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 ADOI: 10.12659/AJCR.934745
Am J Case Rep 2022; 23:e934745
Table 1. Literature review including cases of perianal endometriosis.
Ref no. | Country (year) | Age | Presentation | Examination | EAS involvement | History of episiotomy | Treatment |
---|---|---|---|---|---|---|---|
7 | Canada (1976) | 37 | The patient presented with rectal pain, pruritus ani, and anorectal irritation of 5 months’ duration | An indurated, tender, subcutaneous nodule to the right and anterior to the anus | Yes | Not mentioned | The patient underwent excision of the nodule that involved the sphincter mechanism |
7 | Canada (1976) | 27 | The patient complained of painful bowel movements with some rectal bleeding | A tender perianal lump in the right anterior region at the end of the previous episiotomy scar | Not mentioned | Yes | A mass of 2.9 cm in maximum diameter that contained several cysts filled with chocolate- colored material was excised |
7 | Canada (1976) | 28 | The patient presented with a painful protrusion | A physical examination revealed small tags, slight anal stenosis, and small mixed hemorrhoids | Yes | Not mentioned | The lesion that was excised from the left anterior region was nestled right next to the sphincter mechanism |
7 | Canada (1976) | 36 | The patient presented with a perianal lump | A non-tender mass which was cystic, mobile, and in the right anterior aspect of the perianal tissues | Yes | Not mentioned | The structure, a cystic bluish-hued mass fixed to the external sphincter, was excised |
7 | Canada (1976) | 37 | The patient presented with perianal pain and a mass | A tender nodule was palpable deep within the sphincter mechanism in continuity with the distal end of the old episiotomy scar | Yes | Yes | The mass was excised and a sphincteroplasty was performed |
8 | Austria (1999) | 25 | The patient presented with fluctuating pain in the perianal region | A 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 discerned | Yes | Yes | A 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 |
9 | Greece (2001) | 31 | The patient presented with a palpable painful lesion in the left perineal area | The woman had Painful lesion (3×3×2.5 cm) in the left perineal area good anal sphincter function, confirmed by digital examination and manometry | Yes | Yes | The 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 |
10 | Japan (2002) | 39 | The patient presented with a several-day history of a painful mass in the perineum | A 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 orifices | No | No | The 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 |
11 | Belgrade (2005) | 32 | The patient was referred with a 7-year history of perianal pain and an increasingly palpable mass in an episiotomy scar | A hard 3-cm-diameter perineal nodule intimately associated with the anal sphincter in the right anterior quadrant of the anus corresponding to the episiotomy scar | Yes | Yes | The 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 |
11 | Belgrade (2005) | 43 | The patient was referred with a 16-year history of perianal pain | A firm nodule measuring approximately 4.0×2.0 cm was palpated in the episiotomy scar intimately associated with the anal sphincter | Yes | Yes | Wide 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 |
12 | Japan (2006) | 30 | The patient presented with a 1- year history of perianal pain | A hard mass measuring 2×2 cm in the right anterior perianal region adjacent to an episiotomy scar | Yes | Yes | Wide excision, including the episiotomy scar and part of the external anal sphincter, and a primary sphincteroplasty were performed under spinal anesthesia |
12 | Japan (2006) | 43 | The patient presented with a 3- year history of severe perianal pain | A digital examination revealed a bluish hard mass measuring 2×1 cm in the anterior perianal region | No | Yes | Local excision was performed under spinal anesthesia. The mass had a clear border and was extirpated without damage to the anal sphincter |
5 | UK (2009) | 35 | The patient presented on 3 occasions with a history of severe pain in the perianal area suggestive of an anal abscess | A 2 cm tender nodule in the perianal area at the 2 o’clock position | Not mentioned | Not mentioned | The area was incised and drained twice with no pus seen and an excisional biopsy performed the third time |
13 | Spain (2011) | 43 | The patient reported increased size and discomfort in the perianal area in recent weeks without associated incontinence | A 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 function | Yes | Yes | Surgical 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 |
14 | Poland (2014) | 39 | The patient came with recurrence of endometriosis located in the episiotomy scar | A 4 cm nodule in the anterior and left lateral quadrants of the anal canal | Yes | Yes | Excision of 2 nodules dissected from the fibers of the EAS |
14 | Poland (2014) | 33 | The patient presented with a painful nodule in the episiotomy scar | A 2 cm painful nodule in the episiotomy scar | Yes | Yes | Excision 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 |
14 | Poland (2014) | 42 | The patient presented with an ano vaginal fistula | An anovaginal fistula located 1.5 cm from the vaginal verge and 2 cm from the anal margin | No | Yes | Excision of the fistula with its internal anal opening; anocutaneous advancement flap; suture of the vaginal opening |
14 | Poland (2014) | 34 | The patient complained of a painful perianal mass without purulent discharge or rectal bleeding suggestive of an anal abscess | Mobile and painful 4 cm nodule in the posterior right lateral quadrant of the anal canal 1 cm from the anal margin | No | Not mentioned | Excision of a firm lesion, 3×9×5 cm located in the right perianal space adjacent to the anal sphincter |
6 | Brazil (2017) | 36 | The patient presented with anal itching, pain, and drainage suggested of an anal abscess and fistula | Ultrasound showed 1.8×1.2 cm×1.7 mm irregular hypoechoic area between the 9 and 11 o’clock positions comprising perianal fat | Yes | Yes | Dissection 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 |
15 | Spain (2017) | 45 | The patient presented with a 2-year history of severe perineal pain and tenesmus | A hard, irregular, and very painful nodule measuring 3×4 cm in the right anterior perineal region | Yes | Yes | The mass was dissected and the resection medially completed from the ischiorectal space was attached, incorporating a small portion of the EAS |
16 | Romania (2019) | 42 | The patient presented with perianal pain associated with purulent secretions and bleeding | MRI and ultrasound detected a perianal abscess of about 3 cm | Yes | Yes | Incision, evacuation of the abscesses, fistulotomy, multiple sphincter and ischiorectal biopsies, and wound dressing |
Our case | 33 | The patient presented with a 1-year history of swelling in the perianal area with intermittent pain | A 3×4 cm palpable tender perineal mass at the 11 o’clock position. No redness or discharge was seen from the mass or surrounding area | No | Yes | Incision around the cyst wall very close to an external anal muscle cyst; the lesion was excised | |
EAS – external anal sphincter. |