uterine myomas , also referred to as fibroids , are benign tumors of the smooth muscle of the uterus and are the most commonly encountered type of tumor in women , occurring in nearly 50%70% of women of childbearing age .
the status of fibroids during pregnancy is especially complex , because fibroids can affect the pregnancy and pregnancy can affect the fibroids .
degeneration has been estimated to occur in 10% of fibroids during pregnancy , and is characterized by abdominal pain , leukocytosis , and mild fever .
enterouterine fistulas can occur following : ( 1 ) carcinoma of either the intestine or uterus with subsequent invasion of the other structure and communication of the lumina , ( 2 ) rupture of the uterus ( either spontaneous or produced during labor ) , or ( 3 ) inflammatory disease ( such as pathological puerperium and appendicular abscess ) causing peritonitis , diverticulitis with abscess formation and crohn disease .
a 25-year - old patient presented with an 87-cm posterior wall fibroid diagnosed for the first time during pregnancy at 12 weeks .
the course of the pregnancy was smooth , with mild enlargement of the fibroid to the size of 109 cm .
the patient delivered by caesarean section at a private clinic due to malpresentation ( breech presentation ) . in the first week postpartum , the patient experienced malodorous vaginal discharge .
the patient sought medical advice and antibiotics were given for 14 days , but the discharge did not resolve and the patient felt a mass inside the vagina .
the patient presented to tanta university hospitals where she was admitted , and under general anesthesia , an examination revealed a solid mass extending from the cervix into the vagina .
a biopsy was taken from the mass for histopathological examination , and it was identified as a degenerated cellular fibroid polyp .
antibiotics also were given for 14 days after a culture and sensitivity test , but the discharge still did not resolve . at this point , the patient became frustrated and sought medical advice from more senior practitioners , who advised her to receive gonadotropin - releasing hormone analogues for 2 months .
nonetheless , the discharge was not cured ; it became more malodorous as well as greenish and stool - like in character .
the patient developed abdominal pain , distension , vomiting , and absolute constipation 1 week later and was readmitted to tanta emergency hospitals where thorough investigations were performed , including a pelvic ultrasound and a computed tomography scan with gastrointestinal tract contrast .
an examination revealed cachexia and toxicity facies , the patient 's vital signs were a blood pressure of 100/60 mm hg , a pulse of 110 beats per minute and a temperature of 38.1. an abdominal examination revealed distension , tenderness with guard and rigidity , and resonance over all quadrants of the abdomen .
a pelvic examination demonstrated the presence of tender fornices and a stool - like offensive discharge coming through the vagina , and examination using a speculum found a stool - like discharge coming through the cervix .
the following laboratory studies were performed : a complete blood count , urinalysis , a liver function panel , a kidney function panel , and serum electrolytes .
ultrasound revealed the absence of peristalsis in the small bowels and a large posterior wall fibroid measuring 107 cm with degeneration . computed tomography with gastrointestinal tract contrast revealed fistulous communication between the ileum and uterus .
written consent was obtained from the patient and her relatives for a range of treatment options , including hysterectomy .
a midline infraumbilical incision was made by the surgical team , and we found the abnormal invasion of the fibroid to the ileum approximately 30 cm from the ileocecal junction ( figure 1 ) .
dissection of the intestine from the uterus showed the site of the fistula very clearly at the posterior wall of the uterus through the fibroid ( figure 2 ) .
the gynecologists managed the case by myomectomy and repair of the endometrial cavity with placement of an intrauterine catheter for antiseptic washing and to prevent asherman syndrome ( figure 3 ) .
two intraperitoneal drains were inserted , and the catheter was removed 7 days after the operation .
written consent was obtained from the patient and her relatives for a range of treatment options , including hysterectomy .
a midline infraumbilical incision was made by the surgical team , and we found the abnormal invasion of the fibroid to the ileum approximately 30 cm from the ileocecal junction ( figure 1 ) .
dissection of the intestine from the uterus showed the site of the fistula very clearly at the posterior wall of the uterus through the fibroid ( figure 2 ) .
the gynecologists managed the case by myomectomy and repair of the endometrial cavity with placement of an intrauterine catheter for antiseptic washing and to prevent asherman syndrome ( figure 3 ) .
two intraperitoneal drains were inserted , and the catheter was removed 7 days after the operation .
a fistula is defined as an abnormal connection between two epithelium - lined organs that do not connect . in the uterus
published perhaps the largest review of enterouterine fistulas in 1956 , describing 80 cases , 42 of which followed an obstetric injury , 17 resulted from inflammatory processes , 12 followed curettage , and nine were related to carcinoma .
they may also occur as complications of dilatation and curettage , with a range of post - abortive times of presentation .
an enterovaginal fistula was described by meier - boni et al .   in 1990 . in that case
, an enterovaginal fistula was found 1 year after vaginal hysterectomy ; radiological imaging revealed a fistula between the terminal ileum and the vagina in an 81-year - old patient .
fadel   described an ileo - uterine fistula after myomectomy that was asymptomatic and discovered accidentally during hysterosalpingography for infertility . in our case
, we found a fistulous tract between a degenerated posterior wall fibroid and the ileum , and administered a questionnaire to patient and her relatives in an attempt to identify the causes of that complication .
several factors may have contributed to the formation of the fistula , with possible explanations including post - caesarean infection , operative trauma to the bowel during the caesarean section leading to an infection - caused adhesion between the fibroid and the injured bowel facilitating fistula formation , and potential uterine perforation during uterine sounding - a preliminary step when excising the uterine polyp - which could have led to an infection at that site that may have facilitated fistula formation .
the surgical team excised the fistula and re - anastomosed the gut , following a procedure similar to the operative steps carried out by meier - boni et al . .
myomectomy and repair of the uterine cavity was performed by a gynecology team , with insertion of an intra - uterine foley catheter for seven days to prevent asherman syndrome .
our management strategy was in agreement with mcfarlane et al .   and duttaroy and madhok , who preserved the uterus , whereas dewdney et al .   and gutierrez et al .  
preferred hysterectomy , because the patients in their cases were 50 and 44 years of age , respectively .
ileo - uterine fistula is a rare complication of uterine fibroids that occurred in our patient following degenerative changes in a myoma during pregnancy with presentation following delivery by caesarean section .
it was treated by myomectomy and conservative treatment of the uterus after division of the bowel loops and resection and anastomosis of the bowel ends .
 uterine fibroids are benign tumors of the myometrium with a diverse range of manifestations . 
 fibroids can dramatically increase in size during pregnancy due to the increase in estrogen levels . 
 after delivery , the fibroids usually shrink back to their pre - pregnancy size . 
 uterine myomas may have many complications , including abnormal uterine bleeding , infertility , pressure on nearby organs , degeneration , and malignant transformation . 
 no previous reports have indicated that a fistula may develop between a uterine fibroid and the bowel loops , although previous studies have documented the occurrence of fistulas from the uterus to the bowel following myomectomy or uterine artery embolization performed to treat a myoma . in our case report 
 , we document the rare complication of a fistula occurring between a degenerated myoma in the posterior wall and the ileum 1 week postoperatively in a patient who underwent a caesarean section but did not have a history of uterine artery embolization . 
Introduction
Case report
1. Operative details
Discussion