Recurrent fibroepithelial vaginal polyp in a 2-year-old girl: a case report and review of the literature

Introduction and importance: Fibroepithelial vaginal polyps (FEPV) are rare mucosal polypoid lesions primarily found in adult women. However, FEPV in paediatric patients, especially beyond the neonatal period, is exceedingly uncommon. Documenting cases improves diagnosis and management. FEPV can mimic malignancy, posing challenges for interpretation. Early detection, treatment, and follow-up are crucial for optimal outcomes. Case presentation: The authors present the case of a 2-year-old girl with a recurrent FEPV. The patient had a painless, reddish, smooth, soft, rubbery polypoid vaginal mass measuring 2.3 × 1.5 cm. Physical examination revealed no concurrent systemic issues. Surgical excision of the polyps confirmed them as fibroepithelial polyps. Despite previous excisions, the polyps recurred within a month. The patient’s postoperative recovery was uneventful, and subsequent follow-up showed no recurrence. Clinical discussion: FEPV presents as mucosal polypoid lesions with a connective tissue core covered by benign squamous epithelium. It is rare before menarche and after menopause. Although the pathophysiology remains unclear, hormonal factors and local injuries may contribute. FEPV is usually asymptomatic but may cause pressure, obstruction, bleeding, or discharge. Differential diagnosis includes vaginal connective tissue malignancies. The diagnosis was confirmed by surgical excision and histopathology. Complete excision is crucial for preventing recurrence. Conclusion: This case report highlights recurrent FEPV in a 2-year-old girl. Despite previous excisions, polyps recurred, emphasizing the need for complete excision. Documenting cases will enhance our understanding. Further research is needed to elucidate the pathogenesis of paediatric FEPV. Early detection, treatment, and follow-up are essential for optimal management.


Introduction
Fibroepithelial vaginal polyps (FEPV) in newborns or infant girls are exceedingly rare [1] .Although it is benign, it can sometimes mimic the clinical presentation of sarcoma botryoides, and its histologic features may exhibit atypical characteristics that resemble malignancy, further complicating the clinical interpretation.
This article presents a case report involving a rare case of a two-year-old girl with recurrent vaginal polyps.The purpose of this report is to highlight the clinical presentation, diagnostic evaluation, and management of this particular case, underscoring the significance of early detection, appropriate treatment, and long-term follow-up in similar cases.This case report has been reported in line with the SCARE Criteria [2] .

Case presentation
A 2-year-old girl was presented to our hospital with a recurrent vaginal polypoid mass that was initially discovered by her parents 8 months ago, the parents reported that the vaginal mass was intermittently disappearing.The patient did not experience any abnormal vaginal discharge or bleeding and had no impact on bowel or urine function.Furthermore, the patient did not present with any concurrent systemic issues.She was delivered at 40 weeks of gestation through routine spontaneous vaginal delivery, and the pregnancy proceeded without complications.
The patient was considered the second child of a healthy father and mother who suffered from polycystic ovary syndrome (PCOS), aged 38 and 33 years, respectively, and there was no family history of malignancies or genitourinary anomalies.
Physical examination revealed a painless, reddish, smooth, soft to rubbery polypoid vaginal mass measuring 2.3 × 1.5 cm.The mass originated from the midline of the posterior vaginal wall [Figure 1], and the urethral and anal openings appeared normal.Additional examination findings were unremarkable.
Ultrasound and MRI established that the circumscribed ovoid homogeneous mass originated from the distal vagina, measuring 2.3 × 1.5 cm mass without any invasion to the adjacent organs.
Prior to the current presentation, the patient underwent two surgical excisions at a different hospital.The first surgical excision took place one week after the discovery of the mass, while the second excision occurred three months after the initial excision.However, each excision was followed by polyp recurrence after one month.
Cystoscopy and vaginoscopy were performed by a paediatric urologist together with a paediatric surgeon under general anaesthesia, which revealed a pedunculated vaginal mass originating from the midline point of the posterior vaginal wall.Apart from the presence of the mass, the cystoscopy and vaginoscopy findings were normal.The mass was completely surgically excised with a margin of 3 mm around its base, emphasizing the protection of the hymenal ring and the patient recovered uneventfully after the procedure.
Vaginoscopy was performed after 3 months of follow-up, and there was no evidence of recurrence.

Discussion
FEPV are mucosal polypoid lesions with a connective tissue core covered by a benign squamous epithelium [3] .In 1966, Norris and Taylor first documented the fibroepithelial polyp (FEP) and theorized that it represents a manifestation of maternal or placental hormonal influence in newborn infants, analogous to clitoral or breast enlargement and thickening of the vaginal mucosa [4] .Although FEPV primarily occurs in adult women, it is occasionally observed during pregnancy.However, it is exceedingly rare before menarche and after menopause [5] .The pathophysiology of FEPV remains elusive; however, it is believed to result from a granulation tissue reaction following some local injury of the vaginal mucosa [6,7] .
Clinically, these polyps are usually asymptomatic and commonly detected during postnatal medical examinations or noticed by the family.However, they can cause symptoms such as feeling of pressure, obstruction of the vagina or urethra, vaginal bleeding, and discharge [8] .Despite their benign nature, they may display a bizarre histological appearance, raising concerns about the possibility of misdiagnosis as malignant tumours originating from the vaginal connective tissue.The differential diagnosis for a vaginal mass in a prepubertal girl includes sarcoma botryoides, rhabdomyosarcoma, and mixed mesodermal tumours [9] .Surgery is primarily performed to exclude the presence of malignancy, and histopathology confirms the diagnosis.FEPV polyps have not been reported to undergo malignant transformation or metastasis.
FEVP should be considered for interlabial masses in prepubertal girls [1] .Treatment is simple local excision, and recurrence is extremely rare [10] .Nevertheless, there have been reported cases of recurrence following incomplete excision [5] , which we suspect may have occurred in our case.
The rarity of fibroepithelial polyps and their recurrence in paediatric patients emphasize the importance of documenting such cases for improved diagnosis and management.The literature review revealed seven cases of FEPV in newborn girls.Although these reported cases were infants, our case is the third case of FEPV in a paediatric patient beyond the neonatal period.A comparison between these cases and the current case is presented in [Table 1].Due to the limited number of reported cases of FEPV in paediatric patients, further research is needed to shed light on their pathogenetic mechanisms.
It is worth mentioning that their presence, especially recurrence, can cause distressing symptoms for the patient and his family and raise concerns.A suspected diagnosis of genital organ cancer in a woman's medical history is associated with an elevated risk of developing depression, anxiety, and adjustment disorders [11] .

Conclusion
Future research on these lesions is needed to shed light on their pathogenetic mechanisms, particularly in paediatric patients.Additionally, healthcare providers should be aware of the possibility of FEPV in young children.Complete surgical excision is recommended for appropriate management.However, incomplete resection may result in disease recurrence, which emphasizes the importance of long-term follow-up.

a
Faculty of Medicine, Al-Quds University, Jerusalem and b Department of Pediatric Surgery, Palestine Medical Complex (PMC), Ramallah, Palestine Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Table 1
Comparison of cases reported in literature with current case