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An 81-year-old lady gravida 3 para 3 presented at the emergency department with excruciating pelvic pain and with a large 15-cm mass protruding from her vagina. The patient has no previous history of postmenopausal bleeding or of pelvic prolapse, and her pain started 48 h prior to her admission to the emergency department. The mass was dark red in colour, with thick edematous parts and necrotic aspects, and had a nausea-inducing odour. Further vaginal examination was impossible as there was no space between the pediculated mass and vaginal wall. The patient was immediately resuscitated with intravenous fluids, antibiotics (metronidazole and cephalosporin) and adequate analgesia, and a urinary catheter was inserted. An abdominal scan was unsuccessful in determining the origin of the mass. An urgent CT scan (Figs. 1a, b and 2) was suggestive of uterine inversion. A superficial invagination of the myometrium was noted, but the exact depth could not be assessed due to the marked distortion. Examination under anaesthesia for diagnostic purposes was arranged after 24 h of intravenous antibiotics. Anticoagulant therapy, previously initiated 2 months before her emergency admission due to a leg deep venous thrombosis, had to be corrected prior to surgery. During examination under anaesthesia, vaginoscopy– hysteroscopy did not reveal the origin of the pedicule. Resection of the pedicule was achieved high up, into the vagina, using a vicryl 1/0 stitch for ligation. The specimen was sent for histopathology examination. When the mass was removed, the diagnosis of a three times twisted endometrial polyp was made. Vaginoscopy– hysteroscopy revealed that the uterus was inverted, and at its fundal thin part, a 2-cm circular defect was noted corresponding to the resection point. Following this an abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. Of great surprise during the laparotomy, we noticed that the cornuas of the inverted uterus were twisted as well. The right cornual end with the corresponding fallopian tube was positioned at the left part of the pelvis and the left cornua and fallopian tube at the right of the pelvis with a partial rotation of 180°. Reduction of the torsion was achieved manually, rotating the uterus in anti-clockwise. No cervical ring edema was noted, and the uterosacral ligaments were very flexible and C. Panayotidis (*) Royal Cornwall NHS Hospital—Gynaecology, Truro, UK e-mail: costapan@hotmail.com

Uterine inversion in a postmenopausal woman due to a twisted pediculated endometrial polyp with concomitant uterine torsion