Chronic uterine inversion in a non-pregnant uterus is rare, with just over 100 reported incidences throughout literature in the 20th century. It is often associated with uterine pathologies with prolapsed fibroids tending to be the most common inciting factor. Three contributing factors proposed for uterine inversion are 1) sudden emptying of the uterus which was previously distended by a tumour 2) thinning of the uterine walls due to an intrauterine tumour 3) dilatation of the cervix.
This is a case of a 42 years old nulliparous Chinese female with underlying cauda equina syndrome. She presented to our Emergency Department complaining of heavy menstrual bleeding and generalised weakness and lethargy. On further questioning, she had also noticed a mass gradually protruding per vagina for 3 years duration. She was noted to be pale with no mass palpable per abdomen. Vaginal examination revealed a well circumscribed 6×5 cm mass, thought likely to be a prolapsed fibroid with a thick stalk attached to what was assumed to be an inverted uterus. It was infected and foul smelling with necrotic patches over it. She was started on broad spectrum antibiotics and transfused blood as her haemoglobin level was 4.9 g/dl. In view that the prolapsed fibroid was unreducible, she underwent an examination under anaesthesia and vaginal myomectomy. The uterus could not be reduced due to the constriction band and oedema. After 2 weeks of antibiotics and optimisation of haemoglobin, she was counselled for definitive surgery. She was not keen to conceive, thus she consented for a hysterectomy. We proceeded with a Haultain procedure and a total abdominal hysterectomy and bilateral salpingectomy.
Most reports cite a prolapsed fibroid as the cause of chronic uterine inversion, with some reporting that it was infected. In this case, the predisposing factor was likely to be the cauda equina syndrome and a large submucosal fibroid. The long standing straining to urinate and defecate due to the spine pathology would have precipitated the fibroid to prolapse leading to a chronic uterine inversion. Surgery is the mainstay of treatment for chronic uterine inversion either a hysterectomy or uterine conserving procedures like a Haultain Procedure and Hysteropexy. Management of such cases should be tailored and personalised according to the patient’s wishes and completion of family to avoid recurrence of inversion.