Myomatous node expulsionis a complication of submucous leiomyoma, in which a mobile tumor is expelled from the uterine cavity through the cervical canal into the vagina. It is manifested by acute cramping pain in the lower abdomen, swelling and heaviness in the vagina, intense bleeding, increasing weakness, dizziness, pallor of the skin, cold sweat, pressure drop, increased heart rate, subfebrility. It is diagnosed by gynecological examination, ultrasound of the pelvic organs. Treatment is only surgical with conservative myomectomy, hysterectomy, supravaginal amputation of the uterus and appendages.
Myomatous node expulsionis is a relatively infrequent complication that occurs in 1-1.5% of patients with submucosal fibroids. Pathology is more often detected in 25-40-year-old women who are engaged in heavy physical labor or sports. The relevance of timely diagnosis is due to the high risk of consequences that pose a danger to the patient’s life. Myomatous node expulsionis without the development of acute surgical symptoms is also possible after planned embolization of the uterine arteries. In such situations, the expulsion of a devascularized tumor usually passes without complications and is considered as a favorable result of EMA.
The exit of submucous fibroids into the cervical canal and further into the vagina is most often associated with an increase in intra-abdominal pressure. The expulsion of the node can provoke lifting weights, physical exertion, performing physical exercises to strengthen the lower abdominal press. In rare cases, the birth of a myomatous formation occurs after intense sex with a violent orgasm. There are a number of prerequisites that increase the risk of complication of submucosal leiomyoma by myomatous node expansion:
- Anatomical features of the tumor. A mobile myomatous tumor with a thin leg and located in the lower part of the uterus or neck is more likely to fall out. Reflex contractions of the myometrium, aimed at expelling the volumetric formation, become stronger with an increase in the size of the growing node, which is perceived by the uterus as an alien body.
- Opening of the cervical canal. Myomatous node expulsionis are more often diagnosed during ovulation and menstruation. At this time, the cervical canal opens slightly for the passage of spermatozoa or the release of the rejected endometrium, which simplifies the loss of fibroids. The situation is aggravated by an increase in the tone of the myometrium and an increase in its contractile activity against the background of hypoprogesteronemia.
The mechanism of the birth of leiomyoma somewhat resembles the processes that occur in the first period of labor. The expansion of the myomatous node under the influence of contractions of the myometrium, enhanced by increased pressure in the abdominal cavity, wedges into the internal uterine pharynx. Complete smoothing of the cervical canal, similar to what happens in childbirth, is usually not noted. However, the expansion is sufficient for the fibroids to exit into the neck (the node being born) and the vagina (the node being born). Discoordinated spastic contractions of circular smooth muscle fibers in combination with vasoconstrictor tissue hypoxia cause intense pain syndrome. Violation of the integrity of the endometrium and vessels feeding submucous fibroids leads to bleeding.
The complication often occurs acutely after physical exertion. The patient complains of intense (“dagger”) pain in the lower abdomen, similar to labor pains. There is a feeling of heaviness and bursting in the genital area. Usually there is massive bleeding. The general clinical symptoms are rapidly increasing: a woman experiences pronounced weakness, dizziness, feels a heartbeat, the skin becomes pale, covered with cold sticky sweat. It is characterized by a drop in blood pressure and an increase in pulse. Sometimes the temperature rises to subfebrile digits. There is some bloating of the abdomen and its palpatory soreness in the lower parts.
Prolonged incessant bleeding at the birth of fibroids can provoke the development of hemorrhagic shock, less often – DIC syndrome. Due to the infringement of the leg of the born myomatous node in the cervical canal, tumor necrosis may begin with subsequent inflammation. A serious complication of tumor expansion is eversion of the uterus with infection of its membranes. After surgical removal of leiomyoma, infectious and inflammatory diseases often occur: endometritis, endocervicitis, salpingitis, adnexitis, pelvic peritonitis. A serious long—term consequence of the birth of myomatous formation is infertility.
Diagnosis in patients with diagnosed submucous fibroids is usually not difficult. Women with a characteristic clinic of an expulsive myomatous node in the absence of anamnestic data on the presence of a tumor are examined, which allows them to quickly identify leiomyoma and establish the stage of its birth. Express diagnostics includes such methods as:
- Gynecological examination. With bimanual palpation, the uterus is enlarged in size, sharply painful. During the vaginal examination, the neck is smoothed, the cervical canal is dilated, a tumor-like formation of a soft or dense consistency is palpated in it. When examined in mirrors, abundant bloody discharge from the neck is visible. The lower pole of the myomatous node expansion, depending on the state of blood circulation, may look whitish or purplish-cyanotic.
- Ultrasound of the pelvic organs. An echographic sign of fibroid expansion is an enlargement of the uterus mainly in anteroposterior size. Ultrasound of the pelvis, supplemented by Dopplerography, allows you to identify a myomatous node in the cervical canal with areas of different echogenicity, cystic inclusions, impaired blood supply. Pathological changes in blood flow are also observed in adjacent areas of the muscle layer. Uncomplicated leiomyomas may be detected intrauterine.
In the general blood test, changes characteristic of acute surgical pathology are determined — acceleration of ESR, an increase in the level of leukocytes mainly due to neutrophilosis with an increase in the relative content of rod-shaped forms. Taking into account the severity of symptoms and the need for rapid surgical intervention, other special studies (puncture of the posterior vaginal arch, diagnostic laparoscopy) are carried out only if there are reasonable doubts about the diagnosis.
The myomatous node is differentiated from cervical and other forms of ectopic pregnancy, spontaneous miscarriage, ovarian apoplexy, acute pelvic inflammatory diseases (tubovarial abscess, pyosalpinx), algodismenorrhea, cervical canal polyp, cervical cancer with disintegration, uterine sarcoma. The patient is recommended to have a surgeon’s examination, according to the indications — an oncologist’s consultation.
Wait-and-see tactics are unacceptable. The woman is urgently hospitalized in the department of gynecology. The only method of treatment is laparoscopic or laparotomic surgery with mandatory removal of the submucosal node. At the stage of preoperative preparation, fibrinolysis inhibitors, infusion therapy to compensate for blood loss and stabilize hemodynamics, narcotic analgesics, antibiotics are prescribed. Taking into account the high risk of infectious complications, antibacterial therapy is continued in the postoperative period. When choosing the volume of intervention, the patient’s age, her reproductive plans, the presence of complications, other myomatous nodes (their type, number, size, localization) are taken into account. The recommended types of operations are:
- Cutting off the nascent node. Conservative myomectomy with vaginal access is indicated for women of reproductive age planning childbearing, with an uncomplicated course of pathology. After lowering the submucosal leiomyoma and crossing its pedicle, the uterine cavity is carefully scraped out, a control hysteroscopy is performed.
- Radical interventions. Hysterectomy and supravaginal amputation of the uterus with appendages are the operations of choice for necrosis of the incipient fibroids, prolonged eversion of the uterus, the impossibility of its reduction with a recent complication. The risk of organ-preserving operations in such cases is justified only in young patients.
Prognosis and prevention
If the diagnosis is made correctly and the operation is performed to the appropriate extent, the prognosis in patients is favorable. Prevention is aimed at early diagnosis of submucous leiomyoma, its planned adequate conservative or surgical treatment (myomectomy, supravaginal amputation of the uterus, embolization of the uterine arteries). For the timely detection of myomatous formation, women are recommended to undergo an annual professional examination by an obstetrician-gynecologist and transvaginal ultrasound. In order to avoid possible gynecological and obstetric complications after surgery for the incipient fibroids, ultrasound control is carried out every 3 months during the first year, and then twice a year. Gestation planning is allowed no earlier than six months after node removal.