Puzzler: An unusual cause of pelvic pain

Dr Arnold is a resident in obstetrics and gynecology, University of Oklahoma Health Sciences Center, Oklahoma City.

Presentation

A 47-year-old nulliparous woman presented to an emergency department (ED) for 3 days of nausea and 1 day of abdominal pain. She reported feeling well prior to this episode. There were no signs consistent with an acute abdomen. A transvaginal ultrasound showed 2 ovaries with normal blood flow. No fibroids were noted. On arrival, the patient received 1 mg of hydromorphone and did not require further dosing for approximately 4 hours, but she continued to complain of nausea.

History

The patient denied fevers/chills, changes in bowel or bladder function, or contacts who were ill, and reported that she was generally in good health. Her medical and surgical histories were noncontributory. The patient also denied using cigarettes, alcohol, or drugs. She had no family history of cancer.

The patient was up to date on and had normal Pap smears, reported regular menses and had a normal menstrual period 1 week before. Despite her age, she used oral contraceptives.

Physical examination

The patient’s blood pressure was 142/84 mmHg; pulse 72 bpm; respiratory rate 19; and temperature 36.9^o C. She was in no apparent distress; her abdomen was soft and nontender to palpation in upper quadrants. Inferiorly, a firm mass was palpated in the suprapubic region, also nontender to palpation. No rebound/guarding was present but the right lower quadrant was mildly tender to palpation although no mass was palpable.

On bimanual examination, the uterus was nontender to palpation at midline, and the anterior mass was felt to be connected to the uterus. A firm mass was palpated through the posterior fornix, which was tender to palpation immediately laterally to the right of the uterus. The cervix was normal to palpation and inspection.

Next: Tests and differential diagnosis >>

Tests

Complete blood count and urinalysis were within normal limits; urine pregnancy test was negative. The ED physician ordered a computed tomography (CT) scan that showed an 11-cm x 9.5-cm x 10.5-cm lobulated heterogeneous lesion in the lower abdomen and pelvis anteriorly. A 6.3-cm x 4.2-cm hyperdense mass also was noted in the right lower quadrant of the pelvis. The ovaries were not definitely identified.

Differential diagnosis

A benign or malignant neoplasm was suspected, possibly of ovarian origin, although the differential diagnosis included exophytic or pedunculated uterine fibroid with degenerative changes.

Treatment

Imaging was discussed with the radiologist, who initially felt that the mass in the right pelvis was likely of adnexal origin. Given the patient’s symptoms, ovarian torsion was thought to be the most likely diagnosis.

The woman was counseled for surgical management. Given the uncertainty of diagnosis, she was consented for a total abdominal hysterectomy with removal of adnexal stuctures as indicated by intraoperative findings, and other indicated procedures. The patient desired to have a fertility-sparing procedure if possible. She underwent surgery that day.

Intraoperative findings were as follows: A 12-cm torsed fundal pedunculated fibroid and an additional 8-cm pedunculated fibroid, nongravid uterus, and normal cervix, fallopian tubes, and ovaries bilaterally. Given this, the final procedure was an exploratory laparotomy with myomectomy.

Next: The final diagnosis and discussion >>

Final diagnosis

Torsed uterine fibroid

Discussion

In evaluating a patient with acute onset of pelvic pain in the ED, there is a wide differential of obstetric, gynecologic, and other causes (Table). Initial work-up includes an abdominal and pelvic exam, a pregnancy test, and a pelvic ultrasound. The provider should consider laboratory evaluation as well as a CT scan if a nongynecologic diagnosis is favored.¹

Patients with ovarian torsion typically present with nausea, vomiting, and lower abdominal pain. The adnexa tend to be severely tender with rebound tenderness. On ultrasound evaluation, an enlarged ovary is consistent with the diagnosis. Doppler flow can be evaluated, but normal blood flow does not rule out torsion. Management is prompt surgery to detorse the ovary or oophorectomy if indicated.

In this case, the clinical picture was concerning for torsion, so the decision was made to proceed with surgery. Given the importance of surgery for management of adnexal torsion, a high false-positive rate is acceptable. The literature supports this, with only 38% suspected cases being confirmed intraoperatively.¹

Fibroids are the most common tumor in reproductive-aged women and rarely cause complications. In women their 40s, they can produce symptoms such as heavy uterine bleeding, pelvic pain or pressure, and urinary complaints, but half of women with fibroids are asymptomatic. When complications occur, they can be severe and include thromboembolism, torsion, acute urinary retention, pain with degeneration, and hemorrhage.²

Acute torsion of a fibroid typically is diagnosed at the time of surgery performed for an acute abdomen. Torsion of the vascular supply can lead to gangrene and peritonitis, which can lead to significant morbidity and mortality. Diagnosis prior to surgery is difficult, as the pedicle is often thin and not visible on ultrasound. Diagnosis is suggested by a lesion lateral to the uterus.

Magnetic resonance imaging and CT are both options for diagnosis when ultrasound is inconclusive. Interestingly, fibroids are generally hypointense homogeneous with T2 and isointense on T1 in comparison to the myometrium, but with necrosis, they become heterogeneous and hyperintense with T2. Generally, treatment with excision of the lesion is sufficient.²

Because torsed fibroids are rare, the majority of the literature consists of case reports. Kosmidis et al. reported a case of a woman at 10 weeks’ gestation who underwent diagnostic laparoscopy because of acute abdominal pain and was treated with a laparoscopic myomectomy for torsion.³ Santak et al. report a 61-year-old who presented with right lower quadrant pain, fever, and leukocytosis and was found to have a torsed pedunculated fibroid at surgery.⁴

Deshapande et al. report the case of a 25-year-old at 38 weeks’ gestation who presented with abdominal pain and uterine tenderness. At cesarean delivery for abrupt fetal bradycardia, she was found to have a uterus rotated 180^o due to a right fundal fibroid.⁵ These authors recommend that the uterus be detorsed prior to hysterotomy, but if that is not possible, a hysterotomy can be made on the posterior aspect of the uterus as it is the presenting part. If uterine torsion occurs in the second trimester, some experts recommend plication of the round or uterosacral ligaments and removal via ovarian cystectomy or uterine myomectomy of masses likely to precipitate torsion.

Torsed fibroids are rare and the diagnosis is difficult to establish with imaging, but the condition must be managed surgically and promptly, similarly to adnexal torsion, as complications of ischemic gangrene and peritonitis can occur.⁶

References

1. Zheng T. Comprehensive Handbook: Obstetrics and Gynecology. 2nd ed. Paradise Valley, AZ: Phoenix Medical Press; 2012: 234–238.

2. Gupta S, Manyonda IT. Acute complications of fibroids. Best Pract Res Clin Obstet Gynaecol. 2009;23(5):609–617.

3. Kosmidis C, Pantos G, Efthimiadis C, Gkoutziomitrou I, Georgakoudi E, Anthimidis G. Laparoscopic excision of a pedunculated uterine leiomyoma in torsion as a cause of acute abdomen at 10 weeks of pregnancy. Am J Case Rep. 2015;16:505–508.

4. Šantak G, Glavić, Ž, Begić, L, Šimleša D, Zukanović G. Acute abdomen caused by huge pedunculated uterine leiomyoma in torsion. ANZ J Surg. 2013;83:96–97.

5. Deshpande G, Kaul R, Manjuladevi P. A case of torsion of gravid uterus caused by leiomyoma. Case Rep Obstet Gynecol. 2011; doi: 10.1155/2011/206418.

6. Kim HG, Song YJ, Na YJ, Choi OH. A case of torsion of a subserosal leiomyoma. J Menopausal Med. 2013;19(3):147–150.

7. Vandermeer FQ, Wong-You-Cheong JJ. Imaging of acute pelvic pain. Clin Obstet Gynecol. 2009;52(1):2–20.