Characteristics and Outcome in Non-Puerperal Uterine Inversion

Abstract

Chronic non-puerperal uterine inversion is rare and usually associated with uterine pathology with a diagnosis that is challenging. We present the case of a 47-year-old para 4 Caucasian woman with a history of polyfibromatous uterus who was admitted for severe vaginal bleeding for the past 48 hours associated with hemodynamical instability and was refusing any surgery. Pelvic MRI showed the uterus presenting an unusual appearance with a highly vascularized intracavitary leiomyoma protruding through the cervix. Upon deterioration of her status despite an optimal blood transfusion, resuscitation and anti-fibrinolytic treatment, she accepted total abdominal hysterectomy. The diagnosis of uterine inversion was made intraoperatively and confirmed on histopathologic examination. It revealed two side-by-side benign fundal leiomyomas which had collapsed the fundus and protruded partly from the cervix. Non-puerperal chronic inversion of the uterus is rare, and its diagnosis should be based on ultrasound, pelvic MRI and a high index of suspicion, allowing rapid diagnosis and treatment and thus decreasing patient morbidity and mortality.

Rhabdomyosarcoma-Induced Uterine Inversion

“…NPUI are rare clinical occurrences accounting for approximately 1 in 6 or 16.66% of all uterine inversions [ 3 ]. However, based on our current literature search, there has only been less than 10 published cases of NPUI caused by ERMS ( Table 1 ) [ 4 , 5 , 8 ].…”

“…During the physical examination, it is also important to stage uterine inversions to understand the severity of the condition. Current stages include stage 1 (incomplete inversion with fundus remaining in uterine cavity), stage 2 (complete inversion with uterine fundus through the ring of the cervix), stage 3 (total inversion where fundus protrudes through the vulva), and stage 4 (complete uterine inversion with vaginal involvement through the vulva) [ 1 , 3 ].…”

“…Preoperative diagnosis of NPUI remains difficult, and physicians need to have a high index of suspicion for this clinical condition when patients present with the aforementioned signs and symptoms. The gold standard diagnostic imaging modalities used are ultrasonography and MRI [ 1 , 3 , 4 , 9 ]. Previous studies suggested ultrasonographic findings of a depressed longitudinal groove extending from the uterus to the center of an incompletely inverted uterus that creates a “Y”-shaped uterus or a “U”-shaped uterus in the longitudinal plane of completely inverted uterus [ 1 , 3 , 9 ].…”

“…The gold standard diagnostic imaging modalities used are ultrasonography and MRI [ 1 , 3 , 4 , 9 ]. Previous studies suggested ultrasonographic findings of a depressed longitudinal groove extending from the uterus to the center of an incompletely inverted uterus that creates a “Y”-shaped uterus or a “U”-shaped uterus in the longitudinal plane of completely inverted uterus [ 1 , 3 , 9 ]. In T2-weighted MRI scans, most commonly, a U-shaped uterine cavity with thickened and inverted uterine fundus on sagittal imaging or a “bulls-eye” on axial imaging are suggestive of uterine inversions [ 1 , 3 , 9 ].…”

“…However, unlike PUIs, NPUI are often associated with uterine tumors both benign and malignant. While the most common cause of NPUIs is often a leiomyoma representing 57.5% to 80% of cases, another common cause includes sarcoma representing approximately 13.5% to 20% of cases [ 1 , 3 ]. Of the different types of sarcomas, embryonal rhabdomyosarcoma represents one of the rarest forms to cause uterine inversions, as there are only a few cases published in literature [ 4 , 5 ].…”