Saima Shabbir ( Department of Gynaecology, Kulsoom Bai Valika Social Security Site Hospital, Karachi. )
Muhammad Ghayasuddin ( Department of Gynaecology, Kulsoom Bai Valika Social Security Site Hospital, Karachi. )
Khursheed Baloch ( Department of Gynaecology, Kulsoom Bai Valika Social Security Site Hospital, Karachi. )
Syed Muneeb Younus ( Department of Surgery, Kulsoom Bai Valika Social Security Site Hospital, Karachi. )
Inversion of uterus is a rare clinical condition, if not associated with puerperium or third stage of labour. Non-puerperal uterine inversion usually results secondary to tumour implanted at fundus of the uterus. An unusual case of non-puerperal uterine inversion caused by a large submucosal fundal fibroid is reported where a 39-year-old woman presented with heavy bleeding per vaginum and profuse vaginal discharge.
Uterine inversion was corrected abdominally by Haultain\'s procedure after vaginal myomectomy followed by abdominal hysterectomy. Both the ovaries were conserved.
Keywords: Uterine inversion, Non puerperal, Fibroid.
Uterine inversion is described as part of the uterus indenting towards and eventually prolapsed through the dilated cervix resulting in uterus being turned inside out. Uterine inversion is categorized as puerperal or obstetric and non puerperal or gynaecological complication. Puerperal uterine inversion occurs as obstetrical emergency due to the mismanaged third stage of labour. Non puerperal inversion of uterus is an exceptional condition secondary to intrauterine pathology like polyps and leiomyoma with fundal attachments.1 Contributing factors responsible for uterine inversion include thinning of the uterine walls from the base of the tumour and pressure atrophy, sudden emptying of the uterus which was previously distended by a tumour, and dilatation of the cervix. Common clinical features of non puerperal inversion are chronic vaginal discharge and anaemia due to heavy irregular uterine bleeding. Some may also present with voiding difficulties and lower abdominal heaviness. The recto abdominal method is often the most diagnostic clinical method , as the vagina is occupied by the inverted uterus and on bimanual palpation there is dimpling of uterine fundus. Treatment depends on the stage of the inversion and associated pathology.
Non puerperal uterine inversion is a rare clinical situation as many gynaecologists may not have seen such a case in their entire practice, so it is a diagnostic dilemma and treatment challenge for them.2
There are no figures on the incidence of it in the literature. 150 cases of non-puerperal uterine inversions were documented from 1887 to 2006 by Gomez-Lobo et al.3 Mwinyoglee et al. reported that 97.4% of uterine inversions are associated with tumours, out of which 20% were malignant,4 while Takano et al. reported that 71.6% cases of uterine inversion were associated with leiomyoma.5
Based on the degree of inversion, some authors describe four distinct stages5 as follows:6
Stage-1: Inversion of the uterus is intrauterine or incomplete. The fundus remains within the cavity.
Stage-2: Complete inversion of the uterine fundus through the fibro muscular cervix.
Stage-3: Total inversion, whereby the fundus protrudes through the vulva.
Stage-4: The vagina is also involved with complete inversion through the vulva along with an inverted uterus.7
Due to its insidious onset and rare occurrence the clinical diagnosis of chronic uterine inversion is difficult, specially if inversion is incomplete. Its diagnosis requires a high index of suspicion when tumour is palpable in vagina or seen out of introitus and uterine fundus is not palpable on bimanual examination, Magnetic Resonance Imaging (MRI) is also helpful in the diagnosis. "U" shaped uterine cavity, a thickened and inverted uterine fundus on sagittal section, and a "bull\'s eye" configuration on an axial image are the described MRI findings of uterine inversion.8
Surgical treatment of chronic uterine inversion depends upon patient\'s fertility, stage of inversion and associated pathology. Many abdominal and vaginal surgical approaches have been described to correct inversion. Spinell and Kustner9 are similar trans-vaginal surgical reposition techniques with the basic differences being that Spinell\'s approach is anterior and requires dissection of the bladder and an anterior uterine wall incision, while Kustner\'s is a posterior approach with incision on the posterior uterine wall, which makes it a bit easier and safer.9 Surgical repositioning can also be done through laparotomy using the Huntington procedure, holding the round ligaments and the uterus below the area of inversion and slowly pulling up repeatedly until the uterus is reinverted. Haultain’s procedure uses a vertical incision in the posterior portion of the ring with gentle traction on the round ligaments.10 In our case, vaginal removal of the tumour was attempted followed by Johnson’s method to correct the inversion which was unsuccessful. Laparotomy had to be performed using an anterior vertical incision on the uterine wall which was followed by a total abdominal hysterectomy.
Chronic non-puerperal uterine inversion is an unusual condition but can occur in premenopausal age. Clinical diagnosis of this is often not easy and sometimes this situation can prove to be fatal. A high index of suspicion is necessary for diagnosis when a large prolapsed fibroid is encountered. As the uterus per se may not be palpable on examination or appear concave on bimanual examination or during laparotomy. Uterine inversion has a good outcome if diagnosed and managed timely. Repositioning of uterus may not be possible in all cases, leaving hysterectomy as the only option. This case in many respects is instructive.
1. Safdarian L, Aleyassin A, Forootan M, Kamalian N, Ahmadzadeh A. Non puerperal uterine inversion: a case report. Acta Medica Iranica 2003; 4: 59-61.
2. Eigbefoh JO, Okogbenin SA, Omorogbe F, Mabayoje PS. Chronic uterine inversion secondary to sub mucous fibroid: a case report. Niger J Clin Pract 2009; 12: 106-7.
3. Gomez-Lobo V, Burch W, Khanna PC. Non-puerperal uterine inversion associated with an immature teratoma of the uterus in an adolescent. Obstet Gynecol 2007, 110: 491-3.
4. Mwinyoglee J, Simelela N, Marivate M. Non-puerperal uterine inversions. A two case report and review of literature. Central African J Med 1997; 43: 268-71.
5. Takano K, Ichikawa Y, Tsunoda H, Nishida M. Uterine inversion caused by uterine sarcoma: a case report. Jpn Clin Oncol 2001; 31: 39-42.
6. Skinner GN, Louden KA. Nonpuerperal uterine inversion associated with an atypical leiomyoma. Aust N Z J Obstet Gynaecol 2001; 4: 100-1.
7. Rosales Aujang E, Gonzales Romo R. Non-puerperal uterine inversion. Gynecol Obstet Mex 2005; 73: 328-31.
8. Oguri H, Maeda N, Yamamoto Y, Wakatsuki A, Fukaya T. Non-puerperal uterine inversion associated with endometrial carcinoma - a case report. Gynecol Oncol 2005; 97: 973-5.
9. Fofie C, Baffoe P. Non puerperal uterine inversion: a case report. Ghana Med J 2010; 44: 79-81.
10. Haultain F. The treatment of chronic uterine inversion by uterine hysterotomy. BMJ 1901; 2: 974-80.