Hysterectomy is the most common surgery performed for indications like fibroids, adenomyosis, pelvic inflammatory disease and hormonal causes. Prolapse of bowel, ovary and bladder through vaginal vault is not common, but prolapse of tube and omentumis quite common. Prolapse of ovarian cyst through vaginal vault has so far not been reported in the world literature. Ovarian cysts enlargeto large size especially ovarian tumours like serous or mucinous cystadenomas.

Mrs X, 35 years female married for 20 years, agricultural labourer by occupation, presented with pain lower abdomen and low back achefor the last one year. Pain was intermittent, aggravated by work, used to get relief by medication and rest (Figure 1). H/o sticky watery discharge per vagina for a period of 8-9 months associated with itching. No dyspareunia. Hysterectomised 10 years back (Figure 2).

Figure 1: The lining epithelium was mucin secreting and endocervical in nature.

Past history: Nil Significant.

Menstrual history: Age of menarche 12 years, Menstrual History 5/30 regular, moderate flow, no dysmenorrhea.

Figure 2: MRI Contrast enhanced showed.

Obstetric history: P3L3, all were normal deliveries, not tubectomised, last child birth 15 years ago.

Past Surgical history: Hysterectomy ten years back. Right ovarian cystectomy was done three years back.

Personal / Family history: Nil significant

P/A: Both laparotomies scars were vertical &healthy.

P/S: Irregular mass of size 4 x 3 cm seen prolapsing through the right side of the vault.

Yellowish gelatinous discharge present through vault gaping.

P/V: Cystic mass of 8 x 8 cms palpable on the right side of the vault with restricted mobility.

P/R: Rectal mucosa free. Pelvic mass felt posteriorly 5 x 5 cm firm in consistency.

Parametrium free. Biopsy taken from mass and sent for HPE.

U/s: 11 x 6 x 9.8 cm multi cystic lesions noted in right adnexal region – S/o Rt ovarian cyst

Other routine preoperative Investigations were done and found to be with in normal limits.

Biopsy: Mucosa lined tissue bits with non-specific mixed inflammation and granulation tissue. Huge complex cystic mass – 10.9 cm x 8.3 cm x 9.1 cm in the pelvis prolapsing through the cervical stump? (Ovarian cyst prolapsing through cervical stumper, through the vaginal vault). A cyst of size 4 cm also noted in the left ovary appearing to be a benign lesion.

Intra operative findings

Right side retro peritoneal cystic mass of 10 x 4 cm identified. Left side ovarian cyst of 5 x 4 cm identified. Gaping in vaginal vault was seen (Figure 3).

Figure 3: Laparotomy done for diagnosis of post hysterectomy ovarian cyst.

Operative procedure

A cystic mass of 10 x 4cms in right iliac fossa retroperitoneally seen. A cystic mass of 5 x 4 cms seen in Left iliac fossa. Both masses were adherent anteriorly to bladder, adhesions released carefully from the bladder. Ureter identified and separated from the mass at its lower 1/3^rd. Right ovarian mass found to be extending through the vault in to the vagina and adherent to posterior vaginal wall which is separated and removed. Left ovarian cyst was removed. Gaping of vaginal vault was sutured with vicryl. Peritoneal cavity was washed with saline and metrogyl. Haemostasis secured. Patient withstood procedure well. Abdomen closed in layers. One bottle of packed red cell transfused in the immediate postoperative period. Postoperative period was uneventful.

Important points in this case

Normally ovarian neoplasm presents with mass per abdomen or pain lower abdomen and back. But in this case ovarian neoplasm presented with vaginal discharge. So far that there is no case reported with ovarian mass prolapse through vault. However, one case reported ovarian cyst prolapsed through cervical stump following sub-total hysterectomy. The mass was histologically confirmed as mucinous cystadenoma postoperatively [1]. The incidence of Mucinous cystadenomas is 15% of all ovarian tumors. These are rare before puberty and after menopause 80% are benign and 10% are malignant and 10% are borderline [2-4]. Most frequent complications are torsion, haemorrhage, rupture, pseudomixomatous peritonei. 10% are bilateral [5]. Recurrence is common [6]. Mucinous cyst adenoma sometimes grows to the size of 10 to 30cm and they may infiltrate locally to the surrounding structures. Histologically there may be pockets of foci of malignancy and always a chance to miss. Previously there was an opinion that appendecectomy to be done when laparotomy is attempted for mucinous cystadenoma. But recent concept is that it is not necessary. Hence we have not done appendecectomy in our case. In our case right ovary is involved and tumor size was about 10cm and was complex cyst with multiple septae and benign in nature histologically. The tumor was densely adherent to right ureter and there was gap noticed in the vault. The tumor also invaded the vault and presented as mass per vagina and with gelatinous mucinous discharge. With the help of urologist the dense adhesions of lower 1/3^rd right ureter were released. After releasing adhesions from ureter and vault, redundant vault, ovarian mass was excised.

A mass per vagina in a hysterectomised patient needs to be investigated with ultrasonography and whenever necessary MRI/CT and also Laparoscopy to study the relationship of the mass with the surrounding pelvic organs (bowel, ureter) before planning for surgery. Ideally ovarian tumor should be managed by multidisciplinary teams that consist of Gynaecologist / Surgical oncologist / Urologist / Radiologist and Pathologist.

We sincerely thanks Dr K Prabha Devi, MD, DGO, Professor & HOD, Department of Obstetrics & Gynaecology, NRI Medical College, for her suggestions to prepare this case report.

Human and animals rights statement

This article does not contain any studies with human or animal subjects.

1. Kirwan R, Farquharson GI, Cdicken M. Prolapsed ovarian cyst through cervical stump: A rare complication of a subtotal Hysterectomy. J Obstet Gynaeco. 1998; 18: 494-495.
2. Vizza E, Galati GM, Corrado G, Atlante M, Infante C, Sbiroli C. Voluminous mucinous cystadenoma of the ovary in a 13-year-old girl. J Ped Adoles Gynecol. 2005; 18: 419-422.
3. Mittal S, Gupta N, Sharma A, Dadhwal V. Laparoscopic management of a large recurrent benign mucinous cystadenoma of the ovary. Arch Gynecol Obstet. 2008; 277: 379-380.
4. Crum CP, Lester SC, Cotran RS, Kumar V, Abbas A, Fausto N, et al. Pathology of female genital system and breast. Robbins' Basic pathology. Elsevier Company USA. 2007; 19: 8.
5. Ioffe OB, Simsir A, Silverberg SG. Pathology. Practical Gynaecologic Oncology. Edited by: Berek JS, Hacker NF. Lippincott Williams and Wilkins Company. 2000; 213-214.
6. Ozgun MT, Turkyilmaz C. A giant ovarian mucinous cystadenoma in an adolescent: a case report. Arch Med Sci. 2009; 5: 281-283.