Episiotomy scar endometriosis

Surgical Scar Endometriosis: An Emerging Enigma

Introduction Surgical scar endometriosis is a subtype of extra-pelvic endometriosis that is characterized by the formation of endometrial tissue near the incision site in patients who have previously undergone surgery. In recent times, with the increasing trend in Caesarean sections, the incidence of surgical scar endometriosis has also emerged. This study aims to describe the clinical characteristics and management of surgical scar endometriosis. Methodology We conducted this cross-sectional, observational study over eight years (2015-2022) in a tertiary care centre in Madurai district, Tamil Nadu, India. We conducted this study after acquiring an ethical certificate from the institutional ethics committee (IEC No. VMCIEC/22/2018). In this study, we sampled all women (n = 32) with a pathological diagnosis of scar endometriosis during the study period from hospital records (universal sampling). We searched the data for both general characteristics and lesion characteristics of the patients. The general characteristics include age, body mass index (BMI), parity, mode of delivery, symptoms, and imaging by ultrasound. We have recorded the lesion characteristics of the patient, including location and size of scar endometriosis, layers involved in scar endometriosis, and surgical technique from surgical notes written in the case sheet. The minimum sample size required for this study was 31 study subjects. We entered the data into Excel (Microsoft, Redmond, WA, USA) and analyzed it in SPSS version 21 (IBM Corp., Armonk, NY, USA). We expressed the quantitative variables in terms of mean and standard deviation and the qualitative variables in terms of frequency and percentage. Results The mean age of the study participants was 34 years (range 23-55 years). In our study, 29 patients (90.6%) were multi-para, and only three (9.4%) were nullipara. Among 29 parous women, the majority (25, or 77.7%) had delivered by Caesarean section, while only four (12.5%) delivered by normal vaginal delivery. The surgical procedures preceding the scar endometriosis were predominantly obstetric procedures (87.4%), out of which 25 patients underwent a Caesarean section and only three underwent an episiotomy. The most common presenting symptom of scar endometriosis in our study was cyclical pain in the scar site (90.4%), followed by swelling (81.25%). In 62.5% of patients, the duration between the presentation of surgical scar endometriosis and surgical intervention was greater than one year. Subcutaneous tissue (90.6%) was the most commonly involved layer in surgical scar endometriosis, followed by the rectus sheath (86.2%). The surgical procedure done for scar endometriosis was wide local excision in 78% of patients, and the remaining 22% of patients had wide local excision with mesh repair. Conclusion Cesarean section is an obvious risk factor for surgical scar endometriosis. Clinicians should have a high index of suspicion for surgical scar endometriosis in women presenting with cyclic pain at the scar site. Ultrasound is accurate in diagnosing scar endometriosis. Surgical management by wide local excision with a clear margin with or without mesh repair is the treatment of choice.

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.

Perineal scar endometriosis

Endometriosis is defined as the presence of ectopic endometrial tissue outside the uterine cavity. It is a benign condition commonly observed in women of the reproductive age group. It can occur in both pelvic and extra-pelvic sites. Moreover, pelvic endometriosis is relatively common, as compared to extra-pelvic endometriosis. The most frequent site for pelvic endometriosis is ovary. It can also affect rectum, uterosacral ligaments, rectovaginal septum, urinary bladder. Extra-pelvic endometriosis is rare and when it occurs, does so more frequently in surgical scar sites, especially in caesarean section scar. Endometriosis in an episiotomy scar is extremely rare but can lead to significant morbidity in patients due to local infiltration. This condition can be diagnosed by the presence of the classical clinical triad of history of episiotomy, tender nodule at the scar site and cyclical pain. Magnetic resonance imaging (MRI) is a very useful imaging modality to diagnose and assess the deeper extension of the lesion. Herein, we report one such case of episiotomy scar endometriosis in the perineum.