Uterine fibroids (leiomyomas): Prolapsed fibroids

INTRODUCTION — Uterine fibroids (leiomyomas) are common benign smooth muscle tumors [1,2]. Fibroids may develop anywhere within the muscular wall of the uterus, including submucosal, intramural, or subserosal positions (figure 1). For patients with a pedunculated submucosal fibroid that is contained within the uterine cavity, removal is typically performed using hysteroscopy. Infrequently, uterine contractions will push a pedunculated submucosal fibroid through the cervical canal and it may prolapse into the vagina [3]. Pedunculated fibroids that dilate the cervix or prolapse through the cervix into the vagina can usually be removed via the vagina.

Removal of subserosal or intramural fibroids through a vaginal colpotomy incision is an uncommonly performed procedure that has also been referred to as vaginal myomectomy [4]. This approach has been associated with an increased risk of infection compared with other surgical approaches to myomectomy. This procedure is not discussed here.

Vaginal myomectomy for a prolapsed submucosal uterine fibroid is reviewed here. Hysteroscopic, abdominal, and laparoscopic approaches to myomectomy are discussed separately. (See "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy" and "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure" and "Uterine fibroids (leiomyomas): Laparoscopic myomectomy and other laparoscopic treatments".)

INCIDENCE AND RISK FACTORS — There are no data regarding the incidence or risk factors of prolapsed uterine leiomyomas in particular. In general, uterine leiomyomas are the most common type of pelvic tumor in females, with a prevalence of up to 80 percent. Submucosal fibroids account for approximately 15 to 20 percent of these and an unknown proportion of submucosal leiomyomas prolapse through the cervix. In our experience, this clinical finding is uncommon, but is not exceedingly rare. The epidemiology and risk factors of uterine leiomyomas are discussed separately. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Prevalence' and "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Risk factors'.)

CLINICAL PRESENTATION — Prolapse of a submucosal leiomyoma through the cervix may present with symptoms of vaginal bleeding, discharge, or pelvic pain. Some patients are asymptomatic, and the finding is noted incidentally on pelvic examination.

Symptoms — Patients with a fibroid that has prolapsed through the cervix may present with vaginal bleeding, watery vaginal discharge, pelvic pain or cramping, vaginal pressure [5]. Often, uterine cramping is significant during the process of fibroid expulsion through the cervix. Rarely, profuse bleeding occurs.

General symptoms of submucosal fibroids include heavy menstrual bleeding, dysmenorrhea, and infertility. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Clinical features'.)

Incidental finding on pelvic examination — A prolapsed fibroid may be discovered during a pelvic examination performed for other indications. A prolapsed uterine leiomyoma is visualized on speculum examination as a mass protruding from the cervix. (See 'Pelvic examination' below.)

In our experience, these patients may not have initially complained of associated symptoms, but further questioning often reveals a history of heavy vaginal bleeding, pelvic cramping, or vaginal discharge.

DIAGNOSTIC EVALUATION — Pelvic examination is required to further evaluate symptoms suggestive of a prolapsed fibroid and helps to differentiate a leiomyoma from other lesions. Imaging studies may help delineate other type 0 fibroids (figure 1) that can be addressed during surgery. Pathology evaluation is required to make the final diagnosis.

Pelvic examination — On speculum examination, a prolapsed uterine fibroid appears as a bulbous mass protruding from the external cervical os. In general, the size ranges from approximately 1 to 6 cm in diameter. Larger fibroids are unlikely to prolapse through the cervix. The fibroid may be friable and active bleeding may be present.

The mass should be palpated to identify the consistency and whether there is a pedicle. A fibroid is likely to have a firmer consistency than a cervical or endometrial polyp, which is usually soft and fleshy. A prolapsed fibroid or endometrial polyp will have a palpable pedicle that originates from the uterine cavity, while a cervical polyp will originate from the exocervix or endocervical canal. It is not always possible to differentiate between fibroids and polyps on examination and the final diagnosis is made with pathology evaluation. (See 'Differential diagnosis' below and 'Diagnosis' below.)

A lesion that originates from the uterine cavity but is extensive and has no clear pedicle raises suspicion for a uterine sarcoma.

Imaging studies — Preoperative imaging is not required, but may help delineate other fibroids (eg, type 0) that can be addressed during surgery. It can also be useful for further evaluation of a mass that is not consistent with a leiomyoma or cervical/endometrial polyp (eg, if there is concern for a uterine sarcoma [rare]).

When imaging is performed, pelvic sonography is typically the first line study, since it provides good quality images of uterine lesions and is relatively inexpensive. In our experience, we also use pelvic magnetic resonance imaging (MRI), since it is more likely than ultrasound to provide information about the size and position of the uterine attachment [6]. Limited sequences (T2, sagittal, axial and parallel to the uterus) without contrast are usually sufficient to evaluate the mass and can reduce the cost of imaging. In one case report of a patient with an ultrasound demonstrating a large, prolapsed fibroid connected to the endometrial cavity by a broad stalk, sagittal T2 MR imaging showed the stalk contained multiple fine linear structures, which the authors described as the "broccoli sign" [7]. This appearance may be helpful in diagnosing a prolapsed myoma. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Imaging and endoscopy'.)

Pathology evaluation of mass — Masses that are consistent with common, benign lesions (prolapsed fibroid or endometrial polyp or cervical polyp) are typically removed in their entirety for therapeutic purposes, and the diagnosis is confirmed by pathology evaluation of the specimen. Preoperative biopsy is indicated only if the appearance of the lesion is not consistent with a fibroid or a cervical or endometrial polyp, although uterine sarcomas may be heterogeneous and the pathologic diagnosis based upon a small biopsy may not be possible.

DIAGNOSIS — A presumptive diagnosis of a prolapsed fibroid is made upon visualization and palpation during pelvic examination. The diagnosis is confirmed with pathology examination after removal of the lesion.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis for a prolapsed fibroid primarily includes a cervical polyp or prolapsed endometrial polyp. Cervical polyps are a very common finding and prolapse of an endometrial polyp occurs infrequently. (See "Benign cervical lesions and congenital anomalies of the cervix", section on 'Polyps' and "Endometrial polyps", section on 'Hysteroscopic polypectomy'.)

Differentiating between these lesions on physical examination is discussed above. (See 'Pelvic examination' above.)

Rarely, other types of uterine pathology may prolapse or protrude through the cervix, including:

●A prolapsed uterine sarcoma [8] (see "Uterine sarcoma: Classification, epidemiology, clinical manifestations, and diagnosis", section on 'Clinical presentation')

●A polypoid form of uterine adenomyosis [9] (see "Uterine adenomyosis")

Biopsy should be performed if uterine sarcoma is suspected. Polypoid uterine adenomyosis may mimic a prolapsed fibroid or endometrial polyp on examination, but will be identified with pathology evaluation after removal. (See 'Diagnostic evaluation' above.)

MANAGEMENT — Prolapsed leiomyomas are removed, typically via vaginal myomectomy, for the purpose of diagnosis and relief or symptoms. Most clinicians remove these lesions even in asymptomatic patients, because symptoms eventually develop in nearly all patients. Removal of prolapsed fibroids is also prudent to prevent uterine infection.

The removal of a prolapsed uterine fibroid is performed either in an office setting or with a minimally invasive approach in an operating room. In general, there are few contraindications to vaginal myomectomy with the exception of patients with significant medical comorbidities who have an increased risk of complications associated with anesthesia or who have a bleeding diathesis or are on anticoagulants. These patients require medical consultation prior to surgery. (See "Overview of the principles of medical consultation and perioperative medicine" and "Perioperative management of patients receiving anticoagulants".)

VAGINAL MYOMECTOMY — Vaginal myomectomy is often performed in an office setting during the visit at which a small (<4 cm) prolapsed fibroid is discovered. Some patients require removal of the lesion in an operating room.

Surgical planning

Informed consent — Informed consent should include a discussion of the physical examination and imaging findings and the details of the procedure. The potential need for a further procedure if the fibroid cannot be removed completely should be discussed, including hysteroscopic, laparoscopic, or abdominal myomectomy or possibly hysterectomy. This discussion should be documented in the medical record and on the procedure consent form signed by the patient.

Operative setting — While some prolapsed myomas can be removed in an office setting, other vaginal myomectomy procedures should be performed in the operating room for better access to anesthesia, pain management, measures to control bleeding, and surgical instruments. It is important to assess the feasibility of an office-based procedure before the procedure is attempted to avoid incomplete removal, excessive blood loss, or the need to transfer the patient to the operating room.

There are no data regarding removal in an operating room rather than in an office setting. In our practice, we remove fibroids with the following characteristics in the operating room:

●Larger than 4 cm

●Pedicle cannot be visualized or palpated

●Broad-based (pedicle >2 cm in diameter)

●Cervical fibroid that is not pedunculated and/or prolapsed

Removal in the operating room may also be required for patients who cannot tolerate an office procedure or who have a bleeding diathesis or are on anticoagulants. (See 'Management' above.)

Anesthesia — Vaginal myomectomy of a prolapsed fibroid in an office setting is typically performed with a paracervical block. There are no data regarding the optimal type of anesthesia for this procedure. Some patients can tolerate the removal of small fibroids with a thin pedicle without anesthesia. Use of an anxiolytic or conscious sedation may be used to facilitate an office procedure. (See "Pudendal and paracervical block", section on 'Gynecologic procedures'.)

For procedures in an operating room, the decision to use sedation, regional, or general anesthesia should be made through consultation with the patient and anesthesiologist.

Antibiotic prophylaxis — Prophylactic antibiotics are not required for vaginal myomectomy of a prolapsed myoma for the prevention of surgical site infection or endocarditis [10]. In our practice, however, we give a single dose of perioperative antibiotics if the fibroid is necrotic or obviously infected. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Antibiotic prophylaxis'.)

There is a potential risk of infection, as with any surgical procedure, but there are few data about this procedure and no cases of infection were reported in the two largest series, each with 46 patients [3,11].

Thromboprophylaxis — Procedures performed in an office setting are typically brief and thromboprophylaxis is not required. For patients who undergo vaginal myomectomy in an operating room, since surgery is performed in the lithotomy position and may be prolonged, thromboprophylaxis with an intermittent pneumatic compression device should be used in all but the shortest procedures. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Thromboprophylaxis'.)

Procedure — The procedure for vaginal myomectomy is as follows:

●The prolapsed fibroid is grasped with a towel clamp or tenaculum and pulled down into the vagina and away from the cervix. Excessive traction on the fibroid should be avoided to prevent avulsion of the lesion or uterine inversion.

●If the entire pedicle of the fibroid can be palpated, the entire pedicle can often be clamped across the base. It is then cut and suture ligated using a delayed absorbable suture material. Alternatively, a suture can be passed around the pedicle and tied or a pre-tied surgical loop passed over the fibroid to the pedicle and the base ligated. We secure this with an additional suture ligature. After it is cut, the stalk will usually recede into the uterine cavity.

If the entire pedicle cannot be palpated because it is broad-based or the fibroid is within the cervical canal and the cervix is dilated, access to the fibroid can be obtained by making cervical incisions at 2, 6, and 10:00 (Dührssen incisions [12]). This procedure should only be performed in an operating room with adequate anesthesia.

After making the cervical incisions, using gentle traction, the fibroid can be brought down into the vagina and morcellated using a scalpel or Mayo scissors until the base of the pedicle can be palpated. Once the pedicle can be palpated, clamping or suture ligation can be accomplished and the remainder of the fibroid excised. Care should be taken to avoid extension of the incisions into the lateral vaginal fornices to avoid the uterine vessels. The cervical incisions should then be closed. In our practice, we use a 0-polyglactin (Vicryl) in a running stitch.

If the vaginal myomectomy procedure is performed in the operating room, some surgeons perform hysteroscopy after removal of the fibroid to evaluate the uterine cavity for a remnant of the fibroid and for additional submucous fibroids that may be amenable to hysteroscopic myomectomy. (See "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy".)

Complications — Complications of vaginal myomectomy for a prolapsed fibroid are rare, based upon the few available data [3,5,11]. In two retrospective series of 46 patients, there were no complications [3,5].

The most likely potential complication of vaginal myomectomy is excessive bleeding from the fibroid site. This can be managed with pressure, using either a uterine pack or a bladder catheter balloon placed inside the uterus and inflated or, if the site is accessible, with a suture. These may be left in place for several hours and then slowly removed to ensure hemostasis. If bleeding persists, hysteroscopy should be performed to identify and control the bleeding site. (See "Managing an episode of acute uterine bleeding", section on 'Role of intrauterine tamponade'.)

Uterine inversion due to excessive traction on the fibroid prior to removal is another potential complication. Replacement of an inverted uterus is discussed separately. (See "Puerperal uterine inversion", section on 'Management'.)

There is a theoretical risk of infection, but none was reported in the two largest series, each with 46 patients [3,5].

Outcome — The procedure appears successful in most cases [3,5]. A retrospective series of 46 patients who underwent vaginal myomectomy for a prolapsed fibroid reported two failed procedures in which the lesion could not be removed, both of which were due to difficulty reaching the fibroid pedicle [3]. Another series reported treatment with vaginal myomectomy, abdominal myomectomy, or hysterectomy, but the rate of conversion from a vaginal myomectomy to another procedure was not reported [5].

Recurrence of a prolapsed fibroid or of fibroid-related symptoms appears to occur infrequently. A retrospective series of 46 patients reported that, at 5.5-year follow-up, 9 percent required a repeat vaginal myomectomy and 6 percent had a hysterectomy [11]. Hysterectomy in these cases may have been due to indications other than the original prolapsed myoma.

To avoid recurrent fibroid-related symptoms, preoperative imaging may be performed (see 'Imaging studies' above). Alternatively, hysteroscopy may be performed after removal of a prolapsed fibroid to exclude other pedunculated or submucosal fibroids that may require treatment. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Imaging and endoscopy'.)

Follow-up — Patients may experience uterine cramping and/or vaginal spotting for several days following the procedure. Acetaminophen or nonsteroidal anti-inflammatory drugs are usually adequate if postoperative pain control is necessary. Patients should be advised to call their clinician for fever, purulent vaginal discharge, or bleeding that persists for longer than two weeks or is profuse.

Postoperative care is individualized; many patients do not require a follow-up visit. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)

PREGNANT PATIENTS — Prolapsed fibroids rarely occur during pregnancy. A review of 11 pregnant patients reported that two of the prolapsing fibroids were submucosal while the other nine originated from the portio of the cervix [13]. Magnetic resonance imaging (MRI) may be helpful to determine the size and position of the attachment of the fibroid to the uterus. During pregnancy, prolapsed fibroids should be removed only for excessive bleeding, infection, pain or urinary retention. If obstruction of labor occurs or is predicted, cesarean section can be performed and the fibroid can be removed at a later time. Surgical removal during pregnancy may be associated with rupture of the membranes, preterm labor, or hemorrhage with need for hysterectomy. In two patients reported requiring removal, there were no complications.

Management of uterine leiomyomas in pregnant patients is discussed in detail separately. (See "Uterine fibroids (leiomyomas): Issues in pregnancy", section on 'Indications for antepartum transvaginal myomectomy'.)

REFERRAL TO A SPECIALIST — Patients with a lesion consistent with a prolapsed leiomyoma should be referred to a gynecologist or other clinician who can perform a vaginal myomectomy.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Uterine fibroids (leiomyomas)".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Uterine fibroids (The Basics)")

●Beyond the Basics topics (see "Patient education: Uterine fibroids (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Role of vaginal myomectomy – Vaginal myomectomy is performed for submucosal myomas that have prolapsed through the cervix (figure 1 and figure 2). For patients with submucosal fibroids that have not prolapsed, removal is typically performed hysteroscopically. (See 'Introduction' above.)

●Clinical presentation – Patients with a fibroid that has prolapsed through the cervix may present with vaginal bleeding, watery vaginal discharge, uterine contractions, pressure from a vaginal mass, or they may be asymptomatic. (See 'Symptoms' above.)

●Diagnostic evaluation – In addition to pelvic examination, pelvic sonography is often performed to help delineate other fibroids that can be addressed during surgery. We also use pelvic magnetic resonance imaging (MRI) to provide information about the size and position of the uterine attachment. (See 'Diagnostic evaluation' above.)

●Diagnosis – A presumptive diagnosis of a prolapsed leiomyoma is made upon visualization during a pelvic speculum examination. The diagnosis is confirmed with pathology examination. Preoperative biopsy is not typically required. (See 'Diagnosis' above.)

●Operative setting – Prolapsed leiomyomas require removal and can often be removed in an office setting. We suggest removal in an operating room rather than in an office setting for patients with fibroids with the following characteristics: nonprolapsed, larger than 4 cm, broad-based, the pedicle cannot be visualized or palpated (Grade 2C). Removal in the operating room is also preferable for patients who cannot tolerate an office procedure or who have a bleeding diathesis. (See 'Operative setting' above.)

●Outcomes and complications – Vaginal myomectomy of a prolapsed myoma is usually successful. Conversion to abdominal myomectomy or abdominal hysterectomy has been reported. Complications of the procedure are rare. (See 'Outcome' above and 'Complications' above.)

●Pregnant patients – During pregnancy, prolapsed fibroids should be removed only for excessive bleeding, infection, pain or urinary retention. If obstruction of labor occurs or is predicted, cesarean section can be performed and the fibroid can be removed at a later time. Surgical removal during pregnancy may be associated with rupture of the membranes, preterm labor or hemorrhage and need for hysterectomy. (See 'Pregnant patients' above.)