Figure 1
Ultrasound of pelvis shows a well-defined hypoechoic lesion in the vaginal region indenting upon the anterior cervical lip.
Vaginal leiomyoma - A common tumour at an uncommon location
SectionGenital (female) imaging
Case TypeClinical Cases
Authors
Archita Goel, MD; Bhavana N, DNB; Prashanth R, MD; Sanjaya V, MD
Connected authors
42 years, female
Clinical History
A 42-year-old lady (P1 L1) presented with 3-year history of menorrhagia and dysmenorrhoea and 4-year history of mass per vagina. On pelvic examination, the uterus was enlarged (corresponding to 10-12 weeks pregnant uterus) and deviated towards left. The cervix was normal. A smooth, firm and non- tender mass was seen in the vagina. A provisional diagnosis of vaginal cyst was made.
Imaging Findings
Ultrasound of the pelvis (Fig. 1), revealed a large well-defined hypoechoic mass lesion in the vagina, causing indentation on the anterior lip of cervix. Two other large heterogeneously hypoechoic lesions were noted in the anterior uterine myometrium (with submucosal extension) and the fundal myometrium consistent with uterine leiomyomas. MRI of the pelvis revealed a well-defined round lesion measuring 58 x 43 x 62 mm in the introitus with a beak-like projection into the tissue plane between the urethra and the anterior vaginal wall. The lesion was isointense on T1-weighted images (Fig. 2a), heterogeneously hyperintense on T2-weighted images (Fig. 2b) (compared to skeletal muscle) with no restricted diffusion. The urethra was displaced anteriorly and to the left (Fig. 2c). Cervix was visualised separately from the lesion (Fig. 2d). After intravenous injection of gadolinium, the lesion revealed heterogenous progressive enhancement in the venous and delayed phases (Fig. 2e). Multiple intramural uterine leiomyomas were noted. Bilateral ovaries were normal.
Discussion
Background
Leiomyomas are the most common benign uterine neoplasm and are composed of smooth muscle with varying amounts of fibrous connective tissue [1]. Extrauterine leiomyomas are rare and present a diagnostic challenge. They usually originate from smooth muscle cells of the genitourinary tract but may arise in nearly any anatomic site [2]. Vaginal leiomyomas usually arise in the midline anterior wall and vary in size between 1 and 5 cm [3]. Vaginal leiomyomas most commonly affect women between 35–50 years of age [4].
Clinical Perspective
Vaginal leiomyomas can cause urinary tract symptoms, such as frequency, urgency, dysuria, urinary retention, and bladder neck obstruction [3]. MRI can depict morphology and correct location of the leiomyoma which will help clinicians identify them and decide management approach before surgery with a certain amount of accuracy [4].
Imaging Perspective
Leiomyomas are typically round, well-circumscribed whorl appearing masses, with low-signal intensity on T1WI, a variable signal on T2WI, and show homogenous post-gadolinium enhancement. Hyaline degeneration and calcification contribute to low-signal, and cystic or myxoid degeneration contribute to high T2-signal within the leiomyoma [4].
Outcome
Surgical resection is therapeutic [4]. MRI helps in making the diagnosis, defining perineal anatomy, location of tumour and relation of the tumour with other surrounding structures. Our patient’s tumour was excised in toto.
Take Home Message / Teaching Points
MRI characteristics help in identifying vaginal leiomyomas before surgery so that the surgeon and patient have a reasonable expectation of pathological diagnosis.
Written informed patient consent for publication has been obtained.
Differential Diagnosis List
Vaginal leiomyoma
Paraurethral leiomyoma
Skene gland cyst
Vaginal malignancy
Leiomyosarcoma
Final Diagnosis
Vaginal leiomyoma
References
[1] Eiko Murase, Evan S. Siegelman, Eric K. Outwater, Liza A. Perez-Jaffe, Richard W. Tureck. Uterine Leiomyomas: Histopathologic Features, MR Imaging Findings, Differential Diagnosis, and Treatment. Sep 1 1999 (PMID: 29261455)
[2] Najla Fasih, Alampady K. Prasad Shanbhogue, David B. Macdonald, Margaret A. Fraser- Hill, Demetrios Papadatos, Ania Z. Kielar, Geoffrey P. Doherty, Cynthia Walsh, Matthew McInnes, Mostafa Atri, Leiomyomas beyond the Uterus: Unusual Locations, Rare Manifestations Radiographics. Nov 1 2008 (PMID: 29261455)
[3] Ken Shimada, Isamu Ohashi, Hitoshi Shibuya, Fumiko Tanabe and Takumi Akashi, MR Imaging of an Atypical Vaginal Leiomyoma American Journal of Roentgenology. 2002;178: 752-754. 10.2214/ajr.178.3.1780752 (PMID: 11856713)
[4] Katherine C. Hubert, Erick M. Remer, Raymond R. Rackley, Howard B. Goldman, Clinical and magnetic resonance imaging characteristics of vaginal and paraurethral leiomyomas: can they be diagnosed before surgery? BJUI 24 (PMID: 19889060)
Case information
| URL: | https://www.eurorad.org/case/16621 |
| DOI: | 10.35100/eurorad/case.16621 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Multiplanar MRI shows a well-circumscribed, round lesion in introitus, hypointense on T1FS axial image (Fig. 2a), heterogeneously hyperintense on T2WI (Fig. 2b), with urethra displaced anteriorly and in left lateral aspect (Fig. 2c). Cervix is visualised separately from the lesion (Fig. 2d). On post-contrast study, the lesion shows heterogeneous enhancement (Fig. 2e).
Multiplanar MRI shows a well-circumscribed, round lesion in introitus, hypointense on T1FS axial image (Fig. 2a), heterogeneously hyperintense on T2WI (Fig. 2b), with urethra displaced anteriorly and in left lateral aspect (Fig. 2c). Cervix is visualised separately from the lesion (Fig. 2d). On post-contrast study, the lesion shows heterogeneous enhancement (Fig. 2e).
Multiplanar MRI shows a well-circumscribed, round lesion in introitus, hypointense on T1FS axial image (Fig. 2a), heterogeneously hyperintense on T2WI (Fig. 2b), with urethra displaced anteriorly and in left lateral aspect (Fig. 2c). Cervix is visualised separately from the lesion (Fig. 2d). On post-contrast study, the lesion shows heterogeneous enhancement (Fig. 2e).
Multiplanar MRI shows a well-circumscribed, round lesion in introitus, hypointense on T1FS axial image (Fig. 2a), heterogeneously hyperintense on T2WI (Fig. 2b), with urethra displaced anteriorly and in left lateral aspect (Fig. 2c). Cervix is visualised separately from the lesion (Fig. 2d). On post-contrast study, the lesion shows heterogeneous enhancement (Fig. 2e).
Multiplanar MRI shows a well-circumscribed, round lesion in introitus, hypointense on T1FS axial image (Fig. 2a), heterogeneously hyperintense on T2WI (Fig. 2b), with urethra displaced anteriorly and in left lateral aspect (Fig. 2c). Cervix is visualised separately from the lesion (Fig. 2d). On post-contrast study, the lesion shows heterogeneous enhancement (Fig. 2e).
Ultrasound of pelvis shows a well-defined hypoechoic lesion in the vaginal region indenting upon the anterior cervical lip.
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019
Multiplanar MRI shows a well-circumscribed, round lesion in introitus, hypointense on T1FS axial image (Fig. 2a), heterogeneously hyperintense on T2WI (Fig. 2b), with urethra displaced anteriorly and in left lateral aspect (Fig. 2c). Cervix is visualised separately from the lesion (Fig. 2d). On post-contrast study, the lesion shows heterogeneous enhancement (Fig. 2e).
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019
Multiplanar MRI shows a well-circumscribed, round lesion in introitus, hypointense on T1FS axial image (Fig. 2a), heterogeneously hyperintense on T2WI (Fig. 2b), with urethra displaced anteriorly and in left lateral aspect (Fig. 2c). Cervix is visualised separately from the lesion (Fig. 2d). On post-contrast study, the lesion shows heterogeneous enhancement (Fig. 2e).
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019
Multiplanar MRI shows a well-circumscribed, round lesion in introitus, hypointense on T1FS axial image (Fig. 2a), heterogeneously hyperintense on T2WI (Fig. 2b), with urethra displaced anteriorly and in left lateral aspect (Fig. 2c). Cervix is visualised separately from the lesion (Fig. 2d). On post-contrast study, the lesion shows heterogeneous enhancement (Fig. 2e).
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019
Multiplanar MRI shows a well-circumscribed, round lesion in introitus, hypointense on T1FS axial image (Fig. 2a), heterogeneously hyperintense on T2WI (Fig. 2b), with urethra displaced anteriorly and in left lateral aspect (Fig. 2c). Cervix is visualised separately from the lesion (Fig. 2d). On post-contrast study, the lesion shows heterogeneous enhancement (Fig. 2e).
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019
Multiplanar MRI shows a well-circumscribed, round lesion in introitus, hypointense on T1FS axial image (Fig. 2a), heterogeneously hyperintense on T2WI (Fig. 2b), with urethra displaced anteriorly and in left lateral aspect (Fig. 2c). Cervix is visualised separately from the lesion (Fig. 2d). On post-contrast study, the lesion shows heterogeneous enhancement (Fig. 2e).
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019
© Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, India, 2019