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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 71-73

Cervical leiomyoma: An uncommon presentation


Department of Obstetrics and Gynaecology, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission05-Oct-2020
Date of Decision25-Oct-2020
Date of Acceptance04-Nov-2020
Date of Web Publication25-Nov-2020

Correspondence Address:
Dr. Keerthi Somi Reddy Gari
7-1-282/C/1/12/A, Opposite Indian Oil Petrol Pump, Balkampet, Hyderabad - 500 038, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjhs.mjhs_9_20

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  Abstract 


Leiomyomas are the most common benign tumors of the uterus. Majority of the leiomyomas occur in the body of the uterus; only 1%–2% of cases are confined to the cervix. A cervical leiomyoma is usually single and is either interstitial or subserosal; rarely, it becomes submucous and polypoidal. Here, we report an uncommon case of cervical leiomyoma. A 45-year-old female para 2 live 2 admitted with complaints of burning micturition and retention of urine. Ultrasound revealed a well-defined heteroechoic lesion measuring 9.6 cm × 7.5 cm × 7.5 cm noted along the posterior wall of the cervix suggestive of partially exophytic fibroid. Single posterior wall fibroid 10 cm × 8 cm was noted intraoperatively. Enucleation followed by hysterectomy was done successfully without injury to the bladder and ureters.

Keywords: Cervical leiomyoma, enucleation, hysterectomy


How to cite this article:
Reddy Gari KS, Nalini Y L, Ramana Bai P V, Rani S, Lakshmi V. Cervical leiomyoma: An uncommon presentation. MRIMS J Health Sci 2020;8:71-3

How to cite this URL:
Reddy Gari KS, Nalini Y L, Ramana Bai P V, Rani S, Lakshmi V. Cervical leiomyoma: An uncommon presentation. MRIMS J Health Sci [serial online] 2020 [cited 2021 Jan 27];8:71-3. Available from: http://www.mrimsjournal.com/text.asp?2020/8/3/71/301484




  Introduction Top


Leiomyomas are the most common benign tumors of the uterus. The incidence of leiomyoma is 20% in the reproductive age group.[1] Leiomyomas are usually situated in the body of the uterus, but 1%–2% of cases are confined to the cervix to the supravaginal part. The growth of leiomyoma is estrogen dependent.[2] They increase during reproductive years and gradually regress after menopause. Histologically, leiomyomas are composed of smooth muscle and fibrous connective tissue.[3] Uterine leiomyomas are also known as fibroids, myoma, or fibromyoma. Cervical leiomyomas usually present with symptoms of retention of urine, urinary frequency, menstrual irregularities, constipation, abdominal mass, dyspareunia, and postcoital bleeding depending upon their location. Laparotomy is the most common mode of treatment. As cervical leiomyomas are difficult to handle and meticulous, surgical dissection is important. Due to their proximity, there is an increased risk of the ureter, bladder, and bowel injuries along with the risk of intraoperative bleeding.


  Case Report Top


A 45-year-old patient para 2 live 2 was admitted with complaints of burning micturition for 3 days and retention of urine for 1 day. Her menstrual cycles were regular with normal flow. General examination revealed no abnormality. Her vitals were normal. Per abdomen examination revealed a mass of 16 weeks size of the gravid uterus. External genitalia were healthy. On per speculum examination, the vagina was found to be healthy, mass seen projecting into the vagina 6 cm × 6 cm from the cervix. On bimanual vaginal examination, the uterus was anteverted, mass arising from the left lateral and posterior lip of the cervix; mass could not be felt separately from the uterus [Figure 1] and [Figure 2].
Figure 1: (a and b) Cervical leiomyoma arising from the posterior wall

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Figure 2: Specimen of the uterus and enucleated cervical fibroid

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Baseline investigations were done. Her hemoglobin was 10.4 g/dl; complete urine examination, renal function test and liver function test, random blood sugar, viral serology, and thyroid profile were normal. Ultrasound revealed anteverted uterus 11.5 cm × 6.5 cm × 4.8 cm. Endometrial thickness of 7 mm. A well-defined heteroechoic lesion measuring 9.6 cm × 7.5 cm × 7.5 cm was noted along the posterior wall of the cervix suggestive of partially exophytic fibroid. Indentation over the cervical canal was noted. Significant postvoid urine residue 88cc was noted. Bilateral ovaries were cystic. Bilateral  Fallopian tube More Detailss were healthy. Intravenous pyelogram showed bilateral normal excreting kidneys and external indentation of urinary bladder superiorly suggestive of pelvic mass.

The general condition was improved with blood transfusion. Preanesthetic checkup was done and planned for total abdominal hysterectomy after informed and written consent.

Intraoperative findings were uterus 16 weeks, single posterior wall fibroid of 10 cm × 8 cm with ballooning of the cervix noted in the posterior wall, bilateral ovaries were cystic, and bilateral fallopian tubes were healthy. The course of the bilateral ureter in relation to mass was inspected. Enucleation of the leiomyoma was done, followed by total abdominal hysterectomy and the specimen was sent for histopathological examination. Her postoperative period was uneventful. Her postoperative hemoglobin was 11.2 g/dl. Suture removal was done on postoperative day 7 and she was discharged. Histopathology of the specimen confirmed the diagnosis of cervical leiomyoma.


  Discussion Top


Among the various pelvic tumors, Leiomyoma is observed to be the commonest. The incidence of leiomyoma is about 20% in the women who fall under the reproductive age group, whereas only 1%–2% are confined to the cervix.[1] Most of the leiomyomas were proved to be asymptomatic and growing slowly. About 20%–50% of the tumors were manifesting with symptoms, whose severity depends upon the number, size, and location of the tumors.[4] Cervical leiomyomas commonly develop in the supravaginal parts of the cervix, but it is also observed in the vaginal parts of the cervix. Supravaginal fibroids may be interstitial or subperitoneal but rarely polypoidal. Interstitial growth may displace or expand the cervix to a level that it can disturb the pelvic anatomy and ureter. Vaginal fibroids are usually pedunculated and rarely sessile. Cervical leiomyomas are classified as posterior–anterior central and lateral. The symptoms of cervical leiomyoma depend on the type of fibroid. Anterior leiomyoma bulges forward and undermines the bladder causing urine retention and increased frequency. Posterior leiomyoma flattens the pouch of Douglas leading to compression of rectum against sacrum causing constipation. Anterior and posterior cervical leiomyomas lodge in the pouch of Douglas and in turn cause an increase in frequency and retention of urine. This commonly occurs in premenstrual cases as premenstrual congestion results in enlargement of the fibroids.[5] Lateral cervical leiomyoma starts at the side of the cervix burrows into the broad ligament and expands it. Central cervical leiomyoma expands the cervix equally in all directions but commonly produces bladder symptoms. On laparotomy, central cervical fibroid gives the appearance of “Lantern on St Paul's Dome.”[6] Ureters and uterine artery are extracapsular to the fibroids.[7] Color Doppler is specific for differentiating benign and malignant adnexal masses.[8] Imaging modalities such as ultrasound, computed tomography scan, and magnetic resonance imaging help in the differentiation of uterine pathology from adnexal.

Treatment of cervical leiomyoma is either myomectomy or hysterectomy. Challenges anticipated in the treatment of cervical leiomyoma are: (1) upward and outward displaced uterine vessels. (2) A pulled up bladder. (3) Ureter anatomy distortion. They lead to greater surgical difficulty due to inaccessibility and proximity to the bladder, ureter, and uterine vessels.[9] Ureteric injury can be prevented by the intraoperative delineation of the ureters and preoperative ureteric stenting. As intravenous pyelogram was normal in our case, ureteric stenting was not performed. The principle followed during surgery is enucleation, followed by hysterectomy.[10] Preoperative gonadotropin-releasing hormone (GnRH) analogs can be given 3 months before surgery to reduce the size and vascularity of fibroids. The GnRH analog destroys the plane of cleavage between the fibroid capsule and the surrounding structures causing difficulty during surgery.[11]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bhatla N. Tumours of the corpus uteri. In: Jeffcoates Principles of Gynaecology. 5th ed. London: Arnold Publisher; 2001. p. 470.  Back to cited text no. 1
    
2.
Bowden W, Skorupski J, Kovanci E, Rajkovic A. Detection of novel copy number variants in uterine leiomyomas using high-resolution SNP arrays. Mol Hum Reprod 2009;15:563-8.  Back to cited text no. 2
    
3.
Samal SK, Rathod S, Rajsekaran A, Rani R. An unusual presentation of central cervical fibroid: A case report. Int J Res Med Sci 2014;2:1226-8.  Back to cited text no. 3
    
4.
Buttram VC Jr., Reiter RC. Uterine leiomyomata: Etiology, symptomatology, and management. Fertil Steril 1981;36:433-45.  Back to cited text no. 4
    
5.
Padubidri VG, Daftary S. Fibroid Uterus. In: Shaw's Textbook of Gynaecology. Padubidri VG, Daftary S, editors. New Delhi: RELX India pvt. Ltd.; 2018. p. 162.  Back to cited text no. 5
    
6.
Singh S, Chaudhary P. Central cervical fibroid mimicking as chronic uterine inversion. Int J Reprod Contracept Obstet Gynaecol 2013;2:687-8.  Back to cited text no. 6
    
7.
Mendiratta S, Dash S, Mittal R, Dath S, Sharma M, Sahai RN. Cervical fibroid: An uncommon presentation. Int J Reprod Contracept Obstet Gynecol 2017;6:4161-3.  Back to cited text no. 7
    
8.
Guerrriero S, Alcazal LJ, Coccia E M, Ajosso S, Scarselli G, Boi M, et al. Complex pelvic mass as a target of evaluation of vessel distribution by colour Doppler sonography for the diagnosis of adnexal malignancies. J Med Ultrasound 2002;21:1105-11.  Back to cited text no. 8
    
9.
Kshirasagar SN, Laddad MM. Unusual presentation of cervical fibroid: Two case reports. Int J Gynecol Plastic Surg 2011;3:38-9.  Back to cited text no. 9
    
10.
Dutta DC, Konar H. Text Book of Gynaecology. 6th ed. Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, 2012. p. 271.  Back to cited text no. 10
    
11.
Monaghan JM, Lopes AB, Naik R. Total hysterectomy for cervical and broad ligament fibroids. In: Huxley R, Taylor S, Chandler K, editors. Bonney's Gynaecological Surgery. 10th ed. Maiden, USA: Blackwell Publishing Company; 2004. p. 74-86.  Back to cited text no. 11
    


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