Deep Dyspareunia: Is It an Unusual Manifestation of Lithopedion?

Faced with an intense deep dyspareunia at the origin of the sexual disorders in a couple in Brazzaville (Congo), the pelvic ultrasound revealed a mass housed in the Douglas’pouch. And at the laparotomy, it was a Lithopedion (abdominal pregnancy having evolved to a fetal death with calcification). After the surgery, when intercourse was resumed, dyspareunia was gone. Was it an unusual manifestation of lithopedion?


Introduction
Lithopedion is an uncommon situation. It is generally well tolerated. Clinical manifestations not evocative and complications can be seen. Can Lithopedion also cause a sexual disorder?

Case Presentation
This was a 27-year-old patient who had consulted at Brazzaville Teaching Hospital for vaginal pain triggered by sexual intercourse. She was a second gesture -primiparous. Her child,3-year-old, was born full-term. In her history, there was an induced abortion 3 years before the birth of her child. The patient had taken Misoprostol while her pregnancy was about 3 to 4 months old. She reports that she had moderate intermittent bleeding for more than a week with abdominal pain. To her surprise, she reports, she had not expelled. Since the pregnancy had not changed and especially, two months later, she had resumed with the menses, regular; for her the problem was over: the pregnancy was gone.
Three years after giving birth, she began to feel pain in the vagina at each intercourse. This situation forced the husband to no longer practice full penetration. What was at the origin of the marital conflicts, which led the woman to consult.
Clinical examination at the general plan was unremarkable, as was the speculum examination. With vaginal touch, the uterus carried a fundal mass the size of a tennis ball, firm, regular, painless. Lateral vaginal fornices were free. There was a firm mass painful in the Douglas' pouch. Ultrasound (poor quality image) had a uterine myoma and an organic cyst with a calcified structure in the Douglas'pouch. The X-ray of the abdomen without preparation had not been made. The diagnosis of uterine fibroid associated with an organic cyst of the ovary was made.
During the laparotomy that was indicated, there was an interstitial fundic myoma about 8 cm in diameter and an extra uterine structure with no relation to the appendages, hard, calcified, lodged in Douglas'pouch and taken in digestive and utero adnexal adhesions. After a laborious adhesiolysis, the structure had been released and extracted: it was a J Womens Health Gyn 2019 | Vol 6: 103 lithopedion. There was no hull around it. The intervention was completed by the myomectomy. The patient had spent a week in the hospital. The postoperative course was simple. Histopathological analyses confirmed the diagnosis of lithopedion and uterine fibroma. Two months after the procedure, she had regained her full sexuality and no longer presented this pain from the vagina when her husband was fully penetrated.

Comments
The frequency of the Lithopedion in general is very low, about 1 case for 11 000 pregnancies, which makes him a very rare medical phenomenon [1][2][3][4]. We know today thanks to the few cases described in the literature, that if its discovery is generally fortuitous after a radiological examination, various circumstances and even complications can be at the origin of its discovery [1][2][3][4][5][6]. Lithopedion can simulate ovarian pathology as in our case [3,5,6]. Digestive complications are often encountered [1,4,5]. But generally, it is a mass well tolerated [1,4].
The retention period of lithopedion is variable. In our case, it would be 6 years in view of the history of the disease. Shorter periods or more than 50 years have been described in the literature [1][2][3][4][5][6].
The supplementary assessment in our case was very poor because of the low socio-economic level of the patient. In our context medical check-up is the responsibility of the patient. In terms of operation, the adhesions are almost constant, sometimes making the procedure laborious as in our case [1,2]. The siege, cul de sac of Douglas, and the multiple digestive and utero-adnexal adhesions can explain the symptomatology described by the patient.
The true lithopedion that we describe, since it was not in a shell, represents about 43% of this entity, next to the lithokeliphopedion where the calcification bears on both the membranes and the fetus (31%), and the lithokeliphos (26%) where the fetus is intact in a calcified shell [1,4].
Questions remain, however. Was the dyspareunia of our patient caused by lithopedion alone? We found that after the intervention, at the resumption of sexual intercourse, the patient no longer had these pains in the vagina. And the lithopedion was housed in the Douglas'pouch. However, we do not exclude the possibility that adhesions or the myoma or all this together is the cause of dyspareunia. Still, this dyspareunia led to the discovery of a lithopaedion

Conclusion
An evolved pregnancy history that has disappeared or an abortion without a conceptional product should make Lithopedion look for. It is also important that in case of pelvic calcifications on ultrasound, even of incidental discovery in a patient who does not complain about anything, to make a radiological examination not to miss this pathology with sometimes serious complications.