Suburethral Endometriosis as a Clinical Finding of Extensive Disease - a Case Report and Review of Literature

Abstract

Study Objective Endometriosis spreading to the vagina is rare, present in only 0.02% of women with symptomatic endometriosis. Suburethral lesion site is exceptional. Our objective is to present a case of primary vaginal suburethral endometriosis and a literature review of the only 4 previously published suburethral endometriosis cases. Design Case report and literature review using key words: urethral endometriosis, suburethral endometriosis and urethral diverticulum. Setting Video laparoscopy, hysteroscopy and cystourethroscopy were performed. Patients or Participants A 31-year-old patient who presented with chronic pelvic pain that worsened with menstruation, dyspareunia and dysuria. Physical exam revealed a 2 cm suburethral bluish cystic-appearing lesion. Her exam was also significant for enlarged, tender uterus and adnexa. Based on examination and imaging, adenomyosis and endometriosis were suspected. Interventions Surgical excision of a 2 cm suburethral lesion revealing a chocolate like material with a fibrocystic wall adherent to the paraurethral tissue with no urethral muscularis invasion. Cystourethroscopy examination revealed no evidence of mucosal involvement of the urethra and no evidence of bladder endometriosis. Laparoscopic treatment of endometriosis was performed with pelvic sidewall and rectovaginal dissection with vaporization, excision of endometriotic lesions and restoration of the anatomy. There was one enlarged presacral lymph node that was excised and was positive for endometriosis on frozen section. A wedge cytoreductive resection of fundal adenomyotic lesion was performed without cavity penetration. The uterus was reconstructed in multiple layers with absorbable polyglactin 910 sutures. Measurements and Main Results Surgical evaluation revealed extensive endometriosis with lymph node involvement at laparoscopic exploration. Suburethral endometriotic lesion was excised confirmed to be endometriosis by histopathology. Dysuria and dyspareunia symptoms completely resolved, and her pelvic pain markedly improved after the surgery. Conclusion Primary vaginal suburethral endometriosis, although rare, could be an indication of extensive endometriosis. This case highlights the importance of careful clinical examination, surgical excision and laparoscopic evaluation when identifying suburethral vaginal endometriotic lesions. Endometriosis spreading to the vagina is rare, present in only 0.02% of women with symptomatic endometriosis. Suburethral lesion site is exceptional. Our objective is to present a case of primary vaginal suburethral endometriosis and a literature review of the only 4 previously published suburethral endometriosis cases. Case report and literature review using key words: urethral endometriosis, suburethral endometriosis and urethral diverticulum. Video laparoscopy, hysteroscopy and cystourethroscopy were performed. A 31-year-old patient who presented with chronic pelvic pain that worsened with menstruation, dyspareunia and dysuria. Physical exam revealed a 2 cm suburethral bluish cystic-appearing lesion. Her exam was also significant for enlarged, tender uterus and adnexa. Based on examination and imaging, adenomyosis and endometriosis were suspected. Surgical excision of a 2 cm suburethral lesion revealing a chocolate like material with a fibrocystic wall adherent to the paraurethral tissue with no urethral muscularis invasion. Cystourethroscopy examination revealed no evidence of mucosal involvement of the urethra and no evidence of bladder endometriosis. Laparoscopic treatment of endometriosis was performed with pelvic sidewall and rectovaginal dissection with vaporization, excision of endometriotic lesions and restoration of the anatomy. There was one enlarged presacral lymph node that was excised and was positive for endometriosis on frozen section. A wedge cytoreductive resection of fundal adenomyotic lesion was performed without cavity penetration. The uterus was reconstructed in multiple layers with absorbable polyglactin 910 sutures. Surgical evaluation revealed extensive endometriosis with lymph node involvement at laparoscopic exploration. Suburethral endometriotic lesion was excised confirmed to be endometriosis by histopathology. Dysuria and dyspareunia symptoms completely resolved, and her pelvic pain markedly improved after the surgery. Primary vaginal suburethral endometriosis, although rare, could be an indication of extensive endometriosis. This case highlights the importance of careful clinical examination, surgical excision and laparoscopic evaluation when identifying suburethral vaginal endometriotic lesions.