An Elongated Endometrial Polyp Prolapsing Through the Introitus in a Virgin.

The objective of the study is to report on the unusual case of an elongated endometrial polyp prolapsing through the introitus. A nulliparous 38-year-old woman presented to the gynecology department with an abnormal mass prolapsing at the vulva area without any abnormal uterine bleeding. Because she had no history of having engaged in sexual intercourse, a pelvic examination was not performed. Ultrasonography revealed an intrauterine hyperechoic lesion 1.5 cm × 0.8 cm in diameter suspected to be endometrial polyp. A hysteroscopy revealed an elongated endometrial polyp 12 cm × 0.5 cm in length, which originated from the midanterior corpus and extended out of the cervix and introitus. Then, the base of the polyp was cut and removed. The pathological report was consistent with an endometrial polyp. This was an unusual case of an elongated endometrial polyp prolapsing through the introitus in a nulliparous woman. Hysteroscopy is the best tool for diagnosis and management in this case.

INTRODUCTION

Endometrial polyps are abnormal outgrowths of endometrial tissue in the uterine cavity that contain glands, stroma, and blood vessels. The consistency of polyps may be soft and cystic or firm and fibrous. They could also be either sessile or pedunculated, and a patient can suffer from a single polyp or multiple polyps. Polyps vary in size from small to large enough to fill in the entire endometrial cavity.[1]

The underlying causes of endometrial polyps are unknown.[2] However, obesity, late menopause, and tamoxifen use are risk factors that affect polyp development.[1] The prevalence of endometrial polyps is approximately 20%–30%.[3] Endometrial polyps have been detected incidentally by transvaginal sonography in 12% of reproductive women and 6%–11% of infertile women.[4]

The International Federation of Gynecology and Obstetrics (FIGO) classification system documented the association between uterine polyps and abnormal uterine bleeding in reproductive women employing the nomenclature “PALM-COEIN” with the “P” denoting a polyp.[5] The prevalence of endometrial polyps is relatively high in women with any type of abnormal uterine bleeding such as heavy menstrual bleeding, intermenstrual bleeding, and postmenopausal bleeding.[1] These polyps are also associated with infertility.[6]

A previous report documented a giant endometrial polyp (8.5 cm in diameter) occupying the endometrial cavity in an asymptomatic postmenopausal woman.[7] The largest polyp that has documented was 15 cm in diameter and protruded through the cervix.[7] However, before this paper, there has never been a report of an endometrial polyp with an elongated stalk prolapsing through the introitus.

CASE REPORT

A nulliparous 38-year-old woman presented to the gynecology department with an abnormal mass prolapsing at the vulva area without any abnormal uterine bleeding [Figure 1a]. She had undergone laparoscopic myomectomy 1 year previously. Because she had no history of having engaged in sexual intercourse, a pelvic examination was not performed. Ultrasonography revealed an intrauterine hyperechoic lesion 1.5 cm × 0.8 cm. In diameter and three heteroechoic masses at the myometrium suspected to be an endometrial polyp [Figure 2] and leiomyoma. Therefore, the protruding mass was likely to be the endometrial polyp, endocervical polyp, or protruding submucous leiomyoma. A hysteroscopy revealed an elongated endometrial polyp 12 cm × 0.5 cm in length, which originated from the midanterior corpus [Figure 1b] and extended out of the cervix and introitus. Then, the base of the polyp was cut and removed in the same session [Figure 3]. The pathological report was consistent with an endometrial polyp.

Figure 1

Prolapsing mass at the introitus (a) and hysteroscopy showing the stalk of endometrial polyp originating from the anterior wall of the uterus and being cut (b)

Figure 2

Transabdominal sonography showed intrauterine hyperechoic mass, 1.5 cm × 0.8 cm in diameter

Figure 3

The endometrial polyp specimen after hysteroscopic polypectomy

DISCUSSION

Endometrial polyps are frequently found in multiparous women in the fifth decade of life. Abnormal vaginal bleeding is a common manifestation, affecting 25% of women (both pre-and post-menopausal women).[8] However, in certain cases, the patient may be asymptomatic.[1]

Most endometrial polyps are <2 cm in width. Polyps are considered giant polyps when they are larger than 4 cm in width. Unbalanced estrogen levels or tamoxifen use are risk factors for developing giant endometrial polyps.[7]

Although polyps are most commonly seen in multiparous women, the endometrial polyp in our report is found in a nulliparous woman. Moreover, the size of polyp is important to take into account. It has been noted that polyps larger than 10 mm in width are associated with malignancy.[9] In this case, the pathological report after the hysteroscopic polypectomy fortunately revealed no suspicious hyperplasia or the malignancy.

We report the unusual finding of an elongated endometrial polyp prolapsing through the introitus in a nulliparous woman. The largest lesion in the previous report was not protruding through the introitus.[7] Transabdominal sonography, the first imaging modality used to evaluate pelvic pathology in nulliparous women, revealed the intrauterine lesion. Further investigation in this patient was conducted using hysteroscopy. Hysteroscopy is the gold standard for diagnosis of intrauterine lesions,[1] and an operation can be conducted to remove the polyps at the time of diagnosis.[710]

CONCLUSION

This case shows the unusual finding of elongated endometrial polyp prolapsing through the introitus in an asymptomatic nulliparous woman. Hysteroscopy is the best tool for diagnosis and management in this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.