An Unusual Case of Nonpuerperal Uterine Inversion Managed by a Novel Vaginal Hysterectomy Technique

Introduction

Inversion of the uterus is a very rare clinical problem. It is mostly encountered as an obstetric emergency and, at times, may present as a diagnostic challenge. Nonpuerperal uterine inversion is very uncommon, with only 150 cases reported in the published literature between 1887 and 2006.^1,2 The condition is difficult to diagnose by clinical examination alone. Most nonpuerperal inversions of the uterus are caused by benign submucousal myomas, while other causes are caused by leiomyosarcomas, rhabdomyosarcomas, malignant mixed Müllerian tumors, and endometrial polyps.

This article describes and discusses a rare case of nonpuerperal uterine inversion that was caused by a small benign submucous leiomyoma in a postmenopausal woman. After removing the leiomyoma, a vaginal subtotal hysterectomy was done by a novel technique, which had not been reported in the literature until this current article.

Case

A 55-year-old postmenopausal woman came to the outpatient section of the department of obstetrics and gynecology, at M.Y. Hospital and MGM Medical College, in Indore, Madhya Pradesh, India. She complained of having a mass arising out of her introitus since 12 months prior to presentations, and this mass had increased over the last 6 months. In addition, she had severe pain in her abdomen and was bleeding vaginally during the past 4 months. She had reached menopause 6 years prior to presentation. She worked as a fruit seller, so she was used to lifting heavy weights. She also had intermittent constipation. Her obstetric history indicated that she was para 3 and had had three full-term normal vaginal deliveries at home.

On general examination she appeared to be pale. When her abdomen was palpated, it felt soft but no mass was discerned. However, during a speculum examination, as the speculum was introduced into the vaginal area, she had a bout of profuse bleeding, and a leiomyomatous polyp of 4×3×2.5–cm was seen arising from her introitus. This same polyp was also felt during a vaginal examination, but the uterus could not be discerned. Subsequently, routine investigations were performed, including a complete hemogram, a urine analysis, renal-function tests, liver-function tests, a chest X-ray, and an electrocardiogram. The results of these tests with the exception of her hemoglobin level, which was −7 g%. Thus, she was given three blood transfusions. Transabdominal ultrasonography revealed that her uterus could not be visualized. A transvaginal scan was not possible, because the polyp started bleeding again when it was touched. After her examination and examination and laboratory investigations were completed, it was determined that the most probable diagnosis was a leiomyomatous polyp with inversion and severe anemia. After counseling the patient regarding her comorbid conditions and the need for a hysterectomy, the patient signed a detailed consent form. Then she was scheduled for a polypectomy, and if the need arose, a hysterectomy.

During examination under general anesthesia, this patient's condition was finally diagnosed to be a case of inversion of the uterus with a small benign submucous leiomyoma, of 4×3×2.5–cm, present at the fundus. During the operative examination, there was profuse bleeding when the the leiomyomatous polyp was touched, so the polyp was clamped, the pedicle was cut and ligated, and the polyp was removed.

On palpation, the constriction ring was found to be very tight and flush with thus vagina, thus, the constriction ring was the cervix. The vagina was atrophic and friable. Because this patient also had chronic anemia and had a acute episodes of profuse bleeding during examination and removal of leiomyomatous polyp, she was not able to received prolonged anaesthesia. In addition, because she was postmenopausal, all of her tissues were friable and atrophic. However, it was desirable to perform a procedure to help alleviate the patient's condition during the same operative time, so, in this case, a decision for a novel approach was taken, as other routine surgeries for inversion could not be performed.

Steps of the novel operation included the following:

(1) After catheterization of the bladder, examination showed that the protrusion outside the vaginal introitus was an inverted uterine fundus, which had a tight constriction ring proximally. A vertical incision was made in the midline, anteriorly and posteriorly, bisecting the prolapsed fundus (Fig. 1).

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FIG. 1.

The prolapsed part being cut anteroposteriorly (first step of the operation).

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FIG. 2.

Cut portions of the patient's prolapsed uterus after hysterectomy.

The whole uterus was removed and the cervix was left to remain in situ along with its blood supply, and the inversion was corrected in a short span of time.

This procedure took only 8 minutes.

Results

The patient's postoperative recovery was uneventful, and she was discharged on the third postoperative day, which is normal for patients who have vaginal hysterectomies. Histopathology revealed a benign leiomyomatous polyp. She was advised to come back for a follow-up after 7 days and given instructions not to lift heavy weights and to have regular Papanicolaou smear screening. She came for regular follow-up visits and was healthy.

Discussion

The surgical techniques used in nonpuerperal inversion involve cutting the ring, repositioning of the fundus, and then performing a hysterectomy through an abdominal or vaginal route. The vaginal procedures—namely Spinelli's and Kustner's techniques discussed by Fofie and Baffoe ³ — and abdominal procedures (the Huntington procedure) ⁴ and Haultin's methods ⁵ were not possible to use in this case, as all of the patient's tissues were atrophic and because reposition after cutting the constriction ring usually involves a lot of handling and pulling of tissues. In this case, because the patient's tissues were friable and atrophic, there was a danger of trauma to the pedicles and extension of tearing up to the uterine vessels. Thus the novel technique described above was useful, especially because this patient was postmenopausal. All conventional surgical methods are only applicable to puerperal and nonpuerperal uteri in women of reproductive age.

In addition, this technique can be used in emergencies for all cases of acute, subacute, and chronic inversions, especially in cases of acute inversion or subacute inversion in which hysterectomy is also required during the same operative time. However, it is important to note that this novel technique cannot be used in cases of inversion associated with malignancy.

The advantages of the technique are that it is easy to perform, it is less time-consuming, requires a shorter duration of anesthesia, and, in certain cases, may prove to be lifesaving.

Conclusions

This novel technique of subtotal vaginal hysterectomy to manage nonpurperal inversion seems to be promising and should be adopted by all in such complicated emergencies.