A case of cystic adenomyoma of the uterus after complete abortion without transcervical curettage
A 30-year-old woman (gravida 2, para 1, and abortion 1) was referred to the emergency room of our tertiary center because of severe, progressive, and intractable dysmenorrhea for 1 year. Abdominal discomfort began on the third day of her menstrual cycle, accompanied by cramping pain, syncope, headache, and cold sweats. Her pain was not relieved by medication, including nonsteroidal anti-inflammatory drugs (NSAIDs) and oral contraceptive pills. Her menarche had occurred at the age of 14 years, and she had no specific problems with secondary sexual development. Her menstrual cycle was regular (28 days) with a duration of 5 days and moderate bleeding. She had no dysmenorrhea prior to 1 year previously when this episode began. Four year ago, she had a natural singleton pregnancy, which culminated in the natural vaginal delivery of a full-term boy. Approximately 1 year previously, she was pregnant. However, at GA 6 weeks, she underwent a complete abortion spontaneously without any transvaginal procedures such as transcervical curettage. After the abortion, severe dysmenorrhea began and progressively increased. On physical examination, the pain localized to the right lower quadrant of the abdomen, and no tenderness to palpation or rebound tenderness was observed. Bimanual pelvic exam revealed a non-mobile, small, palpable mass on the right side of the uterus. Laboratory findings, including level of CA-125 (17 U/mL), were normal. Serum human chorionic gonadotropin level was near zero. Transvaginal sonography performed using a Volusion 730 Pro scanner (GE Healthcare, Milwaukee, WI, USA) showed a normal sized uterus, unremarkable endometrium, and intact ovaries. However, a 2×2 cm hypoechoic mass surrounded by a hyperechoic enhancing rim was seen on the anterior wall of the right side of the uterus. Within this mass, an inner hypoechoic cystic lesion measuring approximately 1.2×0.8 cm was seen (). The mass had no communication with the endometrium. Computed tomography of the abdomen and pelvis revealed a 2×2 cm mass on the uterine side of the uterus with an approximately 1.2-cm cystic area inside the mass (). The appendix was intact. No associated urogenital anomalies were detected. We believed that this condition represented a cystic adenomyoma in light of our previous case report [], and elected to perform laparoscopic excision of the mass.\nA laparoscopy was performed on the 20th day of the patient's menstrual cycle. Under general anesthesia, she was placed in the lithotomy position. An 11-mm trocar (Excel Endopath; Ethicon Endo-Surgery, Cincinnati, OH, USA) was inserted as the primary puncture after making a skin incision along the lower margin of the umbilicus. To create a pneumoperitoneum, CO2 was insufflated into pelvic cavity using a Veress needle. Subsequently, second, third, and fourth punctures using 12-mm and 5-mm trocars were carefully created in the left upper quadrant (umbilicus level), right lower quadrant, and lower midline area of the abdomen. A uterine manipulator was inserted to easily handle the uterus and adnexa.\nThe laparoscopic view showed a bulging mass measuring approximately 2×2 cm in the anterior portion of the right side of the uterus; the mass appeared to be a myoma (). After direct injection of diluted vasopressin (vasopressin 10 units diluted in 100 mL of normal saline) into the uterine mass, an oblique incision was made using monopolar cautery. During enucleation of the mass, chocolate-colored fluid leakage, consistent with an endometrioma, was seen (); the fluid was drained from the cystic portion of the mass (). A harmonic scalpel and a 10-mm screw were used for complete excision of the mass. The excision site was closed with interrupted endosutures using 1-0 monofilament (). Infusion of methylene blue dye through a uterine manipulator showed no communication between the mass and endometrial cavity. Operative time was 70 minutes, and estimated blood loss was less than 20 mL. There were no intraoperative or postoperative adverse events, and the patient was discharged 48 hours after surgery in good condition.\nOn macroscopic examination, the mass measured 2×2 cm in diameter. The inner surface of the mass contained a brownish discolored layer with the appearance of an ovarian endometrioma. Histological examination showed that the central cyst wall was lined with endometrial glandular epithelium and endometrial stromal cells within myometrium, and the surrounding myometrium revealed smooth muscle proliferation forming a myomatous mass compatible with an adenomyosis (). In the 2 years since the surgery, the patient has had regular menstruation with no dysmenorrhea.