Interstitial uterine fibroid is a type of fibroid tumor with intraligmental localization between the leaves of the broad ligament that hold the uterus in the abdominal cavity. The interstitial fibroma of the uterus is clinically manifested by abundant meno- and metrorrhagia, anemia, pain syndrome, violation of the passage of urine with subsequent kidney damage. The recognition of the interstitial fibroid of the uterus is carried out on the basis of a complex of studies – examination on a chair, ultrasound, Echo-hysterosalpingoscopy, hysteroscopy, CT, MRI. Treatment of interstitial uterine fibroids in most cases requires their surgical removal.
Interstitial uterine fibroid belongs to a group of benign, hormone-dependent tumors of the stromal type, formed as a result of hypertrophy and proliferation of connective tissue structures. Gynecology is relatively rare to encounter interstitial localization of uterine fibroids. In this case, the fibroid node is located peritoneal, in the space of the ligamentous apparatus of the uterus and parotid tissue (parametria). The interstitial fibroma of the uterus is quite insidious, because it usually lies deep, often adheres to the main vessels, nerve plexuses, ureter and bladder. Removal of the interstitial fibroma of the uterus is associated with significant technical difficulties.
There is a lot of unexplored in the question of the etiology of interstitial uterine fibroid. The main role in the development of interstitial uterine fibroid is assigned to hormonal imbalance – hyperestrogenism, progesterone deficiency conditions, hypergonadotropism. That is why fibroid nodes develop and grow more often in reproductive age, and in menopause they significantly decrease in size.
Factors that determine the development of uterine inter-connective fibroma include heredity, a history of chronic infections (cervicitis, endometritis, adnexitis, oophoritis), STIs, surgical termination of pregnancy, medical abortions, the use of oral contraception, polycystic ovaries. A direct correlation has been revealed between the interstitial fibroma of the uterus and late menarche, absence of pregnancies, late onset of sexual activity and its irregularity.
Endocrine and cardiovascular diseases, hypertension, varicose veins, obesity, and immunodeficiency often serve as a premorbid background on which the interlinking fibroma of the uterus develops.
The disease begins to develop asymptomatically, but as the fibroid tumor increases, a typical clinic appears. The progressive growth of the intraligmental node causes compression of the ureter, plexuses of nerves, vessels, which determines the clinical symptoms of the interstitial fibroma of the uterus. The most characteristic manifestations of the interstitial fibroma of the uterus are lower back pain, at first frequent and painful urination, and then a violation of the outflow of urine with the development of hydroureter and hydronephrosis.
As in the case of fibroid tumors of other localization, with interstitial uterine fibroid, cyclic (menorrhagia) and acyclic (metrorrhagia) bleeding with the release of blood clots, dysmenorrhea, heaviness and pressure in the abdomen at rest, pain during sexual intercourse, anemia can be noted. In a number of cases, the development of an interlocking uterine fibroma is accompanied by infertility; and at the onset of pregnancy – the threat of miscarriage or spontaneous termination.
Due to stretching of the supporting apparatus, a bend of the uterus, a prolapse of the uterus and vagina may develop. In rare cases, with necrosis of the intraligmental node, its fusion with the pelvic peritoneum, rupture of a blood vessel, an acute abdominal clinic occurs.
Objective signs of interstitial uterine fibroid detected during gynecological examination are enlargement and asymmetry of the uterus, displacement of the vaginal part and uterine pharynx, density of consistency, roughness (tuberosity) of contours.
Gynecological ultrasound makes it possible to clarify the size, location, prevalence of uterine intercommunication fibroma, node structure (calcification, necrosis, etc.), as well as growth dynamics. Patients with meno- and metrorrhagia undergo diagnostic curettage of the cervical canal and uterine cavity with histological examination of the endometrium.
In case of violation of the passage of urine, consultation of a urologist and a nephrologist, excretory urography, ureteroscopy, nephroscopy, ultrasound of the kidneys, CT of the kidneys is indicated. If differential and clarifying diagnostics are necessary, hysteroscopy, ultrasound-GSS, MRI, CT, laparoscopy are resorted to. During the examination, the presence of appendage tumors, ovarian cysts, uterine and ectopic pregnancy, uterine adenomyosis is excluded.
Surgical interventions for interstitial uterine fibroid can be conservative and radical. Radical operations consist in the removal of the uterus with fibroma and are performed in patients with realized reproductive function. The scope of radical intervention may include hysterectomy, in menopause – total pangisterectomy. Carrying out supravaginal amputation of the uterus in case of inter-ligamentous fibroma is not technically possible due to the low location of the nodes.
Carrying out an organ-preserving intervention – conservative myomectomy (exfoliation of the node with suturing of the bed) allows to preserve the childbearing function, but does not exclude the development of new fibroid nodes. The difficulty of removing the interstitial fibroma of the uterus is due to the close location of the organs of the urinary system and blood vessels. Therefore, intraoperative ureteral injuries and bleeding may occur during the operation. Promising minimally invasive methods of treating uterine fibroids are targeted evaporation of the node with high-energy focused ultrasound and embolization of the uterine arteries.
Therapeutic treatment of interstitial uterine fibroid is carried out in the absence of absolute indications for surgery and lack of symptoms. In this case, vitamin therapy, symptomatic hemostatic and analgesic therapy, hormone therapy (progestogens, androgens, gonadoliberin agonists) can be prescribed, allowing to delay or avoid surgery, as well as reduce the likelihood of relapses. Hormonal methods of treatment include the installation of an intrauterine hormonal system.
Prevention and prognosis
Prevention of the development of interstitial uterine fibroid requires rational selection of contraception, timely therapy of female and endocrine diseases, exclusion of abortions and STIs, regular visits to a gynecologist.
The course and management of pregnancy in a patient with interstitial uterine fibroma is fraught with rapid growth of the node, miscarriage, premature birth, anomalies of placental presentation, fetal position and presentation, the development of discoordinated labor and postpartum bleeding. After removal of the interstitial fibroma of the uterus, relapses are not excluded in the future.