Torsion of Non gravid uterus – A rare case

Case History:
55yrs old Mrs. M presented to emergency with complaint of severe lower abdominal pain
for the past 2 days. Pain was sudden in onset, continuous and associated with 2 episodes
of vomiting. She also informed us that she not passed flatus and stools in the last two
days. She also gave history of mass per vagina for the past 2 years.
There was no pallor and vitals were stable. Abdomen was distended and a tense cystic
mass was noted in the supra-pubic region extending up to the umbilicus. Bowel sounds
were sluggish. On speculum and per vaginal examination cervix was high up and in the
retro-pubic position. Uterus could not be made out separately from the mass.
A provisional diagnosis of torsion of Ovary/mesenteric cyst was made.
Her hematological and biochemical parameters were with in normal limits. Ultrasound
showed a cystic lesion with out septations or nodularity.
Emergency laparotomy showed a large right ovarian cyst which had undergone torsion of
3 turns about the infundibulo-pelvic ligament. Interestingly uterus was also twisted about
2 turns along vertical axis and involving the broad ligament. Uterus was congested and
almost dark in color. Left ovary and the tube were normal. Both the cyst and the uterus
were untwisted, right ureter identified and a total abdominal hysterectomy with bilateral
salpingo-oophorectomy was done. Post operative course was uneventful.

Discussion:
Torsion of a non gravid uterus is an extremely rare occurrence with a reported incidence
of less than 20 cases in the world literature. In most instances uterine torsion occurs in
postmenopausal women and is an accomplice to torsion of an adnexal mass. Its diagnosis
can only be made at laparotomy, although a case report discusses the usefulness of MRI
in pre-op diagnosis1. Torsion occurs above the level of the isthmus and involves the body
and the fundus of the uterus. Cervix is not involved due to its firm attachment to cardinal
utero-sacral complex. Hyper-mobility of uterus due to genital prolapse, as in this case,
could have predisposed to uterine torsion2.

Reference:

1. Matsumato H et al,
Torsion of a nongravid uterus with a large Ovarian mass: usefulness of Contrast
MRI.
Gynecol Obstet Invest. 2007;63(3):163-5

2. Nikolov A
Torsion of a nongravid leiomyomatous uterus
Akush Ginekol (sofiia). 2006; 45(5): 49-51