Fibroepithelial Polyp of the Vagina in Pregnancy: A Case Report

Abstract

Fibroepithelial polyps of the Vagina (FEPV) are mucosal polypoid lesions with a connective tissue core covered by a benign squamous epithelium. They are thought to be rare as only a few cases are reported in the literature. Fibroepithelial stromal polyps are mesenchymal neoplasms that can occur in the vagina, vulva, and even on the cervix. These fibroepithelial stromal polyps have also been reported in rare sites such as breast and labia.

Case Report

A 36-year-old unbooked G5P₄⁺⁰ (4 alive) who was unsure of her last menstrual period (LMP), however, she had a first-trimester pelvic ultrasound scan which put her estimated gestational age (EGA) on the day of presentation at 33 weeks, 2 days. She was apparently well until 6 months prior to presentation when she noticed a protrusion from the vagina associated with a dragging sensation, per vaginal bleeding and initially difficulty in achieving sexual intercourse to a point where she cannot have sexual intercourse again due to the mass. She was referred from another hospital with a provisional diagnosis of a genital prolapse.

On examination, she was well nourished, not in pain, not pale. Her pulse rate was 80 beats per minute, with a blood pressure of 90/60 mm Hg. The abdomen was uniformly enlarged, with no area of tenderness. The symphio-fundal height was 34 cm, with a singleton foetus, whose lie was longitudinal and presentation was cephalic. The foetal heart rate was 140 beats per minute and it was regular.

On vaginal examination, there was an oval-shaped mass that was protruding from the vagina. The mass was arising from the right lateral vagina wall, between 6 and 11 o’clock position. It had a necrotic surface, and a broad base, It measured 13 × 9 × 6 cm and also had a pedicle. The cervix looked healthy. It was clinically diagnosed to be a fibroepithelial stromal polyp of the vagina in pregnancy with a necrotic surface, to rule out vaginal fibroid and vagina endometrial stromal sarcoma. Due to the necrotic surface of the vagina and the dragging sensation that it was producing, she was admitted to the ward. The following investigations were done for her: full blood count, serum electrolyte, urea and creatinine, and a swab of the necrotic surface of the mass for microscopy culture and sensitivity. All results were within normal limits and the culture yielded no bacteria growth after 48 h of incubation. Two pints of whole blood were grouped and cross-matched and made available for her. She received twice daily dressing of the necrotic surface of the fibroepithelial polyp of the vagina using normal saline and povidone–iodine solution. She also had a 48-h course of intravenous Amoxicillin clavulanic acid 1.2 g 12 hourly and intravenous metronidazole, infusion of 500 mg 8 hourly. These measures were to control the infected surface of the FEPV. She was counselled, a written consent was obtained and she had an excision of the FEPV in theatre, under regional anaesthesia. Intraoperatively, the mass was arising from the right lateral vagina wall, between 6 and 11 o’clock position with a base. An incision was made circumferentially around the mass, close to the base. With gentle blunt and sharp dissection the vaginal mass was separated from the mucosa. The defect was repaired and haemostasis was secured. She was discharged home 48 h after the surgery and was counselled to book for antennal care in our hospital with the aim of a spontaneous labour and spontaneous vaginal delivery. However, she never represented to our facility but a telephone call placed across to her after about 5 weeks revealed that she had an unsupervised spontaneous vaginal delivery at home. The histopathology result was as follows: it revealed an oval-shaped skin tissue with a protruding solid mass that measured 13 × 9 × 6 cm and weighed 400 g. Transection revealed a solid whitish surface (PE × 7) [Figure 1]. Histological sections from the vaginal mass showed an acanthotic overlying squamous epithelium covering over a stroma that is loose and hypercellular in the areas. The hypercellular areas are composed of stellate stromal cells while the loose areas resembled granulation-like tissue. No Malignancy is seen. The histopathological diagnosis was fibroepithelial polyp [Figure 2a–c]

Figure 1.

The fibroid epithelial polyp of the vagina before its excision

Figure 2.

(a–c) microphotographs of FEPV

Discussion

Fibroepithelial polyps of the vagina (FEPV) are mucosal polypoid lesions with a connective tissue core covered by a benign mucous epithelium.[1] FEPVs are said to be rare as only a few cases are reported in the literature.[2]

The exact aetiology of FEPV has not yet been established. There are, however, suggestions that FEPV may arise as a result of granulation tissue reaction after local injury of the vaginal mucosa. When there is a delay in the differentiation of myofibroblastic stromal cells, granulation tissue may not contract well and rather turn into polyp.[1] The hormones that are liberated during pregnancy may modulate the growth of FEPV. After examination with immunohisto chemistry, it was established that FEPV expressed Vimentin, desmin, and receptors for oestrogen and progesterone which indicates the hormone-dependent nature of these polyp.[3] Our patient did not report a history of previous local injury to the vagina mucosa, but being a multipara, it is possible that she may have sustained a local injury to the vagina during one of her previous deliveries, moreso that she has been having unsupervised home deliveries. These lesions may become larger, and oedematous and may have an abnormal appearance in pregnancy.[4,5] In our patient the lesion became quite big, as it measured 13 × 9 × 6 cm and weighed 400 g. It also became oedematous and infected with a necrotic surface, because it was hanging outside the vagina [Figure 1]. Fibroepithelial polyps have been reported to occur more in women who are on hormone replacement therapy (HRT) or who are receiving treatment with tamoxifen. FEPVs are known to regress after delivery.[3] Our patient was not on tamoxifen, except that she was pregnant.

In most cases of vaginal tumours, they are asymptomatic until they attain a significant size. Pressure sensation, dyspareunia, vaginal or urethral obstruction, and vaginal bleeding may be among the symptoms and signs.[6] FEPV may also manifest as one or more painless polyps. Other symptoms that may be related to FEPV are vaginal discharge and discomfort, these are mainly related to the size of the mass.[4,7,8] Our patient presented with a protrusion of a mass in the vagina of 6 months duration, pressure sensation and dyspaurenia that led to a cessation of coital activity. The differential diagnosis of FEPV include sarcoma botryoides, rhabdomyosarcoma, and mixed mesodermal tumour.[9]

The treatment of FEPV is simple local excision, and its recurrence is uncommon. Due to the high vascularity of FEPV in pregnancy, it is advised that surgery be performed after pregnancy when vascularity has returned to normal.[10,11] We chose to excise this FEPV during her pregnancy after the local infection was controlled because it had prolapsed outside the vagina, was quite huge, was making her to have a dragging sensation, its surface was necrotic, was causing dyspareunia which led to a temporary cessation of coitus and was making her ability to walk difficult.

After excision of the Polyp, it was sent for histopathological analysis. In terms of microscopy, fibroepithelial stromal polyp consists of three components, including a central fibrovascular core, stroma with pedunculated or polypoid proliferation and an overlying squamous epithelium. The stromal cells generally range from spindle to stellate-shaped cells, some are multinucleated, but generally, they have bland nuclear features. The distribution of those cells is usually variable but characteristic. The stellate and multinucleated forms tend to aggregate along the stromal-epithelial function and around the blood vessels of the central fibrovascular core. The squamous epithelium lying on the stromal proliferation is normal to hyperplastic. The stromal cells of a fibroepithelial stromal polyp invariably react to desmin, oestrogen receptors, progesterone receptors, and occasionally smooth muscle actins.[12] In our patient, the histological analysis revealed “an acanthotic overlying squamous epithelium covering over a stroma that is loose and hypercellular in the areas. The hypercellular areas are composed of stellate stroma cells while the loose areas resemble granulation-like tissue. No malignancy is seen. Thus a histological diagnosis of fibroepithelial polyp was made.

Conclusion

By way of definition, FEPV is a mucosal polypoid lesion with a connective tissue core covered by a benign squamous epithelium. We described a rare case of FEPV in pregnancy in a 36-year-old unbooked G₅P₄⁺⁰ (4 alive), whose pregnancy was at 33 weeks, 2 days gestational age. She had excision of the FEPV in pregnancy. She had an uneventful post-operative recovery with no complications, which implies that surgery is the most effective modality for managing FEPV. She was, however, lost to follow-up. But a telephone call put across to her revealed that she had an uneventful but unsupervised spontaneous vaginal delivery at home.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.