Author
Information
Niphadkar
M, Parulekar SV.
(Third
Year Resident, Professor and Head, Department of Obstetrics and
Gynecology, Seth G S Medical College and KEM Hospital, Mumbai, India)
Abstract
Polyps
are benign growths from the endometrial cavity or the cervix and are
a common cause of abnormal uterine bleeding (AUB). The cervical
polyps can be asymptomatic or a cause of intermittent spotting and/or
leucorrhea. Endometrial polyps are found to be responsible for AUB in
many patients. We report a case of a huge endometrial fibroid polyp
in a 25 year old patient with complaints of polymenorrhagia and its
removal by vaginal myomectomy.
Introduction
Endometrial
or uterine polyps are benign hyperplastic projections from the
endometrial cavity. Similarly endocervical polyps are benign
hyperplastic projections from the endocervical lining. These
outgrowths are many times responsible for abnormal uterine
bleeding.[1]
Endocervical
polyps with a slender stalk can easily be removed by continuous
twisting of the lesion which occludes the blood vessels within the
polyp. Polyps with a broader stalk require surgical excision.
Likewise endometrial polyps are removed hysteroscopically. Cervical
polyps are diagnosed clinically while endometrial polyps are
diagnosed on ultrasonography or they might appear as filling defects
in hysterosalpingography.
Case
Report
A
25 year old, para 1 living 1, MTP 1 first presented to the outpatient
clinic with complaints of spotting per vaginum and pain in abdomen.
On clinical examination, a 2-3 cm tender mass was felt in the left
fornix with bilateral forniceal tenderness was found. The patient was
admitted to rule out ectopic pregnancy. Ectopic pregnancy was ruled
out by a negative pregnancy test on urine and ultrasonography (USG).
On USG, a polyp or a submucosal fibroid arising from the left lateral
wall of the uterus was found. The patient was treated for pelvic
inflammatory disease and discharged. On her second visit to the OPD
for follow up after 2 months, clinical examination showed a ballooned
out cervix with a thickened and congested anterior lip. But the polyp
was not visible. Uterus was normal size. The patient followed up in
the OPD with complaints of polymenorrhgia and abdominal pain after 5
months with a USG report showing a large endometrial polyp occupying
almost all of the endometrial cavity and cervix. On per speculum
examination revealed a 3 cm infected mass protruding into the vagina
from the os. The uterus was of normal size above the polyp. The
patient was admitted for polypectomy after correction of anemia. Her
general and systemic examination and investigations for fitness for
anesthesia revealed no abnormality.
The
patient was taken for polypectomy under spinal anaesthesia in
lithotomy postion. On EUA, cervical rim was felt around the fibroid
polyp and the polyp was protruding out from the os in the vagina. The
attachment of the fibroid polyp could not be appreciated well since
it was likely high up near the fundus. After holding the anterior
cervical lip with Allis forceps, traction to the mass was applied
with vulsellum. A loop made of infant feeding tube was passed around
the polyp to attempt avulsion but the base of the polyp was found to
be 2 cm in diameter. A small transverse incision was then taken on
the anterior surface of the fibroid polyp and after careful sharp
dissection a plane was created to enucleate the mass. The mass was
avascular and the part protruding out of the os got detached during
surgery. On examination, the attachment of the mass was found to be
on the right lateral wall of the uterus near the cornu. On careful
sharp dissection with stout scissors and simultaneously maintaining
continuos traction on the mass, the mass was separated from the
endometrial cavity and removed. It measured 9x4.5 cm The cavity was
observed for any signs of active bleeding. The cervix appeared to be
effaced due to the pressure effect of the fibroid polyp. No active
bleeding was found. The uterine cavity was prophylactically packed
with feracrylum soaked roller gauze. Postoperatively, there was no
active bleeding and the roller gauze packing was removed after about
6-8 hours. The patient made an uneventful recovery. Histopathological
examination confirmed the diagnosis of a leiomyomatous polyp.
Figure
1. Sharp dissection within the pseudocapsule of the polyo.
Figure
2. Appearance of the cervix after removal.
Figure
3. Appearance of the polyp after removal.
Discussion
The
above case is of a submucous leiomyomatous polyp protruding from the
os. The striking feature of this case is the speedy and rapid growth
of the fibroid polyp within a span of 7-8 months. On histopathology,
there was no evidence of malignancy. Also the widest dimension of the
lesion was still inside the endometrial cavity and only a part of it
was protruding from the os. Passage of the widest transverse diameter
through the cervix is considered to be a prerequisite for
polypectomy.[2] If not, a posterior or an anterior cervicotomy is
required before the polyp can be removed. But in this case, since the
widest portion of the polyp was inside the cavity, the size of the
polyp was initially underestimated. This was realized during the
procedure.
Barbot
reported that functional and non-functional polyps resulted in
abnormal uterine bleeding.[3] Functional polyps are usually smaller
than the non-functioning polyps and are readily diagnosed on
hysteroscopy. The lining of the functional polyp is similar to that
of the endometrium. While a non-functioning polyp appears as a white
protuberance with branching surface vessels. Hysteroscopic removal is
the method of choice for removal of these polyps. Non-functioning
polyps can be confused with submucous myomas which have a similar
gross appearance.[4] In the past, hysterectomy was recommended if a
diagnosis of submucous myoma was made. But now with the development
of hysteroscopic resection techniques, management of submucous myomas
has become less radical. In the case presented, hysteroscopic
resection was not considered because the cervix was open and uterine
distension could not have been achieved for hysteroscopy.
The
above case posed a challenge to the operating surgeon since the
removal of the mass following sharp dissection was a relatively a
blind procedure. In such cases, the surgeon needs to be mentally
prepared to proceed for hysterectomy if there is accidental injury to
the uterine wall opening into the peritoneal cavity or the bleeding
after removal of the fibroid polyp does not stop despite uterine
packing.
References
- Schorge J, Williams J. Williams gynecology. New York: McGraw-Hill Medical; 2008, p. 227.
-
Parulekar SV. Practical Gynecology and Obstetrics. 5th ed. Mumbai: Vora Medical Publications; 2011. p. 346.
-
Rock J, Jones H, Te Linde R. Te Linde's operative gynecology. Philadelphia: Wolters Kluwer Health. Lippincott Williams & Wilkins; 2008, pp. 377-379.
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Berek J, Novak E. Berek & Novak's gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012, pp. 747, 779.
Citation
Niphadkar M, Parulekar SV. Vaginal Myomectomy For Intrauterine Submucous Leiomyomatous Polyp.
JPGO 2016. Volume 3 No. 3. Available from: http://www.jpgo.org/2016/03/vaginal-myomectomy-for-intrauterine.html