Postcoital bleeding in a case of recto-vaginal endometriosis

Abstract

Introduction: Rectovaginal Endometriosis (RVE) is a severe form of endometriosis, less frequent than peritoneal or ovarian endometriosis. Recto-vaginal endometriosis has multiple diagnostic and management options with long-term outcomes varying according to the management strategy used. Case: A 40 years old woman complained of postcoital bleeding. Detailed history revealed that she suffered from persistent dysmenorrhea, dyschasia and constipation. Vaginal speculum examination revealed a large fleshy polypoidal mass in the posterior vaginal fornix, which was excised and biopsied. Histo-pathological examination revealed vaginal endometriosis. Four months later the mass recurred, in spite of, receiving hormonal treatment. Ultrasound and MRI revealed multiple uterine fibroids, with heterogenous lesion located in the rectovaginal area, and CA-125 was 80 u/ml. exploratory laparotomy was done after proper bowel preparation. Total abdominal hysterectomy with excision of the upper vaginal portion and a part of the anterior aspect of the recto-sigmoid was resected due to the invasion of its musculosa, short of the mucosa, with primary repair. Histo-pathological examination showed advanced endometriosis including the vaginal fornix and the rectal wall. The patient received two doses of Leuprolide Acetate 11.25 mg as an adjuvant treatment. Conclusion: All women with postcoital bleeding or pelvic pain should have a detailed history taken from them and thorough examination including speculum examination and visualization of posterior vaginal fornix to detect vaginal endometriosis. The primary line of management for recto-vaginal endometriosis is surgery, as hormonal therapy is less effective in such cases, which might be explained by difference in origin from the peritoneal disease.