Perineal endometriosis in episiotomy scar with anal sphincter involvement: report of two cases and review of the literature

Abstract

Perineal endometriosis with anal sphincter involvement is a rare occurrence with only nine cases reported so far. Two such cases are presented, and the literature is reviewed. In presented cases, diagnosis was suspected at clinical exam. Anal manometry was performed in both cases and endoanal ultrasound in one case. Wide surgical excision of endometriotic mass together with part of external anal sphincter was carried out in both cases. The procedure was followed by anal sphincter reconstruction in an "overlapping" fashion in the first and "apposition" technique in the second case. Histopathologic tests confirmed endometriosis. The recovery was uneventful in both cases with excellent functional results. Two years after the operation, patients are asymptomatic and fully continent. According to the literature and our own experience, wide excision of endometrioma with primary sphincteroplasty seems to be the best chance of cure with satisfactory functional results and should be recommended.

Scar endometrioma following obstetric surgical incisions: retrospective study on 33 cases and review of the literature

“…Barisic et al advocated wide excision of the nodule with primary sphincteroplasty, in order to achieve good healing with preservation of fecal continence in cases of scar endometrioma due to episiotomy involving the anal sphincter. 39 Kokuba et al found that a technique involving two semicircular defatted flaps was efficient for creating a neo-umbilicus after removing umbilical scar endometrioma. 40 The curative surgery should preferentially be performed some days before the menstrual period, thus avoiding an inflammatory reaction and making tissue removal easier.…”

Diagnosis and Treatment of Perineal Endometriosis

“…Wide excision of the endometrial tissues with a good healthy margin is important even if this necessitates primary sphincteroplasty when the anal sphincter is involved. It has the best chance of cure and is recommended in all cases where such an excision does not compromise function of adjacent structures and organs (Barisic et al, 2006).…”

“…This may necessitate primary sphincteroplasty to lesson the risk of fecal incontinence. A PubMed search showed only 13 cases of perineal endometriosis with anal sphincter involvement in eleven different case reports since 1957 (Bacher et al, 1999;Barisic et al, 2006;Beischer et al, 1966;Dougherty & Hull, 2000;Gordon et al, 1976;Hambrick et al, 1979;Kanellos et al, 2001;Martı´nez et al, 2002;Prince & Abrams, 1957;Sayfan et al, 1991;Toyonaga, 2006). In the 13 cases of PEM with anal sphincter involvement, the wide excision (WE) and primary sphincteroplasty (PSp) were performed in 6 cases, narrow excision (NE) and PSp in 5 cases, and incomplete excision (IE) in 1 case, and spontaneous regression after a subsequent delivery was registered in 1 case.…”

“…In the group where WE was performed, there were no complications, no incontinence or recurrence during variable follow-up (minimal 3 months, maximal 36 months). Based on these studies, WE and PSp is recommended as the best treatment for PEM with anal sphincter involvement (Barisic et al, 2006;Dougherty & Hull, 2000;Kanellos et al, 2001;Martı´nez et al, 2002;Sayfan et al, 1991;Toyonaga, 2006). Some authors suggest in younger patients, wide excision with PSp may be optimal to obviate the need for additional therapy.…”

Endometrial Tumors in Postoperative Scars-Pathogenesis, Diagnostics and Treatment

“…An investigation of this disease and making firm conclusions is not easy because of inconsistent and small series of patients, often casuistic (2, 5,6,8,11,12,13,16,19,22,30,36,39,42,46,48,52). Up to now only one large systemic review (29) was published and two biggest single retrospective studies (57,41) included 81 and 72 patients appropriately.…”