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23: A perplexing vaginal mass: Prolapsed uterus or fibroid, or both?

      Objective

      Pedunculated uterine leiomyomata may prolapse into the vagina. The objective of this video is to describe the evaluation and management of an unusual presentation of a prolapsed uterine leiomyoma in a postmenopausal woman with uterine procidentia.

      Description

      Prolapse of a pedunculated uterine leiomyoma is typically acute and dramatic. Physical examination is sufficient for diagnosis in almost all cases. A 64 year-old Gravida 1, Para 1, female presented with increasing discomfort from a 12-cm long, solid, irreducible chronic vaginal protrusion. The differential diagnosis included uterine procidentia with a cervical leiomyoma, prolapsed pedunculated uterine leiomyoma, and uterine inversion, Magnetic Resonance imaging indicated that she had a Stage IV uterovaginal prolapse with an extremely elongated cervix and likely a leiomyoma at the most distal end. Upon surgical exploration, this was found to be a pedunculated leiomyoma originating from the cervical canal which prolapsed outside the cervix unusually very slowly and fused with the posterior cervix in the background of a Stage IV uterovaginal prolapse. In this video, the use of magnetic resonance imaging and successful surgical management of this patient are reviewed.

      Conclusion

      This patient presented at 2-week follow-up in an excellent condition and reported a significantly improved quality of life.