A postmenopausal woman with sciatica from broad ligament leiomyoma: a case report

Pathology of the broad ligament is rare and the prevalence of broad ligament leiomyoma is <1 % [1]. Leiomyomas (fibroids) are benign tumors of the uterus affecting 30 % of women of reproductive age and its prevalence declines after the menopause [2]. While leiomyomas are the most common female genital neoplasm, 50 % of women affected are asymptomatic and it is rare for broad ligament leiomyomas to be clinically significant [3].

A 62-year-old Macedonian secundipara woman was referred to our gynecological department for 2-year history of unexplained left iliac fossa pain and pain in her left leg on walking. Our patient was 15 years postmenopausal with no history of hormonal replacement therapy use. There had been no symptoms referable to the bladder or bowels or abnormal per vaginam bleeding. Our patient’s family and surgical history was unremarkable. The family physician has attributed her pain to lumbar canal stenosis based on clinical examination and subsequently prescribed increasing doses of analgesia with minimal effect.

On physical examination, there was minimal abdominal tenderness. A speculum examination showed atrophy consistent with postmenopausal status. A bimanual pelvic examination revealed a non-tender, mobile mass in the left adnexal region with no other signs suggestive of malignancy.

Our patient is of interest for a number of reasons. Her age of 62 years with postmenopausal status is unusually late for patients with broad ligament or other gynecologic leiomyomas. In a postmenopausal woman, the presence of an adnexal abnormality raises the possibility of malignancy such as leiomyosarcoma [3] or ovarian cancer [4]. A broad ligament leiomyoma is not usually in the differential diagnosis of an adnexal mass.

Further, symptoms of leiomyoma are typically those of abnormal uterine bleeding, menstrual disturbances, pelvic pain, and pressure symptoms such as bloating, urinary frequency or bowel disturbances [2]. Unilateral lower abdominal pain or sciatic nerve pain, such as in our patient is said to be extremely rare [5, 6]. While our patient did have a positive history of lumbar canal stenosis, she reported alleviation of her symptoms after surgery, suggesting the leiomyoma to be causing, if not at least contributing, to her sciatica.

Surgically, laparoscopic broad ligament myomectomy is difficult to perform for leiomyomas lying low on the sacrum as these may receive sacral blood supply. Although prospective randomized trials have shown that complication rates for laparoscopic myomectomy are comparable to abdominal myomectomy [7, 8], these trials were based on premenopausal women with uterine myomectomy. More research into the risks of broad ligament myomectomy, either laparascopic or abdominal, is needed to better inform patients about the potential surgical complications of such procedures. Our patient reported alleviation of symptoms upon postoperative review in clinic.

Unilateral lower abdominal pain or sciatic nerve pain is a common presentation in the elderly population. Although broad ligament leiomyoma is a rare cause of such presentation, our case highlights the importance of staying mindful of alternate diagnoses.