What is your diagnosis?

Abstract

A 40-year-old lady with previous two deliveries by lower segment caesarian section presented with a long history of lower abdominal heaviness and menorrhagia and a mass coming out of vagina recently. There were associated problems in voiding urine. On local examination, a large, elongated, soft, reddish mass, measuring 14×3.8×4 cm, was protruding out of the vagina. A firm whitish mass with a well-demarcated rim was observed at the end of the large reddish mass, measuring 5×5 cm. The entire mass could be incompletely reduced inside the vagina. On genital examination, the cervical rim could not be posteriorly felt. There was ulceration with discharge of pus from the top of the mass, which was sent for culture and sensitivity tests. The culture was positive for Pseudomonas aeruginosa, which was sensitive to levofloxacin. Prolapsed part was reposited back and was restrained using a glycerine acriflavine-soaked vaginal tampon. The patient was put on oral antibiotics with a dressing of the local wound. Healing was achieved in 10 days. An ultrasonography of the pelvis was ordered. Ultrasonography revealed an upside-down uterine fundus, filling in between the cervix making mirror image of normal uterine contour. Outer serosal surfaces were coming in contact together making typical pseudo stripe sign. The uterine fundus was observed between the vaginal walls giving a typical target sign. There was a heterogeneous mass lesion observed at the uterine fundus that probably arised from the submucosa and exhibited heterogeneous internal vascularity. The uterine artery pedicle and ovaries of both the sides were pulled along with the uterine fundus; however, there was no involvement of the urinary bladder (Figure 1 a-d).