22 SA MEDIESE TYDSKRIF DEEL 62 3 JULlE 1982

Treatment of prolapsed submucous

fibroids
P. RILEY

whom had undergone total abdominal hysterectomy for fibroids

Summary
Prolapsed submucous fibroids are not uncommon,
and patients present with a vaginal mass which is
often necrotic and infected.
This is a retrospective study of 41 such patients
seen at the King Edward VIII Hospital, Durban, over
a 3-year period. Twenty-eight were treated by
vaginal myomectomy and 13 by abdominal
hysterectomy. Postoperative morbidity was slightly
higher with hysterectomy, but comparable to that
for hysterectomy for un prolapsed fibroids.
S Atr Med J 1982; 62: 22-24.
not presenting vaginally, was therefore studied to see if the
presence of a vaginal fibroid increased morbidity in patients
undergoing hysterectomy.
When differences between groups of patients were discovered,
the significance of the differences was statistically teste.<! using
S rudent's [ test.
Results
Age
The mean age of all the patients in the study was 40 years, with
no significant difference between the various groups. In the
vaginal fibroid group the youngest patient was 22 years old and
the oldest 54.

Uterine fibromyomas are the commonest tumours of the female

genital tract in all racial groups. They are particularly common in
Black Africans and West Indian and American Negroes. In a
study in Augusta, Georgia, USA, one of the few in which the
racial composition of the population studied was accurately
described, Torpin e al.' found that fibroids were three and one-
third times as common in Blacks as in Whites.
In a relatively small proportion of patients pedunculated
submucous fibroids may be expelled from the uterine cavity into
the vagina, where they remain attached to the uterine body by
their pedicle. They then present as a vaginal tumour. Such
fibroids are treated surgically, either by vaginal myomectomy or
total abdominal hysterectomy.
Since fibroids presenting in the vagina (which hereafter will be
referred to as 'vaginal fibroids') are frequently infected and
necrotic, some surgeons feel that hysterectomy exposes the
patient to an unjustified risk of infection. Vaginal myomectomy,
on the other hand, leaves behind a uterus which may well contain
further fibroids which may cause symptoms at a later date. In
this study the immediate outcome of the two different modes of
treatment is looked at.
Patients and methods
Race
Three of the patients with vaginal fibroids were Indians and
the remainder were Black.
Parity and period since last delivery
The average parity of the patients with vaginal fibroids was 4,4
and that of the patients with uterine fibroids 3,6; this difference
is not statistically significant. The average number of years since
the last delivery was 11 in the former group and 13 in the latter;
again this is not statistically significant.
Presenting symptoms
The most frequent presenting symptoms are listed in Table I
(many patients presented with more than one symptom).
Abdominal pain in the patients with prolapsed fibroids was
sometimes due to contraction of the uterus expelling the fibroid.
Discharge in these patients was often profuse and offensive
owing to necrosis and infectioll of the fibroid.

Forty-one patients with fibroids presenting as vaginal masses

were seen in the Department of Obstetrics and Gynaecology at
King Edward VIII Hospital, Durban, between I January 1976 TABLE I. PRESENTING SYMPTOMS
and 31 December 1978. Details of these cases were collected for a
retrospective study, the patients being traced by examination of No. %
Vaginal fibroid group
the histology records of the Department of Pathology. Of the 41
Abnormal vaginal bleeding 36 88
patients, 28 had been treated by vaginal myomectomy alone and
Lower abdominal pain 18 44
13 by total abdominal hysterectomy. Plainly, since hysterectomy
Abnormal vaginal discharge 18 44
is a more major procedure, its attendant morbidity could be
Sensation of 'something coming down' 6 15
expected to be greater. An additional group of 13 patients, all of
Headache, dizziness and other symptoms
probably relating to anaemia 5 12
Unprolapsed fibroid group
Department of Urology, King Edward VIII Hospital, Durban Lower abdominal discomfort 8
P. RILEY, M.B.CH.B., .\1.R.CO.G. (Present address: Department of Abnormal vaginal bleeding 7
Anaesthetics) Feeling of a mass in the abdomen 7

Date received: 20 October 1981.


Examination findings on admission
Most of the patients with vaginal fibroids were found to be in
good health on admission, apart from the more anaemic patients,
some of whom showed signs of anaemia and I of whom was in
cardiac failure. Abdominal examination revealed uterine
enlargement in a number of patients, apparently due to multiple
fibroids in the uterus. One patient presented with acute urinary
retention requiring catheterization.
Vaginal examination revealed masses which were often
necrotic and offensive. Examiners' descriptions of the size of the
masses were varied; I was said to be 'bigger than a fetal head',
others were 'the size of a small paw-paw' and a 'goose-egg', and
several were only 3 cm in diameter.
Anaemia
Table II shows the average haemoglobin concentrati.on of
patients on admission and the number of units of blood
transfused before operation. The difference in haemoglobin
values between the two groups of patients is statistically
significant (P < 0,005).
The lowest haemoglobin value recorded was 3,0 g/dl, and 7 of
the 41 patients with vaginal fibroids had levels of 6,0 g/dl or less.
TABLE 11. ADMISSION HAEMOGLOBIN VALUES AND
PRE-OPERATIVE TRANSFUSION (MEAN I SO)
Haemoglobin No. of units of
(g/dl) blood transfused
Vaginal fibroid group 8,6 2,7 2,3
Unprolapsed fibroid group 11,4 1,9 1,5
Operative procedure
One patient had an epidural block; all the others were operated
on under general anaesthesia.
Twenty-eight patients were treated by vaginal myomectomy.
In all cases this appears to have been relatively easy. In many
cases the fibroid was simply twisted off, but in others the pedicle
was sutured or ligated. Where access to the pedicle was difficult
because of the size of the fibroid, the latter was removed
piecemeal. Where satisfactory haemostasis had not been secured
at the end of the procedure vaginal packs were inserted, and in no
case was troublesome postoperative bleeding recorded.
Thirteen patients with vaginal fibroids were treated by total
abdominal hysterectomy. In 7 of these, however, vaginal
myomectomy was performed before the abdomen was opened.
Difficulty was apparently encountered in only I case, in which an
incision in the vaginal wall was required to allow delivery of the
fibroid into the abdominal cavity.
In all 13 patients who underwent total abdominal
hysterectomy for unprolapsed fibroids presenting abdominally
the operation was straightforward and no undue difficulty was
experienced.
TABLE Ill. POSTOPERATIVE PYREXIA
No. of patients
developing pyrexia on day:
2 3
Vaginal myomectomy 1 1
TAH for vaginal fibroids 4 3
TAH for unprolapsed fibroids 4 1
TAH = lotal abdominal hysterectomy.
SA MEDICAL JOURNAL VOLUME 62 3 JULY 1982 23
Postoperative course and morbidity
In a retrospective study it is difficult to obtain adequate
information to judge postoperative morbidity. The factors
selected were: (I) elevation of temperature above 38C, even on
one occasion (taken as an indication of infection); (h) number of
units of blood transfused postoperatively (as an indication of
peri-operative blood loss); and (iil) duration of hospital stay after
operation.
Postoperative pyrexia. The number of patients who
developed postoperative pyrexia is shown in Table Ill. Records
were available for only 12 of those with vaginal fibroids treated
by hysterectomy. The difference between the vaginal
myomectomy and hysterectomy groups was statistically
significant (P < 0,01).
Postoperative blood transfusion. The mean numbers of
units of blood ( SD) transfused per patient in the three groups
were: (I) vaginal myomectomy 0,6 1,3 U; (il) total abdominal
hysterectomy for vaginal fibroids 1,4 1,6 U; (iii) total
abdominal hysterectomy for unprolapsed fibroids 1,1 0,9 U.
The differences are not statistically significant.
Hospital stay. The length of stay in hospital after operation
in the various groups is shown in Table IV. The difference
between the patients with vaginal fibroids treated by vaginal
myomectomy and those treated by hysterectomy was statistically
significant (P < 0,0001). The difference between the two
hysterectomy groups was not statistically significant.
TABLE IV. AVERAGE DURATION OF
POSTOPERATIVE HOSPITAL STAY
No. of days
Vaginal myomectomy 3,2
TAH for vaginal fibroids 10,1
TAH for unprolapsed fibroids 9,9
TAH = total abdominal hysterectomy.
Histological reports
In 40 cases histological reports confirmed that the masses
presenting vaginally were uterine fibromyomas. In I case,
however, the reported microscopic appearance (confirmed by
two different pathologists) was suggestive of possible
sarcomatous change in a leiomyoma.
Follow-up
Of the patients with vaginal fibroids, 8 of those treated by
vaginal myomectomy and 7 of those treated by hysterectomy
were seen at follow-up visits in the gynaecological outpatient
clinic, generally within 6 weeks of discharge. None reported any
serious problems. There was no record of any longer-term
follow-up.
Total No.
4 5 6 of pyrexial Total No.
patients in group
3 28
8 12
2 9 13
24 SA MEDIESE TYDSKRIF DEEL 62 3 JULlE 1982
Discussion
The number of patients with prolapsed submucous fibroids
presenting as vaginal masses found in this study demonstrates
that this is not an uncommon problem in gynaecological practice
at this hospital.
The high parity of our patients goes against the comments of
Shaw,2 who stated that 60% of fibromyomas arise in women who
have either never been pregnant or have only had one child.
AbitboP published details of 14 pregnancies in patients with
submucous fibroids. There was a high incidence of premature
labour, feral loss and third-stage complications. None of his
patients presented with fibroids prolapsed into the vagina, but in
4 cases the fibroid was subsequently expelled by the uterus.
The long average period since the last delivery in the patients
in this study may well be explained simply by the fact that most
were past the regular age ofchild-bearing rather than by reduced
fertility due to fibroids.
Lawson and Stewart 4 comment that 'Particularly heavy
bleeding ... almost always occurs when submucous fibroids are
being extruded, because these are always congested, and are
frequently infected or even necrotic.' This is clearly illustrated in
this study by the fact that the patients with extruded submucous
fibroids were much more anaemic than those whose fibroids
remained above the level of the cervix.
With regard to the type of operation that should be performed
for prolapsed pedunculated fibroids, Philpott j states that vaginal
myomectomy 'is particularly indicated when the tumour is
necrotic and infected'. However, Lawson and Stewart 4 suggest
that 'Even this simple procedure carries some risk of sepsis and
subsequent venous thrombosis and embolism. If there are other
fibroids in the uterus and the patient is in good condition, it may
be as safe, or safer, to do a total abdominal hysterectomy.'
Jeffcoate 6 makes a cautionary comment in relation to vaginal
myomectomy. Tumours attached to the interior of the uterus by
a stalk and then expelled into the vagina may produce inversion
of the uterus. 'The patient's symptoms are those of the polyps
and the associated inversion may be missed unless the possibility
is kept in mind. If it is overlooked, the result can be disastrous
because, in dividing what is regarded as the pedicle ofthe polyps,
the surgeon cuts across the fundus of the uterus and opens into
the peritoneal cavity. Before any such polyp is removed the
length of the uterine cavity should always be tested by a sound. '6
This study demonstrates that vaginal myomectomy is a
relatively straightforward procedure with low postoperative
morbidity. Postoperative morbidity in patients treated by
hysterectomy is higher; the latter operation, however, offers the
patient freedom from the risk of future recurrence of fibroids
and, incidentally, from that of uterine or cervical cancer.
Postoperative morbidity was similar in the two groups of
patients treated by hysterectomy. It seems, therefore, that
prolapse of a submucous fibroid does not contraindicate
hysterectomy where this is thought to be in the patient's interest;
initial vaginal myomectomy reduces the risk of spill of infected
material into the peritoneal cavity.
Novak and Woodruff! state that 'the incidence of uterine
sarcoma is extremely difficult to compute, for there is
considerable divergence of opinion among pathologists in
establishing acceptable criteria for differentiating a low-grade
sarcoma from a cellular myoma. The majority of uterine
sarcomas apparently originate as a malignant alteration in a
previously benign myoma ... it seems fair to state that the
incidence of malignancy is less than 0,5% ... Leiomyosarcoma is
rarely diagnosed pre-operatively or at the operating table. It is
occasionally r.ecognized at gross pathological examination, but
most frequently is an unexpected finding at microscopic
examination. '
Conclusions
The low postoperative morbidity found to be associated with
vaginal myomectomy in this study suggests that It is a
satisfactory treatment for prolapsed fibroids. The lack of long-
term follow-up of patients in this study does not allow any
comments about the eventual recurrence of uterine lesions i~
these patients.
This study shows that the postoperative morbidity associated
with hysterectomy in patients with 'vaginal fibroids' is no greater
than in patients with unprolapsed fibroids. The occurrence of
these tumours is therefore no contraindication to hysterectomy if
this is felt to be in the interests of the patient.
The recommended plan of management is therefore:
I. Preparation of the patient for operation, with a blood
transfusion if necessary and vaginal toilet with antiseptic agents.
2. Vaginal myomectomy under anaesthesia, after sounding to
rule out chronic inversion of the uterus. If any doubt exists, the
myoma should be 'shelled out' of its capsule-.
3. After myomectomy, examination under anaesthesia should
be performed. If evidence of further uterine lesions is revealed
and if the patient does nor want any more children the vagina
should be sterilized as far as possible and abdominal
hysterectomy performed.
ShawB (admittedly in dealing with abdominal procedures)
defined myomectomy as 'the enucleation of myomata from the
uterus with conservation of a potentially functional organ
capable of future childbearing'. If one thinks in terms of lifetime
cure of a patient'S disease, the presence of a diseased uterus in a
woman who does not want more children is sufficient
justification for hysterectomy at the time of removal of the
fibroid (even if the latter be per vaginam).
I am most grateful to Professor R. H. Philpott for suggesting the
topiC of this investigation and to Dr P. Truter, Chief Medical
Superintendent of the King Edward VIII Hospital, for permission
to publish details of these patients.
REFERENCES
I. Torpin R, Pund E, Peeples BS. The etiologic and pathologic factors in a series
of 1741 fibromyomas of the uterus. Alii J Obslel GVl1ecol 1942; 44: 569-574.
2. Shaw W. Textbook of G.\'l1aecology. 5th ed. London: Churchill, 1948.
3. Abltbol MM. Submucous fibroids complicating pregnancy, labor and delivery.
Ob51el G.\'l1ecol 1957; 10: 529-533.
4. Lawson JB, Stewart DB. Obslelrics und GVlluecology in fhe Tropics. London:
Edward Arnold, 1967. . .
5. Philporr RH.. Uterine fibromyomata. In: Charlewood GP, ed. GYl1aecologv ill
SOllrhem Afnco: Johannesburg: Witwatersrand University Press, 1972.
6. Jeffcoate N. Pnl1Clples of GVl1uecology. 4th ed. London: Butterworths, 1975.
7. Novak ER,\~roodruff JO. No,'ak's GYl1ecologic alld Obslelri< Palhologv. 7th ed.
Philadelphia: WB Saunders, 1974.
8. Howkins J, ed. Sha,e's Textbook of Operari"e Gynaecolog.\'. 3rd ed. London:
Churchill LIVIngstone, 1968.