Perineal Endometriosis: A Rarity

Dear Sir,

A previously healthy 28-year-old G1P1 woman presented with a 6-month history of a painful palpable lesion arising within the right perineum during menstruation. She delivered a year ago and remained well for 6 months before she started developing pain at the earlier site of episiotomy. She experienced cyclical pain and swelling at the site of the lesion. However, no bloody discharge was present from the scar site during menstruation. On examination, the episiotomy scar was seen on the right side of the perineum, and a hard subcutaneous nodule was felt at the previous episiotomy scar site. A clinical diagnosis of episiotomy scar endometriosis was considered. On transperineal ultrasonography, a focal hypoechoic lesion with small cystic spaces was noted in the subcutaneous plane of the right perineal region [Figure 1], measuring 3.0 cm × 2.8 cm × 3.2 cm, and a possible diagnosis of perineal endometriosis stated. The patient was taken up for surgical exploration through a transperineal incision. A cystic fluctuant swelling was seen in the deep subcutaneous tissue. The mass was excised with a rim of adjoining healthy tissue. Histopathology revealed fibroconnective tissue with many foci of endometrial glands and stromal elements [Figure 2] without nuclear atypia and the diagnosis of endometriosis confirmed. Postoperative follow-up was scheduled every 3–6 months to monitor any recurrence of the lesion, which was not reported by the patient. Endometriosis is defined as the presence of endometrial tissues outside of the uterine cavity, is one of the most common diseases in women of reproductive age. Perineal endometriosis can be diagnosed on the basis of clinical features. Perineal endometriosis is often diagnosed late.[1] Endometriosis presenting as a tender nodule in the perineum could sometimes be felt only on deep palpation and many a times can be missed on superficial examination. Typical characteristics of perineal scar endometriosis have been described, which are elucidated as (1) Past perineal tear of episiotomy during vaginal delivery, (2) A tender nodule or mass at the perineal lesion, and (3) Progressive and cyclic perineal pain. If these criteria were met, the predictive value of perineal endometriosis was 100%.[2] Sonography due to its convenience and noninvasive character can be a useful modality for discovering the depth of invasion, nature, and precise size of the perineal mass. Magnetic resonance imaging can be used for the diagnosis of deep lesions. Treatment of extrapelvic endometriosis includes surgical intervention and hormonal suppression.[3] If hormonal suppression fails, surgical excision of the perineal endometrioma should be carried out. Gonadotropin-releasing hormone (GnRH) agonists are the first-treatment choice in endometriosis. GnRH-agonists could effectively deplete the pituitary of endogenous gonadotropins and inhibit further synthesis, thus interrupting the menstrual cycle and resulting in a hypoestrogenic state, endometrial atrophy, and amenorrhea. Oral contraceptive pills and progestogens can be used either preoperatively or postoperatively.

Figure 1.

Transperineal ultrasonography image demonstrating a focal hypoechoic lesion with multiple cystic spaces in the subcutaneous plane of the right perineum

Figure 2.

Pelvic perineal biopsy demonstrating characteristic features of endometriosis, with endometrioid glands (arrows) surrounded by stroma (H and E, ×200)

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