located on lateral and posterior vaginal wall [5]. In generally, physical examination demonstrates the existence of a mass in the vagina whose average size is under 6 cm and which has non-specific characteristics and soft features [6]. No symptom is detected in most of the patients in the early period. However, patients have (some patients may be have) different symptoms such as dysuria, dyspareunia, and pelvic pain related to the pressure and size of the mass as a result of the growth observed in the mass [4]. Vaginal leiomyoma cannot be diagnosed in clinical examination; therefore, the disorder should be histopathologically diagnosed in order to prevent misdiagnosis of the cases and oversight of the sarcomatous change [4] [6]. Differential diagnosis should be introduced in the patients having vaginal leiomyoma in order not to confuse the disorder with bladder tumor, rabdomyoma, endometriosis, cervical pathologies, melanoma, leiomyosarcoma and uterine prolapsed [4]. In this study, we have analyzed the case of a patient applying to our clinic with the complaint of post-coital bleeding and having had dyspareunia in her history for a year. A mass was found on her posterior vaginal wall during her examination, and she was diagnosed with leiomyoma in excision material.

Figure 1. Macroscopic view of the mass originating in the posterior vaginal wall and filling the vagina.

A 52-year-old woman, para 4, living 4, presented with vaginal bleeding after sexual intercourse. At the examination a mass arising from posterior of the mid-vagina wall was detected (Figure 1). She had a firm, symptomatic, regular-shaped and pedunculated mass. Gynecologic exam revealed a firm, solid, mobile, non-ulcerated, non-fragile and painless mass in a diameter of 4 cm originating from posterior of the mid-vagina wall (Figure 2). The vaginal tissue over the mass was normal. She had normal menstrual cycles until three years ago, and she has been through menopause for three years. There were disparonia symptoms in her medical history for one year. The family history were not remarkable. Her laboratory tests such as hemogram, coagulation and biochemical were normal. The results of pap smear screening was normal and histological evaluation of the endometrium was atrophic endometrium, respectively. The pathological diagnosis of the lesion was a leiomyoma (Figure 3).

Figure 2. Macroscopic view of the excised mass.

Leiomyoma most commonly occurs in the uterus in woman's genital system; it can also be detected in round ligament, uterosacral ligament, ovarian and inguinal canal [4]. The cases of vaginal leiomyomas are rarely seen; there are 300 reported cases of vaginal leiomyoma in the literature [7]. The above-mentioned disorder is generally observed in the patients between the ages of 35 and 50 [8]. In general, the masses are located on the middle line of anterior vaginal wall and their sizes are between 0.5 and 15 cm [4] [9] ; those masses may be found on posterior or lateral vaginal walls in rare cases [10].

Figure 3. Microscopic view of pathological analysis of vaginal leiomyoma. Normal vaginal epithelium and leiomyoma are observed in the same incision. Immunohistochemical staining of this mass by actin (original magnification x 100).

Vaginal leiomyoma is generally asymptomatic; certain complaints may be noted depending on urinary system pressure in patients. Most common urological symptoms are difficulty in urination and dysuria, sensation of pressure of urine. In addition, dyspareunia is the most common gynecological complaint. Vaginal mass may be the only finding in some of the patients. Post-coital bleeding is also a rare symptom [11]. Translabial ultrasound is recommended in the diagnosis of vaginal leiomyoma according to the literature; Magnetic Resonance Imaging (MRI) can also be used for the differentiation of leiomyosacoma and vaginal malignancy [13] [14]. Surgical procedure is generally advised for the treatment of vaginal leiomyoma [15]. The important point is to decide whether to benefit from vaginal procedure or abdominal procedure [16]. Practically, it is recommended that the mass is excised under control through vaginal path;however, serious bleeding may be observed during the excision and it might be impossible to reach the bottom of the mass [17] [18] [19]. In the surgical operation through vaginal path, catheter implantation in urethra makes contribution to the protection of urethra; this measure facilitates the operation [20].

In clinical analysis of vaginal leimyoma, it is recommended that surgical operation should be urgently proceeded subsequent to the diagnosis and based on appropriate approaches since augmentation in the size of the tumor increases the risks of sarcomatous transformation and the progression of symptoms [18]. It may be necessary to combine the abdominal procedure with perineal approach in the large-sized tumors [15]. Histopathological examination is the best standard method in terms of diagnosis in the patients having vaginal leiomyoma [20]. Even though vaginal leiomyomas are generally unique, benign and slowly growing masses, there are certain cases in which sarcomatous growth is reported [18] [21]. Observation rate of sarcomatous growth after leiomyoma is 2-3% for all gynecological malignancies while this rate is noted to be 10% for the masses out of uterus. Sarcomatous growth is more commonly seen in the masses originating from the posterior vaginal wall [22]. Therefore; follow-ups of the patients to whom surgical excision was administered is quite essential since those follow-ups provide us with the information about the type, extension, recurrence and sarcomatous pattern of the tumor [18] [19].

Consequently, vaginal leiomyoma is a rare disorder seen in the woman's genital system in the postmenopausal period; it most frequently causes the complaints of dyspareunia, and it is defined as benign tumoral mass. It can be mostly excised via vaginal surgical procedure. Physicians should pay attention to the benign vaginal masses during the examination of the patients suffering from post-menopausal, post-coital bleedings. Prudent follow-ups of the patients after surgical operations are crucial in terms of sarcomatous growth and recurrence.

No authors have any conflict of interest to declare.