Uterine Torsion in an Elderly Woman Associated with Leiomyoma and Continuously Elevating Muscle Enzymes: A Case Study and Review of Literature

Abstract

Uterine torsion is extremely rare in postmenopausal women. Total ischemia of the uterus may cause life-threatening conditions; hence, accurate diagnosis and surgical intervention are crucial. However, preoperative diagnosis is often challenging due to nonspecific clinical features and laboratory findings. We report a case of uterine torsion in a 73-year-old woman who presented with mild but gradually worsening intermittent abdominal pain. During a 5-day observation, repeated blood exams showed elevating serum muscle enzyme levels, lactate dehydrogenase (LDH), and creatinine kinase (CPK), in addition to nonspecific signs of inflammation. Computed tomography (CT) scans were obtained before and after the worsening of symptoms, which revealed changes in size and position of the enlarged uterus with a large leiomyoma, even within a 5-day interval. Based on these findings, the preoperative diagnosis was uterine torsion. Emergency surgery revealed a 540-degree torsion of the uterus at the cervix and uterine body junction. Total hysterectomy and bilateral salpingo-oophorectomy were performed. Plasma muscle enzyme levels normalized after surgery, and the patient recovered without complications. In conclusion, uterine torsion should be considered during differential diagnosis in elderly women with large leiomyoma, even when symptoms are mild. Elevating plasma muscle enzymes may be an indication of uterine torsion; hence, repeated laboratory works and CT scanning should be performed when symptoms progress. Comparison of CT images, taken before and after the worsening of symptoms, may also be relevant for diagnosis. Since uterine torsion may cause rapid deterioration and become life-threatening, early diagnosis and surgical intervention are crucial to avoid serious complications.

Uterine torsion in non-gravid women: A case report and review of cases reported in the last 20 years

“…A previous report suggested that peritoneal signs are frequently absent in patients aged ⩾60 years. 21 However, our review revealed that peritoneal signs were also frequently absent in cases involving premenarcheal or young menstruating women ( Table 1 ). Regarding laboratory data, there are currently no known biomarkers that specifically indicate uterine torsion.…”

“…A case exhibiting gradual elevation of lactate dehydrogenase and creatinine phosphokinase levels after the onset of symptoms has been reported. 21 Similarly, there is a reported case wherein the patient developed coagulopathy. 10 However, these findings were not common in uterine torsion based on our review of recent cases (Table 1).…”

“…However, the most characteristic and common finding is the “whirl sign” of the uterine cervix. 2 , 5 , 7 , 8 , 13 , 21 , 22 “Whirl sign” might be labeled as “whorled structure” or “whirled appearance,” or “twisted cervix” in some reports; however, these descriptions refer to the same finding. The “whirl sign” cannot be observed on ultrasonography; it can only be observed on CT scan and MRI.…”

The twisted uterus: A rare presentation of uterine torsion

“…Uterine torsion is a rare gynecological emergency. Risk factors include structural anomalies that distort pelvic anatomy, such as pregnancy, uterine fibroids [4], ovarian cysts [5] and adnexal tumors, and ligamentous laxity in the pelvis [6,7]. Presentation is variable and often includes non-specific features, ranging from intermittent abdominal pain to acute deterioration with hemodynamic instability [8][9][10].…”

“…increasing the risk of uterine torsion include structural anomalies that distort pelvic anatomy, such as pregnancy, uterine fibroids [4], ovarian cysts [5], and adnexal tumors, and ligamentous laxity in the pelvis [6,7]. Multiple case reports have described torsion either in the gravid uterus [2,6] or in postmenopausal women [7][8][9], yet rarely in the non-gravid, premenopausal uterus. To the best of our knowledge, there remains only a single case of uterine torsion in a premenopausal non-gravid woman in the literature, described in 1935 [1].…”