Parulekar SV
Nonpuerperal chronic inversion
of the uterus is as much a rarity as a curiosity. Most of the clinicians go
through a busy lifetime without ever seeing a case. There are fewer than a
couple of hundred case reports in the world literature. It is curious that
there were enough cases to go round in the past that Hippocrates wrote about
it, Themison (50 BC) advised amputation of the bleeding and sloughing inverted
corpus of the uterus, Soranus actually did it 150 years later, and methods were
described for surgical correction of the inversion by stalwarts like Aran,
Marion Sims, Barnes, Thomas, Browne, Kustner, Piccoli, Morisani, Spinelli,
Haultain, Dobbin, and Huntigton. One wonders if any of them had sufficient
number of cases to show the merits and demerits of any given method. It is
equally doubtful if anyone in modern times has sufficient experience to
recommend one method over another. The conditions which predispose to
nonpuerperal chronic inversion of the uterus have not changed over years, because
they are gynecological conditions which are not preventable, as can be said
about obstetric inversions. Hence incidence of this condition has remained more
or less constant over years, while obstetric inversions have declined. The
diagnosis of this condition is not easy. In fact, the dictum ‘what looks like a
chronic inversion of the uterus clinically will be anything but that’ is true
even today. It will most probably be a leiomyomatous polyp, with or without
uterine prolapse. With advances in imaging like computerized tomography and
magnetic resonance imaging, the diagnosis of a chronic inversion is more likely
to be made accurately. In this issue we present two cases, one of nonpuerperal
chronic inversion which was diagnosed accurately with such imaging, and another
which was falsely diagnosed so. Opinion is divided over the best method to
treat such cases. I feel that a vaginal technique is preferable to an abdominal
technique for a number of reasons. The first reason is that a chronic inversion
is often associated with a neoplasm of the uterine fundus, most commonly a
leiomyoma. It needs to be removed first, so that the inverted uterus can be put
back in original shape and position. That can be done best by the vaginal
route. The second reason is that the constricting of the cervix is low down and
is approached more easily vaginally than abdominally. One ends up cutting a lot
of wall of the uterine corpus before dividing the ring by the abdominal route.
The third reason is that a trained gynecologist is more comfortable by the
vaginal route and resorts to the abdominal route only when vaginal surgery
cannot be done. Amongst the vaginal operations, Kustner’s operation is safer,
because it involves dividing the cervical ring posteriorly, which is a lot safer
than any operation that divides the ring anteriorly, with the inverted urinary
bladder so close. Modern surgeons want to do everything by the endoscopic
method, and there are a few reports of laparoscopic correction of chronic
inversions. The vaginal route has the same advantages over the laparoscopic
route as over the abdominal route. The only advantage of the laparoscopic route
would be to make a correct diagnosis before cutting into any tissues, in case
the imaging techniques have not helped make a correct diagnosis.We have added one more feature to the journal for the benefit of postgraduate students and those readers interested in continuing medical education. A quiz is added at the end of the journal. There are multiple choice questions of the best one answer out of four type. They are based on the articles published in the current issue of the journal. The answers will be given in the next issue. We request the readers not to send us their answers, but check them themselves.