SPONTANEOUS FALLOPIAN TUBE EVISCERATION IN PROCIDENTIA AND PERFORATING CARCINOMATOUS VAGINAL WALL ULCER – CASE REPORT

Abstract

Background. Total prolapse of female pelvic organs is not only painful and troublesome because of difficulties with micturition and defecation but it could be very dangerous since prolapsed vagina presents a predilection area for ulcer and/or rupture of different etiology and with evisceration of abdominal content. Eviscerations usually occur rarely, but when they do occur, it is important to intervene quickly. Most frequent is the evisceration of small bowel, rarely omentum and sporadically other abdominal structures. Neither in literature nor on the internet there were not any examples of primary eviscerated fallopian tube which was not a consequence of preceeding gynecological-surgical procedure found.

Methods. 77-year-old woman was appointed to our out patient department with diagnosis of Prolapsus uteri totalis and Dolores abdominalis. In history there was prevulvar bulge in the size of an apple, which persisted for 20 years, and almost disappeared when lying supine. Three days before admission to the hospital the bulge was exceedingly enlarged by straining and did not diminish when lying supine. The patient walked only hardly and could not sit. Micturition and defecation was possible only in the upright position. There were also difficulties while placing the patient on a gynecologic chair, because between her legs there was a bulge in the size of 14 × 10 × 9 cm3 with fallopian tube hanging out (Figure 1). On the outermost part of total uterovaginal prolapse the outer ostium of the cervical canal was recognizable. The bulge was fully stretched, painful and unreponible. Around a hole where a fallopian tube exits, vagina was eritematous, rough folded – swollen and vulnerable (Figure 2). In outpatient department eviscerated fallopian tube and prolapsed vagina with its contents were aseptically treated and Dalacin and Orho Gynest crème were applicated. Foley catheter was inserted. Prolapsed vagina with uterus and other contents remained stretched even after catheterization and unreponible likewise. In surgical procedure Steckel´s incision was used to avoid widely the area of vagina where tube exits. We did not try to repone the tube, so pouch of Douglas was opened first and after that uterovesical pouch as well. Hysterectomy with bilateral adnexectomy in situ and almost total vaginectomy has been made. In lower part of abdominal cavity there were not any pathological signs. Peritoneal cavity was closed with circular suture. Vesicorrhaphy in three layers and minimal rectorrhaphy with kolpoperineoplasty were made. Postoperative course of treatment was without complications. After eight days our patient has been discharged from the hospital. Pathohistologic findings were: Invasive squamous cell carcinoma of the vagina, large cell and keratinizing. Invasive growth is present near the opening through which a part of the uterus prominates. Maximal thickness of invasive growth is 0.8 cm, on the borders there is not any cancerous tissue left. Considering the pathologic findings, the patient has been appointed to the Gynecologic – oncologic counsel at University Department of Gynecology, Ljubljana. Diagnosis was Ca. vaginae stadium I.. State after vaginal histerectomy with colpectomy. The lesion removed with safety border. As for therapy; considering the age of the patient, consilium decided for observation.

Conclusions. Because of the perforated vagina and opened path to the abdominal cavity the total uterine prolapse in this case was a life-threatening emergency. The fallopian tube partly closed the communication and it also acted as a wedge so the prolapsed uterus and vagina could not repone. An urgent operation has been necessary – we resolved the procidentia and removed the cancer.