Uterine Inversion Secondary to a Large Prolapsed Leiomyoma: Diagnostic and Management Challenges

Abstract

Uterine inversion is characterised by the collapse of the fundus into the uterine cavity. Nonpuerperal uterine inversion is an extremely rare entity, with less than 200 reported cases thus far. In light of the non-specific presentation, its diagnosis is challenging. Furthermore, in case of malignancy suspicion associated with its presentation, the management should be guided by the recommendations of a central multidisciplinary team. Here, we present the case of a 47year-old, para 1 woman presented in the emergency department with hypovolaemic shock secondary to menorrhagia as well as urinary retention. MRI scan revealed uterine enlargement and a heterogeneous mass protruding into the vagina. The findings were in keeping with a large prolapsed leiomyoma causing uterine inversion and acute bilateral hydronephrosis; yet, the possibility of uterine leiomyosarcoma could not be excluded. The patient underwent urgent total abdominal hysterectomy, bilateral salpingo-oophorectomy and omental biopsy to alleviate pressure. A 20-cm pelvic mass filling the vagina was found, which was reported to be a pedunculated uterine leiomyoma with no evidence of malignancy. Surgical management led to a positive outcome with no post-surgical complications.

Management of Nonpuerperal Uterine Inversion Using a Combined Vaginal and Abdominal Approach

“…may promote uterine inversion. A clinical examination might help in the diagnosis when a protruding vaginal mass is accompanying the absence of the uterus in its normal position or palpation of fundal depression on bimanual examination [ 2 , 5 ]. Our case presented with a complaint of bleeding and large protruding vaginal mass immediately preceded by urinary retention and intense straining.…”

“…MRI is the best imaging modality to diagnose uterine inversion and can show the anatomic anomalies more accurately than CT. MRI is useful not only in diagnosis but also to characterize the uterine mass [ 5 ]. On MRI scans, “U”-shaped uterine cavity, thickened and inverted uterine fundus are indicative of uterine inversion [ 8 ].…”

“…Treatment of nonpuerperal uterine inversion depends on the patient's desire for future fertility and the nature of the intrauterine prolapsed mass (benign or malignant). If future fertility is desired and malignancy is excluded, surgical procedures to reposition and preserve the uterus should be attempted [ 5 , 10 ]. Thus, there is a need for histologic diagnosis prior to definitive surgery.…”

“…Once repositioning was successful, hysterectomy with bilateral salpingo-oophorectomy was carried out using standard procedural steps. Recent reviews also show that a combined vaginal and abdominal approach, to first remove the cause of inversion vaginally and then proceed to uterine repositioning abdominally, is an effective surgical strategy [ 5 ]. The repositioning of the uterus to the exact anatomy is vital before proceeding to hysterectomy.…”

Postnatal inversion of the uterus – management in specific cases.

“…This complication is most frequently connected with the coexistence of uterine tumours, e.g. myomas, sarcomas [8][9][10][11]. In the instance of puerperal inversion, depending on the time between the labour and the diagnosis, the following types of inversion can be distinguished: acute inversion of the uterus if the diagnosis was made within 24 hours after labour (83.4% of all cases of inversion), subacute if the diagnosis was made after 24 hours up to 4 weeks after labour (2.62%), and chronic when inversion of the uterus was diagnosed more than four weeks after the labour (13.9%) [12].…”