A Case Report of Uterine Torsion in a Postmenopausal Female with a Large Leiomyoma

Abstract

This case report discusses a diagnosis of uterine torsion in an 84-year-old woman who presented with five days of right lower quadrant abdominal pain, nausea, vomiting, constipation, and poor intake. Computed tomography (CT) imaging demonstrated a whorled configuration at the junction of the cervix and lower uterine segment, with the left gonadal vein crossing midline, and two previously known right leiomyomas now appearing on the left. These findings were consistent with the diagnosis of uterine torsion. She then underwent an urgent exploratory laparotomy, and the uterus was found to be dextroverted 270 degrees, with dark mottled purple tissue and engorged vessels. A supracervical hysterectomy and bilateral salpingo-oopherectomy were performed. Final pathology demonstrated extensive necrosis. This case reviews the classic presentation and imaging findings for the rare diagnosis of uterine torsion and options for management of both non-gravid and gravid patients.

Keywords: Gynecologic Emergency; Leiomyoma; Pelvic CT; Pelvic MRI; Uterine Torsion; Whirlpool Sign; X-Shaped.

Figure 1

84 yo with uterine torsion of large leiomyoma. FINDINGS: (A) Coronal and (B) axial contrast-enhanced CT obtained on HD#5 shows swirling at the junction of the cervix and lower uterine segment (arrows) and involving the gonadal veins bilaterally. The “whirlpool sign” is a highly specific imaging marker for torsion. TECHNIQUE: (A) Coronal contrast-enhanced CT, CTDIvol Min: 16.8 mGy, CTDIvol Max: 16.8 mGy, DLP: 1001.6 mGy.cm, 2.50 mm slice thickness, 350–150 ml iohexol (B) Axial contrast-enhanced CT, CTDIvol Min: 16.8 mGy, CTDIvol Max: 16.8 mGy, DLP: 1001.6 mGy.cm, 2.50 mm slice thickness, 350–150 ml iohexol

Figure 2

84 yo with uterine torsion of large leiomyoma. FINDINGS: (A) Coronal non-contrast CT on initial presentation shows multiple calcified leiomyomas with the dominant leiomyoma positioned at the medial superior aspect of the uterus (arrow). (B) Coronal contrast-enhanced CT obtained 5 days later shows flipped or reversed configuration of the leiomyomas with the dominant leiomyoma now at the lateral superior aspect of the uterus (arrow). In patients with short interval repeat imaging and intermittent torsion, leiomyomas can serve as landmarks to determine changes in orientation. TECHNIQUE: (A) Coronal CT without contrast, CTDIvol Min: 15.4 mGy, CTDIvol Max: 15.4, DLP: 818 mGy.cm, 1.25 mm slice thickness, no radiation (B) Coronal contrast-enhanced CT, CTDIvol Min: 16.8 mGy, CTDIvol Max: 16.8 mGy, DLP: 1001.6 mGy.cm, 2.50 mm slice thickness, 350–150 ml iohexol

Figure 3

Intraoperative image of the uterus shows twisting along its vertical axis (arrow)