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Torsion of a Uterine Leiomyoma
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TORSION OF A UTERINE LEIOMYOMA Yueh-Ju Tsai1, Sew-Khee Yeat1, Cherng-Jye Jeng1,2,3*, Su-Chee Chen1 Department of Obstetrics and Gynecology, Cathay General Hospital, 2Department of Medicine, College of Medicine, Fu-Jen Catholic University, and 3Department of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
1
SUMMARY Objective: To report a case of torsion of a pedunculated uterine leiomyoma. Case Report: A 38-year-old female virgin presented at the emergency department with complaints of severe lower abdominal pain on November 30, 2005. A transabdominal sonogram revealed multiple uterine masses, including a pedunculated mass. With a preoperative diagnosis of torsion of a pedunculated subserosal leiomyoma, the patient underwent an abdominal myomectomy. On gross inspection, the resected myoma was ischemic, and both focal hemorrhage and necrosis were noted in the pathology report. Conclusion: Torsion of a pedunculated uterine myoma is rare but represents a surgical emergency to improve symptoms and avoid consumptive coagulopathy. [Taiwanese J Obstet Gynecol 2006;45(4):333–335] Key Words: torsion, uterine leiomyoma
Introduction Uterine leiomyomas are smooth muscle tumors of the uterus. They are found in women throughout the world. Leiomyomas may be submucosal, intramural, subserosal or found in the broad ligament [1]. Occasionally, subserosal leiomyomas may become pedunculated. It is even less common for pedunculated leiomyomas to undergo torsion. There are only a few reported cases in the literature. The incidence of pedunculated uterine leiomyomas that have undergone torsion is unknown to the authors. We present a case of pedunculated uterine leiomyoma that underwent torsion.
Case Report A 38-year-old female virgin presented at the emergency department with complaints of severe lower abdominal pain on November 30, 2005. Physical examination revealed tenderness to deep palpation as well as rebound
*Correspondence to: Dr Cherng-Jye Jeng, Department of Obstetrics and Gynecology, Cathay General Hospital, 280, Section 4, Jen-Ai Road, Taipei 106, Taiwan. E-mail: [email protected] Accepted: July 4, 2006
Taiwanese J Obstet Gynecol • December 2006 • Vol 45 • No 4
tenderness in the right lower quadrant. Abdominal X-ray revealed gas and air–fluid levels in the small bowel. Bowel obstruction or ileus was suspected. White blood cell count was 12,610/μL and serum C-reactive protein level was elevated to 13,991 mg/dL. There were no signs of gastrointestinal symptoms such as vomiting, diarrhea or constipation. No Rovsing’s sign, psoas sign or obturator sign were noted and, according to the progress of her symptoms, the possibility of acute appendicitis was excluded by the attending surgeon. A transabdominal sonogram revealed multiple uterine masses that were consistent with multiple uterine leiomyomas. The largest one measured 7.1 × 6.7 cm and was located in the myometrium of the uterine fundus. There was another large mass measuring 6.6 × 5.2 cm in size (Figure 1). Its pattern was homogeneous and the same as the myoma in the uterine fundus. We considered that it was a uterine subserosal mass in the right side of the pelvis. Other small uterine masses were also visible through direct eye inspection. Given that the painful area was in the same location as the uterine subserosal mass, our preoperative diagnosis was a pedunculated uterine myoma that had undergone torsion. The patient gave consent to surgical intervention. A pedunculated leiomyoma that had undergone torsion around the stalk twice was discovered intraoperatively. The leiomyoma was approximately 8 cm in
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Figure 1. Ultrasound shows a subserosal leiomyoma measuring 6.6 × 5.2 cm (left “M”).
Figure 2. Pedunculated leiomyoma (bluish mass on the left side) that had undergone torsion is seen at laparotomy.
diameter and grossly bluish in color (Figure 2). An uncomplicated myomectomy was performed. Focal hemorrhage and necrosis were noted in the pathology report. The patient had an uneventful postoperative course and was discharged on December 4, 2005.
by the enlarged uterus and was therefore difficult to resect. Roy et al reported that the diagnosis of torsion of uterine leiomyoma could be established by computed tomography or ultrasound examination, but ultrasound is less sensitive [3]. In our case, we were able to find a pedunculated myoma with ultrasound. However, the sonographic findings alone did not reveal that the leiomyoma had undergone torsion. In other words, the preoperative diagnosis of torsion was based on sonographic findings as well as clinical presentation. The management of torsion of a uterine leiomyoma should be immediate in the case of infarction or necrosis. Abdominal myomectomy is the most common surgical intervention. Katsumori et al described uterine artery embolization for the treatment of pedunculated leiomyomas [4]. Their cases were confirmed with baseline sagittal and axial magnetic resonance imaging. They found no serious complications after embolization of pedunculated leiomyomas with stalk diameters ≥ 2 cm. Regarding the case presented here, we did not use advanced radiographic imaging techniques such as computed tomography or magnetic resonance imaging. We felt that ultrasonography and clinical presentation were sufficient. We conclude that early diagnosis of torsion of a uterine pedunculated myoma is important because ischemia or necrosis can cause consumptive coagulopathy or severe pain. Consumptive coagulopathy is very dangerous for the patient. Severe pain for a long time without relief is intolerable and is an indication for emergency surgery. The diagnosis can be made based on ultrasound and clinical findings. Emergency surgery
Discussion Torsion of a leiomyoma is rare. The existence of a pedunculated leiomyoma is a requisite for torsion. The stalk of the pedunculated myoma must be thin and long in order for it to undergo rotation and torsion. The size of the myoma is a key factor for irreversible torsion. It is easy to correct torsion spontaneously in pedunculated leiomyomas that are small. However, large pedunculated leiomyomas are difficult to correct because there is little room to undergo torsion. Another important factor in the etiology of torsion is the relationship between the myoma and adjacent organs, such as the uterine corpus, the bowel or the pelvic sidewall. After rotation of the stalk of a pedunculated leiomyoma, the leiomyoma may become fixed in place by surrounding organs. This leiomyoma may then become ischemic or necrotic, with resultant abdominal pain. The consideration of a pedunculated leiomyoma that has undergone torsion in the differential diagnosis is the key for early surgical intervention and treatment. Mickel et al reported that torsion of pedunculated leiomyomas could not only complicate pregnancy and delivery but could also disturb the puerperium due to compression of the bowel [2]. The authors found that the leiomyoma that had undergone torsion was fixed
334
Taiwanese J Obstet Gynecol • December 2006 • Vol 45 • No 4
Torsion of a Uterine Leiomyoma
must be performed as early as possible to improve symptoms and avoid consumptive coagulopathy.
References 1.
Berek JS. Chapter 13: Benign Disease of the Female Reproductive Tract. In: Novak’s Gynecology, 13th edition. Philadelphia: Lippincott Williams & Wilkins, 2002:380–7.
Taiwanese J Obstet Gynecol • December 2006 • Vol 45 • No 4
2.
3.
4.
Mickel I, Bollmann R, Chaoui R, Lau HU. Torsion of the myoma pedicle as a rare cause of ileus in puerperium. Geburtshilfe Frauenheilkd 1995;55:721–3. Roy C, Bierry G, Ghali SE, Buy X, Rossini A. Acute torsion of uterine leiomyoma: CT features. Abdom Imaging 2005; 30:120–3. Katsumori T, Akazawa K, Mihara T. Uterine artery embolization for pedunculated subserosal fibroids. AJR Am J Roentgenol 2005;184:399–402.
335
TORSION OF A UTERINE LEIOMYOMA Yueh-Ju Tsai1, Sew-Khee Yeat1, Cherng-Jye Jeng1,2,3*, Su-Chee Chen1 Department of Obstetrics and Gynecology, Cathay General Hospital, 2Department of Medicine, College of Medicine, Fu-Jen Catholic University, and 3Department of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
1
SUMMARY Objective: To report a case of torsion of a pedunculated uterine leiomyoma. Case Report: A 38-year-old female virgin presented at the emergency department with complaints of severe lower abdominal pain on November 30, 2005. A transabdominal sonogram revealed multiple uterine masses, including a pedunculated mass. With a preoperative diagnosis of torsion of a pedunculated subserosal leiomyoma, the patient underwent an abdominal myomectomy. On gross inspection, the resected myoma was ischemic, and both focal hemorrhage and necrosis were noted in the pathology report. Conclusion: Torsion of a pedunculated uterine myoma is rare but represents a surgical emergency to improve symptoms and avoid consumptive coagulopathy. [Taiwanese J Obstet Gynecol 2006;45(4):333–335] Key Words: torsion, uterine leiomyoma
Introduction Uterine leiomyomas are smooth muscle tumors of the uterus. They are found in women throughout the world. Leiomyomas may be submucosal, intramural, subserosal or found in the broad ligament [1]. Occasionally, subserosal leiomyomas may become pedunculated. It is even less common for pedunculated leiomyomas to undergo torsion. There are only a few reported cases in the literature. The incidence of pedunculated uterine leiomyomas that have undergone torsion is unknown to the authors. We present a case of pedunculated uterine leiomyoma that underwent torsion.
Case Report A 38-year-old female virgin presented at the emergency department with complaints of severe lower abdominal pain on November 30, 2005. Physical examination revealed tenderness to deep palpation as well as rebound
*Correspondence to: Dr Cherng-Jye Jeng, Department of Obstetrics and Gynecology, Cathay General Hospital, 280, Section 4, Jen-Ai Road, Taipei 106, Taiwan. E-mail: [email protected] Accepted: July 4, 2006
Taiwanese J Obstet Gynecol • December 2006 • Vol 45 • No 4
tenderness in the right lower quadrant. Abdominal X-ray revealed gas and air–fluid levels in the small bowel. Bowel obstruction or ileus was suspected. White blood cell count was 12,610/μL and serum C-reactive protein level was elevated to 13,991 mg/dL. There were no signs of gastrointestinal symptoms such as vomiting, diarrhea or constipation. No Rovsing’s sign, psoas sign or obturator sign were noted and, according to the progress of her symptoms, the possibility of acute appendicitis was excluded by the attending surgeon. A transabdominal sonogram revealed multiple uterine masses that were consistent with multiple uterine leiomyomas. The largest one measured 7.1 × 6.7 cm and was located in the myometrium of the uterine fundus. There was another large mass measuring 6.6 × 5.2 cm in size (Figure 1). Its pattern was homogeneous and the same as the myoma in the uterine fundus. We considered that it was a uterine subserosal mass in the right side of the pelvis. Other small uterine masses were also visible through direct eye inspection. Given that the painful area was in the same location as the uterine subserosal mass, our preoperative diagnosis was a pedunculated uterine myoma that had undergone torsion. The patient gave consent to surgical intervention. A pedunculated leiomyoma that had undergone torsion around the stalk twice was discovered intraoperatively. The leiomyoma was approximately 8 cm in
333
Y.J. Tsai, et al
Figure 1. Ultrasound shows a subserosal leiomyoma measuring 6.6 × 5.2 cm (left “M”).
Figure 2. Pedunculated leiomyoma (bluish mass on the left side) that had undergone torsion is seen at laparotomy.
diameter and grossly bluish in color (Figure 2). An uncomplicated myomectomy was performed. Focal hemorrhage and necrosis were noted in the pathology report. The patient had an uneventful postoperative course and was discharged on December 4, 2005.
by the enlarged uterus and was therefore difficult to resect. Roy et al reported that the diagnosis of torsion of uterine leiomyoma could be established by computed tomography or ultrasound examination, but ultrasound is less sensitive [3]. In our case, we were able to find a pedunculated myoma with ultrasound. However, the sonographic findings alone did not reveal that the leiomyoma had undergone torsion. In other words, the preoperative diagnosis of torsion was based on sonographic findings as well as clinical presentation. The management of torsion of a uterine leiomyoma should be immediate in the case of infarction or necrosis. Abdominal myomectomy is the most common surgical intervention. Katsumori et al described uterine artery embolization for the treatment of pedunculated leiomyomas [4]. Their cases were confirmed with baseline sagittal and axial magnetic resonance imaging. They found no serious complications after embolization of pedunculated leiomyomas with stalk diameters ≥ 2 cm. Regarding the case presented here, we did not use advanced radiographic imaging techniques such as computed tomography or magnetic resonance imaging. We felt that ultrasonography and clinical presentation were sufficient. We conclude that early diagnosis of torsion of a uterine pedunculated myoma is important because ischemia or necrosis can cause consumptive coagulopathy or severe pain. Consumptive coagulopathy is very dangerous for the patient. Severe pain for a long time without relief is intolerable and is an indication for emergency surgery. The diagnosis can be made based on ultrasound and clinical findings. Emergency surgery
Discussion Torsion of a leiomyoma is rare. The existence of a pedunculated leiomyoma is a requisite for torsion. The stalk of the pedunculated myoma must be thin and long in order for it to undergo rotation and torsion. The size of the myoma is a key factor for irreversible torsion. It is easy to correct torsion spontaneously in pedunculated leiomyomas that are small. However, large pedunculated leiomyomas are difficult to correct because there is little room to undergo torsion. Another important factor in the etiology of torsion is the relationship between the myoma and adjacent organs, such as the uterine corpus, the bowel or the pelvic sidewall. After rotation of the stalk of a pedunculated leiomyoma, the leiomyoma may become fixed in place by surrounding organs. This leiomyoma may then become ischemic or necrotic, with resultant abdominal pain. The consideration of a pedunculated leiomyoma that has undergone torsion in the differential diagnosis is the key for early surgical intervention and treatment. Mickel et al reported that torsion of pedunculated leiomyomas could not only complicate pregnancy and delivery but could also disturb the puerperium due to compression of the bowel [2]. The authors found that the leiomyoma that had undergone torsion was fixed
334
Taiwanese J Obstet Gynecol • December 2006 • Vol 45 • No 4
Torsion of a Uterine Leiomyoma
must be performed as early as possible to improve symptoms and avoid consumptive coagulopathy.
References 1.
Berek JS. Chapter 13: Benign Disease of the Female Reproductive Tract. In: Novak’s Gynecology, 13th edition. Philadelphia: Lippincott Williams & Wilkins, 2002:380–7.
Taiwanese J Obstet Gynecol • December 2006 • Vol 45 • No 4
2.
3.
4.
Mickel I, Bollmann R, Chaoui R, Lau HU. Torsion of the myoma pedicle as a rare cause of ileus in puerperium. Geburtshilfe Frauenheilkd 1995;55:721–3. Roy C, Bierry G, Ghali SE, Buy X, Rossini A. Acute torsion of uterine leiomyoma: CT features. Abdom Imaging 2005; 30:120–3. Katsumori T, Akazawa K, Mihara T. Uterine artery embolization for pedunculated subserosal fibroids. AJR Am J Roentgenol 2005;184:399–402.
335