Spontaneous expulsion of a large vaginal mass – a case of complete ejection of a detached fibroma in statu nascendi

Objective: Pedunculated fibroids are a subtype of submucousal fibroids, that can prolapse into the cervical canal and vagina while remaining attached to the uterine cavity by a pedicle. This condition is known as fibroma in statu nascendi and its exact prevalence is unknown. As the most frequently presented symptoms are abnormal vaginal bleeding/discharge and lower abdominal pain, a complete release of the pedicle leading to spontaneous expulsion of an isolated fibroid is a rarity. Methods: A case report describing a complete, spontaneous release of a pedunculated fibroid measuring 8x5 cm. Results: A 63-year-old woman with no gynecological history was referred by her general practitioner after spontaneous expulsion of a large vaginal mass, which measured 8x5 cm. She had no vaginal bleeding since menopause and she had experienced a few days of whitish discharge and a sensation of something filling the vagina before the mass was expelled. Gynecological examination revealed a normal-appearing vagina and transvaginal ultrasound showed a thin endometrial echo. Histo-pathological diagnosis confirmed the suspicion of fibroma in statu nascendi. Conclusion: Prolapsed submucousal fibroids are a well-known condition, that frequently presents as abnormal vaginal bleeding/discharge and lower abdominal pain. Total, spontaneous detachment of the fibroid is rare. The diagnosis is typically evident; however, differential diagnoses, such as endometrial polyps and sarcomas, must be considered and clarified via histopathological evaluation.


INTRODUCTION
terine leiomyomas or fibroids are benign tumors originating from myometrial cells and are the most common pelvic tumor in women (1).A subtype of the submucosal fibroids is the pedunculated type that can prolapse into the cervical canal and extrude into the vagina while remaining attached to the uterine cavity by the pedicle (2).This condition is known as fibroma in statu nascendi, and its exact prevalence is unknown (3).In women with fibroids requiring surgery, the relative rate was found to be 2.5-3.8%(2,4).Complete release of the pedicle leading to an isolated fibroid in the vagina is rare and we here present a such case of a complete, spontaneous expulsion of a large fibroma in statu nascendi.

CASE
63-year-old woman with no gynecological history was referred to our clinic by her general practitioner after spontaneous expulsion of a vaginal mass during initiation of the gynecological examination.She had no vaginal bleeding since meno-pause at 50 years old and no prior gynecological complaints.She had experienced a few days of whitish discharge and a sensation of something filling the vagina.The gynecological examination revealed a normal-appearing vulva and vagina, except for slightly reddish vaginal discharge from where a swab culture was obtained.Cervical cytology and endometrial vabrasio were performed and transvaginal ultrasound revealed a thin endometrial echo at 4 mm with a fibroid in the anterior uterine wall measuring 4 x 4.5 cm (figure 1).The patient brought in the expelled mass, which measured 8 x 5 cm (figure 2).Cervical cytology and endometrial vabrasio were normal, swab culture was negative, and histopathological diagnosis confirmed the suspicion of fibroma in statu nascendi.
The patient provided written consent for this case report to be published.

DISCUSSION
his case report describes a complete, spontaneous release of a large, prolapsed submucosal fibroid in a postmenopausal woman with no symptoms until a few days prior to presentation.This rare condition is reflected by the sparse literature on the topic.Most studies cover the presentation and surgical management of prolapsed submucosal fibroids that are attached to the uterine cavity by a pedicle.These fibroids are classified as type 0 submucosal leiomyomas (5) according to the FIGO subclassification system of leiomyomas (6).
Due to compromise of the blood supply as the pedicle stretches, fibroids often become necrotic or infected (7).The most frequently presented symptoms are abnormal vaginal bleeding (74-88%), lower abdominal pain as the fibroid dilates and passes through the cervical canal (19-65%), abnormal vaginal discharge (44-59%), anemia (42.8-57%) and the "sensation of something filling the vagina" (19%) (2-4, 7, 8).One case reported acute urinary retention due to urethral compression by the fibroid (7).The patient in our clinic presented monosymptomatically with abnormal vaginal discharge without infection.Transvaginal ultrasound revealed a normal-appearing cavity, and the patient went home from our outpatient clinic the same day.

Figure 1 .
Figure 1.Transvaginal ultrasound revealed a thin endometrial echo at 4 mm with a fibroid in the anterior uterine wall measuring 4 x 4.5 cm (arrow)

Figure 2 .
Figure 2. The expelled vaginal mass measuring 8x5 cm.Histopathological evaluation confirmed the suspicion of fibroma in statu nascendi