Scot. med, J., 1977, 22: 307
ENDOMETRIOMA OF THE PERINEUM ASSOCIATED WITH EPISIOTOMY SCARS L. Sully Plastic Surgery Unit, Canniesburn Hospital, Glasgow and The London Hospital, Whitechapel, London
Summary. Two cases of endometrioma occurring in the perineum, associated
with episiotomy scars and involving the external anal sphincter are described. Previous similar cases in the literature are reviewed and discussed. Misdiagnosis of this uncommon lesion is the rule when it is seen outside gynaecological practice. If, however, its existence is appreciated then correct diagnosis is simple and treatment is straight forward. CASE REPORTS Case 1. A 38-year-old housewife presented with fresh bleeding per rectum and a painful lump at the anal verge. Initially there was only a vague association of her symptoms with menstruation. Episiotomy had been carried out during vaginal delivery of an only child 12 years previously. Examination revealed a prolapsed pile at 11 o'clock and sigmoidoscopy was normal. The pile was injected. On follow-up at one month the rectal bleeding had ceased but a painful lump remained antero-lateral to the anus. On this attendance it was noted that the lump swelled and became more painful at menstruation and was related to her episiotomy scar. A diagnosis of episiotomy stitch abscess was made. At operation an endometrial 'chocolate' cyst was found, 2 cm. in diameter, partly buried in the external anal sphincter. The lesion was excised and the sphincter repaired. Histology showed endometriosis in an epithelial scar. The wound healed soundly following primary skin closure. On review after 3 months there was no recurrence, pain or faecal incontinence. Case 2. A 25-year-old housewife presented with a painful lump which had been present at 11 o'clock on the anal verge for one year. A history of exacerbation of pain associated with menstruation was not elicited. She had previously been seen at 2 other hospitals and treated with antibiotics, short-wave diathermy and incision of the mass which produced discharge of blood only. Episiotomy had accompanied a forceps delivery 7 years previously, after which she had no further children or gynaecological surgery. On examination there was extreme tenderness precluding adequate assessment. She was therefore admitted for examination under anaesthetic (E.U.A.), no firm diagnosis having been made. At operation a circumscribed, bluish, cystic mass of 2 ern. diameter was excised (Fig. 1). This was partly buried in the external anal sphincter. The sphincter was repaired with wire sutures and the wound left open (Fig. 2). Histology showed cystic collections of endometrial glands with surrounding stroma and a diagnosis of endometriosis was made. The wound healed well and her symptoms were initially improved, but after 2 months she returned complaining of further pain on the opposite side of the anus, together with dyspareunia. Clinical examin-
ation and further E.U.A. were negative. It was felt that she might well have further endometrial deposits in the pelvis.
Discussion
Both these patients presented at a General Surgical Clinic with a proctological interest and in neither case was the correct diagnosis made initially. The mechanism of spread of the endometrium in these cases is probably direct implantation. There are, however, some difficulties even with this apparently simple explanation, since episiotomy is so common and yet endometrioma of episiotomy scars is quite rare. Moreover, the uterine lining at term is decidua rather than endometrium and this is thought much less likely to implant, although it has been known to do so, producing caesarian section scar endometriosis. In both the cases described the episiotomy healed by primary intention and no curettage was carried out in the interval between delivery and onset of symptoms. A much higher incidence of endometriosis involving episiotomy scars (15 cases out of 2028 consecutive deliveries) is recorded by Paull and Tedeschi (1975) in a series of women following episiotomy and routine curettage at delivery. During the same period 13,800 additional women were delivered without curettage. In this group not a single case of perineal endometriosis was observed. Ridley and Edwards (1958) found that degenerated endometrium could be successfully implanted in women following the injection of menstrual blood into the anterior abdominal wall. Presumably cells are im-
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ENDOMETRIOMA OF THE PERINEUM ASSOCIATED WITH EPISIOTOMY SCARS L. Sully Plastic Surgery Unit, Canniesburn Hospital, Glasgow and The London Hospital, Whitechapel, London
Summary. Two cases of endometrioma occurring in the perineum, associated
with episiotomy scars and involving the external anal sphincter are described. Previous similar cases in the literature are reviewed and discussed. Misdiagnosis of this uncommon lesion is the rule when it is seen outside gynaecological practice. If, however, its existence is appreciated then correct diagnosis is simple and treatment is straight forward. CASE REPORTS Case 1. A 38-year-old housewife presented with fresh bleeding per rectum and a painful lump at the anal verge. Initially there was only a vague association of her symptoms with menstruation. Episiotomy had been carried out during vaginal delivery of an only child 12 years previously. Examination revealed a prolapsed pile at 11 o'clock and sigmoidoscopy was normal. The pile was injected. On follow-up at one month the rectal bleeding had ceased but a painful lump remained antero-lateral to the anus. On this attendance it was noted that the lump swelled and became more painful at menstruation and was related to her episiotomy scar. A diagnosis of episiotomy stitch abscess was made. At operation an endometrial 'chocolate' cyst was found, 2 cm. in diameter, partly buried in the external anal sphincter. The lesion was excised and the sphincter repaired. Histology showed endometriosis in an epithelial scar. The wound healed soundly following primary skin closure. On review after 3 months there was no recurrence, pain or faecal incontinence. Case 2. A 25-year-old housewife presented with a painful lump which had been present at 11 o'clock on the anal verge for one year. A history of exacerbation of pain associated with menstruation was not elicited. She had previously been seen at 2 other hospitals and treated with antibiotics, short-wave diathermy and incision of the mass which produced discharge of blood only. Episiotomy had accompanied a forceps delivery 7 years previously, after which she had no further children or gynaecological surgery. On examination there was extreme tenderness precluding adequate assessment. She was therefore admitted for examination under anaesthetic (E.U.A.), no firm diagnosis having been made. At operation a circumscribed, bluish, cystic mass of 2 ern. diameter was excised (Fig. 1). This was partly buried in the external anal sphincter. The sphincter was repaired with wire sutures and the wound left open (Fig. 2). Histology showed cystic collections of endometrial glands with surrounding stroma and a diagnosis of endometriosis was made. The wound healed well and her symptoms were initially improved, but after 2 months she returned complaining of further pain on the opposite side of the anus, together with dyspareunia. Clinical examin-
ation and further E.U.A. were negative. It was felt that she might well have further endometrial deposits in the pelvis.
Discussion
Both these patients presented at a General Surgical Clinic with a proctological interest and in neither case was the correct diagnosis made initially. The mechanism of spread of the endometrium in these cases is probably direct implantation. There are, however, some difficulties even with this apparently simple explanation, since episiotomy is so common and yet endometrioma of episiotomy scars is quite rare. Moreover, the uterine lining at term is decidua rather than endometrium and this is thought much less likely to implant, although it has been known to do so, producing caesarian section scar endometriosis. In both the cases described the episiotomy healed by primary intention and no curettage was carried out in the interval between delivery and onset of symptoms. A much higher incidence of endometriosis involving episiotomy scars (15 cases out of 2028 consecutive deliveries) is recorded by Paull and Tedeschi (1975) in a series of women following episiotomy and routine curettage at delivery. During the same period 13,800 additional women were delivered without curettage. In this group not a single case of perineal endometriosis was observed. Ridley and Edwards (1958) found that degenerated endometrium could be successfully implanted in women following the injection of menstrual blood into the anterior abdominal wall. Presumably cells are im-
Sully
t> -~
;t~
....-...
iiiIo
