What is the evaluation and management of a vaginal polyp in a woman of reproductive age?

Evaluation and Management of Vaginal Polyp in a Woman of Reproductive Age

A vaginal polyp in a reproductive-age woman should be evaluated with pelvic examination and transvaginal ultrasound, followed by complete surgical excision with histopathological examination to definitively rule out malignancy, as these lesions—while typically benign—can harbor atypical cells that mimic sarcoma and require tissue diagnosis for definitive management. 1, 2

Initial Clinical Evaluation

Key clinical features to assess:

• Age and hormonal status: Fibroepithelial stromal polyps typically occur during the reproductive years and are likely hormonally driven, arising from mesenchymal cells in the hormonally sensitive subepithelial stromal layer 1, 2
• Presenting symptoms: Most commonly vaginal bleeding (seen in approximately 55% of cases) or awareness of a vaginal "growth" (approximately 33% of cases) 3
• Location: These polyps typically arise from the upper vagina or lateral vaginal walls 4, 3
• Size: Document polyp dimensions, as larger lesions (>1.5 cm) carry higher risk of pre-malignant or malignant changes in endometrial polyps, though vaginal polyps are generally benign 5

Diagnostic Workup

Imaging:

• Transvaginal ultrasound should be the initial imaging modality to characterize the polyp and assess surrounding structures 6, 7
• Sonohysterography can help distinguish focal lesions from diffuse pathology if the origin is unclear 7

Critical diagnostic pitfall: Visual inspection alone is insufficient—these polyps can display hypercellularity and cytologic atypia that mimics malignancy, particularly sarcoma botryoides, making histopathological examination mandatory 1, 2, 3

Management Approach

Definitive treatment:

• Complete surgical excision is the treatment of choice for all vaginal polyps in reproductive-age women 1, 3
• Local resection is typically adequate and curative 3
• Simple observation is not recommended, even for small asymptomatic lesions, due to the need for histopathological diagnosis 1

Histopathological examination is non-negotiable because:

• Vaginal polyps contain atypical, pleomorphic, hyperchromatic cells within loose connective tissue with myxoid changes 3
• These bizarre microscopic features have historically been confused with sarcoma botryoides 3
• Pseudosarcomatous changes can occur, particularly in pregnancy-related polyps, where atypical cells in hypercellular stromal areas may be misclassified as malignant 2
• Rare variants like tubulo-squamous polyps (composed of squamous and glandular components) require tissue diagnosis to differentiate from other pathology 4

Post-Excision Follow-Up

Surveillance strategy:

• Routine clinical follow-up to monitor for recurrence, though recurrence is rare after complete excision 1
• No evidence of recurrence has been documented in cases followed for 4+ years after complete resection 1
• No additional imaging or biopsy surveillance is needed if histopathology confirms benign fibroepithelial polyp 1, 3

Special Considerations

Pregnancy-related polyps:

• Pregnant or recently postpartum women can present with fibroepithelial vaginal polyps, likely hormonally mediated 2
• These may show particularly prominent atypical features but remain benign 2
• Excision with histopathological confirmation remains the standard approach 2

Key caveat: While vaginal polyps in reproductive-age women are overwhelmingly benign, the wide morphologic variability and potential for atypical histology means that clinical judgment alone cannot exclude malignancy—tissue diagnosis through complete excision is mandatory in all cases 1, 2, 3