Torsion of subserosal leiomyoma of the uterus

Torsion of subserosal leiomyoma of the uterus refers to the twisting of the attached pedicle of a pedunculated subserous leiomyoma of the uterus with subsequent ischemia, necrosis and gangrene ¹. 

Clinical presentation

• acute abdominal pain

• GIT symptoms (e.g diarrhea)

• tenderness in the lower abdomen ¹

Pathology

• gross picture: the torsed mass appears dark blue on a twisted pedicle

• microscopic picture: hemorrhagic leiomyoma shows multifocal hemorrhage, congestion and vascular ectasia ^1. 

Radiographic features

Ultrasound:

• normal uterus with heterogeneous echogenicity of pedunculated para- uterine mass

• mild pelvic free fluid

• color Doppler demonstrates twisted pedicle with no blood flow within the mass

MRI:

• T1: intermediate to high signal intensity related to hemorrhagic necrosis

• T2: peripheral low signal and central high signal intensity

• T1 with contrast: no enhancement

The uterus is of normal signal and enhancement ¹. 

Treatment and prognosis

Once suspected, immediate surgical interference is mandatory to avoid complications.

Complications

 If left untreated; gangrene, bleeding or peritonitis may occur ^2,3.

Differential diagnosis

• uterine leiomyoma with secondary degeneration

• ovarian torsion: twisted pedicle of an enlarged ovary and non-identification of one of the ovaries

• GIT conditions: appendicitis and gastroenteritis

• pelvic inflammatory disease ¹