Torsion of a Large Myomatous Uterus Associated with Progressive Renal Failure and Paralytic Ileus in an 86-Year-Old Woman

Case reports in Obstetrics & Gynecology
02 Dec, 2019 ,

Guiwen Wang et al report the case of torsion of a large myomatous uterus in an 86-year-old woman who was presented with progressive renal failure and paralytic ileus. She was presented with abdominal discomfort, loss of appetite, and oliguria. A large myomatous uterus with broad calcification was identified when she underwent surgery to repair an umbilical hernia one year before the symptoms developed. Computed tomography revealed that one year later, the myomatous uterus significantly increased in size and the calcified lesion of the fibroid was largely displaced. She was also presented with paralytic ileus, and her general condition progressively worsened. Her serum creatinine levels were increased (3.5 mg/dL) and hemoglobin levels were low (8.5 g/dL). Emergency laparotomy revealed that the uterus was rotated 360 degrees clockwise at the level of the isthmus. The uterus was discolored, appearing dark red, and accompanied by broad congestion, and the cervix was elongated. The patient's renal function and ileus recovered after a hysterectomy. In conclusion, torsion of a large myomatous uterus could become life-threatening in an oldest-old woman, and early release of the torsion is necessary to avoid serious complications.

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An 86-year-old woman (2 gravida, 2 para), who was presented with an increased pelvic mass, was referred to our facility. She had undergone surgery to repair an umbilical hernia one year previously, and a large abdominal mass with broad calcification, measuring 16 × 13 × 13.1 cm (longitudinal × transverse × anteroposterior), was identified by plain computed tomography (CT) before the hernia repair surgery. The mass was consistent with a uterus containing calcified uterine fibroids.

The patient felt the increased pelvic mass and experienced gastric discomfort related to the stomach being compressed by the mass, resulting in complete appetite loss for the previous week. She was also presented with continuous uterine bleeding and urinary discomfort. The latest CT examination showed that the myomatous uterus significantly increased in size, measuring 27 × 16.5 × 17 cm, and the calcified lesion was largely displaced.

Computed tomography (CT) findings of the myomatous uterus. (a) Coronal section of the abdomen one year before the uterine torsion. The myomatous uterus and calcified portion are observed. (b) Coronal section of the abdomen at the time of uterine torsion. The myomatous uterus significantly increased in size, and the calcified lesion was displaced. (c) Three-dimensional reconstruction images of the lower abdomen one year before the uterine torsion. (d) Three-dimensional reconstruction images of the lower abdomen at the time of uterine torsion. The calcified area inside the uterus was largely displaced.

On admission, her height was 150 cm and body weight was 60 kg. Her body temperature was 35.8°C, pulse rate was 81/min, and blood pressure was 88/40 mmHg. Although she was lucid, her Eastern Cooperative Oncology Group (ECOG) performance status was level 3, accompanied by disabling fatigue.

Her abdomen was distended by an irregular hard mass equivalent to 28 weeks' gestation. There was mild tenderness without rebound tenderness on the mass. On pelvic examination, the portio was normal and no vaginal bleeding was observed. Transabdominal ultrasound showed a large pelvic mass with peripheral calcification suggestive of uterine fibroids. Both ovaries were undetectable and minimal ascites was observed. Both kidneys were normal, with no dilatation of the renal pelvis and ureter. Plain CT images revealed that the uterine cervix was elongated and moved upward compared with its position one year before.

Blood tests showed an elevated white blood cell count (32,500/μL), low hemoglobin levels (9.9 g/dL), elevated C-reactive protein (16.4 mg/dL), and high serum creatinine (2.45 mg/dL). We initially suspected a malignant tumor arising from the uterus or ovary, such as uterine leiomyosarcoma, carcinosarcoma, or ovarian cancer, based on the patient's advanced age, abnormal uterine bleeding, rapidly growing abdominal mass, and ascites. Therefore, we performed cervical cytology, endometrial cytology, and a puncture of the pouch of Douglas to assess the cytology of the ascites. The results of all cytological examinations were negative for malignancy. Transvaginal ultrasonography revealed that the endometrium was thin; therefore, we did not perform an endometrial biopsy.

On the second hospital day, the patient's vital signs were stable, but her ECOG performance status fell to level 4. She was completely confined to the bed and could not carry out any self-care tasks; this change in status was accompanied by delirium. Paralytic ileus developed and her bowel was decompressed with a gastric tube. A small amount of uterine bleeding was observed, and her urine volume gradually decreased. Her hemoglobin level decreased (8.5 g/dL), and her white blood cell count (37,800/μL) and serum creatinine levels (3.5 mg/dL) were elevated. On the third hospital day, she remained in a state of delirium.

Hemorrhagic fluid was collected from the pouch of Douglas by a needle aspiration. The preoperative diagnosis was degeneration and infection of the large myomatous uterus; however, the relationship between the diagnosis and the deleterious change in her general condition remained unknown. During emergency surgery, the uterus was found to be rotated 360 degrees clockwise at the level of the isthmus. The rotated uterus had suffered total infarction. A small amount of hemorrhagic fluid was present in the peritoneal cavity.

A part of the small intestine was compressed by the uterus. We performed a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The weight of the uterus was 3.8 kg. The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. Histopathology showed fibroids and extensive uterine and adnexal hemorrhagic infarcts consistent with uterine torsion.