Case Report
Thirty-eight-year-old lady, mother of two children, came to OPD with history of cyclic pain in the perineal region which was gradually increasing in intensity and duration for 1 year. Pain was intense in last 4 months. Pain was related to her menstrual cycles. She also gave history of itching over perineal region.
She delivered her first child 10 years back with right mediolateral episiotomy followed by one more full-term normal delivery with episiotomy 7 years back.
Her menstrual history was normal, and her last menstrual period was 10 days back.
On examination, her vitals were within normal range and systemic examination did not reveal any abnormality.
Locally on inspection, previously healed episiotomy scar was seen. Perineal skin looked healthy. On palpation, a tender induration was felt along the entire episiotomy scar.
Clinically, episiotomy scar endometriosis was diagnosed, and she was prepared for surgical excision of endometriotic nodule.
Excision was done under anaesthesia. Excised tissue consisted of cystic spaces filled with chocolate-coloured fluid. Wound was repaired with proper haemostasis. Skin was closed with silk no.1.
Histopathology confirmed scar endometriosis (Figs. 1 and 2).
Fig. 1.
Endometriotic glands and stroma in the subcutaneous tissue
Fig. 2.
Section shows an epidermis lined tissue
Patient was injected with Leupride 11.25 mg post-operatively. She resumed her cycles after 4 months post-surgery. Surgical outcome was successful with painless subsequent menstruation and no recurrence till date.
Conclusion
A comprehensive history and meticulous pelvic examination are essential to the diagnosis of perineal endometriosis. Interval between surgical procedure and development of symptoms is highly variable.
Surgical intervention is the best approach for treatment, and permanent cure is usually achieved after excision of the perineal endometriosis.
Case Discussion
Scar endometriosis is a rare entity. The incidence has been estimated to be only 0.03–0.15 % of all cases of endometriosis [1]. The incidence of episiotomy scar endometriosis was estimated to be 15 of 2028 consecutive deliveries [2].
Patil et al. [3] studied 17 cases of extrapelvic endometriosis in a time span of 15 years and found a total of three cases of episiotomy scar endometriosis.
Luterek et al. reported a case of a 33-year-old woman with a medical history of recurrent perianal endometriosis. An endometriotic giant mass (8 cm in diameter) was widely excised together with the episiotomy scar. They concluded that a wide excision is mandatory as it is the only way to prevent tumour recurrence [4].
Treatment of choice is wide excision of the lesion and medical management, if required. Only medical treatment with the use of progestogen, oral contraceptive pills and danazol is not effective and gives only partial relief in symptoms. Recently, there has been report of use of gonadotropins agonist but only with prompt improvement in symptoms with no change in the lesion size. These patients need to be followed up because of the chances of recurrence, which require re-excision. In case of continual recurrence, possibility of malignancy should be kept in mind [5].
Dr. Shanti Jeyaseelan
She is the Head of Department, Obstetrics and Gynecology, in Holy Family Hospital, Delhi, since 2002. She has done her undergraduate and postgraduate from AIIMS, New Delhi. She worked for 15 years in St. Stephens Hospital followed by 9 years in LKP Salve Institute before joining Holy Family Hospital as HOD. She is a life member of FOGSI and ICMCH. She has keen interest in high-risk obstetrics and gynaecological surgeries.
Compliance with Ethical Standards
Conflict of interest
Dr. Shanti Jeyaseelan and Dr. Neha kwatra declare that they have no conflict of interest.
Footnotes
Dr. Shanti Jeyaseelan, MD Obstetrics and Gynecology, Head of Department, Holy Family Hospital; Dr. Neha Kwatra, DNB Resident, Holy Family Hospital, Room No. 101, Aradhana Bhawan, Okhla Road, Delhi, 110025, India.
References
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