Uterine inversion, a rare complication is defined as the invagination of fundus of the uterus like an overturned finger glove. During their professional practice, few gynecologists have faced it  . Several degrees are described according to the localization of the uterine fundus   :
・ 1st degree: the uterine fundus is still in the cavity and has not passed the cervix;
・ 2nd degree: the fundus has passed the external orifice of the cervix;
・ 3rd degree: the uterine fundus is externalized at the vulva;
・ 4th degree: when the vaginal walls participate in the inversion.
This accident usually occurs during puerperal period and non-puerperal cases are exceptional   . The non-puerperal uterine inversion (NPUI) is generally caused by an endocavity tumor which will provoke a traction force and cause the inversion  . Its prognosis is linked to the precocity of the diagnosis and a rapid treatment which helps avoid hysterectomia and even the death  . However, the extreme rarity of the disease can make diagnosis difficult   .
From two observations of NPUI, we report our experience of management of this complication in an undermedicalized country, insisting on the diagnostic difficulties and hysterectomy treatment.
2. Clinical Cases
2.1. Case 1
Mrs D K, a 34 years jobless woman, having 3 children born by cesarean section, consulted at the gynecological emergency unit in our service for a large mass externalized to the vulva. The history revealed intermittent metrorrhagia for several months associated with vaginal discomfort and progressive worsening difficulties of urine voiding. Two months earlier, she had consulted for a large intravaginal mass for which the diagnosis of polyp delivered by the cervix was made. She then refused a surgical procedure. On admission, the patient had paleconjunctivae, blood pressure was 120/70 mm Hg and the temperature at 37˚C. The gynecological examination revealed a pink, large, externalized vulvar mass, measuring 20 cm in the long axis with a lower big end (Figure 1). The suprapubic palpation showed the absence of uterus in the hypogastric region. The diagnosis of 3rd degree uterine inversion was clinically made. Hemogram showed a haemoglobin rate of 4 g/dl. The patient was transfused and then operated. An abdominal hysterectomy was performed. This was done after excision of uterine myoma vaginally, then reduction of the inversion by a posterior median
Figure 1. Complete inversion of the uterus and the fibroid nodule through the cervix (Observation 1).
colpo-hysterotomy according to the Haultain method. Figure 2 shows an abdominal view of the uterine before hysterectomia. The following days were uneventful and she was allowed to go home on the fifth postoperative day. The pathological examination of the surgical specimen revealed an infarcted uterus with myomas.
2.2. Case 2
Mrs. SYC, 41 years, gravidity 3, parity 1, jobless and primary school education level, consulted at the gynaecological emergency unitin our service for abundant metrorrhagia associated with severe abdominal pain and vaginal discomfort. On examination, the patient was in shock and actively bleeding. The gynecological examination revealed an ulcerated, necrotic and haemorrhagic firm large mass, which filled the entire vaginal cavity. The cervical orifice was not identified. The diagnosis of polyp delivered by the cervix was made. Hemogram revealed a hemoglobin rate of 3.6 g/dl. During the reanimation, following a violent effort of vomiting, the patient presented at the vulva, an externalization of a red and regular soft vulvar mass prolonged at its lower extremity by another mass of about 10 cm in diameter; ulcerated, necrotic with firm consistance and fetid (Figure 3). The diagnosis of 3rd degree NPUI was therefore retained. The exposed endometrium was necrotic and infected. A total vaginal hysterectomy was performed. The operating procedure was performed by abdominal surgery in two steps: subtotal hysterectomy away from the bladder and totalization of the hysterectomy after reintroduction of the cervix into the pelvic cavity and bladder dissection. The pathological examination of the surgical specimen confirmed the diagnosis of uterine fibroid. The following days were uneventful and she was allowed to go home on the fifth postoperative day.
Figure 2. Abdominal view after correcting inversion.
The NPUI is a rare complication and literature relates only few clinical cases      . In a literature review published in 2005, Lupovitch et al. had recorded only150 cases since 1887  , which actually confirm this rarity. At the pathogenic level, the occurrence of this complication requires the presence of a large endo-uterine fundus tumor, which exerts a force of traction   . The mainetiology found is the submucosalmyoma    . More rarely, it may be a sarcoma or carcinoma  .
The epiomiologic and clinical characteristics of our patients (Table 1) share several commun point with such described cases in the African literature as the young age of the patients, difficult and even wrong diagnosis, and little resort to medical imaging   
The diagnosis of NPUI is primarily clinical but often difficult because we do not think about it at a first glance  . These diagnostic difficulties are mainly met in the 1st and 2nd degree types  . A polyp delivered by the cervix can have the same clinical aspect (as the NPUI) and is the most cited diagnostic trap   . Indeed in our observations, the intra-vaginal masses initially mistaken for polyps delivered by the cervix were uterine inversion of 2nd degree that had been misdiagnosed. The diagnosis of uterine inversion is based on the pathognomonic sign:
Figure 3. Complete inversion of the uterus and the fibroid nodule (Observation 2).
Table 1. Epidemiological and clinical characteristic of our 2 patients.
the non-perception of the cervical orifice. As we examined the first patient, we did not have knowledge of that sign which delayed the diagnosis. In the second case, although we had knowledge of this sign, we could not highlight it. Two reasons can explain this failure: the volume of the intra-vaginal mass and its haemorrhagic character masked the inversion. In case of doubt, pelvic ultrasound, magnetic resonance imaging or laparoscopy may be useful   .
But the cost of such investigations and their non-availability in emergency situations limit their use in our context of work. On the other hand, in the externalized forms, the diagnosis seems easier by the visualization on at the vulva of the inverted uterus associated with submucosal fibroids. The absence of uterine fundus during abdominal palpation can confirm the diagnosis, and it is possible to perceive tubal ostia  . This sign was found in our patients probably because of the uterine gangrene. The NPUI is characterized in the 3rd degree by the constitution of a cervical neck ring that consequently exposes to uterus reintegration difficulties, infection and uterine gangrene   . Hysterectomy is therefore the only option. It can be performed vaginally or by abdominal surgery depending on the operator’s habits or surgical conditions   . In the second case, we resorted to vaginal surgery. This has the advantage to limit the inoculation of the abdominal cavity with germs from the vaginal cavity. However, it exposes to a risk of ureter-bladder injuries due to the modifications of current anatomical landmarks  . To avoid this risk, we used the same technical artifice like Pelissier  . In the first case, we opted for the abdominal surgery, because of probable pelvic adhesions in connection with previous cesarean sections. The association of laparoscopy with vaginal surgery as described by Auber would certainly have been a good indication in this case  .
As for maternal prognosis linked to hysterectomia, several series do not reveal any death  -  . However this intervention can be responsible for a non neglectful morbidity in connection with infectious and hemorraghic complications  . Moreover the psychological consequences of these hysterectomies, which lead to definitive sterility, are important in these young women in full genital activity.
The NPUI is so exceptional that its extreme rarity can make the diagnosis difficult, if it is not an obvious external form. The gynaecologist must always have in mind the possibility of this complication in any polyp delivered by the cervix and search the cervical orifice through a painstaking examination. The prognosis depends on early diagnosis and rapid management in order to avoid hysterectomy.