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Endometriosis of the perineum
Endometriosis of the perineum A report of 5 new cases
VLADIMIR TRAMPU2, M.D.
Ljubljana, 'Yugoslavia
UNTIL 1957 only 25 cases of endometriosis of the perineum could be found in the literature after a precise review by Prince and Abrams. 3 These authors described a new case and since then there have been published two more, one by Murray1 in 1959 and one by StingP in 1960. From 1957 until August, 1961, we have found among the patients of two districts of Ljubljana and Jesenice 5 cases of endometriosis of the perineum. Four of these patients were hospitalized in the Gynecological and Obstetrical Clinic at the University of Ljubljana and one in the Gynecological and Obstetrical Department of the General Hospital in Jesenice. The clinical course in all 5 cases was instructive.
sion, on the suspicion that the process was inflammatory. Gynecologic examination at the admission to our clirJc disclosed to the right of the anus an indurated mass about 3 by 3 by 2 em., covered by bluish colored skin which showed across the middle of the tumor a scar of the mediolateral episiotomy. The internal gftnitals were normal. On March 15, 1957, the mass with the episiotomy scar was excised and the perineum was repaired. The surgical specimen consisted of a mass of fibrous tissue, partially hemorrhagic, containing many small "tarry" cysts. Microscopic examination of the surgical · specimen showed endometrial stroma with typical endometriai giands (Fig. 1 ) . The patient has remained well and menstruated regularly without discomfort during the 4 years since the operation. Case 2. A. M., aged 45 years, gravida i, para i, was admitted to the Department of Obstetrics and Gynecology, General Hospital, Jesenice, on Dec. 17, 1958. The patient had been delivered by means of low forceps and right mediolateral episiotomy in 1953. During the last 2 years she had noticed a small mass and had experienced severe pains in the right part of the perineum, beginning with each menstrual period and continuing for 14 days afterward. Because of these difficulties she had been treated conservatively but without success for one year. Gynecologic examination at the time of admission to the hospital disclosed in the right part of the perineum close by the scar of the mediolateral episiotomy a mass measuring 2 by 2 by 3 em. extending downward toward the rectum. On Dec. 19, 1958, the excision of the mass of the perineum was performed and the perineum repaired. The surgical specimen consisted of fibrous tissue containing many "tarry" cysts.
Case 1. A. B., aged 32 years, gravida i, para i, was admitted to the Gynecological and Obstetrical Clinic, Ljubljana, on March 13, 1957. She had been delivered of a full-term baby in 1951 at our clinic by means of a right mediolateral episiotomy. After this delivery each menstrual period was accompanied by pains in the right part of the perineum. These pains lasted about a week each month, beginning at the end of the period. Two years after this delivery the patient became aware of a mass of the size of a pea in the same region. The mass increased steadily in size and was swollen during each menstrual period. She was treated in several gynecologic offices, conservatively and by inciFrom the Gynecological and Obstetrical Clinic, University of Ljubljana and the Department of Obstetrics and
Gynecology, General Hospital, ]esenice, Yugoslavia. 1522
Volume 84 Number 11, Part 1
Microscopic examination of the surgical specimen showed endometriotic tissue with enlarged glands of corporeal type with hemolyzed blood and periglandular hemosiderosis (Fig. 2). The postoperative course was uneventful. After discharge from the hospital the patient has remained well without discomfort until the present, 212 years after the operation. Re-examination at this time discloses no endometriotic changes in the perineum. Case 3. M. G., aged 31 years, gravida i, para i, was admitted to the Gynecological and Obstetrical Clinic, Ljubljana, on March 30, 1959, complaining of 6 months of severe pain. The pains were felt at the time of each menstrual period in the region of the scar of a right medialateral episiotomy performed in 1954 at her first delivery. At the time of admission, the pelvic examination disclosed a mass of the size of a nut at the lower end of the scar of a right mediolateral episiotomy and a second mass the size of a bean at the upper end of the episiotomy scar in the right vaginal wall. At the portio vaginalis uteri there was an erythroplakia (ectopia). The remainder of the findings were normal. In April 8, 1959, the excision of the tumor in the perineum and in the vaginal wall was performed. The surgical specimen of the perineum and the vagina consisted of fibrous tissue with very small typical endometriotic cysts. Microscopic examination of both surgical specimens revealed fibrous tissue including foci of typical endometrioid tissue (Fig. 3) . After discharge from the hospital the patient remained well and menstruated regularly without discomfort. In 1960 she conceived again and was delivered on Nov. 24, 1960. During this second delivery she sustained a second degree tear of the perineum without other pathologic findings of the perineum and the vagina. Case 4. A. M., aged 30 years, gravida i, para i, was admitted to the Gynecological and Obstetrical Clinic, Ljubljana, on Oct. 3, 1960, because of severe pains, felt to the right of the anus, especially during defecation. The patient had been delivered on Aug. 2, 1953, with the aid of a right mediolateral episiotomy. Six years after this delivery the pains had begun, starting every month after the end of the menstrual period and lasting 10 to 15 days. She was conservatively treated by gynecologists and surgeons without success until her admission to the clinic.
Endometriosis of perineum 1523
Fig. 1. Microscopic appearance of the section of endometrioma in Case 1.
Fig.. 2. Microscopic appearance of the section of
endometrioma in Case 2. Gynecologic examination at the time of admission showed in the right part of the perineum beneath the lower end of the episiotomy scar a mass the size of a nut. This extended into the ischiorectal fossa and medially to the anus. A second mass the size of a bean was also noted in the upper right part of the vaginal wall. On the cervix there was found erythroplakia, which was by biopsy histologically identified as carcinoma in situ. The remainder of the genitals were normal. On Oct. 18, 1960, the excision of the tumors of the perineum and the vaginal wall as well a conization of the portio vaginalis uteri was performed. The surgical specimens of the perineum and the vagina consisted of fibrous tissue with few small "chocolate" cysts. Microscopic examination of the surgical specimens of the perineum and vagina showed endometrioid tissue with all elements typical of the endometrium (Fig. 4).
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1524 Trampuz
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.\ rn. j . ()!, ,1. & ( ~ "" "' .
Fig. 3. Microscopic appearance of the section of endometrioma in Case 3.
Fig. 4. Microscopic appearance of the section of endometrioma in Cast> +.
Fig. 5. Microscopic appearance of the section of endometrioma in Case 5.
After discharge from the hospital the patient remained well for 3 months, when mild pains at the time of menstruation were again felt on the right side close to the anus. A trial with treatment by testosterone propionate in 25 mg. daily doses by injection for 7 days before the menstrual period has been followed by disap-
pearance of the pains. Gynecologic examination now reveals no evidence of endometrioma at the site of the previous excision. Case 5. C. B., aged 34 years, gravida ii, para i, was admitted to the Gynecological and Obstetrical Clinic, Ljubljana, on July 11, 1961. She had been delivered by means of episiotomy
Volume 84 Number II, Part I
Endometriosis of perineum
in 1948. One month after this delivery she became aware of an indurated mass in the scar of the episiotomy, which enlarged during each menstrual period. During the last 8 years this mass had become Vf~ry painful during each menstrual period. Conservative therapy, in the belief that this was an inflammatory process, had been without success. Gynecologic examination at the time of admission disclosed in the perineum on the site of the scar of a right mediolateral episiotomy a tumor the size of a nut, covered by skin with the episiotomy scar. On the cervix there was a small leukoplakia. The examination showed no other abnormality of the genitals. On July 14, 1961, the excision of the tumor in the perineuni was performed and the peri-
neum was repaired. The surgical specimen consisted of fibrous tissue containing many typical "tarry" cysts, the size of lentil and pea. Microscopic examination of the surgical specimen showed areas of typical endometrioid tissue surrounded by fibrous tissue (Fig. 5). The postoperative course was uneventful.
1525
3. In all cases the time which elapsed between the first appearance of symptoms and the establishment of an accurate diagnosis, i.e., the period of inadequate treatment was long--on the average 4 years. 4. The excision of the endometrioma brought relief of pains promptly and definitively in all cases but one. This patient reported a recurrence of mild symptoms, which shortly disappeared, perhaps as the result of testosterone therapy.
Conclusion Endometriosis of the perineum is more frequent than recent reports suggest but is often overlooked as a cause of perineal pain. Case 2 was reported by Dr. Tatjana Zalokar at the annual meeting of the Medical Association in Jesenice. I am grateful to Dr. Zalokar for her contribution. The tissue study was done by Prof. Dr. Franc Hribar, pathologist at the Medical Faculty, University of Ljubljana, to whom I am indebted.
Summary
l. Five cases of endometriosis of the perineum with previous episiotomy in all cases are reported. 2. The period of latency between the original episiotomy and the manifestation of typical symptoms varied from 1 month to 5 years.
additional patients with a tumor in the episiot-
omy scar revealing all microscopic and macroscopic characteristics of endometriosis. An excision of the mass in the perineum in both patients was performed with good results after 6 months of observation.
3. Prince, L., and Abrams,
REFERENCES
L Murray, R.: U. S. Armed Forces M. 1463, 1959. 2. Sting!, A.: Klin. med. 15: 325, 1960.
Addendum. Since this report was written, we observed in our Clinic in October, 1961, two
J. 10:
GYNEC.
73: 890, 1957.
Univerza v Ljubljana Ljubljana, Yugoslavia
J.: AM. J.
0BST.
&
VLADIMIR TRAMPU2, M.D.
Ljubljana, 'Yugoslavia
UNTIL 1957 only 25 cases of endometriosis of the perineum could be found in the literature after a precise review by Prince and Abrams. 3 These authors described a new case and since then there have been published two more, one by Murray1 in 1959 and one by StingP in 1960. From 1957 until August, 1961, we have found among the patients of two districts of Ljubljana and Jesenice 5 cases of endometriosis of the perineum. Four of these patients were hospitalized in the Gynecological and Obstetrical Clinic at the University of Ljubljana and one in the Gynecological and Obstetrical Department of the General Hospital in Jesenice. The clinical course in all 5 cases was instructive.
sion, on the suspicion that the process was inflammatory. Gynecologic examination at the admission to our clirJc disclosed to the right of the anus an indurated mass about 3 by 3 by 2 em., covered by bluish colored skin which showed across the middle of the tumor a scar of the mediolateral episiotomy. The internal gftnitals were normal. On March 15, 1957, the mass with the episiotomy scar was excised and the perineum was repaired. The surgical specimen consisted of a mass of fibrous tissue, partially hemorrhagic, containing many small "tarry" cysts. Microscopic examination of the surgical · specimen showed endometrial stroma with typical endometriai giands (Fig. 1 ) . The patient has remained well and menstruated regularly without discomfort during the 4 years since the operation. Case 2. A. M., aged 45 years, gravida i, para i, was admitted to the Department of Obstetrics and Gynecology, General Hospital, Jesenice, on Dec. 17, 1958. The patient had been delivered by means of low forceps and right mediolateral episiotomy in 1953. During the last 2 years she had noticed a small mass and had experienced severe pains in the right part of the perineum, beginning with each menstrual period and continuing for 14 days afterward. Because of these difficulties she had been treated conservatively but without success for one year. Gynecologic examination at the time of admission to the hospital disclosed in the right part of the perineum close by the scar of the mediolateral episiotomy a mass measuring 2 by 2 by 3 em. extending downward toward the rectum. On Dec. 19, 1958, the excision of the mass of the perineum was performed and the perineum repaired. The surgical specimen consisted of fibrous tissue containing many "tarry" cysts.
Case 1. A. B., aged 32 years, gravida i, para i, was admitted to the Gynecological and Obstetrical Clinic, Ljubljana, on March 13, 1957. She had been delivered of a full-term baby in 1951 at our clinic by means of a right mediolateral episiotomy. After this delivery each menstrual period was accompanied by pains in the right part of the perineum. These pains lasted about a week each month, beginning at the end of the period. Two years after this delivery the patient became aware of a mass of the size of a pea in the same region. The mass increased steadily in size and was swollen during each menstrual period. She was treated in several gynecologic offices, conservatively and by inciFrom the Gynecological and Obstetrical Clinic, University of Ljubljana and the Department of Obstetrics and
Gynecology, General Hospital, ]esenice, Yugoslavia. 1522
Volume 84 Number 11, Part 1
Microscopic examination of the surgical specimen showed endometriotic tissue with enlarged glands of corporeal type with hemolyzed blood and periglandular hemosiderosis (Fig. 2). The postoperative course was uneventful. After discharge from the hospital the patient has remained well without discomfort until the present, 212 years after the operation. Re-examination at this time discloses no endometriotic changes in the perineum. Case 3. M. G., aged 31 years, gravida i, para i, was admitted to the Gynecological and Obstetrical Clinic, Ljubljana, on March 30, 1959, complaining of 6 months of severe pain. The pains were felt at the time of each menstrual period in the region of the scar of a right medialateral episiotomy performed in 1954 at her first delivery. At the time of admission, the pelvic examination disclosed a mass of the size of a nut at the lower end of the scar of a right mediolateral episiotomy and a second mass the size of a bean at the upper end of the episiotomy scar in the right vaginal wall. At the portio vaginalis uteri there was an erythroplakia (ectopia). The remainder of the findings were normal. In April 8, 1959, the excision of the tumor in the perineum and in the vaginal wall was performed. The surgical specimen of the perineum and the vagina consisted of fibrous tissue with very small typical endometriotic cysts. Microscopic examination of both surgical specimens revealed fibrous tissue including foci of typical endometrioid tissue (Fig. 3) . After discharge from the hospital the patient remained well and menstruated regularly without discomfort. In 1960 she conceived again and was delivered on Nov. 24, 1960. During this second delivery she sustained a second degree tear of the perineum without other pathologic findings of the perineum and the vagina. Case 4. A. M., aged 30 years, gravida i, para i, was admitted to the Gynecological and Obstetrical Clinic, Ljubljana, on Oct. 3, 1960, because of severe pains, felt to the right of the anus, especially during defecation. The patient had been delivered on Aug. 2, 1953, with the aid of a right mediolateral episiotomy. Six years after this delivery the pains had begun, starting every month after the end of the menstrual period and lasting 10 to 15 days. She was conservatively treated by gynecologists and surgeons without success until her admission to the clinic.
Endometriosis of perineum 1523
Fig. 1. Microscopic appearance of the section of endometrioma in Case 1.
Fig.. 2. Microscopic appearance of the section of
endometrioma in Case 2. Gynecologic examination at the time of admission showed in the right part of the perineum beneath the lower end of the episiotomy scar a mass the size of a nut. This extended into the ischiorectal fossa and medially to the anus. A second mass the size of a bean was also noted in the upper right part of the vaginal wall. On the cervix there was found erythroplakia, which was by biopsy histologically identified as carcinoma in situ. The remainder of the genitals were normal. On Oct. 18, 1960, the excision of the tumors of the perineum and the vaginal wall as well a conization of the portio vaginalis uteri was performed. The surgical specimens of the perineum and the vagina consisted of fibrous tissue with few small "chocolate" cysts. Microscopic examination of the surgical specimens of the perineum and vagina showed endometrioid tissue with all elements typical of the endometrium (Fig. 4).
Dc:ccmtJcf 1.
1524 Trampuz
l~ ~h :!
.\ rn. j . ()!, ,1. & ( ~ "" "' .
Fig. 3. Microscopic appearance of the section of endometrioma in Case 3.
Fig. 4. Microscopic appearance of the section of endometrioma in Cast> +.
Fig. 5. Microscopic appearance of the section of endometrioma in Case 5.
After discharge from the hospital the patient remained well for 3 months, when mild pains at the time of menstruation were again felt on the right side close to the anus. A trial with treatment by testosterone propionate in 25 mg. daily doses by injection for 7 days before the menstrual period has been followed by disap-
pearance of the pains. Gynecologic examination now reveals no evidence of endometrioma at the site of the previous excision. Case 5. C. B., aged 34 years, gravida ii, para i, was admitted to the Gynecological and Obstetrical Clinic, Ljubljana, on July 11, 1961. She had been delivered by means of episiotomy
Volume 84 Number II, Part I
Endometriosis of perineum
in 1948. One month after this delivery she became aware of an indurated mass in the scar of the episiotomy, which enlarged during each menstrual period. During the last 8 years this mass had become Vf~ry painful during each menstrual period. Conservative therapy, in the belief that this was an inflammatory process, had been without success. Gynecologic examination at the time of admission disclosed in the perineum on the site of the scar of a right mediolateral episiotomy a tumor the size of a nut, covered by skin with the episiotomy scar. On the cervix there was a small leukoplakia. The examination showed no other abnormality of the genitals. On July 14, 1961, the excision of the tumor in the perineuni was performed and the peri-
neum was repaired. The surgical specimen consisted of fibrous tissue containing many typical "tarry" cysts, the size of lentil and pea. Microscopic examination of the surgical specimen showed areas of typical endometrioid tissue surrounded by fibrous tissue (Fig. 5). The postoperative course was uneventful.
1525
3. In all cases the time which elapsed between the first appearance of symptoms and the establishment of an accurate diagnosis, i.e., the period of inadequate treatment was long--on the average 4 years. 4. The excision of the endometrioma brought relief of pains promptly and definitively in all cases but one. This patient reported a recurrence of mild symptoms, which shortly disappeared, perhaps as the result of testosterone therapy.
Conclusion Endometriosis of the perineum is more frequent than recent reports suggest but is often overlooked as a cause of perineal pain. Case 2 was reported by Dr. Tatjana Zalokar at the annual meeting of the Medical Association in Jesenice. I am grateful to Dr. Zalokar for her contribution. The tissue study was done by Prof. Dr. Franc Hribar, pathologist at the Medical Faculty, University of Ljubljana, to whom I am indebted.
Summary
l. Five cases of endometriosis of the perineum with previous episiotomy in all cases are reported. 2. The period of latency between the original episiotomy and the manifestation of typical symptoms varied from 1 month to 5 years.
additional patients with a tumor in the episiot-
omy scar revealing all microscopic and macroscopic characteristics of endometriosis. An excision of the mass in the perineum in both patients was performed with good results after 6 months of observation.
3. Prince, L., and Abrams,
REFERENCES
L Murray, R.: U. S. Armed Forces M. 1463, 1959. 2. Sting!, A.: Klin. med. 15: 325, 1960.
Addendum. Since this report was written, we observed in our Clinic in October, 1961, two
J. 10:
GYNEC.
73: 890, 1957.
Univerza v Ljubljana Ljubljana, Yugoslavia
J.: AM. J.
0BST.
&