|Year : 2012 | Volume
| Issue : 2 | Page : 87-90
Chronic non-puerperal uterine inversion: Case series
Zakari Muhammad, Saidu Adamu Ibrahim, Ibrahim Adamu Yakasai
Department of Obstetrics and Gynecology, Bayero University, Kano, Nigeria
|Date of Web Publication||12-Mar-2013|
Ibrahim Adamu Yakasai
Department of Obstetrics and Gynecology, Bayero University/Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Inversion of the uterus is a rare clinical problem. Non-puerperal inversion usually results from a tumor arising from the fundus of the uterus. We report two cases of chronic non-puerperal uterine inversion in a 38-year-old and a 54-year-old postmenopausal woman. They both presented with vaginal bleeding, a mass protruding from the vagina and lower abdominal pain. Diagnosis was made based on these clinical features. At first, vaginal myomectomy was performed and after that, a Kustner procedure and vaginal hysterectomy was performed in both cases. Early diagnosis and appropriate surgical treatment of the inverted uterus are important to prevent further complications.
Keywords: Fibroid, inversion, non-puerperal, uterus
|How to cite this article:|
Muhammad Z, Ibrahim SA, Yakasai IA. Chronic non-puerperal uterine inversion: Case series. Niger J Basic Clin Sci 2012;9:87-90
|How to cite this URL:|
Muhammad Z, Ibrahim SA, Yakasai IA. Chronic non-puerperal uterine inversion: Case series. Niger J Basic Clin Sci [serial online] 2012 [cited 2019 May 23];9:87-90. Available from: http://www.njbcs.net/text.asp?2012/9/2/87/108473
| Introduction|| |
Inversion of the uterus is a rare clinical problem, with over a hundred case reports of chronic non-puerperal inversion of the uterus in the literature. Most reports cite a prolapsed fibroid as the cause, with some reporting that the fibroid was infected. , Non-puerperal uterine inversion is associated with uterine tumors. It occurs when the uterus contracts to expel a submucous leiomyoma with fundal attachment.  Sometimes endometrial sarcoma may also have similar effect, causing thinning of the uterine wall, thereby predisposing to inversion. ,
Non-puerperal uterine inversion can be classified into acute and chronic based on the onset and evolution. The acute is more dramatic and characterized by severe pain and hemorrhage whereas the chronic is insidious in onset with chronic vaginal discharge and irregular uterine bleeding leading to anemia and feeling of something coming down the vagina. 
Treatment depends on the preoperative diagnosis, but abdominal or vaginal hysterectomy is recommended for benign causes if childbearing has been completed.  However, when the inversion is associated with malignancy, radical abdominal hysterectomy with appropriate biopsy is indicated.  The following are case reports of women who presented with non-puerperal uterine inversion secondary to uterine fibroid at Aminu Kano teaching hospital, Kano, Nigeria.
| Case Reports|| |
A 38-year-old P 4 +1 , her last childbirth was two years prior to presentation. She was referred to our Centre from Muhammad Abdullahi Wase Specialist Hospital, Kano, with a month history of vaginal protrusion, which became more prominent with micturition and defecation. She menstruated for five days in a regular 28-30 days' cycle. However, in the previous four years before she presented the duration of her menstrual blood flow had increased to 10 days with excessive blood loss.
she had started her menstruation a week before she presented to our hospital. It started as light brown discharge, but progressed to heavy fresh bleeding associated with dizziness and lower abdominal pain.
She was not on contraception and had no history of chronic cough or constipation. All her four children were delivered normally. She was married to a driver in a monogamous setting. There was nothing relevant in her past medical and surgical history.
On examination, she was ill-looking, pale with a pulse rate of 112 beats per min, regular and of good volume. She had a blood pressure of 100/60 mmHg with first and second heart sounds. Her abdomen was soft, had lower abdominal tenderness but the liver, spleen, and kidneys were not palpably enlarged. There was no demonstrable ascites.
Pelvic examination revealed a protruding mass from the vagina, which was firm, about 15 cm × 8 cm, globular and hemorrhagic. A working diagnosis of fibroid polyp was made. She was counseled and prepared for examination under anesthesia (EUA). Her Packed Cell Volume (PCV) was 20%. She had three pints of blood transfused before the EUA. The post-transfusion PCV was 30%.
Examination under anesthesia was done three days after presentation. She was found to have complete uterine inversion with a uterine fibroid measuring about 10 × 8 cm attached to the uterine fundus. The external urethral meatus looked grossly normal, but the cervix could not be identified [Figure 1]a.
|Figure 1: (a) Uterine inversion at presentation; (b) Appearance of vulva after surgery|
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Myomectomy was done vaginally, and then a Kustner procedure was used to replace the inverted uterus. The Kustner's operation involves opening of the posterior cul-de-sac transversely. The cervix and posterior wall of the uterus were incised along the midline. At the completion of this step a thumb pressure applied along the sides of the uterus produce reversion, the wounds were closed with interrupted sutures, and the uterus replaced in the pelvic cavity. The colpotomy was then closed. Vaginal hysterectomy was then performed [Figure 1]b.
She had postoperative prophylactic antibiotics for five days. She did well and was discharged home on the fifth postoperative day.
Histology confirmed leiomyoma uteri and benign nature of the hysterectomy specimen.
A 54-year-old P8 + 2 , 4 alive, 4 years postmenopausal, her last child birth was 13 years before presentation. She was referred to our centre from Sir Sanusi General Hospital, Kano with four months' history of recurrent vaginal bleeding and three months' history of vaginal protrusion associated with lower abdominal pain.
Examination revealed a chronically ill-looking woman, pale but not jaundiced. Her pulse rate was 100 beats per min, regular and of good volume. She had a blood pressure of 110/70 mmHg with first and second heart sounds. Her abdomen was normal.
Pelvic examination revealed a huge mass protruding from the vaginal introitus, measuring 20 × 12 cm with areas of necrosis and ulceration. The cervix was not identifiable. There was no active bleeding from the mass. An initial diagnosis of third-degree uterovaginal prolapse was made.
Her PCV was 26%. She had two pints of blood transfused preoperatively. The serum electrolyte and urea were within normal limits.
Two days after admission she had examination under anesthesia, The findings were a globular mass measuring 20 × 12cm with areas of necrosis and ulceration. In addition she had a huge submucuos gangarenous fibroid measuring 10 × 10cm on the fundal region of the inverted uterus. She had vaginal myomectomy done and Kustner procedure was used to replace the inverted uterus and vaginal hysterectomy was performed as shown in [Figure 2]a and b.
She was commenced on prophylactic antibiotics for five days. She did well postoperatively and she was discharged home on the seventh postoperative day.
Histology confirmed leiomyoma and benign nature of the uterus.
|Figure 2: (a) Uterine inversion at presentation; (b) Appearance of vulva after surgery|
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| Discussion|| |
Non-puerperal uterine inversion is usually precipitated by tumors sited at the fundus of the uterus which exert traction force to cause the inversion, although some cases have been reported with no association with tumors.  Chronic uterine inversion is a rare clinical problem and over a period of 10 years, in this center, only five cases have been recorded. When uterine inversion occurs outside the puerperium it poses a diagnostic dilemma as it was in both cases presented,  where fibroid polyp and third-degree uterovaginal prolapse were the initial diagnoses.
Most cases of non-puerperal uterine inversions are usually chronic  as were the cases presented, however, 8.6% of the cases are of acute onset. 
The uterine inversions in the cases presented were due to submucous uterine fibroids. Other causes of chronic uterine inversion include endometrial polyp, uterine sarcoma, endometrial carcinoma and mixed mesodermal tumors. ,
The major factors that contribute to its occurrence are: Tumor attachment site, thickness of the tumor pedicle, tumor size, thin uterine wall and dilatation of the cervix. Different studies have reported different causative factors of uterine inversion. In our center all the cases seen over the previous years were due to uterine fibroid. This is similar to the studies by Takano et al., who reported 92% association with tumors out of which 63/88 (71.6%) were leiomyomas and 20% malignant tumors. 
Symptoms of non-puerperal uterine inversion are vaginal bleeding, vaginal mass, as was the case in the presented series. Other symptoms include lower abdominal pain and urinary disturbance.  In addition the patient may complain of pressure in the vagina or of something protruding or coming down the vagina. 
In chronic cases, diagnosis is difficult. In the cases presented, the initial diagnoses were fibroid polyp and third-degree uterovaginal prolapse. The diagnoses were confirmed during examination under anesthesia.
Magnetic resonance imaging (MRI) and computerized tomography (CT) scan, are useful diagnostic tools.  MRI can examine the characteristic image of uterine inversion. A U-shaped uterine cavity and a thickened and inverted uterine fundus on a sagittal image and a 'bulls-eye' configuration on an axial image are signs indicative of uterine inversion. 
The above investigations were not done in the cases presented because, we have no MRI machine in our Centre and the CT scan is expensive. Ultrasound scan was not done for the diagnosis in the cases presented, however, where this is available the ultrasound features shows the uterus appearing as a "target sign" with hyperechoic fundus surrounded by a hypoechoic rim, representing fluid within the space between the inverted fundus and the vaginal wall. 
The fundal myomas in both cases presented were removed vaginally from the uterine wall and hemostasis secured using vicryl No 1 sutures. The uterine inversion was then corrected using Kustner's procedure. Vaginal hysterectomy was then performed.
This was the treatment of choice because Mrs. UP desired no further fertility and Mrs. IJ was a post-menopausal woman.Their postoperative recovery was satisfactory. They were discharged home on the fifth and seventh postoperative day respectively.
| Conclusion|| |
Chronic non-puerperal inversion of the uterus is uncommon, with little more than 100 reports in the literature. Its presence should be suspected when a woman presents with something coming down the vagina associated with vaginal bleeding and lower abdominal pain, or when a larger prolapsed fibroid is encountered. An attempt at vaginal restoration using surgical techniques has been reported.
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[Figure 1], [Figure 2]