Uterine fibroids are one of the most common benign tumors of women. It is estimated between 50 and 70% of women in the reproductive age will experience fibroids. Most patients are asymptomatic. The symptoms a patient experiences depend upon the location of her fibroids. Submucosal fibroids can produce significant bleeding symptoms and constitute 15–20% of all fibroids [1]. Submucosal fibroids can be classified by the amount of the fibroid that protrudes into the uterine cavity. Type 0 fibroids are entirely in the uterine cavity, type 1 have more than 50% in the uterine cavity, and type 2 fibroids have less than or equal to 50% in the uterine cavity. Uterine contractions over time can elongate the attachment of fibroids resulting in the eventual prolapse of a fibroid through the cervical canal. Prolapsed uterine fibroids have been found in up to 3.8% of women undergoing surgery for fibroids [2].

Most women (90%) with a prolapsed uterine fibroid have symptoms, while a few women may be identified on physical examinations that are asymptomatic. Vaginal bleeding is seen in 70–84% of women [2, 3]. Symptomatic women can experience menometrorrhagia, menorrhagia, or postmenopausal bleeding. Women may also experience abdominal cramping or weakness and up to 42.8% may be anemic [2]. The presence of the fibroid in the vagina can produce a pressure sensation, vaginal discharge, or in rare circumstances voiding dysfunction.

Women who have symptomatic fibroids frequently have multiple fibroids resulting in enlargement of the uterus. In one of the larger series describing women treated for prolapsed fibroid, 59% of the women had a uterus greater than 10-week size, and 65% of the women had a prolapsed fibroid greater than 3 cm [3]. Rarely, a prolapsed fibroid has been reported as large as 3.5 kg [4].

The differential diagnosis of a mass protruding from the cervix includes a fibroid emanating from the uterine cavity or the cervix, uterine polyp, cervical polyp, cervical cancer, endometrial adenocarcinoma, endometrial stromal sarcoma, adenosarcoma, and leiomyosarcoma. It is often difficult to assess the nature of a prolapsed mass as the process of prolapsing through the cervix with the resulting restriction of blood flow due to elongation of the stalk results in ischemic necrosis. Clinical management should await final pathology as intraoperative frozen section diagnosis is challenging in the setting of necrosis.

The physical examination of the patient with a prolapsed uterine fibroid typically results in the correct diagnosis. Speculum placement may be very difficult in such patients, as the fibroid may obstruct the vaginal canal and the cervix is often not visible. Depending on the size and location of the fibroid, it may not be possible to identify or palpate the entire cervix. If the fibroid is small and does not completely obscure the cervix, it may be possible to reduce the fibroid and thereby identify if it originates from the cervix or the uterine cavity. It is not uncommon, however, for the fibroid to be greater than 3 cm and prevent adequate assessment of the cervical anatomy.

Prolapsed uterine fibroids may originate from the uterine cavity, cervix, or lower uterine segment. Depending on the length of time, the fibroid has been prolapsed the elongated stalk to the uterus may be very long, with the longest reported case being 76 cm [5]. This unusual case was notable for the fact that the prolapsed section of the fibroid originated not directly from the endometrial cavity or cervix but from a 6 cm submucosal fibroid. Fibroids often have multiple small fibroids contained within an outer capsule. In this case the prolapsing portion was only one part of the fibroid.

Patients that have prolapsing fibroids will require surgical intervention; therefore, it is important to image the uterus to completely investigate the uterine anatomy for surgical planning. Clinically it is very helpful to assess the entire uterus so as to provide accurate counseling to the patient regarding the ability of the planned procedure to alleviate the patient’s symptoms. The objective of imaging is to identify the origin of the fibroid for surgical planning as well as evaluate the entire uterus for the overall fibroid burden. A pelvic ultrasound is the most cost-effective first step in the evaluation. If the ultrasound does not provide adequate information, a pelvic MRI can provide greater detail of the uterine anatomy. A soft tissue stalk connecting a cervical mass to the uterine cavity identified on MRI has been termed the “broccoli sign .” This finding is not specific to a prolapsed fibroid and has been associated with endometrioid adenocarcinoma, carcinosarcoma, and adenosarcoma [6].