Fibroid-Associated Bulk Symptoms

Fibroid associated bulk symptoms are the pressure effects of a large fibroid uterus on the bladder, bowel, ureters, pelvic nerves and veins, or the abdominal wall.

• They occur when the uterus is the size of a 12 to 14 week pregnancy or larger.
• They may exist without heavy periods.
• Treatment aims to reduce volume by drugs or surgery.

Urinary frequency, urgency, nocturia, incomplete emptying or retention, constipation, rectal pressure, lower backache, abdominal distension, early satiety, and leg swelling.

• A firm, irregular mass arising from the pelvis, sometimes reaching the umbilicus.
• Differential diagnosis: ovarian tumour, pregnancy, ascites, pelvic kidney, adenomyosis, leiomyosarcoma, bladder tumour, bowel tumour.
• Complications: hydronephrosis and renal impairment, urinary tract infection, deep vein thrombosis, bowel obstruction, and surgical complexity.

Diagnosis is by examination and imaging, with renal ultrasound to exclude obstruction.

• Abdominal and bimanual examination, measuring uterine size in weeks.
• Abdominal and transvaginal ultrasound, with renal ultrasound for hydronephrosis.
• Pelvic MRI or CT scan to plan surgery and show the ureters.
• Urea and creatinine; full blood count and ferritin; urinalysis and culture; pregnancy test.
• CA-125 and imaging features if sarcoma or ovarian tumour is possible.

Relieve pressure symptoms, shrink the uterus before surgery when helpful, and operate when symptoms warrant.

• Supportive: treat constipation with lactulose 15 mL oral 12-hourly or macrogol 1 sachet oral daily, and fluids; timed voiding; bladder catheter for retention; support stockings and leg elevation.
• Pharmacological: leuprorelin 3.75 mg IM every 4 weeks for up to 3 months to shrink the fibroids before surgery, or goserelin 3.6 mg subcutaneous every 4 weeks; add norethisterone 5 mg oral daily as add-back if used longer than 3 months. Paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) and ibuprofen 400 mg oral 8-hourly with food (maximum 1.2 g in 24 hours) for pain. Urinary tract infection: nitrofurantoin modified-release 100 mg oral 12-hourly for 5 days. Anaemia: ferrous sulphate 200 mg oral 8-hourly, continued for 3 months after haemoglobin normalises.
• Procedures: myomectomy (open or laparoscopic) to keep the uterus; hysterectomy when fertility is complete; uterine artery embolisation; ureteric stenting before surgery for hydronephrosis.
• Special groups: in pregnancy give paracetamol and treat constipation with lactulose; avoid ibuprofen from 28 weeks. In renal impairment (creatinine clearance below 30 mL/min) avoid ibuprofen and nitrofurantoin.
• Red flags: hydronephrosis, acute urinary retention, rapid growth, postmenopausal growth, leg swelling with pain.
• Follow-up: review at 3 months; ultrasound and renal function at 6 months if observed.