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A tale of 2 pedunculated myomas

ARTICLE in AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY DECEMBER 2005

Impact Factor: 4.7 DOI: 10.1016/j.ajog.2005.08.026 Source: PubMed

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Ihab M Usta Elie Hobeika

American University of Beirut American University of Beirut
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Anwar H Nassar
American University of Beirut
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Retrieved on: 29 January 2016
American Journal of Obstetrics and Gynecology (2005) 193, 17535

www.ajog.org

A tale of 2 pedunculated myomas

Ihab M. Usta, MD, Elie M. Hobeika, MD, Anwar H. Nassar, MD

Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon

Received for publication July 13, 2005; revised July 21, 2005; accepted August 11, 2005

KEY WORDS We present 2 unusual cases of prolapsed pedunculated submucous myomas. In 1 patient, the pro-
Submucous myoma lapsed part measured 12 cm, with a 64-cm intrauterine part. The second patient had prolapsed
Pedunculated pedunculated submucous myoma, which subsequently retracted into the uterus. Gynecologists
should be aware of unusual presentations of pedunculated submucous myoma to plan surgery.
2005 Mosby, Inc. All rights reserved.

Uterine leiomyomas are the most common benign
tumors of the female genital tract; 5% are submucosal,
and 1.3% to 2.5% are pedunculated.1,2 Of the peduncu-
lated submucous myomas (PSMs), 19.2% to 26.1%
measure O3 to 5 cm.2 PSMs rarely may induce labor-
like pain, eventually dilating the cervix and prolapsing
through it with possible avulsion of the twisted necrotic
prolapsed portion.2
We present 2 cases of PSM; 1 case had an unusual
appearance, and another case had unusual behavior.
Case 1
A 37-year-old woman (G3P3) had chronic foul-smelling
discharge, acute bleeding, and labor-like pain that was
followed by the protrusion of a mass on the perineum. A
12-cm eshy, dark-red mass was seen originating from
the uterus and prolapsing through a dilated cervix
(Figure 1,A). Ultrasound examination revealed a 17-cm
uterus with a large myoma occupying the uterine cavity,
which was continuous with the prolapsed part. Abdom-
inal hysterectomy was performed. The myoma consisted
of a 6-cm intramural round fundal broid tumor, with an
elongated soft mid-portion coiled within the uterine
Reprints not available from the authors.
cavity and a distal portion that was prolapsed partially
through the cervix. The vaginal part was delivered vagi-
nally; the other parts were removed abdominally. The
length of the reconstituted myoma was 76 cm (Figure
1,B).
Case 2
A 46-year-old grandmultiparous woman had a 4-month
history of menorrhagia. Ultrasound examination re-
vealed an irregular uterus that measured 10.6 ! 6.8 !
7.8 cm, with a posterior 6.0 ! 4.1 cm broid tumor.
One week later, she experienced severe bleeding and
labor-like abdominal cramps. Speculum examination
showed a 5-cm pedunculated violaceous broid tumor
that protruded through a 5-cm dilated cervix. The
bleeding decreased, and the pain subsided 1 hour after
admission. In the operating room, 7 hours later, a
speculum examination by the same examiner revealed
a closed cervix and retraction of the prolapsed myoma
into the uterus. Intraoperatively, the myoma consisted
of a whitish fundal lobe that was attached to the
uterus O3.5-cm base and a violaceous lobe, which was
the same part that had previously prolapsed through the
cervix.

0002-9378/$ - see front matter 2005 Mosby, Inc. All rights reserved.
doi:10.1016/j.ajog.2005.08.026
1754
Figure 1 Case 1. A, The prolapsed part of the myoma. B, The myoma on a 90-cm table. The thin arrow shows the intramural part;
the thick arrow shows the prolapsed part.
Figure 2 Case 2. A, The myoma 1 week before prolapse. B,
Pathology specimen. The thin arrows show the base of the my-
oma; the thick arrows show the part that prolapsed and
retracted.
Comment
Various imaging modalities can be used to diagnose
and characterize prolapsed PSMs and to obtain infor-
mation that might aid in the choice of the surgical
approach. In our cases, only ultrasound examination
Usta, Hobeika, and Nassar
was used, because both patients had acute vaginal
bleeding.
Vaginal myomectomy is an option for treating small
PSMs. Twisting, ligation and excision, and morcellation
of larger tumors have been used.1,2 More recently, hys-
teroscopically assisted techniques have been used.3
However, the size of the myoma in the rst case was pro-
hibitive for the attempt at such techniques. The longest
myoma ever reported measured 13 cm,3 which makes
our case one of the largest and probably the longest
myoma reported in the literature.
The second case represents the rst report of the
regression of a myoma into the uterine cavity after
prolapse. Vaginal expulsion was not possible because no
such expulsion was reported by either the nursing sta
or the patient, and the pathologic specimen was the
exact size and conguration of the image that was seen
on ultrasound examination (Figure 2,A and B). Manual
replacement of prolapsed myomas was reported previ-
ously in 3 patients before hysterectomy to prevent the
contamination of the abdominal cavity.1 In our case, re-
placement during vaginal scrubbing was possible; how-
ever, the cervix was closed, which suggested that the
myoma had retracted earlier.
These cases illustrate the potential challenges gyne-
cologists might face during the treatment of PSMs.
Underestimation of the size of the myoma in the rst
case and attempts at vaginal myomectomy in similar
situations might have led to disastrous results. Further-
more, a disappearing prolapsed myoma, such as in the
second case, does not necessarily imply spontaneous
expulsion; retraction of the prolapsed part should be
kept in mind.
Usta, Hobeika, and Nassar
References
1. Brooks GG, Stage AH. The surgical management of prolapsed pe-
dunculated submucous leiomyomas. Surg Gynecol Obstet 1975;141:
397-8.
2. Ben-Baruch G, Schi E, Menashe Y, Menczer J. Immediate
and late outcome of vaginal myomectomy for prolapsed
1755
pedunculated submucous myoma. Obstet Gynecol 1988;72:
858-61.
3. Kanaoka Y, Hirai K, Ishiko O, Ogita S. An intranodal morcellation
technique employing loop electrosurgical excision procedure
for large prolapsed pedunculated myomas. Oncol Rep 2001;8:
1149-51.