Posthysterectomy fallopian tube prolapse.

A 35-year-old, presented with symptoms of watery discharge per vaginum, lower abdominal pain, and dyspareunia of 1 month duration. She had undergone total abdominal hysterectomy with left salpingo-oophorecomy with right cystectomy 20 months back. Her post operative recovery was uneventful. Per speculum examination revealed a polypoidal, strawberry colored growth 1.5 cm × 1.5 cm, at the vaginal vault. It was not bleeding on touch but was tender PAP smear was unremarkable. The growth was excised. Histopathology revealed ciliated columnar lining polypoidal projections and papillae resembling tubal plicae, lamina propria showed chronic inflammatory cells along with few smooth muscle bundles clinching the diagnosis of prolapsed fallopian tube [Figures 1 and 2 ]. Microphotograph showing fallopian tubal epithelium thrown into papillary folds, lamina propria showing congested blood vessels and dense chronic inflammatory infiltrate along with few smooth muscle bundles. (H and E 10×) Microphotograph showing fallopian tube lining of pseudostratified ciliated columnar epithelium (H and E 40×)

Tubal prolapsed is seen commonly after vaginal hysterectomy as compared to abdominal hysterectomy[ 4 ] and rarely following interposition and colpotomy.[ 5 ] The first two cases to occur after abdominal hysterectomy were described in 1955 by Funnel et al .[ 4 ] The exact incident of fallopian tube prolapse is difficult to estimate since few cases may resolve before detection.[ 3 ] The median age of presentation is 29 years (range from 17 to 40 years). Predisposing factors include postoperative fever, hematoma formation, poor physical state of the woman, insufficient vaginal preparation preoperatively, difficult surgical procedure, failure to achieve adequate hemostasis, failure to close vaginal cuff, profuse postoperative drainage vaginally and use of intraperitoneal vaginal drains and packs.[ 6 7 ] The presentation can be soon after hysterectomy as early as 2 months, or up to 8 years afterwards.[ 4 ] The most common symptoms are vaginal discharge, dyspareunia and lower abdominal pain.[ 2 ] Some patient may be asymptomatic.[ 2 ] The diagnosis of FTB should be suspected when a red granular polypoidal mass is seen at the vaginal cuff protruding into the vagina after hysterectomy.[ 2 ] Rarely urinary bladder and uterus are the sites of tubal prolapse.[ 8 ] The differential diagnosis includes, proliferative granulation tissue related to surgery, granuloma not related to surgery, malignant lesion and endometriosis.[ 2 3 ] The fallopian tube tissue is firmer than granulation tissue and also more tender. The easy passage of probe into the lumen of the tube will aid establishing the diagnosis.[ 5 ] Differential diagnosis on microscopy includes cysts of mesonephric and paramesonephric duct, vaginal adenosis, endometrosis, primary and metastatic adenocarcinoma.[ 2 5 ] Exfoliation cytology of fallopian tube prolapse reveals small ciliated columnar cells with prominent nucleoli.[ 4 ] It can be misdiagnosed as malignancy as vaginal vault is not the site for columnar cells.[ 4 ] If difficulty persist, IHC staining for cytokeratin can be of use.[ 4 ] The technique of management varies from partial vaginal excision to total vaginal excision to combined abdominal and vaginal approaches. While total vaginal salphingectomy may be sufficient to annul the chances of recurrence where adhesion and concomitant pelvic pathology is anticipated, a combined vaginal and laparoscopic approach is preferable.[ 9 ] Prevention of tubal prolapse can be achieved by suturing the adnexae high in the pelvis at abdominal hysterectomy, and the incidence decreased if the pelvic peritoneum is closed and the vault not drained. Awareness of this complication will provoke more efficient referral and prevent inadequate treatment which prolong the patient's distress.[ 10 ]

Fallopian tube prolapse after hysterectomy into the vaginal vault is a rare occurrence, although failure to recognized this has lead to its under reporting.[ 1 ] Since the first description of this condition by Piozzi in 1902, fewer than 100 cases have been reported so far, the majority following vaginal hysterectomy probably due to non closure of the vault and the pelvic peritoneum.[ 1 ] It accounts for cumulative incidence of 0.5% with vaginal hysterectomy and 0.06% following abdominal hysterectomy.[ 2 ] The definitive diagnosis is by histology alone.[ 3 ]