A LARGE INTRAMURAL FIBROID WITH STAGE 3 UTERO VAGINAL PROLAPSE - A RARE CLINICAL PRESENTATION

Fibroid uterus are the benign tumors of the uterus comprising of smooth muscle fibres. There are 3 main types of fibroid uterus - submucosal, subserosal and intramural. Fibroid with the prolapse usually present as submucosal fibroid prolapsing into the vagina or intramural fibroid becoming submucosal and prolapsing out. A large intramural fibroid usually pulls up the uterus due to its growth and hence uterine prolapse is little rare scenario. In this case a perimenopausal women with mass descending per vaginum and pain abdomen for four years, on examination found to have a large intramural fibroid of size 20*10 cm and uterovaginal prolapse with cervix as leading point with cystocele, enterocoele and rectcoele. After routine pre operative work up, hysterectomy was planned by abdominovaginal route. Supracervical hysterectomy done abdominally followed by removal of cervical stump and anterior and posterior colpoperineoraphy by vaginal route.子宫平滑肌瘤（fibroid uterus）是源自子宫的良性肿瘤，由平滑肌纤维组成。子宫平滑肌瘤主要分为3种类型：黏膜下肌瘤（submucosal fibroid）、浆膜下肌瘤（subserosal fibroid）及肌壁间肌瘤（intramural fibroid）。伴脱垂的子宫平滑肌瘤通常表现为两种情形：一是黏膜下肌瘤脱垂至阴道内，二是肌壁间肌瘤转变为黏膜下肌瘤并向外脱出。体积较大的肌壁间肌瘤可随生长牵拉子宫，因此子宫脱垂的情况相对少见。 本病例为一名围绝经期女性，主诉4年来反复出现经阴道肿物脱出伴腹痛；查体可见一枚大小为20×10 cm的巨大肌壁间肌瘤，同时合并子宫阴道脱垂（uterovaginal prolapse），以宫颈作为脱垂先露部位，并发膀胱膨出（cystocele）、小肠膨出（enterocoele）及直肠膨出（rectocele）。完成常规术前检查与评估后，临床计划采用经腹阴道联合途径实施子宫切除术。手术先行经腹子宫次全切除术，随后经阴道途径切除宫颈残端，并完成阴道前后壁会阴修补术（colpoperineorrhaphy）。