Jain N*, Chaudhari H**, More V***.
(* Second Year Resident, ** Associate professor, *** Assistant Professor. Department of Obstetrics and Gynecology, Seth G.S. Medical college and KEM hospital , Mumbai, India.)
Uterine inversion is defined as descent of the uterine fundus to or through the cervix. Chronic, non puerperal, postmenopausal uterine inversion is an extremely rare entity. Here we are presenting a case of a 60 year old, postmenopausal woman who presented as a case of prolapse but who had chronic non puerperal uterine inversion secondary to multiple uterine submucosal pedunculated leiomyoma, She was managed by vaginal myomectomy followed by correction of inversion of the uterus by Kustner’s method followed by abdominal hysterectomy.
Uterine inversion is defined as descent of uterine fundus to or through the cervix. Uterine inversion can present as an acute or puerperal and chronic or non puerperal type. Chronic inversion is rare as compared to acute inversion. Incidence of chronic non puerperal inversions are one sixth of all inversion cases.[1,2] Chronic non puerperal postmenopausal uterine inversion is extremely rare condition. It is reported that 97.4 % chronic non puerperal uterine inversions were associated with tumors out of which only 20% were malignant. Most common predisposing factor is fundal submucous leiomyoma as seen in our case. Others are endometrial polyp, and uterine sarcoma. We present a rare case of chronic uterine condition in non puerperal stage managed surgically.
A 60 years old, postmenopausal woman, para 4 living 1, all full term normal vaginal home deliveries, came with complaints of something coming out from vagina since 1 month which was non reducible. She had foul smelling vaginal discharge since 2 months. She was a known case of hypertension since 2 years; well controlled on medication. Her general condition was fair and vital parameters were stable. Abdomen was soft. On local examination there was a large, elongated, congested, firm mass of approximate 15 x 10 cm present, mass was irreducible, 2 areas of ulcerations of size 3x3 cm covered with foul smelling slough were seen. Two submucosal fibroids were present of size approximate 4x4 cm on right lateral wall near right cornua and 3x3 cm on left lateral wall behind left cornua. Cervical ring was seen and felt. Clinical impression was chronic non puerperal infected uterine inversion associated with multiple fibroid. Other differential diagnosis was uterine procidentia.
Figure 2. MRI scan showing inverted fundus. Yellow arrow marks inverted fundal cup, Green arrow shows the adnexa, Pink arrow depicts the inverted endometrium ‘F’ is the fibroid.
All blood investigations except blood sugar were within normal limit. She was diagnosed with diabetes mellitus after hospitalization and started on oral hypogycemic drugs. Daily twice dressing of inverted uterine mass was done using povidine iodine, and the prolapsed mass was covered with glycerine and acroflavin dressing. She had an episode of transient stroke in the ward. Neurologist advised a CT scan of the brain but no abnormality was detected. She was started on anticoagulants. 2D Echo done was within normal limit with ejection fraction of 60%. She also had urinary tract infection which was treated according to culture sensitivity report. Corrective Surgery was postponed as she was unfit. She was planned for surgery after getting fitness from anesthetist, endocrinologist and neurologist. Procedure performed was vaginal myomectomy followed by correction of inversion of uterus by Kustner’s method followed by abdominal hysterectomy. Surgery was performed under general anesthesia. Posterior colpotomy was done and diagnosis of inversion was confirmed.
Submucosal fibroid was enucleated. Reposition of the uterine inversion was done by Kustner’s method. Cervical ring was divided vertically in the midline posteriorly. Edges of cervix were held with Alli’sforceps. There was still difficulty in reposition hence the incision was extended upto the isthmus and posterior uterine wall. Following which uterine inversion was corrected, which was confirmed on per speculum examination. Abdominal hysterectomy was done by standard method. Histopathology report showed a leiomyoma. Uterus and cervix had no evidence of malignancy.
Figure 4. Kustner's operation. Incision of the posterior cervical ring and identification of the edges of the cervix.
On day 3 of surgery She developed signs of sepsis. She was shifted to intensive care unit. Higher antibiotics were started. Coagulation profile was deranged and correction with fresh frozen plasma was given as per hematologist’s advice. Her condition deteriorated and she succumbed on post operative day 16 .
Uterine inversion is a condition where the uterus turns inside out, the fundus prolapsing through the cervix. It may be classified as puerperal and non puerperal. Chronic non puerperal inversion is very rare. They represent 1/6th of all cases of uterine inversion.[1,2] Causes of non puerperal chronic inversion are incomplete obstetric inversions unnoticed or uncared for following failure to reduce for a period of 4 weeks or more, submucosal fundal myomatous polyp can cause chronic inversion due to traction effect, sarcomatous changes of fundal fibroma and senile inversion. Most common cause of non puerperal chronic inversion is a uterine leiomyoma in approximately 78 to 85% of the cases,as in our case. Two types of chronic inversion have been described. Incomplete inversion in which fundus protrude through the cervix but lies inside the vagina. Second is complete type in which whole of the uterus including the cervix are inverted, vagina may also be involved in the process. Our patient had complete inversion in which vagina was involved. Uterine inversion can be classified into four stages. Stage 1 is when the inverted fundus remains in the uterine cavity. In stage 2 complete inversion of the fundus occurs through the cervix. In stage 3 the inverted fundus protrudes through the vulva and in stage 4 inversion the uterus and vaginal wall protrude out of the vulva.
They present with symptoms of something coming out from vagina, irregular vaginal bleeding and offensive vaginal discharge.[6, 7] Chronic inversion is some times confused with fibroid polyp. Our patient presented with something coming out from vagina, with foul smelling discharge and multiple ulceration. USG is first diagnostic modality of choice. MRI and CT scan are also useful diagnostic tools.[8, 9]
Rectification surgery is definitive line of treatment. Unlike acute inversion which requires immediate correction, chronic inversion is to be treated electively. Preservation and/ or removal of the uterus along with rectification is determined by factors like age, parity, and associated complicating factors. Since our patient was postmenopausal, rectification surgery followed by hysterectomy was done. Many operative procedures for the treatment of chronic inversion are described amongst these the most common abdominal procedures are Huntington’s and Haultain’s and vaginal procedures are mainly Spinelli’s and Kustner’s operations.[10,11,12] Spinelli’s and kustner’s operation are both performed vaginally, are similar with the exception that in Spinelli’s surgery the approach to divide the cervical ring is anterior whereas in Kustner’s procedure the posterior approach is used and the incision is placed on the posterior cervical ring. Kustner’s approach was suitable here as the risk of damaging the bowel was small, because of the deep reflection of the pouch of Douglas whereas anterior approach included danger of damaging the bladder during separation, risk being more due to complete inversion. In Haultain’s procedure, done transabdominally the constricting ring is incised posteriorly by a vertical incision and then the inversion is corrected. In Dobbin’s procedure, the cervical ring is divided in midline anteriorly by an abdominal approach and then the inversion is corrected.
Once a diagnosis is established the surgical correction can be done by choosing the best option from the different available ones as described in literature.
We thank Dr S V Parulekar for his intraoperative guidance and Dr. Lalita Kambagatti for the intraoperative images.
- Katdare P, Valecha SM, GandhewarM, Dhingra D. Chronic Non-Puerperal Uterine Inversion: Recommendations for Diagnosis and Management. Global Journal of Medical Research Gynecology and Obstetrics. 2013; 13(2):45-47.
- Takano K, Ichikawa Y, Tsunoda H, Nishida M. Uterine inversion caused by uterine sarcoma: a case report. Jpn J Clin Oncol. 2001;31(1):39-42.
- Mwinyoglee J, Simelela N, Marivate M. Non-puerperal uterine inversions: a two case report and review of literature. Central African J Med. 1997;43(9):268-71
- Kagne SS, Thawal YA, Tambe SG. An extremely rare case of chronic non-puerperal uterine inversion treated by myomectomy preceding vaginal hysterectomy. Journal of evolution of medical and dental sciences. 2013;46: 8976-8979.
- Lupovitch A, England ER, Chen R. Non-puerperal uterine inversion in association with uterine sarcoma: case report in a 26-year-old and review of the literature. Gynecol Oncol. 2005;97(3):938-41.
- Krenning RA, Dörr PJ, de Groot WH, de Goey WB. Non-puerperal uterine inversion. Case report. Br J Obstet Gynaecol. 1982;89(3):247-9.
- Gowri V. Uterine inversion and corpus malignancies: a historical review. Obstet Gynecol Surv. 2000;55(11):703-7.
- Salomon CG, Patel SK. Computed tomography of chronic nonpuerperal uterine inversion. Journal of Computer Assisted Tomography.1990;14(6):1024-1026.
- Lewin JS, Bryan PJ. MR imaging of uterine inversion. J Comput Assist Tomogr. 1989; 13: 357-359.
- Lascarides E, Cohen M. Surgical management of nonpuerperal inversion of uterus. Obstet Gynaecol. 1968; 32:376-381.
- Haultain FWN. The treatment of chronic uterine inversion by abdominal hysterectomy, with a successful case. Br Med J. 1901; 2(2127): 974-976.
- Huntington JL, Irving FC, Kellogg FS. Abdominal reposition in acute inversion of the puerperal uterus. Am J Obstet Gynecol. 1928; 15(1): 34-40.
- Bakre T, Gupta AS, Hira Priya, Parulekar SV. Chronic Non Pueperal Inversion Of Uterus Secondary To Submucosal Fundal Myoma. Available from http://www.jpgo.org/2014/10/chronic-non-pueperal-inversion-of.html
Jain N, Chaudhari H, More V. Chronic Nonpuerperal Inversion Of Uterus Secondary To Submucous Myoma. JPGO 2018. Volume 5 No.6. Available from:http://www.jpgo.org/2018/06/chronic-nonpuerperal-inversion-of.html