Submucosal fibroids are a common occurrence. However spontaneous necrosis of submucosal fibroid is rarely observed other than in case reports described following uterine artery embolization. To our knowledge, the sequelae of severe pelvic inflammatory disease (PID) with bilateral tuboovarian abscesses (TOA) and subacute bowel obstruction has not been reported in the published literature.
We report an interesting case in a 25-year-old nulliparous female with 9x4x4 cm prolapsing submucosal fibroid that underwent spontaneous necrosis. This patient had a 6-month history of a known 7x6x6 cm intramural fibroid that was managed conservatively. She represented to her gynaecologist with offensive vaginal discharge with repeat ultrasound confirming a 9cm prolapsing submucosal fibroid. She was urgently referred for surgical management with oral antibiotics commenced in the interim.
Immediately prior to procedure patient developed nausea, vomiting and abdominal pain. The aim of surgical management was to debulk and remove the necrotic fibroid along with a diagnostic laparoscopy to exclude myometrial or serosal uterine involvement. The diagnostic laparoscopy noted unexpected severe pelvic adhesions with severely distorted anatomy. Adhesions also involved large bowel with dilatation of bowel loops. The pelvis was occupied with large multi-lobed masses suspicious of TOA, endometriomas or an undiagnosed malignancy. Vaginal examination and limited hysteroscopy noted an open cervix with a necrotic mass originating from endometrium avulsed into the vagina. Uterine mass was debulked and sent for urgent histopathology and microscopy. Given unconfirmed pathology, a decision was made to abandon procedure and proceed to an urgent MRI and commence triple antibiotics whilst planning definitive management.
The patient underwent an MRI the next day confirming a residual submucosal fibroid and bilateral TOA with moderate gaseous distension of the large bowel and sigmoid. The patient had ongoing symptoms and a subacute bowel obstruction. A week later the second laparoscopy was performed which noted improved adhesions and tissue inflammation post intravenous antibiotics. Surgical treatment required extensive adhesiolysis, drainage of the bilateral TOA, appendicectomy and removal of fibroid that was benign on histopathology. Patient significantly improved post procedure and was discharged on day two of surgery with the resolution of all symptoms by one week.
There is minimal literature on prolapsed necrotic fibroids causing severe PID with TOA. Here we a describe the minimally invasive surgical approach with videos demonstrating both initial and second laparoscopy which demonstrate the evolution of severe PID following intravenous antibiotics treatment and removal of necrotic fibroid source.