Presentation
The patient presented for a pelvic ultrasound following inability to pass urine twice (in 24 hours) and a subsequent catheterization, plus a history of per vaginal bleeding and a one-day severe lower abdominal pains, to rule out prolapsed uterine fibroid.
Patient Data
Grey mapping sonographic pelvic examination demonstrates an acute tilting/malrotated uterine fundus infero-medially (bordering the proximal vaginal vault) and into the Douglas pouch. The uterine cervix and the external cervical lips are inverted upwardly supero-laterally to the right urinary bladder wall aspect extrinsically. The bilateral oviducts appeared relatively telescoped within the infero-medial endometrial canal up to the internal cervical ostium level. Both the ovaries were seen tapered externally at the level of the external cervical ostium/ipsilateral right lower abdominal quadrant.
The non-gravid uterine volume of 262 ml noted was moderately bulky and was accompanied with a conspicuous, mildly hypo to isoechoic solitary myometrial uterine fibroid (5.1 x 4.5 cm in size) visualized fundally. However, the urinary bladder (not shown in the images) was partially collapsed, with the Foley's balloon and bladder catheter in situ.
Case Discussion
Uterine malrotation/incarceration/inversion is the resultant acute tilting, plus the subsequent partial or total entrapment of the uterus into the cul-de-sac 1. This may present with acute/severe lower abdominal pains and occasionally per vaginal bleeding/spotting. The clinical sign of an inability of the patient to voluntarily void that then prompts an immediate bladder catheterization is one of the hallmark features of this condition.
Complete uterine tilting is quite a rare phenomenon with most of the mentioned cases (in the existing literature), being mainly of the gravid uterine status and is prevalent in 1 out of 3000 cases 2.
Whereas the uterus was not gravid as in this particular case, the likelihood of a solitary fibroid playing a role in the uterine malrotation could not be excluded. Up to now, this could be the first published case of non-gravid complete uterine malrotation sequelae of uterine fibroid predisposition, sonographically.
In this particular case, a surgery was performed and a total abdominal hysterectomy was done with the subsequent clinical notes confirming a malrotated uterus with a myometrial uterine fibroid.