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04 January 2022: Articles

Isolated Perianal Endometrioma: A Case Report and Literature Review

Unusual clinical course, Challenging differential diagnosis

Riyadh Hakami A , Shahad AlMansour B , Hassan Mohammad Aloraini E* , Norah I. Alturki E , Mohammed Alswayyed C , Reem A. Alharbi A , Khayal Alkhayal A

DOI: 10.12659/AJCR.934745

Am J Case Rep 2022; 23:e934745

Table 1. Literature review including cases of perianal endometriosis.

Ref no.Country (year)AgePresentationExaminationEAS involvementHistory of episiotomyTreatment
7Canada (1976)37The patient presented with rectal pain, pruritus ani, and anorectal irritation of 5 months’ durationAn indurated, tender, subcutaneous nodule to the right and anterior to the anusYesNot mentionedThe patient underwent excision of the nodule that involved the sphincter mechanism
7Canada (1976)27The patient complained of painful bowel movements with some rectal bleedingA tender perianal lump in the right anterior region at the end of the previous episiotomy scarNot mentionedYesA mass of 2.9 cm in maximum diameter that contained several cysts filled with chocolate- colored material was excised
7Canada (1976)28The patient presented with a painful protrusionA physical examination revealed small tags, slight anal stenosis, and small mixed hemorrhoidsYesNot mentionedThe lesion that was excised from the left anterior region was nestled right next to the sphincter mechanism
7Canada (1976)36The patient presented with a perianal lumpA non-tender mass which was cystic, mobile, and in the right anterior aspect of the perianal tissuesYesNot mentionedThe structure, a cystic bluish-hued mass fixed to the external sphincter, was excised
7Canada (1976)37The patient presented with perianal pain and a massA tender nodule was palpable deep within the sphincter mechanism in continuity with the distal end of the old episiotomy scarYesYesThe mass was excised and a sphincteroplasty was performed
8Austria (1999)25The patient presented with fluctuating pain in the perianal regionA narrow episiotomy scar was noted; no inflammatory signs, nodules, or fistula orifices were found. In the right anterior position, the pain was enhanced, but no mass was discernedYesYesA firmly rounded bluish nodule was excised. The transected specimen was a fibrotic cyst filled with a chocolate-colored fluid. The external sphincter was loosely reconstructed
9Greece (2001)31The patient presented with a palpable painful lesion in the left perineal areaThe woman had Painful lesion (3×3×2.5 cm) in the left perineal area good anal sphincter function, confirmed by digital examination and manometryYesYesThe endometriotic mass was completely excised under general anesthesia with portions of the episiotomy scar and external anal sphincter. The procedure was followed by overlapping sphincter reconstruction
10Japan (2002)39The patient presented with a several-day history of a painful mass in the perineumA perianal examination revealed redness and swelling in the right anterior direction. On palpation, a soft tumor was felt but there was no evidence of episiotomy scar or of fistula orificesNoNoThe mass was enucleated under local anesthesia without injury to the anal sphincter. The operation was performed uneventfully through a fusiform incision. The tumor mass had a generally clear border and was extirpated without damage to the sphincter
11Belgrade (2005)32The patient was referred with a 7-year history of perianal pain and an increasingly palpable mass in an episiotomy scarA hard 3-cm-diameter perineal nodule intimately associated with the anal sphincter in the right anterior quadrant of the anus corresponding to the episiotomy scarYesYesThe mass was dissected away from the ischiorectal fat laterally, and a wide excision was carried out, along with the excision of the involved part of the anal sphincter. Primary anal sphincter repair was performed using the apposition technique
11Belgrade (2005)43The patient was referred with a 16-year history of perianal painA firm nodule measuring approximately 4.0×2.0 cm was palpated in the episiotomy scar intimately associated with the anal sphincterYesYesWide excision of the mass together with the scar tissue and partial excision of the external anal sphincter was performed, followed by primary anal sphincter repair in an overlapping fashion. The skin wound was left open to heal
12Japan (2006)30The patient presented with a 1- year history of perianal painA hard mass measuring 2×2 cm in the right anterior perianal region adjacent to an episiotomy scarYesYesWide excision, including the episiotomy scar and part of the external anal sphincter, and a primary sphincteroplasty were performed under spinal anesthesia
12Japan (2006)43The patient presented with a 3- year history of severe perianal painA digital examination revealed a bluish hard mass measuring 2×1 cm in the anterior perianal regionNoYesLocal excision was performed under spinal anesthesia. The mass had a clear border and was extirpated without damage to the anal sphincter
5UK (2009)35The patient presented on 3 occasions with a history of severe pain in the perianal area suggestive of an anal abscessA 2 cm tender nodule in the perianal area at the 2 o’clock positionNot mentionedNot mentionedThe area was incised and drained twice with no pus seen and an excisional biopsy performed the third time
13Spain (2011)43The patient reported increased size and discomfort in the perianal area in recent weeks without associated incontinenceA 3-cm-diameter tumor in the right anal margin and in intimate contact with the external anal sphincter with a hard consistency and absence of pain on palpation; preserved sphincter functionYesYesSurgical intervention was performed involving complete excision of the perianal lesion, which was intimately adhered to some muscle fibers of the external anal sphincter that were also removed
14Poland (2014)39The patient came with recurrence of endometriosis located in the episiotomy scarA 4 cm nodule in the anterior and left lateral quadrants of the anal canalYesYesExcision of 2 nodules dissected from the fibers of the EAS
14Poland (2014)33The patient presented with a painful nodule in the episiotomy scarA 2 cm painful nodule in the episiotomy scarYesYesExcision of a nodule in the deeper part of the rectovaginal septum with a small portion of the anterior EAS. Repair of the EAS using the “end-to end” technique
14Poland (2014)42The patient presented with an ano vaginal fistulaAn anovaginal fistula located 1.5 cm from the vaginal verge and 2 cm from the anal marginNoYesExcision of the fistula with its internal anal opening; anocutaneous advancement flap; suture of the vaginal opening
14Poland (2014)34The patient complained of a painful perianal mass without purulent discharge or rectal bleeding suggestive of an anal abscessMobile and painful 4 cm nodule in the posterior right lateral quadrant of the anal canal 1 cm from the anal marginNoNot mentionedExcision of a firm lesion, 3×9×5 cm located in the right perianal space adjacent to the anal sphincter
6Brazil (2017)36The patient presented with anal itching, pain, and drainage suggested of an anal abscess and fistulaUltrasound showed 1.8×1.2 cm×1.7 mm irregular hypoechoic area between the 9 and 11 o’clock positions comprising perianal fatYesYesDissection of an irregular and large deep nodular lesion invading the deep middle third beam of the external anal sphincter muscle, the superficial middle third beam, and the subcutaneous middle third beam. The internal anal sphincter was repaired
15Spain (2017)45The patient presented with a 2-year history of severe perineal pain and tenesmusA hard, irregular, and very painful nodule measuring 3×4 cm in the right anterior perineal regionYesYesThe mass was dissected and the resection medially completed from the ischiorectal space was attached, incorporating a small portion of the EAS
16Romania (2019)42The patient presented with perianal pain associated with purulent secretions and bleedingMRI and ultrasound detected a perianal abscess of about 3 cmYesYesIncision, evacuation of the abscesses, fistulotomy, multiple sphincter and ischiorectal biopsies, and wound dressing
Our case33The patient presented with a 1-year history of swelling in the perianal area with intermittent painA 3×4 cm palpable tender perineal mass at the 11 o’clock position. No redness or discharge was seen from the mass or surrounding areaNoYesIncision around the cyst wall very close to an external anal muscle cyst; the lesion was excised
EAS – external anal sphincter.

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923