The present case report describes a challenging case of a large cervical fibroid in a nulliparous unmarried lady. She presented with acute retention of urine, and a mass protruding out per vaginum. Myomectomy was performed in this case by a combined abdominal and vaginal approach, along with removal of a large ovarian cyst.

Introduction

Uterine leiomyomas are a major public and women’s health problem. Leiomyomas account for one of the most common tumours of the uterus and female pelvis1 and are responsible for 1/3rd of admissions in hospitals for gynaecological services. Their growth is dependent on oestrogen production. The incidence of cervical fibroids is around 1-2%.1

Case Report

A 30 year old unmarried lady presented with complaints of acute retention of urine associated with a mass protruding per vaginum. The patient also had menometrorrhagia with dysmenorrhoea since 3 months. Past menstrual cycles revealed heavy and irregular cycles. She had a past history of anterior abdominal sling surgery done 5 years ago. The patient’s general and systemic examination was within normal limits. On per abdominal examination, the urinary bladder was distended with diffuse tenderness in lower abdomen; A pfannenstiel scar of sling surgery was observed. On per speculum examination, there was a 10 x 9 cm size fungating mass protruding through the introitus with a foul smelling discharge. On per vaginal examination the uterus was felt separate from the mass. Cervical lips were thinned out. The examining fingers could not define the upper limit of this mass. The patient was investigated; her complete haemogram showed Hb-8 g% with CBC-11,000/cmm, other baseline haematological investigations were normal. X-ray chest was within normal limits.

Pelvic ultrasound was suggestive of a bulky uterus with normal endometrial lining with ET-12 mm and evidence of a large polypoidal cervical fibroid arising below the level of the isthmus and distending the cervix measuring 10 x 10 x 15 cm. There was a simple right ovarian cyst of 8 x 5 cm.

The patient was hospitalised and a self retaining no 16 Foley’s catheter was inserted.The patient was administered broad spectrum antibiotics namely injectable ceftriaxone, metronidazole and amikacin. Patient was counselled along with her parents about the decision of performing a vaginal myomectomy. It was a problematic situation as the patient was nulliparous with an infected cervical fibroid with a previous sling surgery with urinary tract infection and most importantly a strong desire to preserve her reproductive potential.

Vaginal myomectomy was a difficult procedure due to restricted access, as the fibroid was completely distending the vaginal canal. It was impossible to reach the pedicle and the mass was precariously close to the bladder anteriorly.

Vaginal myomectomy was performed. The fibroid was morcellated and excised piece-meal. During myomectomy downward traction on the tumour was avoided to prevent inversion of uterus. Eventually the pedicle was identified, clamped as high as possible and ligated. At this juncture it was decided to combine the procedure with an abdominal approach, as there was a right ovarian cyst for which cystectomy was performed. This also helped rule out inversion of the uterus which was a potential risk during excision of the fibroid. The bladder was separated and the course of the ureter was traced to avoid ureteral injury and displaced away from the field.

The patient’s post-operative recovery was satisfactory. She was discharged on Day 10. On follow up examination the patient’s cervix was healthy and both cervical lips had begun to regain a normal anatomical configuration. The histopathological examination of the mass was consistent with the diagnosis of a benign leiomyoma and a benign ovarian cyst.

Fig. 1 : Cervical fibroid in a nulliparous lady.

Discussion

A Cervical fibroids constitute 1-2 % of the total fibroids and are rare.1 Out of the three types viz, interstitial, supravaginal and polypoidal, 1 the latter is rare and was seen in the present case.

A review of literature suggests that the initiation of leiomyomas involve a multistep cascade of separate tumour initiators and promotors. The initial neoplastic transformation of the normal myocyte involves somatic mutations. Although the initiators of somatic mutations remain unclear, the mitogenic effect of progesterone may enhance the propagation of somatic mutations. Myoma proliferation is the result of clonal expansion and likely involves the complex interactions of oestrogen, progesterone and local growth factors. Oestrogen and progesterone appear equally important as promoters of myoma growth.2

In the present case the patient was in a moribund state with complaints of mass protruding per vaginum, menometrorrhagia with dysmenorrhoea and acute retention of urine and features suggestive of urinary tract infection which are due to pressure symptoms due to the site of the tumour. It was a tough and technically challenging situation as the patient was nulliparous with an infected cervical fibroid with previous sling surgery with urinary tract infection and a strong desire to preserve reproductive function. After individualization of the case and counselling of the patient and relatives, a decision of vaginal myomectomy was taken after treating the infection with broad-spectrum antibiotics. Though operative laparoscopy would have been an effective alternative option, a combined laparotomy had to be resorted in this case for removal of the ovarian cyst and also ensure that there was no inversion of the uterus during vaginal removal of the fibroid.

Ever since Atlee performed the first vaginal myomectomy the procedure has been developed and modified by many surgeons and gynaecologists.3 Goldrath used laminaria japonicum to dilate the cervix to gain access to submucous pedunculated myomata that are higher in the endocervical canal or uterine cavity. A Duhrssen’s incision can also be made over the cervix .3 A vaginal hysterotomy has also been described where the bladder is advanced and the cervix dilated and an anterior midline incision is made in the cervix high enough to identify the myoma.3 Recently in 1999 Davies and colleagues reported a prospective study regarding the safety and efficacy of intramural and subserosal leiomyoma by a vaginal route. Preoperative criteria included uterine size of less than or equal to 16 weeks, good uterine mobility, adequate vaginal access, the presence of intramural or subserosal myoma and the absence of any adnexal pelvic pathology. Essentially an open abdominal myomectomy technique was performed through an anterior and posterior colpotomy. The uterus was manipulated to bring the myoma into the colpotomy. The management of 35 women was described. Here 8.6% required laparotomy and 11.4% developed pelvic haematomas.5

Conclusions

In a case of cervical fibroid or submucosal pedunculated fibroid, it is imperative to have a thorough preoperative evaluation, anticipate operative challenges and strike a judicious and rational approach about deciding the route of myomectomy. It would be prudent to exclude concomitant adnexal pathology for which a

laparotomy or laparoscopy may need to be performed.

References

1. Chapter18, Benign lesions of the uterus, Textbook of Gynaecology D.C.Dutta.2nd edition 1994,New central book agency (P) ltd.
2. Rein MS, Barbieri RL, Friedman AJ. Progesterone : A critical role in the pathogenesis of uterine myomas. Am J Obstet Gynaecol 1995; 172 : 14.
3. Leiomyomata uteri and myomectomy John D Thompson, John A Rock in TeLinde’s textbook of operative gynecology 9th edition.
4. Goldrath MH. Vaginal removal of the pedunculated submucous myoma: historical observations and development of a new procedure. J Reprod Med 1990; 35 : 921.
5. Davies A, Hart R, Magos AL. The excision of the uterine fibroids by the vaginal myomectomy: a prospective study. Fertil Steril 1999; 7 : 1961.