Vaidya A*, Chaudhari HK**, Mali K***
(* Third year resident, ** Associate Professor, *** Assistant Professor. Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India.)
Leiomyomas are the commonest type of uterine and pelvic tumors. Leiomyomas constitute around 20% of tumors in the reproductive age group. If we consider cervical leiomyomas, this incidence is quite less. Here we report a rare case of cervical leiomyoma with severe anemia secondary to menorrhagia. The 37 year old patient who had previous two cesarean sections presented to our out-patient department with a complaint of abnormal uterine bleeding. The patient underwent a total abdominal hysterectomy followed by vaginal morcellation of the leiomyoma.
Cervical leiomyomas can present as abdominal masses associated with abnormal uterine bleeding or even without any other major symptoms. Their incidence is quite less at 1-2 %. The location of cervical leiomyomas is in the supravaginal portion. They can arouse the clinical suspicion of an ovarian tumor.[3, 4] Other symptoms associated may be abdominal distension, infertility, difficult labor if given a vaginal trial, menorrhagia or metrorrhagia, urinary disturbances, dyspareunia, infection, torsion, constipation and degenerative phenomenon. The classic radiological appearance of “Lantern on Saint Paul’s Dome” is due to the upward displacement of the uterus in case of a centrally located cervical leiomyoma. The definitive management of cervical leiomyomas is surgical removal.
A 37 year old woman with previous two cesarean sections presented to the outpatient department with complaints of abnormal uterine bleeding for a period of around 3 months associated with pain in abdomen and distension of the abdomen. She did not have any previous history of menstrual disturbances. Also there was no history of any major medical or surgical illness. On examination, general condition was fair, vital parameters were stable but she had severe pallor. On abdominal examination, there was a mass of around 16 weeks’ size. On speculum examination, there was a polypoidal mass of 10x10 cm size occupying the whole of the vagina. The cervical rim could not be felt on per vaginal examination and uterine size was estimated at around 16 weeks.
She was investigated and her hemoglobin was 4.5 gm% with normal iron studies. All other investigations were within normal range. She was given 3 units of blood transfusion and her hemoglobin was built up to 9.5 g/dl. She had persistent menorrhagia for which she was administered injectable tranexamic acid and bleeding was controlled. Ultrasonography of the pelvis revealed a bulky uterus with small anterior intramural leiomyoma of around 1.1x1.2 cm. There was a 8.6x5.2 cm sized heterogeneous lesion with minimal vascularity in the anterior cervical wall pushing the endometrium posteriorly. After pre-operative investigations she was scheduled for total abdominal hysterectomy. Vaginal myomectomy followed by hysterectomy was not contemplated as the pedicle was thick and short, she had undergone 2 prior cesarean births and it was not possible to visualize the cervix on speculum examination. Abdomen was opened by a midline vertical midline incision. Dense adhesions that were found between the abdominal wall and urinary bladder were released. Clamps were applied in the sequence of round ligaments, then ovarian ligaments, uterine vessels and finally the uterosacral ligaments bilaterally. The uterus was then bisected. There was a large submucous pedunculated leiomyoma that had dilated the cervix and was located in the vagina. The thick pedicle of the cervical polyp was cut. An attempt was made to remove the polypoidal mass abdominally but could not be achieved. An intraoperative decision for vaginal morcellation of the polypoid mass was taken and she was given lithotomy position and the spherical mass of around 10x10x10 cm size was morcellated and removed vaginally. The hysterectomy procedure was then completed abdominally. She had an uneventful post-operative course and was discharged on day 5.
Figure 1. Vaginal morcellation.
Figure 2. Morcellated cervical fibroid.
Uterine leiomyomas are categorized according to their situation as subserosal, intramural, submucosal, broad ligament or cervical. Submucosal leiomyomas grow in the inner side of the myometrium and protrude into the uterine cavity. If pedunculated, they may project through the gradually dilating cervical canal and prolapse into the vagina. Large myomas can also slip forward into the vagina. Most women with uterine leiomyomas are asymptomatic and they therefore often remain undiagnosed. Symptomatic women typically complain of excessive and long lasting bleeding, especially if the leiomyoma is located intramurally or submucosally . Some authors suggest magnetic resonance imaging (MRI) as the best diagnostic method to determine an intracavitary pathology when precise mapping of tissue is needed.[5,6]
Dissecting and enucleating a large leiomyoma (whether cervical or uterine) by limiting the dissection to within the capsule of the leiomyoma is a key surgical technique to prevent ureteric injury in addition to careful dissection of ureters and bladder and clamping any pedicle with keeping ureters under direct vision. Cervical leiomyomas can either mimic ovarian torsion or even uterine inversion.
Submucosal pedunculated cervical leiomyomas are rare occurrences and require careful handling. Due to its close association with the ureters and urinary bladder, during any surgical procedure, whether it be a hysterectomy or myomectomy there can be an injury to these vital structures.
- Bhatla N. Tumours of the corpus uteri. In Tindall V editor: Jeffcoates Principles of Gynaecology. 5th ed. London: Arnold Publisher; 2001. pp. 470.
- Tiltman AJ. Leiomyomas of the uterine cervix: a study of frequency. Int J Gynaecol 1998;17(3):231-4.
- Suneja A, Taneja A, Guleria K, Yadav P, Agarwal N. Incarcerated procidentia due to cervical Fibroid: An unusual presentation. Aust N Z J Obstet Gynaecol. 2003;43:252-253.
- Dutta DC. Benign lesions of the uterus. In: Textbook of Gynaecology including Contraception. 3rd ed. India: New Central Book Agency (p) Ltd; 2004. pp. 264.
- Rice KE, Secrist JR, Woodrow EL, Hallock LM, Neal JL. Etiology, diagnosis, and management of uterine leiomyomas. J Midwifery Womens Health. 2012;57(3):241-7.
- Shiota M, Kotani Y, Umemoto M, Tobiume T, Hoshiai H. Estimation of preoperative uterine weight in uterine myoma and uterine adenomyosis. Asian J Endosc Surg. 2012;5(3):123-5.
Vaidya A, Chaudhari HK, Mali K. Large Submucosal Cervical Leiomyoma. JPGO 2017. Volume 4 No.11. Available from: http://www.jpgo.org/2017/11/large-submucosal-cervical-leiomyoma.html