A COMMON TUMOR AT AN UNCOMMON SITE Case Presentation By Dr. Mariam Zahir Post Graduate Trainee Department Of Obstetrics and Gynaecology Benazir Bhutto Hospital

PATIENT PROFILE Mrs. XYZ 50 years female No formal education House wife Divorced for the last 14 years Resident of Attock Date of Admission: 11-8-16 Mode of Admission: OPD

PRESENTING COMPLAINTS Swelling over the vulval region for last 10 years Postmenopausal bleeding for last 1 month

HISTORY OF PRESENT ILLNESS The patient was in her usual state of health when she started noticing a mass at introitus 10 years back. Initially it was small then gradually increased in size. There were no associated urinary and bowel complaints. History of post menopausal bleeding for last one month.

GYNAECOLOGICAL HISTORY Menarche : 12 years Menstrual cycle: Previous cycle 7/28 days, regular, average blood flow. No history of dysmenorrhea , dyspareunia, postcoital bleeding or intermenstrual bleeding Never practiced any contraception.

GYNAECOLOGICAL HISTORY Cont…. No history of PAP smear Menopause: 2 years back at the age of 48 years. Post menopausal bleeding: 1 month

OBSTETRICAL HISTORY Patient is P4+1 All uneventful spontaneous vaginal deliveries at home. One son and three daughters. Last child birth 21 years back. Last miscarriage 15 years back followed by ERPC.

Past Surgical History: Not significant Past Medical History: Not significant Past Surgical History: Not significant Family History: No history of breast, colon and ovarian malignancy Drug History: No history of anticoagulant intake or HRT Systemic Inquiry: Non-significant

GENERAL PHYSICAL EXAMINATION A lady of average built well oriented in time and space. Vital signs: Pulse : 88/min BP : 110/70 mm Hg Temp: 98.6 o F Respiratory rate: 16/min

GENERAL PHYSICAL EXAMINATION Cont... Pallor : -ve Weight: 48 Kg Height : 155 cm BMI: 20 Kg/m2

SYSTEMIC EXAMINATION ABDOMINAL EXAMINATION: CARDIOVASCULAR SYSTEM: Soft non tender, no mass palpable CARDIOVASCULAR SYSTEM: Normal heart sounds, No added sounds. RESPIRATORY SYSTEM: Normal vesicular breathing. CENTRAL NERVOUS SYSTEM: Grossly intact

LOCAL EXAMINATION

INVESTIGATIONS LABS DATE 20 AUG,2016 DATE 13 OCT,2016 Blood group AB positive CBC: Hb 9.1 11.8 Platelet 286 398 Clotting profile Normal Random blood sugar 105 MSU Clear LFT’s ALT 34 ,ALP 72 Bilirubin 0.3 ALT14 ,ALP 100, AST 28 RFT’s Urea 15 , creatinine 0.6 HBsAg and AntiHCV Antigen Negative

ULTRASOUND OF MASS A hypoechoic solid mass measuring 6 x 8cm with no calcifications. Peripheral area more echogenic than central relatively anechoic area

TRANSVAGINAL ULTRASOUND Uterus 6x4x3.5 cm Endometrial echo 4 mm Bilateral adenexa normal

For further evaluation Examination Under Anesthesia and Cystoscopy was planned.

EXAMINATION UNDER ANESTHESIA(EUA) A 6 X 8 cm firm mass at introitus. A 4x5 cm ulcer at the most dependent part. Ulcer

EXAMINATION UNDER ANESTHESIA(EUA)

EXAMINATION UNDER ANESTHESIA(EUA)

EXAMINATION UNDER ANESTHESIA(EUA) SPECULUM EXAMINATION : Cervix normal looking. Vagina normal looking and free of mass. PAP smear taken. BIMANUAL EXAMINATION: Uterus 6 week size, mobile with bilateral adenexa clear Normal Cervix

EXAMINATION UNDER ANESTHESIA(EUA) Urethra deviated to 2 o’ clock position. Patient was catheterized to ascertain path of urethra

CYSTOSCOPY Date: 22 October,2016 Surgeon : Prof. Dr. Mumtaz assisted by Dr Zeeshan Findings:. Urethral opening was normal. Bladder was trabeculated. No communication of mass into urethra and bladder seen.

CYSTOSCOPY VIDEO

MICTURATING CYSTOURETHROGRAM Left Oblique View: Urethra deviated towards left side.

MRI PELVIS

MRI PELVIS

TREATMENT Excision and enucleation of the mass was planned.