Prolapsed Submucosal Fibroid

A prolapsed submucosal fibroid is a submucosal fibroid that has been pushed by uterine contractions through the cervix into the vagina, often called a fibroid polyp.

• It is attached to the uterine cavity by a stalk that may stretch to the vaginal introitus.
• It may ulcerate, become infected and bleed heavily.
• Removal through the vagina is usually possible.

Heavy or irregular vaginal bleeding, foul-smelling discharge, cramping lower abdominal pain, a vaginal mass, dysuria or urinary retention, and anaemia.

• A smooth or ulcerated mass in the vagina with the cervix dilated around its stalk.
• Differential diagnosis: uterine inversion, cervical polyp, cervical cancer, endometrial polyp, retained products of conception, vaginal tumour, uterine sarcoma.
• Complications: haemorrhage, anaemia, infection, sepsis, urinary retention and pyometra.

Diagnosis is by speculum and bimanual examination, with ultrasound to exclude uterine inversion.

• Speculum and bimanual examination to find the stalk and exclude inversion (fundus palpable above the pubic bone).
• Transvaginal ultrasound to confirm the fundus and show the stalk.
• Full blood count, ferritin, group and cross-match, pregnancy test, blood culture if febrile.
• Pelvic MRI if the origin is unclear.
• Histology after removal.

Resuscitate if needed and remove the fibroid through the vagina.

• Supportive: bed rest, IV access, crystalloid resuscitation for bleeding, analgesia, catheterise for retention, prepare for theatre.
• Pharmacological: 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). Ceftriaxone 1 g IV daily plus metronidazole 500 mg IV 8-hourly if infected, then amoxicillin-clavulanate 625 mg oral 8-hourly to complete 7 days. Paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); morphine 2.5 to 5 mg IV for severe pain. Transfuse when haemoglobin is below 7 g/dL. Ferrous sulphate 200 mg oral 8-hourly for 3 months after haemoglobin normalises.
• Procedures: under anaesthesia, clamp the stalk, twist and divide or ligate it with absorbable suture; vaginal myomectomy; hysteroscopic resection of the remaining base; hysterectomy when fertility is complete or when bleeding is uncontrollable. Send the tissue for histology.
• Special groups: in pregnancy give paracetamol and observe; operate only for bleeding, infection or obstruction. 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: shock, fever with foul discharge, uterine inversion, rapid growth, suspected sarcoma.
• Follow-up: review at 1 and 6 weeks; ultrasound at 3 months to exclude residual fibroids; check haemoglobin and ferritin.