Broad Ligament Fibroid

A broad ligament fibroid is a smooth muscle tumour that grows within the folds of the broad ligament, either from the uterine side wall or from smooth muscle of the ligament. It lies beside the uterus.

• It displaces the uterus to the opposite side and often pushes the ureter, uterine vessels and bladder out of their normal position.
• It is commonly mistaken for an ovarian or adnexal mass.
• Surgery is technically harder because of the ureter and uterine artery.

Pelvic or abdominal mass, pelvic pressure, urinary frequency, retention, constipation, backache and dyspareunia; menstrual bleeding is often normal.

• A firm, fixed lateral pelvic mass felt separately from the uterus, which is pushed to one side.
• Differential diagnosis: ovarian tumour, pedunculated subserosal fibroid, tubo-ovarian abscess, ectopic pregnancy, pelvic kidney, retroperitoneal tumour, leiomyosarcoma.
• Complications: hydronephrosis, ureteric injury at surgery, haemorrhage, degeneration, venous compression and rarely sarcoma.

Diagnosis is by examination and imaging that shows the origin of the mass and the course of the ureter.

• Bimanual examination, transvaginal and abdominal ultrasound.
• Pelvic MRI or CT scan to show origin and the course of the ureter.
• Renal ultrasound; urea and creatinine; full blood count and ferritin; pregnancy test.
• CA-125 when an ovarian tumour cannot be excluded.
• Histology after removal.

Observe asymptomatic tumours and operate with the ureter identified when treatment is needed.

• Supportive: observe asymptomatic tumours with ultrasound every 6 to 12 months; counsel on pressure symptoms; bladder catheter for retention.
• Pharmacological: ibuprofen 400 mg oral 8-hourly with food (maximum 1.2 g in 24 hours) and paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) for pain. Leuprorelin 3.75 mg IM every 4 weeks for up to 3 months before surgery to reduce size. Anaemia: ferrous sulphate 200 mg oral 8-hourly, continued for 3 months after haemoglobin normalises; iron sucrose 200 mg IV per dose for severe anaemia. Transfuse when haemoglobin is below 7 g/dL.
• Procedures: laparoscopic or open myomectomy or hysterectomy by an experienced surgeon with the ureter identified, and a ureteric stent placed when it is displaced. Uterine artery embolisation in selected women. Tranexamic acid 1 g IV before incision.
• Special groups: in pregnancy give paracetamol for pain, avoid ibuprofen from 28 weeks and plan caesarean delivery if the mass blocks the pelvis. Avoid GnRH analogues in pregnancy.
• Red flags: hydronephrosis, rapid growth, sudden severe pain, fever, heavy bleeding with shock.
• Follow-up: review at 6 weeks after surgery; ultrasound and renal ultrasound at 3 to 6 months.