Characteristics and long-term outcomes of perineal endometriosis: A retrospective study

Misdiagnosed as a perianal abscess: case report of perianal endometriosis

Perianal endometriosis represents a rare form of endometriosis occurring outside the pelvic cavity. Owing to its infrequency in clinical practice, this condition is highly susceptible to misdiagnosis and inappropriate treatment. This case report details a young female patient who was erroneously diagnosed with a perianal abscess. We conducted a para-anal mass resection under spinal anesthesia, and subsequent histopathological examination definitively confirmed the diagnosis of perianal endometriosis.

Primary vulvar endometriosis in postmenopausal woman: a case report and review of the literature

Endometriosis is a benign, estrogen-dependent condition that commonly affects women during the reproductive age. Postmenopausal endometriosis is a rare condition because of the absence of estrogenic hormone production. Furthermore, extrapelvic endometriosis is a rare and complex phenomenon. For this reason, it is usually a misdiagnosed disease. An 84-year-old female patient with no medical history of endometriosis or dysmenorrhea and no hormone replacement therapy was found to have a 4.4×3 cm tender, mobile mass on the left labium majus detached from the underlying perineal muscle. The patient underwent surgical excision under sedation and local anesthesia. The mass was easily removed intact and was not adherent to the vagina or the perineal muscles. Surgical resection of the lesion should be performed in order to remove the lesion and to confirm the diagnosis histologically. The diagnosis of long-standing endometriotic cyst was made. Primary vulvo-perineal endometriosis is a rare and difficult diagnosis especially in postmenopausal women without previous surgical procedures and no history of endometriosis. A better awareness of symptoms and signs of uncommon locations of extrapelvic endometriosis should be encouraged in order to optimize patient care. Finally, more research is needed to elucidate the pathogenesis of endometriosis in postmenopausal women.

Clinical presentation of perineal endometriosis and prognostic nomogram after surgical resection

Background

This retrospective study evaluated the clinical features of perineal endometriosis (PEM) and established a prognostic nomogram for recurrence probability in patients treated with surgical resection.

Methods

This study enrolled 130 PEM patients who had received surgical treatment in Peking Union Medical College Hospital (PUMCH) between January 1992 and September 2020. We collected their clinical features and conducted outpatient or telephone follow-up. The predictive nomogram was constructed based on 104 patients who had completed follow-up by July 2021. The Cox proportional hazards regression model was used to evaluate the prognostic effects of multiple clinical parameters on recurrence. The Index of concordance (C-index) and calibration curves were used to access the discrimination ability and predictive accuracy of the nomogram respectively, and the results were further validated via bootstrap resampling. Calculating the area under the curve (AUC) via risk scores of patients aimed to further access the predictive power of the model. In addition, the survival curve was depicted using Kaplan–Meier plot and compared by log-rank method.

Results

Most PEM patients had been symptomatic for 24–48 months before the lesion resection. With a median 99.00 (interquartile range: 47.25–137.50) months of postoperative observation, there were 16 (15.1%) out of 104 cases who finished follow-up reported symptomatic recurrence. On multivariate analysis of derivation cohort, multiple lesions, microscopically positive margin (mPM) and anal sphincter involvement (ASI) were selected into the nomogram. The C-index of the nomogram for predicting recurrence was 0.84 (95% CI 0.77–0.91). The calibration curve for probability of recurrence for 36, 60 and 120 months showed great agreement between prediction by nomogram and actual observation. Furthermore, the AUCs of risk score for 36, 60 and 120 months were 0.89, 0.87 and 0.82 respectively.

Conclusions

PEM is a rare kind of endometriosis and surgery is the primary treatment. Multiple lesions and ASI are independent risk factors for postoperative recurrence, and wide resection with more peripheral tissue could be preferred. The proposed nomogram resulted in effective prognostic prediction for PEM patients receiving surgical excision. In addition, this predictive nomogram needs external data sets to further validate its prognostic accuracy in the future.

Diagnosis and Treatment of Vulvo-Perineal Endometriosis: A Systematic Review

Objective: To describe the available knowledge on vulvo-perineal endometriosis including its diagnosis, clinical management and recurrence rate.

Methods: We followed the PRISMA guidelines for Systematic Reviews and our study was prospectively registered with PROSPERO (CRD42020202441). The terms “Endometriosis” and “Perineum” or “Vulva” were used as keywords. Cochrane Library, Medline/Pubmed, Embase and Clinicaltrials.gov were searched. Papers in English, Spanish, Portuguese, French or Italian from inception to July 30, 2020 were considered. Reference lists of included articles and other literature source such as Google Scholar were also manually scrutinized in order to identify other relevant studies. Two independent reviewers screened potentially eligible studies according to inclusion criteria.

Results: Out of 539 reports, 90 studies were eligible including a total of 283 patients. Their mean age was 32.7 ± 7.6 years. Two hundred sixty-three (95.3%) presenting with vulvo-perineal endometriosis have undergone either episiotomy, perineal trauma or vaginal injury or surgery. Only 13 patients (4.7%) developed vulvo-vaginal endometriosis spontaneously i.e., without any apparent condition favoring it. The reasons that motivated the patients to take medical advice were vulvo-perineal cyclical pain increasing during menstruations (98.2% of the patients, n = 278). Out of the 281 patients for whom a clinical examination was described, 274 patients (97.5%) showed a vulvo-perineal nodule, mass or swelling while six presented with bluish cutaneous lesions (2.1%) and 1 with bilateral polyps of the labia minora (0.4%). All but one patients underwent surgical excision of their lesions but only 88 patients (28.1%) received additional hormonal therapy. The recurrence rate was 10.2% (29 patients) considering a median follow-up period of 10 months (based on 61 studies).

Conclusion: In conclusion, vulvo-perineal endometriosis is a rare entity with approximately 300 cases reported in the literature since 1923. With the available knowledge shown in this systematic review, we encourage all practitioners to think about perineal endometriosis in case of perineal cyclical pain with or without previous perineal damage. Diagnosis should be done with clinical exam, perineal ultrasound and pelvic MRI when available. In case of anal sphincter involvement, perianal ultrasound should be performed. Surgical excision of the lesion should be realized in order to remove the lesion and to confirm the diagnosis histologically. Hormonal treatment could be proposed to attempt to decrease the size of a large lesion before surgery or to avoid recurrence of the lesion. As evidence-based approach to the diagnosis, treatment and recurrence rate of affected patients remains a challenge given its low prevalence, the variations in management found in the articles included and the limited quality of available studies, we suggest that a prospective database on vulvo-perineal endometriosis should be generated to increase knowledge but also awareness among healthcare professionals and optimize patients' care.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier: CRD42020202441.

Perineal endometriosis: a rare case of a unique sizeable nodule

Endometriosis is the presence of endometrial tissue in abnormal locations outside the uterine cavity. These locations are usually the ovaries, the peritoneum, and the uterine ligaments. Less frequently, the endometrial tissue can affect the perineum especially after surgical procedures or obstetric lesions. In this case report, we describe the case of a patient suffering from pain and swelling, with a sizeable nodule in an old episiotomy scar. Clinical examination, ultrasonography (USG) and magnetic resonance imaging (MRI) helped evoke the diagnosis of perineal endometriosis, and there were no signs of other endometriosis locations. Hormonal treatment was provided at first, but there was no clinical improvement after three months, so the treatment had to be surgical. Histopathological examination of the endometriotic mass confirmed the diagnosis. There were no immediate postoperative complications, and no clinical symptoms or recurrence signs six months and one year after.