|Year : 2013 | Volume
| Issue : 3 | Page : 209-211
Torsion of the postmenopausal uterus: A surgical emergency
Anupama Hari1, CV Laxmi Rao2, G Swetha2, A Jijiya2
1 Department of Obstetrics and Gynaecology, Gandhi Medical College, Secunderabad, Andhra Pradesh, India
2 Department of Pathology, Gandhi Medical College, Secunderabad, Andhra Pradesh, India
|Date of Web Publication||29-Aug-2013|
Department of Obstetrics and Gynecology, Gandhi Medical College, Secunderabad, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Torsion of the non-gravid uterus is rare, but can present as an acute abdominal emergency. As it causes irreversible ischemic damage to uterus and its adnexae, emergency laparotomy is mandatory as a diagnostic and therapeutic procedure. We report a case of torsion of fibroid uterus in a post-menopausal woman who presented with an acute abdomen requiring laparotomy .
Keywords: Post-menopausal, torsion of uterus, uterine fibroids
|How to cite this article:|
Hari A, Laxmi Rao C V, Swetha G, Jijiya A. Torsion of the postmenopausal uterus: A surgical emergency. J NTR Univ Health Sci 2013;2:209-11
| Introduction|| |
The clinical presentations as an acute abdomen in patients with uterine fibroids may include red degeneration, torsion of the subserous fibroid, torsion of the uterus along with fibroid and sarcomatous degeneration.  As uterine torsion due to fibroids leads to an irreversible ischemic damage to uterus and its appendages, prompt diagnosis and treatment are needed.
In the present case, the woman presented with severe abdominal pain due to torsion of fibroid uterus along with its adnexae. Accurate diagnosis and subsequent emergency management saved the woman from this potentially fatal complication.
| Case Report|| |
A 52-year-old tribal woman was admitted to our hospital on 26 th January 2013 with severe pain in the abdomen for 2 days. She had two living children and the last child birth was 22 years ago. Both were of normal vaginal deliveries. She reached menopause 3 years ago. On probing, she volunteered that there was mild abdominal heaviness of nearly 2-month-duration before coming to the hospital.
On examination, her general condition was stable; pulse was 90 per minute, BP was 130/80 mm of Hg. Abdominal examination revealed 18-week-size midline tender and firm mass, on bimanual examination the same mass was felt and cervical movements were also tender. Ectocervix and vagina were found to be normal on speculum examination. Clinically torsion of an ovarian mass was diagnosed. Computerized tomographic scan of abdomen and pelvis showed a large pelvic mass of 15.7 Χ 12.8-cm size, which was continuous with the uterus with multiple intra-lesional areas of degeneration and a preoperative diagnosis of fibroid uterus was made.
Doppler Ultrasound revealed hypervascularity of the mass.
The investigations revealed Hb 9.8 Gm%, bleeding time and clotting time were 2'18'' and 3'30'', respectively, fasting blood glucose 80 mg/dl, blood urea 26 mg/dl, serum creatinine 0.9 mg/dl, CA 125 27 ΅g/dl, T3 1.29 ng/ml, T4 9.4 ΅g/ml, and TSH 2.16 ΅IU/ml. The electrocardiogram was normal.
Laparotomy under spinal anesthesia, was done using subumbilical midline incision. Laparotomy findings: Multiple fundal subserous fibroids with cumulative measurement of 22 Χ 15 cm along with several seedling fibroids. Uterine torsion of 360 degrees along with its adnexae was found at the level of isthmus [Figure 1]; both Fallopian tube More Detailss and ovaries were highly congested and gangrenous. Posterior surface of the fibroids showed arborising dilated vessels [Figure 2].
|Figure 1: Torsion of 360 degrees of uterus and its adnexae with multiple fundal fibroids|
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|Figure 2: Dilated tortuous vessels over the fi broids and congestion of adnexae|
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In view of the gangrenous appendages, total abdominal hysterectomy along with fibroids and bilateral salpingo-oophorectomy was performed. Total weight of the specimen was 1.5 kg. Her postoperative period was good. Patient was started on higher antibiotics. One unit of compatible blood was transfused during the postoperative period. The case was discharged on 10 th postoperative day in a stable condition.
Histopathology of specimen revealed subserous myomata with areas of hemorrhagic necrosis and congestion of uterine body and its adnexae [Figure 3].
|Figure 3: Areas of hemorrhagic necrosis in the Hematoxylinand Eosin-stained section within the myoma|
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| Discussion|| |
Uterine torsion is defined as rotation of uterus in its long axis by more than 45 degrees.  Uterine torsion during pregnancy has been reported in more than 100 cases, but torsion of non-gravid uterus is very rare.  Very few cases of torsion of uterus in post-menopausal women were reported till date.  The torsion of uterus is usually at the level of supravaginal cervix, so that uterine vessels are obstructed leading to gangrenous uterus. , Non-gravid uterus undergoes torsion only when the uterus is asymmetrical because of tumor or abnormal Mullerian duct fusion. 
As uterine torsion causes vascular damage to uterus leading to rapid clinical deterioration, prompt diagnosis and urgent management are needed.  In the present case, the woman ignored the symptoms which were going on for 2 months, ultimately resulting in an emergency laparotomy.
Uterine torsion should be considered as a differential diagnosis in all 'acute abdomen' cases. The other causes of acute abdomen in fibroid uterus apart from torsion of fibroid are uncommon. Red degeneration and sarcomatous degeneration, though rare, were also to be considered.  Very rarely torsion of fibroids may lead to hemoperitoneum as a result of rupture of veins over the fibroid.  Cases of torsion of a puerperal uterus with fibroids were also reported. 
Myomatous uterine torsion is difficult to diagnose preoperatively.  The clinical spectrum ranges from pain abdomen to distention to shock.  The differential diagnosis in a post-menopausal woman should include appendicitis, torsion of pelvic tumor, and bowel obstruction.
Management of torsion of fibroid uterus includes prompt diagnosis and immediate laparotomy to save the life. In most of the cases, the operation involves removal of diseased uterus along with its appendages. But in young women who desire to retain fertility, myomectomy is to be considered after assessing the viability of uterus along with detorsion of the uterus.  The round ligaments and uterosacral ligaments should be plicated to prevent the recurrence of torsion if the uterus is to be conserved. 
In our case, the probable cause of uterine torsion by 360 degrees might be due to the weight of the subserous fibroids acting on weak musculature of the post-menopausal uterus and also post-menopausal status of the supporting ligaments. Hence the entire uterus along with fibroids was congested, necrosed, and gangrenous. A total hysterectomy with bilateral salpingo-oophorectomy was performed.
Whenever large subserous fibroids are diagnosed, they should be surgically treated even though they are asymptomatic as they are prone for life-threatening complications like torsion of the uterus, avulsion of the fibroid, and hemoperitoneum. 
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[Figure 1], [Figure 2], [Figure 3]