A 32-year-old woman comes to the emergency department due to severe pelvic pain. The patient developed pelvic cramping 2 days ago, the day after her menstrual period ended. She describes the pain as "worse than labor contractions," and it has been unrelieved by ibuprofen. The patient has monthly menstrual cycles with heavy flow, and she occasionally passes clots. She has no chronic medical conditions. Her only surgery was a dilation and curettage for a spontaneous abortion 5 years ago. The patient is sexually active and does not use routine contraception. Blood pressure is 140/90 mm Hg and pulse is 113/min. Pelvic examination shows an irregularly enlarged uterus. The cervix is dilated 5 cm with a spherical mass visible through the external os. The mass is firm and round, and slight bleeding is noted around it. Which of the following is the most likely cause of this patient's presentation?

Question

A 32-year-old woman comes to the emergency department due to severe pelvic pain.  The patient developed pelvic cramping 2 days ago, the day after her menstrual period ended.  She describes the pain as "worse than labor contractions," and it has been unrelieved by ibuprofen.  The patient has monthly menstrual cycles with heavy flow, and she occasionally passes clots.  She has no chronic medical conditions.  Her only surgery was a dilation and curettage for a spontaneous abortion 5 years ago.  The patient is sexually active and does not use routine contraception.  Blood pressure is 140/90 mm Hg and pulse is 113/min.  Pelvic examination shows an irregularly enlarged uterus.  The cervix is dilated 5 cm with a spherical mass visible through the external os.  The mass is firm and round, and slight bleeding is noted around it.  Which of the following is the most likely cause of this patient's presentation?

Quizplus · Accepted Answer

11ec25c8_d9ec_46b4_bc81_9bb884cc860e_MD0003_00 This patient has leiomyomata uteri (uterine fibroids), common and benign smooth muscle tumors that vary in size, number, and uterine location. Subserosal or intramural fibroids often cause bulk symptoms (eg, pelvic pressure) and irregular (ie, unevenly shaped) uterine enlargement. Submucosal fibroids can protrude into the endometrial cavity, which causes both endometrial distortion and increased surface area that lead to heavy, prolonged menses. This patient with both bleeding and bulk symptoms likely has fibroids in multiple locations. Subserosal or intramural fibroids During a heavy menstrual cycle, prolonged endometrial shedding and uterine cramping can increase intrauterine pressure and cause intracavitary fibroids, which protrude completely into the uterine cavity, to prolapse through the cervix. Prolapsed leiomyoma uteri are most commonly the intracavitary type because these fibroids have smaller attachments to the myometrium (typically a small pedicle) and greater mobility. As the prolapsed fibroid passes through the cervical canal, patients typically develop pelvic cramping followed by labor-like pain from cervical dilation. Examination typically reveals a dilated cervix and firm, round mass visible through the external os. The diagnosis of a prolapsed fibroid is clinical, although ultrasonography can be performed for confirmation. Treatment is with surgical removal of the prolapsed fibroid. (Choice A) Condylomata acuminata (ie, genital warts) are usually pink or skin-colored, verrucous (warty) lesions located on the external genitalia (eg, anogenital area). They are typically asymptomatic. Condylomata acuminata (Choice B) Hydatidiform moles are nonviable, intrauterine gestations caused by the proliferation of abnormal trophoblastic villi. Patients can have uterine enlargement, vaginal bleeding, and hydropic (ie, soft, cystic) villi visible through the external os. However, unlike fibroids, hydatidiform moles do not cause irregular (ie, unevenly shaped) uterine enlargement or a firm mass. (Choice D) Pelvic examination in a patient with a retained tampon would reveal a soft, malodorous foreign body in the posterior vagina rather than a firm, round mass within the cervix. (Choice E) Sarcoma botryoides, a type of embryonal rhabdomyosarcoma, can present as nodular masses (cluster of grapes) from the uterus that protrude into the vagina. This condition almost exclusively affects infants, making this diagnosis unlikely. Sarcoma botryoides Educational objective: Leiomyomata uteri (fibroids) that protrude into the endometrial cavity (ie, submucosal or intracavitary fibroids) are associated with heavy, prolonged menses and are at risk for prolapse through the cervix. Patients with a prolapsed fibroid typically have labor-like pain due to cervical dilation as the fibroid passes through the cervix. References: Submucosal uterine fibroid prolapsed into vagina in a symptomatic patient with IUS. (http://www.ncbi.nlm.nih.gov/pubmed/24739657) Spontaneous expulsion of a submucosal uterine fibroid without embolization in a pre-menopausal woman. (http://www.ncbi.nlm.nih.gov/pubmed/32477566)

A 32-Year-Old Woman Comes to the Emergency Department Due to Severe