(Professor and Head, Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai, India.)
Prolapse of the fimbria of the fallopian tube is an uncommon complication of hysterectomy. It is usually confused for vault granulation tissue in the vault of vagina. Usually the patient presents with blood stained vaginal discharge or postcoital vaginal bleeding and lower abdominal pain. A case with a different presentation is presented here. Such a presentation has not been reported in the world literature before.
The incidence of fimbrial prolapse after hysterectomy is less than 1%. It is much lower in better centers. It is a benign condition, but needs to be treated as it causes inconvenience to the patient. It is very often misdiagnosed in cases of vault granulations. Pain is often a distressing symptom in cases of fimbrial prolapse, which is absent in cases of vault granulations. A case with a different location of severe pain is presented here.
A 44 year old woman, gravida 2 para 2 with two living children, presented with a complaint of intense pain in left lower abdomen, left lumbar region, and left side of the chest up to the left axilla. This pain was experienced more intensely during coitus. She had undergone an abdominal hysterectomy for abnormal uterine bleeding due to uterine leiomyomas one year ago. The pain started about one month after that operation, and rapidly progressed to its severe form in another month. She visited her doctor for this pain, who referred her to us for further management. She had suffered from menorrhagia for four months, prior to which her menstrual cycles had been regular and with moderate flow and mild pain in lower abdomen and back. She was diagnosed to have multiple uterine leiomyomas and had undergone an abdominal hysterectomy for the same. Her recovery from that operation had been uneventful. Her past medical history was not contributory. She had two normal deliveries in the past.
On examination her vital parameters were within normal limits. General and systemic examination revealed no abnormality. A speculum examination showed a 2x2x1 mm pink fleshy mass with three finger-like projections near the left angle of the vault of the vagina. It did not bleed to touch during the process of obtaining of a Pap smear, but there was intense pain similar to the pain she had during coitus. Bimanual pelvic examination revealed no pelvic mass, but intense pain as described before. The mass was held gently with sponge-holding forceps and mild traction was made. This resulted in reproduction of her pain. So a diagnosis of fimbrial prolapse was made. A pelvic ultrasonography (USG) did not show any pelvic mass. The patient was counseled to undergo excision of the prolapsed left tubal fimbria vaginally. But she was lost to follow up. She followed up after one and a half year with a complaint of pain in the left iliac fossa. She stated that she had got the prolapsed fimbria excised by abdominal route at a center near her place of residence. Histopathological examination had confirmed the diagnosis. Her examination at that time showed that she had mild pelvic infection. There was a cyst in the left adnexa measuring 2 cm in diameter. USG confirmed the diagnosis of left simple ovarian cyst. She was given a course of cefixime, doxycycline and metronidazole over 14 days as per national guidelines for management of pelvic infection. She came back after one month, with a complaint of pain in right part of her Pfannensteil scar and continuation of the pelvic pain. On palpation, a tender irregular nodular mass measuring 2 cm in width and 1 cm in diameter was felt in the left part of the Pfannensteil scar. A differential diagnosis of abdominal wall sepsis and scar endometriosis was made. She was given ceftriaxone, gentamycin and metronidazole parenterally for 7 days. The symptoms did not resolve. She was asked to report during her next episode of pain. She came back after a week with pain. At that time the pain in her pelvis and abdominal wall were found to have increased. The abdominal wall lesion had become bigger and more tender. There was no palpable pelvic mass. A diagnosis of scar endometriosis was made. She was given leuprolide depot 11.25 mg intramuscularly. Her pain did not recur on a monthly basis after that. The abdominal lesion regressed over 6 months. She was advised to report in case of recurrence of her symptoms.
Figure 1. Speculum examination of the vagina showing fimbrial prolapse near the left angle of the vault of the vagina.
Pozzi reported a prolapse of the of the fallopian tubal fimbria for the first time in 1920. It is an uncommon complication after hysterectomy. Its incidence is 0.06% after an abdominal hysterectomy, 0.5% after a vaginal hysterectomy. Risk factors for development of this condition include low socio-economic status, postoperative formation of hematoma and/or infection of the vault, and an open vaginal cuff are risk factors for the development of this condition. The lower incidence in better centers may be related to adequate closure of the pelvic peritoneum, achieving proper hemostasis so as to prevent formation of a vault hematoma and low occurence of sepsis in the vault of vagina. Use of modified Heaney's technique of vault suspension rather than Bonney's technique could also contribute to this lower incidence, as the latter involves suspension of the center of the vault of vagina from the cornual and uterosacral pedicles tied together, which puts the tubes right next to the vault. Fimbrial prolapse develops usually about four months after the hysterectomy, while the longest reported time is 32 years.
The diagnostic test for fimbrial prolapse is the traction test. It involves holding the lesion with sponge holding forceps and making gentle traction on it. If it fimbria have prolapsed, the fallopian tube above the vault gets pulled and the patient experiences the same pain that she gets at other times. In case of vault granulation tissue, it gets detached painlessly and easily. This tissue can be examined histologically and its nature determined. Histopathological examination of the tissue removed confirms the diagnosis of granulation tissue.
The case presented here was unique. Normally the pain elicited on traction test is confined to the pelvis and lower abdomen on the side of the fallopian tube. In this case the pain was experienced from pelvis up to the axilla on the same side. This can be explained partly by the nerve supply of the peritoneum of the infundibulopelvic ligament (T6 level). Thus traction on the ligament would cause pain at the level of sixth intercostal space on the lateral thoracic wall. However the axilla is supplied by the second intercostal nerve (T2). The pain experienced by this patient in the axilla cannot be explained by normal anatomy.
Endometriosis can develop in the abdominal wall after a laparotomy, when the uterine cavity is opened during the operation, as after cesarean section, hysterotomy and sometimes myomectomy. None of these conditions was applicable to the given case. However it is possible that metaplasia occurred in tubal cells implanted in the incision during abdominal removal of the prolapsed fallopian tube. There is no way this can be proved in this case.
It is extremely unusual that fimbrial prolapse causes pain in the axilla. This is the first case of this nature in the world literature. Removal of a fallopian tube through an abdominal incision can cause implantation endometriosis.
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