A RARE CASE STUDY OF TORSION OF A NON-GRAVID UTERUS Affiliation

Torsion of a non gravid uterus is a rare but poten ally fatal event. It may lead to rapid clinical deteriora on causing irreversible ischemic damage to the uterus. The rarity of the condi on and its non specific clinical presenta on make the clinical diagnosis difficult. In this report we discuss a case of uterine torsion in a 55 year old postmenopausal lady who presented in emergency with acute abdomen. On examina on a huge abdominal mass arising from pelvis was noted. The opera ve finding was huge fundal myoma with uterine torsion.


INTRODUCTION
Torsion of the uterus is defined as rota on more than 45 degrees around the long axis.Torsion from 60 degrees to 720 degrees has been described.¹Most of the cases of uterine torsion have been described in a gravid state, whereby it results in serious maternal and fetal consequences.In a nongravid uterus the torsion results from uterine leiomyomas, mullerian anomalies, pelvic adhesion and the laxity of abdominal wall or uterine ligaments.²Uterine torsion is a poten ally life threatening condi on and may cause irreversible ischemic damage to the uterus, leading to rapid clinical deteriora on.³Thus early and accurate diagnosis is essen al for its effec ve management.

CASE REPORT
A 55 years old postmenopausal lady presented to emergency department of Tribhuwan University Teaching Hospital (TUTH) with complaints of gradually increasing distension of abdomen for 5 years and acute onset of pain abdomen for 5 days.Five years back she was diagnosed to have a mass in uterus and advised for surgery but she did not seek further treatment at the me.Five days prior to the presenta on to emergency she developed pain lower abdomen which was sudden in onset, later became generalized and also radiated to the back and inner aspect of bilateral thigh.She had three children, all delivered vaginally at home.She had a ained menopause 10 years back at the age of 45 years.
At the me of examina on, she had pulse rate of 100 beats /minute, blood pressure 160/100mmHg, afebrile without pallor or dehydra on.Abdomen was distended with a mass occupying whole of the upper and lower region measuring 36cmx30cm, firm in consistency, smooth surface and regular margin with a groove felt on le .Cervix was difficult to visualize with speculum and on bimanual examina on, cervix was pulled up and uterus could not be figured out.
The Computed Tomography (CT) scan of abdomen showed approximately 20 cm x 16.8 cm x 32.2 cm size lobulated mass in pelvis extending up to the level of renal vessels and L2 vertebra inseparable from uterus.Mass was abu ng the lower margin of liver and displacing bowels superiorly and bladder inferiorly.Mass showed slight heterogenous enhancement and increased vascularity on contrast administra on.Ovaries were not visualized separately and no significant lymph nodes or free fluid noted.Thus the diagnosis of uterine fibroid with possibility of sarcomatous degenera on was made and was admi ed in ward for observa on.
A er pre-opera ve evalua on, emergency laparotomy was performed.Abdomen was opened via midline ver cal incision.Mass of 40cm x 25cm arising from right cornufundal area of the uterus with torsion of uterus at the level of isthmus by 180° was noted (Figure 1).The mass was bilobed with each lobe measuring 20 x 25cm, irregular surface and so in consistency.(Figure 2 were stretched over the mass.The vessels around the isthmus were engorged and tortuous.(Figure 1 & 3) Total abdominal hysterectomy with bilateral salphingooophorectomy was performed.(Figure 4) The post-opera ve stay at hospital was uneven ul and she th was discharged on 7 post-opera ve day with advice to follow up with histopathology report.The Histopathology report revealed leiomyoma with atrophic endometrium with chronic cervici s and unremarkable bilateral tubes and ovaries.The mechanism of an axial rota on in a normal uterus is difficult to explain.The uterus in its normal state is firmly held in place by the broad ligaments and the uterosacral ligaments.These supports resist any tendency to torsion.Uterine axial torsion is usually caused by the presence of pathological or abnormal condi on in the uterus or the adjacent structures, uterine fibroids being the most common predisposing factor.A large heavy myoma, especially subserosal, fundal myoma, may rotate and exert trac on on the uterus.Torsion usually occurs at the level of isthmus.Because of the rela vely weak lateral a achment of the body of uterus, it is rela vely mobile as compared to well supported cervix via lateral cervical and uterosacral ligaments.⁶ The presenta on of uterine torsion ranges from asymptoma c condi on diagnosed at the me of surgery to non specific symptoms to acute abdomen and shock.⁷The associated symptoms may include obstructed labor in cases of gravid uterus, intes nal or urinary symptoms, Figure 4: Cut sec on of the specimen abdominal pain as in our case, vaginal bleeding and hypotension.Pre-opera ve diagnosis of uterine torsion is made difficult by the lack of specific clinical symptoms and signs.However, specific clinical signs including vaginal bleeding, uterine tenderness, a twisted vaginal canal and urethral displacement have been reported.⁸Various radiological features of uterine torsion have been reported which, if combined with clinical features and high degree of suspicion, help in pre-opera ve diagnosis of this condi on.On ultrasound, change in the posi on of fibroids from that noted in previous ultrasound scan may indicate torsion of myomatous uterus.Similarly, gas in the uterine cavity on plain radiographs and CT scanning has been described as a feature of uterine torsion.⁹Magne c resonance features of uterine torsion have also been described.The wall of the upper vagina changes from the normal H configura on to an X-shaped configura on in uterine torsion.¹⁰Torsion of the uterus may progress to conges on and gangrenous changes in the uterus or adnexae.Because of the rarity of the condi on, the cri cal me a er which ischemic change is irreversible is not well documented.¹¹Irreversible ischemic damage to the uterus can worsen pa ent's clinical condi on within a short period of me and pose a serious threat to life.Prompt surgical treatment is necessary to minimize the probability of developing sepsis (related to necrosis) and hemorrhage.In young women of reproduc ve age, conserva ve surgical procedures can be done.The anatomical causes of torsion (adhesions, myomas and ovarian cysts) are removed and the uterus is de-rotated to its anatomical posi on whenever possible.In peri-and postmenopausal women total hysterectomy with 8 salpingoophorectomy is performed as in our pa ent.

CONCLUSION
Torsion of a non gravid uterus is a rare clinical event but should be thought as a rare possibility if a women with big myoma or adnexal mass present with features of acute abdomen.Prompt surgical treatment is necessary for avoiding possible fatal outcomes.