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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 1  |  Issue : 2  |  Page : 56-59

Infected huge prolapsed polypoidal fibroid: Issues of neglect and delayed access to surgical treatment


Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria

Date of Web Publication20-Apr-2017

Correspondence Address:
Fadimatu Bakari
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/archms.archms_5_17

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  Abstract 

Gravitational pull and subtle uterine contractions on huge polypoidal submucous uterine fibroid may dilate the cervix and prolapse into the vagina. Such prolapsed fibroid can either be removed through the vaginal route if it is connected with a long stalk or through an abdominal route if it has a broad base or if it is coexisting with multiple uterine fibroids. We present two cases of grand multiparous women with huge prolapsed submucous fibroids where neglect led to presentation with life-threatening infection and bleeding.

Keywords: Hemorrhage, infection, neglect, prolapsed fibroid


How to cite this article:
Bakari F, Omobayowa MS, Adesiyun AG, Sulayman HU, Ameh N, Shuaib HU. Infected huge prolapsed polypoidal fibroid: Issues of neglect and delayed access to surgical treatment. Arch Med Surg 2016;1:56-9

How to cite this URL:
Bakari F, Omobayowa MS, Adesiyun AG, Sulayman HU, Ameh N, Shuaib HU. Infected huge prolapsed polypoidal fibroid: Issues of neglect and delayed access to surgical treatment. Arch Med Surg [serial online] 2016 [cited 2019 Mar 23];1:56-9. Available from: http://www.archms.org/text.asp?2016/1/2/56/204803


  Introduction Top


Leiomyoma (fibroids) are common benign smooth muscle tumors which may develop anywhere within the wall of the uterus.[1] It could be submucous, intramural, or subserous depending on its location within the uterine musculature. Submucous myomas account for about 15%–25%.[2]

Uterine contractions sometimes push a polypoidal submucous fibroid through the cervix into the vagina leading to a prolapsed fibroid.[3] Gravitation force on a huge prolapsed fibroid may further enhance its descent beyond the vagina.

A few cases of prolapsed uterine fibroids have been reported in the literature; although the incidence is unknown, it is uncommon but not exceedingly rare.[2]

Different approaches to treatment have been described in the literature for prolapsed fibroid depending on the presentation and nature of the prolapse.[2],[3] The two cases presented here had similar presenting features but had different approaches to surgical treatment that best suits the characteristics of their individual prolapsed fibroid.


  Case Reports Top


Case 1

Mrs. IF was a 49-year-old Para 6+0 whose last childbirth was 10 years before presentation. She presented to the emergency ward with a week history of profuse vaginal bleeding that was associated with blood clots and progressively worsening dizziness and easy fatigability. She had an associated mass that was protruding from her vagina, and this was accompanied with dysuria, lower abdominal pain, and urinary frequency. She presented to our health facility due to persistent bleeding and dizziness.

She was admitted at a secondary health-care facility 18 months before presentation where she was treated for menorrhagia and had blood transfusion. The uterine fibroid was diagnosed following evaluation, and she was counseled for surgery. She, however, declined surgery because she could not afford the cost. She has taken several herbal medications with the hope that it will “dissolve the fibroids.”

She has had six previous vaginal deliveries all at home, and all the children are alive.

Examination revealed an acutely ill-looking woman who was pale, febrile, anicteric, not dehydrated and had no lymphadenopathy and pedal edema. Her respiratory rate was 28 cycles per minute and it was regular. The lung fields were clinically clear. Her pulse rate was 114 beats per minute, regular and small volume. The blood pressure was 80/60 mmHg. The heart sounds were normal. Her abdomen was full and moved with respiration. There were 28 weeks pregnancy size abdominopelvic mass that extended to the right lumbar region. It was firm in consistency with limited mobility from side to side. Pelvic examination revealed blood-soaked perineal pad and a huge mass occupying the entire vagina up to the lower third. It had a smooth but boggy surface and was firm in consistency without any contact bleeding. She had an offensive vaginal discharge.

An impression of an infected huge prolapsed fibroid coexisting with multiple uterine fibroid and severe anemia was made.

Her hematocrit was 19%, and total white cell count was 6.0 × 109/L. The neutrophils were increased. Electrolyte, urea, creatinine, chest X-ray, and electrocardiogram were normal. Abdominopelvic ultrasound revealed a bulky uterus containing multiple hyper-echoic masses. There was a huge mass measuring 20 cm × 18 cm seen in the region of the lower part of the uterus and the cervix extending down through the vagina. The cervix was not distinctly identified. There were multiple cystic areas within the masses which took color on Doppler. The right kidney was normal in size and outline but with dilatation of the pelvi-caliceal system. The left kidney was preserved. Radiologist conclusion was that of multiple uterine fibroids with right hydronephrosis.

She was resuscitated with intravenous fluids and had a total of 5 units of blood transfused. She was also commenced on intravenous ceftriaxone and metronidazole. A urethral catheter was passed and about a liter of urine was drained. She was counseled for examination under anesthesia and laparotomy. Her posttransfusion hematocrit was 34%.

She had laparotomy 2 days after admission. Intra-operative findings were clean peritoneal cavity, uterus was about 26 week size with multiple intramural fibroids and a huge 22 cm × 20 cm lower segment fibroid that had fully dilated the cervix, stretching the lower uterine segment, displacing the bladder superiorly and prolapsed into the vagina. The  Fallopian tube More Detailss were adherent to the body of the uterus bilaterally. The ovaries were atretic. The liver was grossly normal. She had no ascites. She had a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The prolapsed fibroid was delivered intact together with the uterus abdominally [Figure 1]. Postoperative period was uneventful. The histopathology report revealed uterine fibroids with degenerative changes.
Figure 1: Hysterectomy specimen; uterus and prolapsed myoma.

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Case 2

Mrs. SA was a 35-year-old Para 10+0 whose last childbirth was 5 years before presentation and her last normal menstrual period was a year before presentation. She presented to the emergency unit with a week history of a mass protruding outside the vagina and an associated history of progressively worsening dysuria, urinary frequency, and feeling of incomplete voiding. She had no loin pain. There was a history of lower abdominal pain that was described as severe, dragging in nature, and radiating to the back. Five days before presentation, she developed profuse vaginal bleeding with blood clots, dizziness, and easy fatigability. She has been having heavy menstrual flow, postcoital bleeding, and inter-menstrual bleeding for the past 12 months.

She was being treated by a nurse and was also on herbal medication at home but decided to present to the hospital because of worsening symptoms.

She attained menarche at the age of 13 years and had a regular menstrual cycle of 28 days with moderate flow of 3–4 days duration before onset of symptoms.

She was Para 10+0, 8 alive. All pregnancies were registered for antenatal care but deliveries were all at home.

She was admitted to a private hospital during an episode of heavy menstrual bleeding 4 months before presentation and was transfused with 2 units of blood. She was evaluated while on admission and a diagnosis of uterine fibroid was made. She was counseled for myomectomy, but she declined surgery for financial constraints. The heavy menstrual flow persisted and was later associated with an offensive vaginal discharge.

Examination revealed an ill-looking woman who was in intermittent painful distress. She was pale, febrile (temperature: 37.8°C), anicteric, not dehydrated, without any lymphadenopathy or pedal edema. Her respiratory rate was 27 cycles/min and regular. The lung fields were clinically clear. Her pulse rate was 108 beats/min, regular and small volume. The blood pressure was 90/60 mmHg. The heart sounds were normal. Her abdomen was full and moved with respiration; she had tenderness in the supra-pubic region making it difficult to assess the uterine size. The liver, spleen, and kidneys were not palpably enlarged. There was no ascites, and the bowel sounds were normal. Pelvic examination revealed a huge mass protruding outside the vagina with an offensive discharge. It measured 20 cm × 14 cm, boggy with some areas of necrosis. It was firm in consistency with a long stalk that was attached to the uterus. The cervical rim was not felt, and there was no contact bleeding.

A clinical impression of septic huge prolapsed polypoidal uterine fibroid with hypovolemia and severe anemia was made.

Her hematocrit was 17%, white cell count was 20.0 × 109/L, and neutrophils were 80%. Electrolytes, urea, and creatinine were normal. Abdominopelvic ultrasound revealed globular uterine contour but with an abnormally appearing uterine fundus. The enlarged uterus measured 10.5 cm in maximum anteroposterior diameter. The endometrial cavity seems to contain mixed echogenic fairly rounded lesion surrounded by echogenic fluid.

She was resuscitated with intravenous fluids and was commenced on antibiotics. A urethral catheter was passed, and about 850 ml of urine was drained.

The prolapsed necrotic fibroid was twisted around its pedicle, avulsed, and the stalk ligated in the emergency unit. Pelvic examination performed after removal of the fibroid polyp revealed an inverted uterus with the uterine fundus at the level of the middle third of the vagina. She had 5 units of blood transfused and was counseled for examination under anesthesia, laparotomy with a possibility of an abdominal hysterectomy.

She had surgery 2 days after admission. On examination under anesthesia, a distended vagina that contained an inverted uterus that measured about 10 cm × 8 cm in dimension was seen. At laparotomy, a fully inverted uterus was seen with only the round ligaments, the fallopian tubes, and ovaries in view abdominally [Figure 2]. She had total abdominal hysterectomy after repositioning the uterus back into the abdominal cavity with preservation of both ovaries. Her postoperative recovery was satisfactory. Hematocrit after surgery was 30%. She was discharged on the 5th day after surgery.
Figure 2: At laparotomy: A fully inverted uterus, round ligament, fallopian tubes, and ovaries in view.

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Pathology report of the prolapsed fibroid reported a leiomyoma with cystic degeneration and hemorrhagic areas.

The hysterectomy specimen showed no metaplastic or neoplastic changes.


  Discussion Top


Leiomyoma are common benign smooth muscle tumors with a prevalence of up to 80%,[1],[2] and contributes 70%–80% of all tumors in the female genital tract in Nigerian women.[4]

Prolapsed submucous myoma is a rare presentation because of often times a submucous myoma would have manifested with heavy menstrual bleeding and would have been removed surgically before it grows big and prolapses. Both patients under review had earlier presented to a health-care facility with menorrhagia and they were both counseled for myomectomy, but because they could not afford the cost of treatment, they declined surgery which led to the neglect of their disease condition until it reached an enormous size and prolapsed into the vagina. The inability to afford the cost of healthcare is a major factor that affects the health-seeking behavior of the populace in a resource-poor setting like Nigeria.[5],[6] Due to financial constraints, some patients are forced to patronize unorthodox medical practitioners where the costs of treatments are perceived to be more affordable and accessible. Both patients had resorted to herbal concoctions as an alternative to surgery for their disease condition and only decided to present to the hospital when all unorthodox avenues have been exhausted without relief of their symptoms. In addition, ignorance and lack of economic empowerment have been identified as significant contributors to poor health-seeking behavior in low-income economy like ours.[6] The lack of health insurance to alleviate most of the cost of health care has also been identified as a mitigating factor to access health care in developing countries.[5]

The usual presenting features of patients with prolapsed myoma are symptoms of mass in the vagina or mass outside the vagina, abnormal vaginal bleeding, and dysmenorrhea.[7] Heavy vaginal bleeding with features of infection, shock, severe anemia, obstructive/irritative lower urinary tract symptoms, and pressure symptoms are usually features of delayed presentation. These were the features that these two patients presented with. This clearly demonstrated the challenge in developing countries like sub-Saharan Africa where the age long issue of delay in seeking health care when disease conditions are at their early stages leads to life-threatening conditions.

As found in these patients, a prolapsed myoma may become infected and necrotic because of inadequate blood supply to the pedicle. These can lead to offensive odor, vaginal discharge, and contact bleeding leading to a suspicion of a genital malignancy.

Complications that may be associated with prolapsed myoma include uterine inversion due to the gravitational pull on the uterus, fistula and urinary retention as a result of the compression effect of the mass.

Most cases of prolapsed submucous myoma reported in the literature were associated with chronic nonpuerperal uterine inversion.[7],[8],[9]

Both patients had evidence of chronic urinary retention during catheterization whereby about 1000 mls and 850 mls of urine was drained from the bladder respectively. Uterine inversion was diagnosed intra-operatively in Case 2 when the classical flower vase pattern was noted as shown in [Figure 3].
Figure 3: Huge polypoidal prolapsed and necrotic uterine fibroid at vaginal examination.

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Management options for prolapsed submucous myoma include vaginal myomectomy, abdominal myomectomy, abdominal hysterectomy usually following the removal of the prolapsed myoma, and vaginal hysterectomy.[10],[11]

The choice of surgical procedures in patients with prolapsed polyp is dependent on the accessibility of the pedicle vaginally and the broadness of the base. Prolapsed polypoidal submucous myomas can be removed vaginally because they are usually easily accessible due to their long pedicle, produce little bleeding and do not require additional dilatation of the cervix.[3] However, large myomas with broad base may be less accessible vaginally, may bleed heavily and pose a risk for uterine inversion during their removal, and hence may require a hysterectomy. The results of these treatment modalities have been good in cases reported so far.

The two cases presented here had two different approaches to surgical treatment that best suits the characteristics of the individual prolapsed fibroid. The first case had abdominal hysterectomy with delivery of the prolapsed myoma still attached to the endometrium, whereas the second case had vaginal removal of the prolapsed polyp first, replacement of inverted uterus, followed by an abdominal hysterectomy. Both had a successful postoperative recovery.

In conclusion, prolapsed submucous fibroid is not a common presentation, but it can be seen in situ ations when initial symptoms of a submucous fibroid are neglected. Women's financial empowerment is paramount, but importantly, highly subsidized health policy such as health insurance is needed in our setting to reduce morbidity and mortality that can result from late presentation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence. Am J Obstet Gynecol 2003;188:100-7.  Back to cited text no. 1
    
2.
Parker WH. Prolapsed Uterine Leimyoma. UpToDate Feb 2017.  Back to cited text no. 2
    
3.
Golan A, Zachalka N, Lurie S. Vaginal removal of prolapsed pedunculated submucous myoma: A short, simple and definitive procedure with minimal morbidity. Arch Gynaecol Obstet 2005;271:11.  Back to cited text no. 3
    
4.
Akinyemi BO, Adewoye BR, Fakoya TA. Uterine fibroid: A review. Niger J Med 2004;13:318-29.  Back to cited text no. 4
    
5.
Tanimola MA, Julius OO. Health care seeking behavior in Anyigba, North Central Nigeria. Res J Med Sci 2009;3:47-51.  Back to cited text no. 5
    
6.
Awoleke JO, Adanikin AI, Awoleke AO. Ruptured tubal pregnancy: Predictors of delays in seeking and obtaining care in a Nigerian population. Int J Womens Health 2015;7:141-7.  Back to cited text no. 6
    
7.
de Vries M, Perquin DA. Non-puerperal uterine inversion due to submucous myoma in a young woman: A case report. J Med Case Rep 2010;4:21.  Back to cited text no. 7
    
8.
Kilpatrick CC, Chohan L, Maier RC. Chronic nonpuerperal uterine inversion and necrosis: A case report. J Med Case Rep 2010;4:381.  Back to cited text no. 8
    
9.
Lai S, Sowmya SS, Kriplani A, Bhata N, Aganwal N. Urethrovaginal fistula due to prolapsed cervical myoma: A case report. Internet J Gynaecol Obstet 2006;7:1-4. [Doi: 10.55 80/19 25].  Back to cited text no. 9
    
10.
Aniebue U, Nwankwo T. Complete utero vaginal prolapse in a woman with prolapsed submucous fibroid. Ann Med Health Sci Res 2015;5:83-5.  Back to cited text no. 10
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11.
Zachalka N, Lurie S, Sagiv R, Glezerman M. Vaginal removal of prolapsed pedunculated submucous myoma: A short, simple, and definitive procedure with minimal morbidity. Arch Gynecol Obstet 2005;271:11-3.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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