Pedunculated Fibroid

A pedunculated fibroid is a fibroid attached to the uterus by a narrow stalk. It may be subserosal (growing into the pelvis) or submucosal (growing into the cavity and sometimes through the cervix).

• A subserosal stalk may twist (torsion) and cause an acute abdomen.
• A submucosal stalk may stretch and push the fibroid through the cervix into the vagina (prolapsed fibroid).
• Both need surgery when symptomatic.

Subserosal: pelvic mass, pressure symptoms, sudden severe pelvic pain with nausea and vomiting if torsion occurs.

• Submucosal prolapsed: heavy bleeding, foul discharge, cramping pain, a mass at the cervix or in the vagina and, sometimes, infection.
• Differential diagnosis: ovarian mass with torsion, ectopic pregnancy, endometrial polyp, cervical polyp, uterine inversion, cervical cancer, leiomyosarcoma.
• Complications: torsion with necrosis, infection, haemorrhage, anaemia, urinary retention and sepsis.

Diagnosis is by examination and Doppler ultrasound, with other imaging when the origin is unclear.

• Speculum and bimanual examination for a prolapsed mass.
• Transvaginal and abdominal ultrasound with Doppler; pelvic MRI or CT scan when the origin is unclear.
• Full blood count, ferritin and group and cross-match; pregnancy test; blood culture if febrile.
• Histology after removal.

Resuscitate if needed, control pain and bleeding, and remove the fibroid surgically.

• Supportive: bed rest and hydration; IV access; analgesia; observe vital signs; prepare for theatre if torsion or severe bleeding.
• Pharmacological: paracetamol 1 g IV or oral 6-hourly (maximum 4 g in 24 hours); morphine 2.5 to 5 mg IV titrated every 5 minutes for severe pain. Tranexamic acid 1 g IV over 10 minutes, then 1 g oral 8-hourly for up to 4 days (maximum 4 g in 24 hours) for heavy bleeding. Infected prolapsed fibroid: ceftriaxone 1 g IV daily plus metronidazole 500 mg IV 8-hourly until afebrile for 24 hours, then amoxicillin-clavulanate 625 mg oral 8-hourly to complete 7 days. Anaemia: ferrous sulphate 200 mg oral 8-hourly, continued for 3 months after haemoglobin normalises; transfuse when haemoglobin is below 7 g/dL.
• Procedures: vaginal removal of a prolapsed fibroid by twisting or ligating and dividing the stalk; hysteroscopic resection; laparoscopic or open myomectomy for subserosal stalked fibroids; laparotomy for torsion with detorsion or excision; hysterectomy when fertility is complete.
• Special groups: in pregnancy give paracetamol and morphine for pain, avoid ibuprofen from 28 weeks and tranexamic acid, and operate only for torsion or necrosis. In renal impairment reduce tranexamic acid to 15 mg/kg (usually 1 g) oral 12-hourly when creatinine is 120 to 249 micromol/L.
• Red flags: acute severe pain with vomiting, fever with foul discharge, bleeding with shock, haemoglobin below 7 g/dL.
• Follow-up: review at 1 and 6 weeks after surgery; ultrasound at 3 to 6 months; check haemoglobin and ferritin.