(14) Advanced Posterior Vaginal Prolapse in an Adolescent

Background: We report a case of a 14 year-old postmenarchal female who presented with vaginal pain and sensation of bulge with examination consistent with Stage III posterior predominant pelvic organ prolapse (POP). On exam under anesthesia, the posterior prolapse was noted to arise from significant redundant posterior vaginal soft tissue with multiple invaginations creating blind-ending pouches. Symptoms resolved after posterior colporrhaphy and resection of redundancy of posterior vaginal wall epithelium.

Case: We report the case of a 14 year-old postmenarchal female presenting with vaginal pain and sensation of bulge with examination consistent with Stage III posterior predominant POP. Her exam was consistent with 5 cm redundancy of posterior vaginal tissue, with an intact rectovaginal septum on rectal exam.(Figure 1). MRI showed normal uterine and ovarian anatomy with soft tissue fullness at the vaginal vestibule. The vaginal fornices, bladder neck, and anorectal junction were above the pubococcygeal line.The patient had been evaluated by both Rheumatology and Genetics for symptoms of joint laxity and arthralgias, with negative diagnostic workup for connective tissue disorder. A pessary was placed in clinic but expelled and the patient declined additional pessary fitting attempts. She underwent examination under anesthesia with hysteroscopy and vaginoscopy which revealed Stage III pelvic organ prolapse, with protruding posterior vaginal mass. Inspection of the mass revealed a significant amount of excessive posterior vaginal wall tissue including four separate blind-ending pouches each approximately 5 mm in diameter and 4 to 5cm in length (Figure 2). Rectal exam revealed intact rectovaginal fascia and absence of a posterior wall defect consistent with rectocele. Posterior colporrhaphy and resection of redundant posterior vaginal wall epithelium was performed, with pathology revealing benign squamous mucosa. Post-operatively the patient reported complete resolution of symptoms.

Comments: This case illustrates a benign posterior vaginal wall mass, possibly a novel urogenital sinus anomaly, presenting as symptomatic pelvic organ prolapse.