Case Report

A 25 years old female was referred for imaging to the hospital. There was history of polymenorrhagia and pelvic pain since last two years. The patient had the complaints of constant, dull aching pain in lower abdomen which increases at night. Two years back her menstrual cycles were of 28 days with normal bleeding of 3-4 days. Since last two years she is complaining of intermenstrual bleeding which is significantly increased since few months. The patient complained of feeling of fullness in the vaginal canal.

On physical examination the patient was pale. Per abdomen examination was unremarkable.

Per vaginal examination revealed red to pinkish mass in the upper vaginal canal with prominent surface vessels which were bleeding on touch. The patient was advised for pelvic ultrasound and MRI.

Ultrasonography of the pelvis revealed a solid mass with prominent vascularity in cervical/ upper vaginal canal. It has multiple hypoechoic spaces within.

To know the exact origin of the mass as well as its extension, Magnetic Resonance Imaging of pelvis was done which revealed a polypoidal mass within the fornix and upper vaginal canal. The mass shows predominately hyperintense signal on T2 weighted images and hypointense signal on T1 weighted images. There were multiple haemorrhagic spaces within the lesion appearing hyperintense on T1 weighted images and mixed signal intensity on T2 weighted images. Few of these spaces showing fluid-fluid levels. There was a central fibro vascular stalk attached to the posterior endometrial wall (Figure 1a and Figure 2a).

Figure 1: Shows- T2 weighted images in sagittal plane (Figure 1a and 1b).

Figure 2

Figure 1 shows- T2 weighted images in sagittal plane shows a large polypoidal mass filling the fornix and vaginal canal (lined by orange arrows) (Figure 1a and 1b). It displays bright signal on T2 weighted image. Also note multiple vascular spaces in the lesion denoted by blue arrows in Figure 1b.

The lesion was attached to the posterior endometrial lining of the uterus by fibro vascular stalk denoted by green arrow in Figure 1a.

T2 weighted axial images shows the mass within the fornix, vaginal canal (denoted by orange arrows) (Figure 2a). Also note the fibro vascular stalk attached to posterior endometrial wall (denoted by green arrow) and haemorrhagic spaces (denoted by yellow arrow) (Figure 2b).

Figure 3 shows T1 sagittal (Figure 3a) and T1 axial (Figure 3b) image showing the lesion being predominately hypointense with vascular spaces/ intra-lesioned haemorrhages denoted by orange and yellow arrows. Also note the fluid-fluid levels within the vascular spaces.

Figure 3

Considering the macroscopic appearance and history of bleeding per vaginally possibility of vascular polyp and polypoidal lesion with vascular spaces like cavernous hemangioma were considered in the differential diagnosis.

For further management the patient was referred to gynaecologist. To decrease the intraoperative loss preoperative angio-embolization was done.

Selective angiogram shows enlarged right and left uterine arteries supplying the lesion (Figure 4a and Figure 4b respectively) with prominent arterial blush. Figure 4c and Figure 4d represent post embolization status with absence of blush.

Figure 4

After pre-operative embolization, hysteroscopic excision of polypoidal lesion was done (Figure 5). The histopathological examination proved the lesion to be hemangioma (Figure 6).

Figure 5: Shows post excision macroscopic appearance of the lesion.

Figure 6: Histopathological image (40X) shows many dilated blood vessels of varying sizes with intimal lining suggestive of hemangioma.