This is the case of a 44-year-old female, with a history of four vaginal deliveries, presenting to the hospital with a huge abdominopelvic mass, moderate to severe pelvic pain, and spotting and intermenstrual bleeding for the last one month. She had a history of a failed laparotomy six months back, attempted to remove the mass. There were minor episodes of heavy menstrual problems earlier. As per old operative records, a diagnosis of fibroid uterus had been made. During the attempted surgery, dense adhesions were encountered around the mass and the abdomen had to be closed without proceeding further.
In the present visit, the mass was found to be of 18 weeks size, uniformly enlarged and firm with restricted mobility. There was both a vertical and a transverse scar, resulting from the previous attempted laparotomy.
An endometrial biopsy was planned. On dilating the cervix, around 30 cc of pus was drained out, which had found no mention in the previous sonography done earlier. Escherichia coli was grown and she was treated with antibiotics according to the culture sensitivity report. Endocervical and endometrial biopsy were done to rule out malignancy or tuberculosis.
Magnetic resonance imaging (MRI) showed a normal uterus and endometrium. A mass, possibly a myoma with a well-defined collection was seen possibly arising from the posterior lower uterine segment and cervix. The draining tract was seen to open into the cervix [Figure 1a-c]. Kidneys and ureters were normal. The correct diagnosis was, however, made only after the surgery. A relaparotomy was planned. Due to the previous failed surgery, she insisted on a panhysterectomy.
On laparotomy, an 18 cm x 15 cm x 9 cm mass was seen arising from the pelvis, behind a normal sized uterus. Cornual structures were normal. Dense bowel adhesions were present between the bowel, uterus, and the mass. Adhesiolysis was done followed by pan hysterectomy. The mass was found to be a fibroid arising from the posterior aspect of the cervix [Figure 2].
In the postoperative period, she started developing high-grade fever from the third postoperative day. A small stitch line infection and urinary tract infection were diagnosed and treated, but she remained febrile. Sonography on day 7 was normal. High-grade fever persisted in spite of higher antibiotics. On day 12, she complained of some dirty discharge for which her vault stitches were dilated and around 30 cc blood mixed discharge was drained from the pelvis. Subsequent to the drainage, the fever finally resolved. Culture showed that it was an aseptic collection, possibly because of the prior antibiotics.
On HPE [Figure 3], grossly, the uterus was normal. Cervix measured 5 cm x 2 cm x 1 cm. A large capsulated leiomyoma measuring 18 cm x 15 cm x 9 cm was seen arising from the posterior wall of the cervix. On cutting open through the leiomyoma a cavity/diverticulum of 4cm in diameter was found, which was communication with the endocervical canal. It was filled with pus-like material admixed with blood. On microscopy, the sections were taken from the diverticulum near the lumen of the endocervical canal and the diverticulum wall adjacent to leiomyoma. Sections from both the diverticula showed endocervical glands embedded in fibrocollagenous tissue and mixed inflammatory infiltrate, while subepithelial area showed smooth muscle proliferation.
The final diagnosis was given as cervical fibroid and diverticulum with inflammation.