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

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

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

4. 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.

5. 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.

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

7. 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.

8. 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

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

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

11. 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

12. LOCAL EXAMINATION

13. 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

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

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

16. For further evaluation Examination Under Anesthesia and Cystoscopy was planned.

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

18. EXAMINATION UNDER ANESTHESIA(EUA)

19. EXAMINATION UNDER ANESTHESIA(EUA)

20. 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

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

22. 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.

23. CYSTOSCOPY VIDEO

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

25. MRI PELVIS

26. MRI PELVIS

27. TREATMENT
Excision and enucleation of the mass was planned.