[ Editorials | Departments and Series | Index ]

Images in Women's Health

Fallopian Tube Prolapse Following Hysterectomy

Armida Moreno, MD; Rebecca Hall, PhD; Kathleen Kennedy, MD

CASE HISTORY

A 27-year-old woman (gravida 4, para 3) underwent total abdominal hysterectomy for menometrorrhagia. Her postoperative course was complicated by a vaginal cuff abscess that was drained transvaginally on postoperative day seven. Six weeks later the patient presented with vaginal bleeding and lower abdominal pain. A red, 3-to-4-cm vaginal cuff mass apparently consisting of granulation tissue was visualized at the left vaginal apex on vaginal examination.

The patient was referred for pelvic ultrasonography. Endovaginal imaging was performed using a high-frequency, 4-to-8-MHz transducer. Findings revealed an irregular, contoured vaginal cuff with increased cuff thickness exceeding 2 cm (Figure 1). Color Doppler and power imaging disclosed hypervascularity of the entire cuff (Figures 1 and 2). The left ovary was identified at midline, directly superior to the cuff and measured within normal limits at 3.3 x 2.2 cm. Directly adjacent and anterior to the left ovary was an adnexal structure with a stellate central cavity measuring 1.6 x 2.5 cm, which was thought to represent a cross-section of the left fallopian tube (Figure 3). Color Doppler and power examination revealed marked hypervascularity extending directly across this structure and into the vaginal cuff (Figure 4). Findings were consistent with fallopian tube hyperemia and prolapse.

Figure not available online

FIGURE 1. Transverse cut of vaginal cuff demonstrates thickened, irregular cuff wall with increased color Doppler flow. Left ovary is directly superior to the cuff. Courtesy of Rebecca Hall, PhD.

Figure not available online

FIGURE 2. Midline sagittal cut of vaginal cuff demonstrates thickened, irregular cuff wall and increased color Doppler power flow in both cuff and tube. Courtesy of Rebecca Hall, PhD.

Figure not available online

FIGURE 3. Sagittal cut, slightly left of midline, demonstrates left tube and ovary contiguity to the thickened cuff. Courtesy of Rebecca Hall, PhD.

Figure not available online

FIGURE 4. Sagittal cut, far left of midline, demonstrates fluid within the fallopian tube and associated color Doppler power hypervascularity extending into the cuff. Courtesy of Rebecca Hall, PhD.

The patient underwent vaginal surgery. The prolapsed end of the fallopian tube was grasped, suture ligated, and released into the peritoneal cavity. This was followed by cuff revision. Surgical pathology of the excised specimen confirmed hyperemic and inflamed fimbriae. Her symptoms subsequently resolved.

back to top

DISCUSSION

Fallopian tube prolapse is a rare complication of hysterectomy. In one review, the cumulative incidence was 0.1% with vaginal hysterectomy accounting for the highest incidence (0.5%), followed by abdominal hysterectomy (0.06%); there were no cases among 940 laparoscopic hysterectomies.1 The common presenting symptoms are pelvic pain, vaginal spotting, heavy discharge, and dyspareunia.Although combined laparoscopic and vaginal approaches are advocated to remove a prolapsed fallopian tube,2,3 rare recurrences have been reported with either route. In many cases there is an incorrect or delayed diagnosis with confirmation only after excision and pathologic investigation.3 In this case the diagnosis was almost certain based on vaginal ultrasonography performed the day the patient presented, and confirmed by pathologic analysis.

CLINICAL PEARLS. Prolapsed fallopian tube is a difficult diagnosis but is usually associated with hyperemia and vaginal cuff irregularity; therefore, the diagnostic capability can be enhanced using high-frequency endovaginal imaging. Color Doppler power capability in pelvic ultrasonography yields lower flow detection in the presence of hypervascularity than does color Doppler flow. Following hysterectomy the vaginal cuff should demonstrate a smooth contour along the entire cuff, with no increased vascular pattern.

back to top

CONCLUSION

This case demonstrates the value of endovaginal ultrasonography in evaluation of the vaginal cuff following hysterectomy—particu-larly the value of color Doppler power imaging to assess hypervascularity of the vaginal cuff and adnexal structures. Ultrasonographic diagnosis is based on changes in the contour of the vaginal cuff, visualization of the adjacent tube, and evidence of flow within the tube wall and extending across the cuff. Color Doppler power imaging is more sensitive in detecting low-velocity vascularity than color Doppler alone, and does not rely on angle correction or specific velocity settings.4

back to top

Armida Moreno, MD, is resident physician; Rebecca Hall, PhD, is associate professor and clinical director, Resident Ultrasound Program; and Kathleen Kennedy, MD, is associate professor and clinical director, WomenÍs Health Clinic. All are in the Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.

References

1. Fan QB, Liu ZF, Lang JH, et al. Fallopian tube prolapse following hysterectomy. Chin Med Sci J. 2006;21(1):20-23.
2. Hernandez CR, Howard FM. Management of tubal prolapse after hysterectomy. J Am Assoc Gynecol Laparosc. 1998;5(1):59-62.
3. Tjalma WA. Surgical management of tubal prolapse. Int J Gynaecol Obstet. 2003;83(2):207-208.
4. Zagzebski JA. Color Doppler and color flow imaging. In: Essentials of Ultrasound Physics. St Louis, MO: Mosby; 1996:115-117.

back to top