Paraurethral leiomyomas are benign tumors of mesenchymal origin [2]. The etiology is unknown [3] but the majority of reported cases in reproductive age women explains the hormonal role in its development [4]. Paraurethral leiomyoma affects both genders but has a female preponderance [4] and usual age of presentation is around 40 to 44 years [3]. Patients present with variable symptoms of pelvic pressure, urinary retention, protruding mass, voiding dysfunction lower urinary tract symptoms or vaginal bleeding. [5, 6]. The differential diagnosis of mass in this area can be urethral leiomyoma, urethral prolapse, urethral caruncle, urethral diverticulum, Bartholin’s duct cyst, Skene’s duct abscess, Gartner’s duct cyst and urethral carcinoma [1]. No malignant transformation and very low risk of recurrence of this entity has been reported. To date, only four patients have developed recurrence [7]. Paraurethral leiomyomas are often mobile while urethral leiomyomas are fixed as seen in our case.
Detailed history and careful clinical examination are significant in diagnosis and evaluation of this case [6]. Radiological imaging techniques like USG, CT scan and pelvic MRI help in exact location and origin of mass and relationship with nearby structures which is essential for surgical planning. Transvaginal, transperineal, translabial USG has a role, which will show well-defined isoechoic or hypoechoic homogeneous mass and inner vascularity on color flow Doppler. MRI will show leiomyoma as homogeneous well-encapsulated mass appearing hypointense or isointense on T1-weighted images and intermediate signal on T2-weighted images [7].
Local surgical excision via transvaginal route has been recommended as the mode of management [4, 6, 8]. For larger paraurethral leiomyomas, abdominoperineal approach may be necessary. Histopathology is the gold standard for diagnosis which shows interlacing fascicles of spindle-shaped smooth muscle cells with oval nuclei and eosinophilic cytoplasm under hematoxylin and eosin stain [9]. Immunohistochemistry is positive for desmin and smooth muscle cell antigen [10].
The patient in our case presented at the age of 48 years with a palpable mass at the vaginal introitus and voiding difficulties which is similar to the symptoms reported in previous case reports [5, 6, 8]. After preoperative evaluation, the mass was surgically excised through transvaginal route. Symptoms were resolved and postoperative recovery was uneventful.