Chronic Uterine Inversion in Post-Menopausal Woman: A Rare Case Report

Chronic uterine inversion is a rare disease presentation in obstetrics and gynecology discipline. It is the descent of uterine fundus inside out through the cervix. It is grossly classified as puerperal and non-puerperal uterine inversion. Non-puerperal uterine inversion is reported in 16% of all uterine inversions. Actual prevalence of puerperal uterine inversion is difficult to estimate in developing countries but estimated to be 1 in 20,000-50,000 cases. Chronic uterine inversion is commonly associated with other uterine pathology, mainly submucous uterine leiomyoma. Endometrial polyp, uterine sarcoma, previous repositioned inverted uterus and increased abdominal pressure are other associated factors. Abnormal vaginal bleeding, mass per vagina, foul-smelling vaginal discharge and lower abdominal pain are frequent clinical symptoms. Uterine inversion is frequently misdiagnosed as uterine prolapse due to anatomical and symptom similarity. Physical examination, radiologic imaging and high index of suspicion help to diagnose and differentiate from uterine prolapse. Abdominal, vaginal or laparoscopic approaches are possible methods of treatment depending on the surgeon's experience. In abdominal and laparoscopic approaches, uterine repositioning prior to surgery is mandatory, either manual or surgical repositioning. Fifty years old, para 6, woman presented with chief complaint of mass per vagina of 3 months duration. It was associated with lower abdominal pain, vaginal bleeding and offensive vaginal discharge. She had intermittent low grade fever since the last one 1 month. On physical examination, she was tachycardic (pulse rate = 110) and febrile (temperature = 37.6°C centigrade). On HEENT examination, her conjunctiva was pale. On genitourinary system examination, there was offensive vaginal discharge, large mass protruding through vagina with 15 × 12 cm sized mass attached to uterus by broad pedicle. Overlying tissue was necrotic and fragile that bleeds easily. Cervix was not palpable. She was investigated with blood tests and abdominal ultrasound. Chronic uterine inversion with pedunculated leiomyoma severe anemia were diagnosed. After stabilizing the patient with transfusion and antibiotics, abdominal hysterectomy was done after uterus placed into abdomen surgically, as manual repositioning was difficult. Haultain's technique was used to reposition uterus into abdomen. Post-operative course was smooth and she was discharged home with improvement. Two weeks after discharge, she visited gynecologic out-patient department and it was smooth course. Chronic uterine inversion is a rare disease. It is grossly classified as puerperal and non-puerperal uterine inversion. Pelvic pathologies like leiomyoma, endometrial polyps, uterine neoplasms, and large bladder stones are predisposing factors. It is frequently misdiagnosed as uterine prolapse. Frequently, physical examination, common radiologic imaging like ultrasound, and a high index of suspicion are adequate to reach a diagnosis. In limited cases, like grade 1 and 2 uterine inversion, patients with no risk factors and adolescents, advanced diagnostic imaging like MRI and CT scans are recommended. Surgical intervention is the primary management, either for uterine preservation or hysterectomy. Although there is no recommended standards of operation approach, Adnominal, laparoscopic or vaginal approaches are possible option of surgical route depending on surgeon's experience. Chronic uterine inversion is a rare disease entity. It has diagnostic and treatment challenges. It is commonly misdiagnosed as uterine prolapse. A high index of suspicion is crucial during the evaluation of a patient presenting with protrusion of mass per vagina as uterine prolapse mimics uterine inversion. There is no standardized surgical management. Surgical approach, either abdominal. Vaginal or laparoscopic, depends on surgeon's experience.