Introduction

Leiomyoma is the commonest of all uterine and pelvic tumors, with an incidence of almost 20% in women of reproductive age group. Cervical fibroids account for 2% of all fibroids [1]. They arise from either supra-vaginal or vaginal portion of cervix. They are classified as anterior, posterior, lateral and central depending on their site of origin. Each fibroid presents differently. Cervical leiomyoma is commonly single and is either interstitial or subserous. Rarely, does it become submucous or polypoidal. Giant cervical polyps are described as polyps greater than 4 cm in size and are rarely seen in clinical practice [2,3].

Case Report

Mrs X was a 60 years old Hindu married para three female who presented to the Department of Obstetrics and Gynecology, R D Gardi Medical College, Ujjain, on 8 September 2020, with the complaint of something coming out per vaginum, vaginal bleeding off and-on-and foul-smelling discharge for 1 month. She complained of heaviness in the vagina, pain in lower abdomen and back for 1 month. There was no associated bladder or bowel dysfunction. She attained menopause 2 years back. At the time of admission, she was in a low general condition; very pale looking, with an offensive odour from whole body. Her blood pressure was 90/60 mm Hg and pulse rate was 104/min. Her abdomen was soft and non-tender. On local examination, a mass of 12 x 15 cm was seen at the vulval opening, finger could not be passed around it looking like uterine inversion. Per speculum examination could not be performed. On careful palpation, the mass was firm and non-tender. Copious pus discharge was present. Per rectal examination confirmed the presence of normal parametrium and rectal mucosa and an atrophied uterus. Hemoglobin (Hb) was 4 gm%, total leukocyte count (TLC) was 17000/cu mm. Rest all investigations were within normal limits. Probable diagnosis of Degenerated cervical fibroid polyp was made.

She was admitted and was given Metronidazole, Gentamycin and Tazobactam-Piperacillin. Frequent applications of antiseptics and metronidazole douche was given. Four units of blood were transfused. The case was then taken for laparotomy followed by hysterectomy, on opening the abdomen uterus was seen small in size sitting on the mass. Specimen was sent for histopathological examination. The patient was discharged on the 10^th postoperative day. Histopathology confirmed it to be a leiomyoma with secondary changes of haemorrhage and necrosis.

Discussion

The presence of this huge fungating mass at the introitus in this patient was confusing. Neglected degenerated cervical fibroid polyp, chronic uterine inversion and a mucous polyp is another differential diagnosis. The histology of this case reported a leiomyoma with no evidence of malignant changes. Carcinomatous change occurs rarely in cervical polyps (seen only in 1.7% of cases). Several authors have contradicting views as to whether excisional biopsy is a more prudent approach or prior biopsy to confirm the diagnosis before resorting to surgery. In situations like ours where cervical carcinoma is very common, we may opt for biopsy first but this will only prolong morbidity and discomfort in the critically ill. Thus, it has been suggested that biopsy of these tumors before excision may not be necessary [4]. Careful evaluation, definition of anatomy, good clinical judgment should decide the course of management. If histology eventually shows malignant degeneration, appropriate therapy can always be advanced.

Conclusion

Giant cervical fibroids are rare and their diagnosis can be quite challenging. It may masquerade cervical malignancy or uterine inversion and prolapse and proper evaluation is needed to make an accurate diagnosis. Hospitalization, clinical optimization, thorough evaluation and clear definition of pathology coupled with meticulous surgery under appropriate anaesthesia, remain the mainstay of successful management of gravely ill patients presenting with a bizarre introital pathology as seen in this woman.

References

1. Kaur AP, Saini AS, Kaur D, Madhulika, Dhillon SPS (2002) Huge cervical fibroid-unusual presentation. J Obstet Gynaecol India 52: 164.
2. Bucello D, Frederic B, Noel JC (2008) Giant cervical polyp: a case report and review of rare entity. Arch Gynecol Obstet 278: 295-298.
3. Massinde AN, Mpogoro F, Rumanyika RN, Magona M (2012) Uterine prolapsed complicated with giant cervical polyp. J Low Genit Tract Dis 16: 64-65.
4. Khalil AM, Azar GB, Kasper HG, Abu-Musa AA, C4hararah IR, Seoud MA (1996) Giant cervical polyp: a case report. J Reprod Med 41: 619-621.