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Prolapseduterineleiomyoma(fibroid)
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Prolapseduterineleiomyoma(fibroid)
Author
WilliamHParker,MD

SectionEditors
RobertLBarbieri,MD
HowardTSharp,MD

DeputyEditor
SandyJFalk,MD,FACOG

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2016.|Thistopiclastupdated:Jul14,2015.
INTRODUCTIONUterineleiomyomas(fibroids)arecommonbenignsmoothmuscletumors[1,2].Fibroidsmay
developanywherewithinthemuscularwalloftheuterus,includingsubmucosal,intramural,orsubserosalpositions
(figure1).Forwomenwithapedunculatedsubmucosalfibroidthatiscontainedwithintheuterinecavity,removalis
typicallyperformedusinghysteroscopy.Infrequently,uterinecontractionswillpushapedunculatedsubmucosalfibroid
throughthecervicalcanalanditmayprolapseintothevagina[3].Pedunculatedfibroidsthatdilatethecervixor
prolapsethroughthecervixintothevaginacanusuallyberemovedviathevagina.
Removalofsubserosalorintramuralfibroidsthroughavaginalcolpotomyincisionisanuncommonlyperformed
procedurethathasalsobeenreferredtoasvaginalmyomectomy[4].Thisapproachhasbeenassociatedwithan
increasedriskofinfectioncomparedwithothersurgicalapproachestomyomectomy.Thisprocedureisnotdiscussed
here.
Vaginalmyomectomyforaprolapsedsubmucosaluterinefibroidisreviewedhere.Hysteroscopic,abdominal,and
laparoscopicapproachestomyomectomyarediscussedseparately.(See"Hysteroscopicmyomectomy"and
"Abdominalmyomectomy"and"Laparoscopicmyomectomyandotherlaparoscopictreatmentsforuterineleiomyomas
(fibroids)".)
INCIDENCEANDRISKFACTORSTherearenodataregardingtheincidenceorriskfactorsofprolapseduterine
leiomyomasinparticular.Ingeneral,uterineleiomyomasarethemostcommontypeofcommonpelvictumorin
women,withaprevalenceofupto80percent.Submucosalfibroidsaccountforapproximately15to20percentof
theseandanunknownproportionofsubmucosalleiomyomasprolapsethroughthecervix.Inourexperience,this
clinicalfindingisuncommon,butisnotexceedinglyrare.Theepidemiologyandriskfactorsofuterineleiomyomasare
discussedseparately.(See"Epidemiology,clinicalmanifestations,diagnosis,andnaturalhistoryofuterineleiomyomas
(fibroids)",sectionon'Prevalence'and"Epidemiology,clinicalmanifestations,diagnosis,andnaturalhistoryofuterine
leiomyomas(fibroids)",sectionon'Riskfactors'.)
CLINICALPRESENTATIONProlapseofasubmucosalleiomyomathroughthecervixmaypresentwithsymptoms
ofvaginalbleeding,discharge,orpelvicpain.Somewomenareasymptomatic,andthefindingisnotedincidentallyon
pelvicexamination.
SymptomsWomenwithafibroidthathasprolapsedthroughthecervixmaypresentwithvaginalbleeding,watery
vaginaldischarge,pelvicpainorcramping,vaginalpressure[5].Often,uterinecrampingissignificantduringthe
processoffibroidexpulsionthroughthecervix.Rarely,profusebleedingoccurs.
Generalsymptomsofsubmucosalfibroidsincludeheavymenstrualbleeding,dysmenorrhea,andinfertility.(See
"Epidemiology,clinicalmanifestations,diagnosis,andnaturalhistoryofuterineleiomyomas(fibroids)",sectionon
'Clinicalmanifestations'.)
IncidentalfindingonpelvicexaminationAprolapsedfibroidmaybediscoveredduringapelvicexamination
performedforotherindications.Aprolapseduterineleiomyomaisvisualizedonspeculumexaminationasamass
protrudingfromthecervix.(See'Pelvicexamination'below.)
Inourexperience,thesewomenmaynothaveinitiallycomplainedofassociatedsymptoms,butfurtherquestioning
oftenrevealsahistoryofheavyvaginalbleeding,pelviccramping,orvaginaldischarge.
DIAGNOSTICEVALUATIONPelvicexaminationisrequiredtofurtherevaluatesymptomssuggestiveofa
prolapsedfibroidandhelpstodifferentiatealeiomyomafromotherlesions.Imagingstudiesarerequiredonlyif
examinationofthemassisnotconsistentwithanyoftheselesions.Pathologyevaluationisrequiredtomakethefinal
diagnosis.
PelvicexaminationOnspeculumexamination,aprolapseduterinefibroidappearsasabulbousmassprotruding
fromtheexternalcervicalos.Ingeneral,thesizerangesfromapproximately1to6cmindiameter.Largerfibroidsare
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unlikelytoprolapsethroughthecervix.Thefibroidistypicallyfriableandactivebleedingmaybepresent.
Themassshouldbepalpatedtoidentifytheconsistencyandwhetherthereisapedicle.Afibroidislikelytohavea
firmerconsistencythanacervicalorendometrialpolypandapolypislikelytobemorefriable.Aprolapsedfibroidor
endometrialpolypwillhaveapalpablepediclethatoriginatesfromtheuterinecavity,whileacervicalpolypwill
originatefromtheexocervixorendocervicalcanal.Itisnotalwayspossibletodifferentiatebetweenfibroidsandpolyps
onexaminationandthefinaldiagnosisismadewithpathologyevaluation.(See'Differentialdiagnosis'belowand
'Diagnosis'below.)
Alesionthatoriginatesfromtheuterinecavitybutisextensiveandhasnoclearpedicleraisessuspicionforauterine
sarcoma.
ImagingstudiesImagingisnottypicallyrequiredpriortoremovingalesionthatisconsistentwithaprolapsed
fibroidonexamination,andshouldbeperformedonlyiftheappearanceofthemassisnotconsistentwithaleiomyoma
orcervicalorendometrialpolyporifthepedicleofthemasscannotbeseenorpalpatedonexamination.Insuch
cases,imaginghelpsguidesurgicalplanningandfurtherevaluatesthepossibilityofauterinesarcoma.(See"Uterine
sarcoma:Classification,clinicalmanifestations,anddiagnosis",sectionon'Diagnosticevaluation'.)
Ifimagingisrequired,pelvicsonographyistypicallythefirstlinestudy,sinceitprovidesgoodqualityimagesofuterine
lesionsandisrelativelyinexpensive.Inourexperience,pelvicmagneticresonanceimaging(MRI)isoftenrequiredas
afollowupstudy,sinceitismorelikelytoprovideinformationaboutthesizeandpositionoftheuterineattachment
thanultrasound(figure2)[6].Limitedsequences(T2,sagittal,axialandparalleltotheuterus)withoutcontrastare
usuallysufficienttoevaluatethemassandcanreducethecostofimaging.Asanexample,acasereportdescribeda
largeprolapsedfibroidconnectedtotheendometrialcavitybyastalk.OnthesagittalT2MRimage,thestalk
containedmultiplefinelinearstructures,whichtheauthorsdescribedasthebroccolisign[7].(See"Epidemiology,
clinicalmanifestations,diagnosis,andnaturalhistoryofuterineleiomyomas(fibroids)",sectionon'Imaging'.)
PathologyevaluationofmassMassesthatareconsistentwithcommon,benignlesions(prolapsedfibroidor
endometrialpolyporcervicalpolyp)aretypicallyremovedintheirentiretyfortherapeuticpurposes,andthediagnosisis
confirmedbypathologyevaluationofthespecimen.Preoperativebiopsyisindicatedonlyiftheappearanceofthe
lesionisnotconsistentwithafibroidoracervicalorendometrialpolyp,althoughuterinesarcomasmaybe
heterogeneousandthepathologicdiagnosisbaseduponasmallbiopsymaynotbepossible.(See"Uterinesarcoma:
Classification,clinicalmanifestations,anddiagnosis",sectionon'Diagnosticevaluation'.)
DIAGNOSISApresumptivediagnosisofaprolapsedfibroidismadeuponvisualizationandpalpationduringpelvic
examination.Thediagnosisisconfirmedwithpathologyexaminationafterremovalofthelesion.
DIFFERENTIALDIAGNOSISThedifferentialdiagnosisforaprolapsedfibroidprimarilyincludesacervicalpolypor
prolapsedendometrialpolyp.Cervicalpolypsareaverycommonfindingandprolapseofanendometrialpolypoccurs
infrequently.(See"Congenitalcervicalanomaliesandbenigncervicallesions",sectionon'Polyps'and"Endometrial
polyps",sectionon'Polypectomy'.)
Differentiatingbetweentheselesionsonphysicalexaminationisdiscussedabove.(See'Pelvicexamination'above.)
Rarely,othertypesofuterinepathologymayprolapseorprotrudethroughthecervix,including:
Aprolapseduterinesarcoma[8](see"Uterinesarcoma:Classification,clinicalmanifestations,anddiagnosis",
sectionon'Clinicalpresentation')
Apolypoidformofuterineadenomyosis[9](see"Uterineadenomyosis")
Biopsyshouldbeperformedifuterinesarcomaissuspected.Polypoiduterineadenomyosismaymimicaprolapsed
fibroidorendometrialpolyponexamination,butwillbeidentifiedwithpathologyevaluationafterremoval.(See
'Diagnosticevaluation'above.)
MANAGEMENTProlapsedleiomyomasareremoved,typicallyviavaginalmyomectomy,forthepurposeof
diagnosisandrelieforsymptoms.Mostcliniciansremovetheselesionseveninasymptomaticpatients,because
symptomseventuallydevelopinnearlyallwomen.Removalofprolapsedfibroidsisalsoprudenttopreventuterine
infection.
Theremovalofaprolapseduterinefibroidisperformedeitherinanofficesettingorwithaminimallyinvasiveapproach
inanoperatingroom.Ingeneral,therearefewcontraindicationstovaginalmyomectomywiththeexceptionofwomen
withsignificantmedicalcomorbiditieswhohaveanincreasedriskofcomplicationsassociatedwithanesthesiaorwho
haveableedingdiathesisorareonanticoagulants.Thesewomenrequiremedicalconsultationpriortosurgery.(See
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"Overviewoftheprinciplesofmedicalconsultationandperioperativemedicine"and"Perioperativemanagementof
patientsreceivinganticoagulants".)
VAGINALMYOMECTOMYVaginalmyomectomyisoftenperformedinanofficesettingduringthevisitatwhich
theprolapsedfibroidwasdiscovered.Somewomenrequireremovalofthelesioninanoperatingroom.
Surgicalplanning
InformedconsentInformedconsentshouldincludeadiscussionofthephysicalexaminationandimaging
findingsandthedetailsoftheprocedure.Thepotentialneedforafurtherprocedureifthefibroidcannotberemoved
completelyshouldbediscussed,includinglaparoscopicorabdominalmyomectomyorpossiblyhysterectomy.This
discussionshouldbedocumentedinthemedicalrecordandontheprocedureconsentformsignedbythepatient.
OperativesettingMostprolapsedmyomascanberemovedinanofficesetting,butsomevaginalmyomectomy
proceduresshouldbeperformedintheoperatingroomforbetteraccesstoanesthesia,measurestocontrolbleeding,
andsurgicalinstruments.Itisimportanttoassessthefeasibilityofanofficebasedprocedurebeforetheprocedureis
attemptedtoavoidincompleteremoval,excessivebloodloss,ortheneedtotransferthepatienttotheoperatingroom.
Therearenodataregardingremovalinanoperatingroomratherthaninanofficesetting.Inourpractice,weremove
fibroidswiththefollowingcharacteristicsintheoperatingroom:

Largerthan4cm
Pediclecannotbevisualizedorpalpated
Broadbased(pedicle>2cmindiameter)
Cervicalfibroidthatisnotpedunculated

Removalintheoperatingroommayalsoberequiredforwomenwhocannottolerateanofficeprocedureorwhohavea
bleedingdiathesisorareonanticoagulants.(See'Management'above.)
AnesthesiaVaginalmyomectomyofaprolapsedfibroidinanofficesettingistypicallyperformedwitha
paracervicalblock.Therearenodataregardingtheoptimaltypeofanesthesiaforthisprocedure.Somewomencan
toleratetheremovalofsmallfibroidswithathinpediclewithoutanesthesia.Useofananxiolyticorconscioussedation
maybeusedtofacilitateanofficeprocedure.(See"Pudendalandparacervicalblock",sectionon'Paracervicalblock
(gynecologic)'.)
Forproceduresinanoperatingroom,thedecisiontousesedation,regional,orgeneralanesthesiashouldbemade
throughconsultationwiththepatientandanesthesiologist.
AntibioticprophylaxisProphylacticantibioticsarenotrequiredforvaginalmyomectomyofaprolapsedmyoma
forthepreventionofsurgicalsiteinfectionorendocarditis[10].Inourpractice,however,wegiveasingledoseof
perioperativeantibioticsifthefibroidisnecroticorobviouslyinfected.(See"Overviewofpreoperativeevaluationand
preparationforgynecologicsurgery",sectionon'Antibioticprophylaxis'.)
Thereisapotentialriskofinfection,aswithanysurgicalprocedure,buttherearefewdataaboutthisprocedureandno
casesofinfectionwerereportedinthetwolargestseries,eachwith46patients[3,11].
ThromboprophylaxisProceduresperformedinanofficesettingaretypicallybriefandthromboprophylaxisisnot
required.Forwomenwhoundergovaginalmyomectomyinanoperatingroom,sincesurgeryisperformedinthe
lithotomypositionandmaybeprolonged,thromboprophylaxiswithanintermittentpneumaticcompressiondevice
shouldbeusedinallbuttheshortestprocedures.(See"Overviewofpreoperativeevaluationandpreparationfor
gynecologicsurgery",sectionon'Thromboprophylaxis'.)
ProcedureTheprocedureforvaginalmyomectomyisasfollows:
Theprolapsedfibroidisgraspedwithatowelclamportenaculumandpulleddownintothevaginaandawayfrom
thecervix.Excessivetractiononthefibroidshouldbeavoidedtopreventavulsionofthelesionoruterine
inversion.
Iftheentirepedicleofthefibroidcanbepalpated,theentirepediclecanoftenbeclampedacrossthebase.Itis
thencutandsutureligatedusingadelayedabsorbablesuturematerial.Alternatively,asuturecanbepassed
aroundthepedicleandtiedorapretiedsurgicallooppassedoverthefibroidtothepedicleandthebaseligated.
Wesecurethiswithanadditionalsutureligature.Afteritiscut,thestalkwillusuallyrecedeintotheuterine
cavity.

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Iftheentirepediclecannotbepalpatedbecauseitisbroadbasedorthefibroidiswithinthecervicalcanalandthe
cervixisdilated,accesstothefibroidcanbeobtainedbymakingcervicalincisionsat2,6and10:00(Dhrssen's
incisions[12]).Thisprocedureshouldonlybeperformedinanoperatingroomwithadequateanesthesia.
Aftermakingthecervicalincisions,usinggentletraction,thefibroidcanbebroughtdownintothevaginaand
morcellatedusingascalpelorMayoscissorsuntilthebaseofthepediclecanbepalpated.Oncethepediclecanbe
palpated,clampingorsutureligationcanbeaccomplishedandtheremainderofthefibroidexcised.Careshouldbe
takentoavoidextensionoftheincisionsintothelateralvaginalfornicestoavoidtheuterinevessels.Thecervical
incisionsshouldthenbeclosed.Inourpractice,weusea0polyglactin(Vicryl)inarunningstitch.
Ifthevaginalmyomectomyprocedureisperformedintheoperatingroom,somesurgeonsperformhysteroscopyafter
removalofthefibroidtoevaluatetheuterinecavityforaremnantofthefibroidandforadditionalsubmucousfibroids
thatmaybeamenabletohysteroscopicmyomectomy.(See"Hysteroscopicmyomectomy".)
ComplicationsComplicationsofvaginalmyomectomyforaprolapsedfibroidarerare,baseduponthefew
availabledata[3,5,11].Intworetrospectiveseriesof46patients,therewerenocomplications[3,5].
Themostlikelypotentialcomplicationofvaginalmyomectomyisexcessivebleedingfromthefibroidsite.Thiscanbe
managedwithpressure,usingeitherauterinepackorabladdercatheterballoonplacedinsidetheuterusandinflated
or,ifthesiteisaccessible,withasuture.Thesemaybeleftinplaceforseveralhoursandthenslowlyremovedto
ensurehemostasis.Ifbleedingpersists,hysteroscopyshouldbeperformedtoidentifyandcontrolthebleedingsite.
(See"Managinganepisodeofsevereorprolongeduterinebleeding",sectionon'Intrauterinetamponade'.)
Uterineinversionduetoexcessivetractiononthefibroidpriortoremovalisanotherpotentialcomplication.
Replacementofaninverteduterusisdiscussedseparately.(See"Puerperaluterineinversion",sectionon
'Management'.)
Thereisatheoreticalriskofinfection,butnonewasreportedinthetwolargestseries,eachwith46patients[3,5].
OutcomeTheprocedureappearssuccessfulinmostcases[3,5].Aretrospectiveseriesof46womenwho
underwentvaginalmyomectomyforaprolapsedfibroidreportedtwofailedproceduresinwhichthelesioncouldnotbe
removed,bothofwhichwereduetodifficultyreachingthefibroidpedicle[3].Anotherseriesreportedtreatmentwith
vaginalmyomectomy,abdominalmyomectomy,orhysterectomy,buttherateofconversionfromavaginal
myomectomytoanotherprocedurewasnotreported[5].
Recurrenceofaprolapsedfibroidoroffibroidrelatedsymptomsappearstooccurinfrequently.Aretrospectiveseriesof
46womenreportedthat,at5.5yearfollowup,9percentrequiredarepeatvaginalmyomectomyand6percenthada
hysterectomy[11].Hysterectomyinthesecasesmayhavebeenduetoindicationsotherthantheoriginalprolapsed
myoma.
Toavoidrecurrentfibroidrelatedsymptoms,hysteroscopymaybeperformedafterremovalofaprolapsedfibroidto
excludeotherpedunculatedorsubmucosalfibroidsthatmayrequiretreatment.Alternatively,apreoperativeimaging
studycanbeusedtoevaluatetheuterusforotherfibroids.(See"Epidemiology,clinicalmanifestations,diagnosis,and
naturalhistoryofuterineleiomyomas(fibroids)",sectionon'Imaging'.)
FollowupWomenmayexperienceuterinecrampingand/orvaginalspottingforseveraldaysfollowingthe
procedure.Acetaminophenornonsteroidalantiinflammatorydrugsareusuallyadequateifpostoperativepaincontrolis
necessary.Patientsshouldbeadvisedtocalltheirclinicianforfever,purulentvaginaldischarge,orbleedingthat
persistsforlongerthantwoweeksorisprofuse.
Postoperativecareisindividualizedmanypatientsdonotrequireafollowupvisit.(See"Patientinformation:Care
aftergynecologicsurgery(BeyondtheBasics)".)
PREGNANTWOMENProlapsedfibroidsrarelyoccurduringpregnancy.Areviewof11pregnantpatientsreported
thattwooftheprolapsingfibroidsweresubmucosalwhiletheothernineoriginatedfromtheportioofthecervix[13].
Magneticresonanceimaging(MRI)maybehelpfultodeterminethesizeandpositionoftheattachmentofthefibroidto
theuterus.Duringpregnancy,prolapsedfibroidsshouldberemovedonlyforexcessivebleeding,infection,painor
urinaryretention.Ifobstructionoflaboroccursorispredicted,cesareansectioncanbeperformedandthefibroidcan
beremovedatalatertime.Surgicalremovalduringpregnancymaybeassociatedwithruptureofthemembranes,
pretermlabororhemorrhageandneedforhysterectomy.Intwowomenreportedrequiringremoval,therewereno
complications.
Managementofuterineleiomyomasinpregnantwomenisdiscussedindetailseparately.(See"Pregnancyinwomen
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withuterineleiomyomas(fibroids)",sectionon'Fibroidsprolapsingintothevagina'.)
REFERRALTOASPECIALISTWomenwithalesionconsistentwithaprolapsedleiomyomashouldbereferredto
agynecologistorotherclinicianwhocanperformavaginalmyomectomy.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereading
level,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesare
bestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatient
educationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgrade
readinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopics
toyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingonpatientinfo
andthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Uterinefibroids(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Uterinefibroids(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Vaginalmyomectomyisperformedforsubmucosalmyomasthathaveprolapsedthroughthecervix.Forwomen
withsubmucosalfibroidsthathavenotprolapsed,removalistypicallyperformedhysteroscopically.(See
'Introduction'above.)
Womenwithafibroidthathasprolapsedthroughthecervixmaypresentwithvaginalbleeding,wateryvaginal
discharge,uterinecontractions,pressurefromavaginalmass,ortheymaybeasymptomatic.(See'Symptoms'
above.)
Apresumptivediagnosisofaprolapsedleiomyomaismadeuponvisualizationduringapelvicspeculum
examination.Pelvicmagneticresonanceimaging(MRI)(withoutcontrast)ishelpfultoprovideinformationabout
thesizeandpositionoftheuterineattachment.Thediagnosisisconfirmedwithpathologyexamination.
Preoperativebiopsyisnottypicallyrequired.(See'Diagnosis'above.)
Prolapsedleiomyomasrequireremovalandcanoftenberemovedinanofficesetting.Wesuggestremovalinan
operatingroomratherthaninanofficesettingforwomenwithfibroidswiththefollowingcharacteristics:non
prolapsed,largerthan4cm,broadbased,thepediclecannotbevisualizedorpalpated(Grade2C).Removalin
theoperatingroomisalsopreferableforwomenwhocannottolerateanofficeprocedureorwhohaveableeding
diathesis.(See'Operativesetting'above.)
Vaginalmyomectomyofaprolapsedmyomaisusuallysuccessful.Conversiontoabdominalmyomectomyor
abdominalhysterectomyhasbeenreported.Complicationsoftheprocedurearerare.(See'Outcome'aboveand
'Complications'above.)
Duringpregnancy,prolapsedfibroidsshouldberemovedonlyforexcessivebleeding,infection,painorurinary
retention.Ifobstructionoflaboroccursorispredicted,cesareansectioncanbeperformedandthefibroidcanbe
removedatalatertime.Surgicalremovalduringpregnancymaybeassociatedwithruptureofthemembranes,
pretermlabororhemorrhageandneedforhysterectomy.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.BairdDD,DunsonDB,HillMC,etal.Highcumulativeincidenceofuterineleiomyomainblackandwhite
women:ultrasoundevidence.AmJObstetGynecol2003188:100.
2.ParkerWH.Etiology,symptomatology,anddiagnosisofuterinemyomas.FertilSteril200787:725.
3.GolanA,ZachalkaN,LurieS,etal.Vaginalremovalofprolapsedpedunculatedsubmucousmyoma:ashort,
simple,anddefinitiveprocedurewithminimalmorbidity.ArchGynecolObstet2005271:11.
4.FaivreE,SurrocaMM,DeffieuxX,etal.Vaginalmyomectomy:literaturereview.JMinimInvasiveGynecol
201017:154.
5.DickerD,FeldbergD,DekelA,etal.Themanagementofprolapsedsubmucousfibroids.AustNZJObstet
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Gynaecol198626:308.
6.ParkerWH.TheutilityofMRIforthesurgicaltreatmentofwomenwithuterinefibroidtumors.AmJObstet
Gynecol2012206:31.
7.KimJW,LeeCH,KimKA,ParkCM.Spontaneousprolapseofpedunculateduterinesubmucosalleiomyoma:
usefulnessofbroccolisignonCTandMRimaging.ClinImaging200832:233.
8.McCluggageWG,AlderdiceJM,WalshMY.Polypoiduterinelesionsmimickingendometrialstromalsarcoma.J
ClinPathol199952:543.
9.ChangA,NatarajanS.Polypoidendometriosis.ArchPatholLabMed2001125:1257.
10.ACOGCommitteeonPracticeBulletinsGynecology.ACOGpracticebulletinNo.104:antibioticprophylaxisfor
gynecologicprocedures.ObstetGynecol2009113:1180.
11.BenBaruchG,SchiffE,MenasheY,MenczerJ.Immediateandlateoutcomeofvaginalmyomectomyfor
prolapsedpedunculatedsubmucousmyoma.ObstetGynecol198872:858.
12.MAYESHW.Dhrssen'sincisions.AmJSurg195181:303.
13.StraubHL,ChohanL,KilpatrickCC.Cervicalandprolapsedsubmucosalleiomyomascomplicatingpregnancy.
ObstetGynecolSurv201065:583.
Topic3295Version13.0

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GRAPHICS
Fibroidlocationsintheuterus

Thesefiguresdepictthevarioustypesandlocationsoffibroids.Awomanmayhave
oneormoretypesoffibroids.
Graphic53241Version4.0

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Transvaginalremovalofaprolapsedsubmucosal
myoma

CourtesyofWilliamJMann,Jr,MD.
Graphic50202Version1.0

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ContributorDisclosures
WilliamHParker,MDNothingtodisclose.RobertLBarbieri,MDNothingtodisclose.HowardTSharp,MD
Nothingtodisclose.SandyJFalk,MD,FACOGNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressed
byvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthe
content.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsof
evidence.
Conflictofinterestpolicy

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