DEEP PERINEAL ENDOMETRIOSIS ON EPISIOTOMYS CAR: ABOUT A RARE CAS L'ENDOMETRIOSE PERINEALE SUR A PROPOS

Imane Benchiba, Nessiba Abdelkader, Nissrine Mamouni, Sanaa Errarhay, Chahrazed Bouchikhi and Abdelaziz Banani Obstetrics and Gynecology I Hassan II University Hospital FezMorocco. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 05 December 2019 Final Accepted: 07 January 2020 Published: February 2020


(02), 142-146
143 Discussion:-Ectopic sites of endometriosis have been reported in very few cases, including the umbilicus, laparotomy scar, vagina, vulva, appendix, lung, pleural cavity and nasal mucosa [2].Endometriosis may be defined as the ectopic location of functioning endometrial glands and stroma. It is estimated that pelvic endometriosis is found in l0 to 25 per cent [3].Schickele, in1923, was apparently the first to report a case of perineal endometriosis [4] when Ramsey reported another case. Paull and TedeschiS reported 15 cases of endometriosis occurring at the site of an episiotomy scat [5,6].A review of the English literature revealed that there have been 66 cases of perineal endometriosis documented since 1923. According to Prince et al [7]. In the literature the patients' ages ranged from 19 to 45 years with an average age of 33. All the patients had at least one successful pregnancy previously, and all patients had clearly suffered some type of vaginal trauma [8,9].
Various theories have been advanced for the pathogenesis of endometriosis; namely, hematogenous or lymphatic spread, coelomicmetaplasia,and implantation [10,11].The first theory attempts to explain the occurrence of endometriosis by metastatic spread of endometrium at the time of menstruation . The coelomic metaplasiadoctrine postulates that abnormal differentiationof germinal epithelium in the pelvic peritoneumleads to endometriosis because the endometrium is developmentally related to coelornic germinal epithelium [10].None ofthese theories have been conclusively proven [11].Despite these controversies, the implantationtheory appears to best explain the pathogenesis ofperineal endometriosis. The mucosal lining of theuterine cavity provides a plausible anatomical basis for the implantation theory. The uterine endometrium consists of two zones, the superficialzonafunctionalis and the inner zonabasalis. Thezonafunctionalis undergoes decidual transformation during the menstrual cycle. The zona basalisis capable of reconstituting the uterine lining. During menses or parturition, the zonafunctionalisdegenerates and is shedded along with varyingamounts of the zonabasalis. When the cells fromthe zonabasalis are transported to a favourable environment such as a fresh wound from an episiotomy, the cells become attached and developinto endometriosis [12].Perineal endometriosis could be explained bythe direct implantation theory in which duringvaginal delivery, viable endometrial cells areimplanted into the episiotomy wound and subsequent growth occurs. Sometimes the cells disappear spontaneously, but sometimesthey growinto endometrioma with a cyclic occurrencewhichcauses.
The clinical painful symptomsendometriosis may manifest many variedpatternsbecause these foci of endometrium are under hormonal influence [13].The diagnosis of perineal endometriosis can bemade based upon the typical clinical history andlocal findings.The clinical manifestations of endometriosis are dependent upon the functionalactivity of the involved tissue.The lesion maypresent as an asymptomatic massor in the classic fashion, with a painfulmass, this specifically being so duringmenstruation. Physical examination usually reveals a tender bluishperineal massAll patients have some type ofperineal trauma, either an episiotomy or curettage.The time of onset of the symptoms is varied andhas been reported to be as long as 14 years. The variable latent periodcan be due to the fact that microscopic implantsof endometrial tissue requires a certain amount oftime before they achieve a sufficient size to produce symptoms. [7,14].
In ultrasound, She takes the nonspecific aspect of nodules usually hypoechoic and heterogeneous (according to their solid and / or liquid component), sometimes hyperechoic (hemorrhagic forms), with external limits, often blurred and irregular, having a variable shape and size [15].Compared to transvaginal ultrasound, MR imaging allowed more accurate localization of the nodule the advantage of MR imaging is the accurate evaluation of most extraperitoneal sites of involvement, contents of a pelvic mass and lesions hidden by dense adhesions [16].Imaging can guide treatment planning and might improve patient management The definite histologicdiagnosis usually requires two of the threefollowing features: stroma, glands, andhemosiderin pigment, the stroma being themost important element. Microscopicallythe edematous endometrial stroma with an inflammatory infiltrate is often characteristic. Glands with their endometrial epithelial lining can be demonstrated togetherwith hemosiderin-laden macrophages, whichmay also frequently be seen. Collections ofblood are also often presentAs wound-healing progresses [5]. Differential diagnosis includes analfistula, anal abscess, thrombosedhemorrhoid, sebaceous cyst, dermoid cyst or malignancies. Thetypical signs and symptoms usually help to makethe diagnosis and usually foundin old episiotomy scars [7].
Once the diagnosis is made, the treatment ofchoice is complete excision of the perineal endometrial tissue [17]the entire endometrial mass must be removed, orrecurrence is likely to take place [12].In doing so, one should takegreat care not to injure the anal sphinctermechanism, as these lesions are not infrequently intimately associated with themuscle. Plastic repairs and reinforcementsof the sphincter may be necessary wherethe lesion is excised, because the sphinctermuscle may be considerably thinned in thearea of the excision [18].Some clinicians have advocated hormonal manipulations using testosterone or medroxyprogesterone based on the fact that endometriomas are multiple and small ones my not be detected at the time of operation or by follow-up studies. Such exogenous hormonesmay cause necrosis of the decidua andabsorption of areas of endometriosis. Theystated those probably six months of treatment would destroy any of the imperceptible implants. However, the value of suchtherapy is not yet proven [12,14] Although themedical treatment may achieve symptomatic relief, the perineal mass often persists [12] Becausemost of these patients are relatively young andhealthy, surgical excision is essential, particularlyif one suspects malignancy. Complete surgical removal is the quickest and most effective means ofachieving permanent cure.

Conclusion:-
Although the pathogenesis of endometriosis is notfully understood, the transplantation of endometrial particles at time of vaginal trauma appearsto best explain the occurrence of this condition.Because patients often present with typical historyand similar local findings, correct diagnosis can be made. Permanent cure can be achieved with surgical excision

Conflicts of interest:
None of the authors have any conflicts of interest to declare.