Although described as a postpartum complication, uterine inversion may also occur in nonpregnant women. We report a case of nonpuerperal uterine inversion, because of a large exteriorized submucous myoma in a 40-year-old woman, which was surgically managed by hysterectomy using a combined laparoscopic and vaginal approach.
Uterine inversion is a rare complication of the postpartum period and an extremely rare event in nonpregnant women. Nonpuerperal uterine inversion is mainly caused by a submucous myoma; however, other causes may also be involved, such as malignant uterine tumors (15%).
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Case Report
A 40-year-old woman, who had previously delivered 4 infants vaginally and who had undergone 3 hysteroscopic resections of benign submucous leiomyomas, responsible for vaginal bleeding during the last year, presented with lower abdominal pain, radiating to the vagina. The pain had become increasingly aggravated during the preceding week. A protruding mass of approximately 7 cm was found on speculum examination, with minimal bleeding and inability to visualize the cervix. The size of the uterus was difficult to appreciate by bimanual abdominopelvic examination because of the distended abdomen and abdominal pain. Transvaginal ultrasonography revealed a uterus measuring 60 × 92 mm, with an endometrium 8 mm thick and a cervicoisthmic mass of 70 mm, suggesting the diagnosis of a prolapsing submucous pedunculated myoma. As this hypothesis was considered accurate, neither magnetic resonance imaging (MRI) nor computed tomography were performed. Following the patient’s request for definitive treatment, a total laparoscopic hysterectomy was planned.
Laparoscopic exploration showed complete invagination of the uterus through the vagina ( Figure 1 ), confirming the diagnosis of a stage 2 uterine inversion. After ligation of the uterine arteries at their origin, the round, broad, and uterosacral ligaments and the fallopian tubes were coagulated and sectioned ( Video ). The procedure was then completed using a vaginal approach; circular colpotomy was performed following the line separating the normal-colored vaginal wall and the ischemic tissue, which had undergone marked color change after uterine artery ligation ( Figure 2 ). The uterus was then retrieved, and vaginal closure was performed using interrupted resorbable sutures. The patient was discharged at postoperative day 3 and showed favorable outcomes. Pathologic examination confirmed uterine inversion resulting from a 7 cm myoma attached to the uterine fundus ( Figure 3 ). Although the majority of the endometrium was removed by prolonged abrasion, small persistent fields of cylindric mucosecretory glandular epithelium free of carcinoma cells remained.
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