Discussion part:
The case above shows the dilemma in diagnosis still in the modern era. Starting from the diagnosis of cancer to granuloma of various origins was tried to fit in the diagnosis to solve the mystery.
A rare case report published by Narendra et al from KMC oncology team in 2010 of extrarenal malignant rhabdoid vulval tumor in a 50-year-old lady who came with complaints of a vulval growth from past 3-months associated with pain and was managed with surgery and radiotherapy.3
Wiebren et al, published a case report on an aggressive nature of rare verrucous carcinoma of clitoris in a 79 years old lady with history Lichen planus.4
Nilima et al published a case report in the year 2020 of clitoral squamous cell cancer in a 68 years old female who presented to the hospital with complaints of vulval swelling and itching and with lymph node involvement. The lady was diagnosed in the advance stage which made the management of the case a challenge to the oncology team.5
Ji-Won Min et al, reported the first case of the GCT of the clitoris in postmenopausal women in Korea. A 45-year woman presented with a mass lesion over the left side of clitoris developing over 2 years. Surgical complete resection was done for her and histo-pathology showed it to be a granular cell. There was no recurrence in one year follow up time.6
There have been rare reported cases of epithelioid hemangioendothelioma, arteriovenous hemangioma, congenital hemangiopericytoma, angiokeratoma, nevus lipomatosus cutaneous superficialis, squamous cell carcinoma, plexiform schwannoma, and Paget’s disease of the clitoris.
A case report and review of pyogenic granuloma of vulva in a post menopausal lady published in 2011. They discussed that although pyogenic granuloma is common to occur due benign vascular proliferations of the skin and mucous membranes, they are relatively rare on the vulva. They presented a case report of postmenopausal multiparous women who presented with a history of foul smell and bleeding multiple lesions at vulva. Like our case she gave a history of itching but no pain. After complete excision, histopathological features suggestive of pyogenic granuloma. 7
Claudio Guerrieri et al in 2019 published a case report in the international journal of gynecological pathology in regards to vulvar Silicone Granuloma in a 51 year old multiparous lady following a labia majora augmentation surgery using silicone-based liquid injection. It’s a type a foreign body granuloma when silicone is used with the intention of enhancing the labia majora as a part of esthetic procedure.8
Ahmad et al discussed a rare idiopathic condition of vulvitis granulomatosa. It is a part of anogenital granulomatosis and is a form of noncaseating granulomas and associated lymphedema. They discussed a 57 year multiparous lady post hysterectomy with no evidence of crohn’s disease presented with labial induration associated with swelling of the skin of the groin. She was treated with oral hydroxychloroquine with significant improvement.9 Vulvitis granulomatosa has also been reported with Melkersson-Rosenthal syndrome.10
Abdulcadir et al discussed a case series of 7 women with clitoral neuroma post trauma due to female genital mutilating surgeries, of which 6 were diagnosed with neuroma during clitoral reconstruction surgeries and one case diagnosed before the surgery. 6 of the operated cases presented with pain while the last case discussed also had a complaint of swelling at the genital region. Post surgery all the patients were relieved of pain. 2
Yukiko et al discussed a case of secondary adenocarcinoma of clitoris presented with pain and swelling at the clitoris, from the uterine cervical cancer involving the vagina, parametrium and obturator lymph nodes. She was treated initially with radiotherapy and later underwent surgical excision of clitoral mass. 16