Author Information
Niranjan M Mayadeo
(Professor, Department of Obstetrics &
Gynecology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India.)
Abstract
Uterine inversion is rarely encountered in
modern day clinical practice; the diagnosis is not always clear cut. USG and
MRI may
not always help to clinch the diagnosis, in fact they can be misleading.
Finally it is the clinical judgment that settles the issue. I present an interesting case of a large submucuos fibroid arising from the right lateral walls of the uterus
and cervix, causing eversion of both cervical lips and
obliterating the internal os. The diagnosis was a dilemma.
Introduction
An HIV positive 42 year old woman, para 3 living
3, presented with a mass coming out of
vagina and menometrorrhagia .This mass
filled the vagina and the cervix could not be delineated
separately, even under anesthesia. Histopathology report was leiomyoma. The Ultrasonography (USG) and magnetic
resonance imaging (MRI) reports suggested
fibroid uterus with prolapse, and possiblty associated with uterine
inversion. Vaginal myomectomy was done after enucleating the leiomyoma through
a circumferential incision. The diagnosis of uterine inversion was ruled out
after identification and opening of posterior peritoneal pouch. Then a vaginal
hysterectomy was done. The leiomyoma was seen to be arising from right lateral wall at the
junction of the uterus and cervix, everting the cervix, which was severely hypertrophied.
Case Report
A 42 year
old woman, para 3, her last delivery
being 20 years ago, presented with
profuse and prolonged bleeding during menses (menometrorrhagia ) for 8 to 10 months. For last 2-3 months she
felt something coming out of
the vagina, contact with which
stained her undergarments with blood.
She also had foul smelling discharge.
There were no other complaints. She was
HIV positive and had never taken antiretroviral treatment. She weighed
42 kg. On examination she was pale, frail, apathetic, had angular stomatitis
and edema feet. Abdominal examination was normal.On local examination of the
vulva, a huge mass (12-15 cms diameter ) was seen coming out of the vagina. It was lined with endometrium like mucosa and
covered with slough and bled on touch . On speculum examination the mass
appeared to occupy the whole of the vagina. The cervical lips could not be identified.
On bimanual examination same was confirmed and separate cervix was not
delineated. Rest of the clinical examination showed no abnormal findings. The provisional diagnosis was fundal leiomyoma with probably an inversion
of uterus.
USG & MRI were done for definitive
diagnosis. The USG showed a fundal leiomyoma with uterine inversion. The MRI
reported a leiomyomatous uterus with
prolapse, but inversion could not be
ruled out. Investigations revealed Hb 6 grams %, liver and renal function tests were normal, CD4 count was 192.
Figure 1. MRI of the abdomen and pelvis.
She was transfused with 3 units of blood to
bring her Hb to 8.5 gram %. Examination under anesthesia revealed that the
cervix could not be delineated separate from the mass, nor could
a convincing tight ring be felt
suggestive of inversion. However on per
rectal examination the uterine fundus appeared to be indented, giving an impression
of inversion, but no constricting ring was felt. The clinical impression was that of a fundal leiomyoma
with uterine inversion. A biopsy from the
mass was obtained to check the
nature of the mass. The report was uterine leiomyoma with slight necrotic
changes. There was no evidence of any malignancy.
Figure 2. Preoperative
appearance of the mass.
Figure 3. Appearance of the mass after myomectomy.
Vaginal myomectomy was done under general
anesthesia through a circumferential incision around the base of the mass. The leiomyoma
was enucleated away from the mucosa (which
looked like endometrium). After enucleation of the leiomyoma , an attempt to
reposit the remaining portion was done.
After reposition the severely hypertrophied cervical lips and the Pouch of
Douglas and the anterior fornix could be identified . The uterus was very small
and thin- walled and one third the size of the hypertrophied cervix. Vaginal
hysterectomy was done. On cutting the specimen, the leiomyoma was found arising
from right lateral wall at the junction of the uterus and cervix causing eversion of the cervix. This explained the
difficulty in identifying the cervical lips.
Discussion
The classic abdominal USG picture in incomplete
chronic inversion of uterus is the "target sign", a hypoechoic area
between uterine fundus and vaginal fornices; in complete inversion it is "pseudostripe" - image
of the opposing serosal surfaces of the
uterus.[1,2] On MRI the "Bulls eye sign" on axial image is
seen in complete inversion and the U shaped uterine cavity in partial inversion.[3]
The classic picture was not seen in this case.
It is a well known fact that a submucous fundal
fibroid can cause inversion of the uterus.[4] However submucous leiomyomas,
arising at the uterocervical junction, which grow to large dimensions and protrude outside, cause a severe drag on the
uterine and cervical walls which have to sustain the increased weight.[5]
This would explain the hypertrophy and
eversion of the cervix seen in this case. Subsequent infection, due to its dependant position,
venous congestion and debilitating and immunocompromised status of the patient,
would cause erosion and sloughing of its surface. If the infection is recurrent
it can form adhesions in both the lips of the cervix and also obliterate the
external os thus posing a diagnostic dilemma and mimicking inversion which is
exactly what happened in this case.
When the clinical impression is that of
inversion the radiologists too tend to
get biased; they may also form similar
opinions because pictures of inversion and prolapsed uterine fibroid are
remarkably similar. Erroneous and
misleading diagnosis can emerge from the imaging modalities. Not knowing
the clinical diagnosis may probably help to arrive at more accurate diagnosis
from radiological perspective. A careful evaluation by another experienced radiologist may help to distinguish the two.
References
- Rana KA, Patel PS. Complete Uterine Inversion An Unusual Yet Crucial Sonographic Diagnosis. JUM 2009;28:1719-1722.
- Hu C-F, Lin H. Ultrasound diagnosis of complete uterine inversion in a nulliparous woman. Acta Obstet Gynecol Scand 2012; 91:379–381.
- Lewin JS, Bryan PJ. MR imaging of uterine inversion. J Comput Assist Tomogr. 1989;13(2):357-9.
- Kagne CS, Tambe S, Thawal Y. Chronic Non puerperal uterine invension - myomectomy preceding vaginal hysterectomy . Medical Journal of Western India. 2013;41:72-74.
- Mayadeo NM and Tank PD. Non puerperal incomplete lateral uterine inversion with submucous leiomyoma: A case report J Obstet Gynaecol Res 2003;29(4):243-5.
Citation
Mayadeo NM. Prolapsed Leiomyoma Or Uterine Inversion: Radiology Doesn't Always Help. JPGO 2014. Volume 1 Number 10. Available from: http://www.jpgo.org/2014/10/prolapsed-leiomyoma-or-uterine.html