(Professor and head of the department, Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai, India.)
Prolapse of the fimbria of the fallopian tube is a rare complication of hysterectomy. It has a number of differential diagnoses. A biopsy is diagnostic. There are no clinical tests described to diagnose it. A clinical test is described here to make a diagnosis of posthysterectomy fimbrial prolapse.
The incidence of fimbrial prolapse after hysterectomy is less than 1% of all hysterectomies, and hence one does not encounter too many cases in a lifetime.[1,2] There are no tests described to make an accurate diagnosis and hence the diagnosis is usually made by appearance of the lesion. But it resembles a number of conditions like granulation tissue in the vault, primary or metastatic adenocarcinoma, endometriosis, cysts of the mesonephric and paramesonephric ducts and vaginal adenosis.[3,4] A biopsy is diagnostic. But to have to use a surgical procedure for making the primary diagnosis is not desirable. A clinical test is described to make a diagnosis of posthysterectomy fimbrial prolapse.
A speculum examination is done. The lesion is exposed well. It is held with sponge holding forceps. Gentle traction is made. In case of a prolapse of fimbria of the fallopian tube, the patient experiences a sharp dragging sensation in the pelvis, on the side of the prolapse of the tubal fimbria. Care has to be taken not to traumatize the fimbriae, which can cause bleeding. In case of vault granulations, they come off easily without causing any discomfort. There is mild bleeding after separation of the granulations, which soon stops. In case of the other lesions, they do not come off, nor do they cause any discomfort or pain.
Usually the lateral end of the fallopian tube prolapses in the form of one or more fimbriae. The prolapsed part is in continuity with the rest of the fallopian tube, which has its nerve supply intact. As a result, when the prolapsed part is held with sponge holding forceps and traction is made, it gets transmitted to the non prolapsed part of the tube and causes a dragging sensation and/or pain. This test is positive even if there is fibrosis between the vault and the tube that has prolapsed through a defect in it. Granulation tissue is soft and easily gets detached on traction. Other lesions do not show either of these findings. The appearance of an adenocarcinoma can be surprisingly like a fimbria, and distinction needs to be made in order to treat the patient adequately. The lesions of adenocarcinoma also get detached readily on traction. Histopathological examination differentiates the two from each other. There is some risk of bleeding after removal of a part of an adenocarcinoma. Hence the test is best performed in a procedures room or minor operation theater if an adenocarcinoma is suspected from other clinical findings.
Traction test is a simple clinical test that makes the diagnosis of posthysterectomy prolapse of the fallopian tube easy and accurate.
1. Fan QB, Liu ZF, Lang JH, et al. Fallopian tube prolapse following hysterectomy. Chin Med Sci J. 2006;21(1):20-23.
2. Ramin SM, Ramin KD, Hemsell DL. Fallopian tube prolapse after hysterectomy. South Med J 1999;10:963–966.
3. Ouldamer L, Caille A, Body G. Fallopian Tube Prolapse after Hysterectomy: A Systematic Review. PLOS ONE 2013;8(10):e76543.
4. Song YS, Kang JS, Park MH. Fallopian tube prolapse misdiagnosed as vault granulation tissue: a report of three cases. Pathol Res Pract 2005;201(12): 819-822. doi:10.1016/j.prp.2005.09.001.