Episiotomy Scar Research Articles

Endometriosis of the perianal region – epidemiology, diagnosis and treatment

Endometriosis is the presence of the uterine endometrium beyond the uterus. The disease usually affects women of childbearing age. Foci of endometriosis are mostly (in 95% of cases) located in the peritoneal cavity (cervix uteri, vaginal vault, vulva, urinary bladder, inguinofemoral region) and only rarely found beyond it. Occasionally, endometriosis is found in the perineal tissues, usually in the episiotomy scar, and, exceptionally rarely, in the anorectal region. Endometriosis usually develops in the period of hormonal activity. The disease may be asymptomatic or manifest with dyspareunia, pelvic pain syndrome, fertility problems, menstrual disorders and heavy menstruation. The diagnosis of anorectal endometriosis is established through a thorough interview and additional tests, including transrectal and transvaginal ultrasound or optionally magnetic resonance imaging. The final diagnosis is determined in a histopathological examination, usually of samples collected intraoperatively. Also, an endoscopic examination should be performed (at least rectoscopy) to rule out other pathological lesions. Treatment includes pharmacotherapy and surgery. In young patients, in the period of hormonal activity, extensive resection with primary sphincter reconstruction seems to be the most optimal option. In older patients, nearing menopause, conservative treatment is a better solution as endometriosis regresses and disease symptoms subside after menopause. In these cases, conservative treatment helps avoid iatrogenic sphincter injury and faecal incontinence.

Perineal Endometriosis in an Episiotomy scar: A Case Report and Review of Literature

Introduction: Perineal endometriosis is a rare entity which can be explained by direct implantation of endometriotic cells over the fresh episiotomy wound and subsequent development of scar endometriosis. Case Report: Present patient presented with pain at episiotomy site which is associated with menstruation. Examination during menstruation revealed reddish brown spots with blood oozing from the spots. Clinical diagnosis was confirmed by FNAC. Mass excised and sent for histopathological examination. Conclusion: Although diagnosis essentially remains clinical, preoperative evaluation with FNAC and endo-anal ultrasound can be performed. Wide local excision remains treatment of choice and follow up for recurrence is recommended. Histopathological examination is obligatory to exclude rare possibility of malignant changes.

Endometriotic Foci in Bartholin's Cyst

Background: Endometriosis is a condition in which endometrial glands and stroma grow outside the endometrial cavity. Although endometriotic deposits are most often found within the pelvis, implants may rarely occur at several other sites. Endometriotic implants in the vulva and Bartholin's gland are very unusual. Case: A 35-year-old parous woman presented to the urogynecology clinic of the KK Women's and Children's Hospital, Singapore, with a lump arising through her vagina since a normal vaginal delivery 4 years prior. On examination, a 4 × 4 cm fluctuant, nontender vaginal cyst was noted in the lower one-third of the vagina on the left lateral side, close to an episiotomy scar. She was counseled to undergo excision of the cyst and she consented to do so. The cyst wall was inadvertently ruptured during the procedure, and a thick chocolate-colored fluid poured out from within the cyst. The cyst wall was excised and the dead space and vulval skin were closed. Results: The patient recovered well. The histopathologic examination was consistent with a Bartholin's cyst with endometriotic foci. Conclusions: Vulvar endometriosis should be considered as a possible, although rare cause of cystic masses of the vulva, especially those associated with variability in size and tenderness during the menstrual cycle. Surgical excision and histopathologic examination is necessary to establish a definitive diagnosis. (J GYNECOL SURG XX:1)

Epizyotomi Skarında Gelişen Ağrısız Kitle: Endometriozisin Değişik Bir Prezentasyonu

Epizyotomi Skarında Gelişen Ağrısız Kitle: Endometriozisin Değişik Bir Prezentasyonu

Epizyotomi Skarında Gelişen Ağrısız Kitle: Endometriyozun Değişik Bir Prezantasyonu

Epizyotomi Skarında Gelişen Ağrısız Kitle: Endometriyozun Değişik Bir Prezantasyonu

Endometriosis in an episiotomy scar

Endometrial bez ve stroma yapisinin uterin kavite disinda baska bir yerde bulunmasi seklinde tanimlanan endometriozis, dogurganlik yasindaki kadinlarin %5-10’unda gorulmektedir. Endometriozis vucudun hemen her yerinde bulunabilmekle birlikte en sik pelvik peritonda, overlerde, uterin ligamentlerde ve douglasta yerlesim gosterir. Bu hastaligin gelisiminde yer alan teoriler; endometrial hucre gruplarinin retrograd yayilimi, hematojen ve lenfatik yayilim ile immun sistem disfonksiyonudur. Perine ve vulvayi tutan endometriozis oldukca nadir gorulur ve genellikle epizyotomi skarinda ortaya cikar. Skar dokusunda endometriozisin iatrojenik yani cerrahi sirasinda insizyon skari icine mekanik transplantasyon sonucu meydana geldigi dusunulmektedir. Skar zemininde gelisen endometriozis olgularinda en uygun tedavi secenegi cerrahi ekzisyondur. Cerrahide dikkat edilmesi gereken rekurrensi onlemek icin geride endometriotik odak birakmamaktir. Bu yazida, bes yil once vajinal dogum yapan, son bir yildir mediolateral epizyotomi hattinda adet donemlerinde tekrarlayan agri ve sislik sikayeti olan, cerrahi ekzisyon sonrasi patolojik inceleme ile endometriozis tanisinin dogruladigimiz olguyu sunduk. Vulvar endometriozis nadir gorulse de vajinal dogum yapmis, vulvada ozellikle menstruasyon donemlerinde agrili olan ve boyutu artan vulvar kitle ile basvuran hastalarda akla gelmelidir.

Clear cell carcinoma arising in previous episiotomy scar: a case report and review of the literature

BackgroundMalignant transformation of endometriosis associated with episiotomy scar is a rare event, especially histological type of clear cell adenocarcinoma. There are only three clear cell carcinoma in episiotomy scar reported, no standard treatment established.Case presentationA 36-year-old woman presented with a two-month history of painless but puritic perineal lump which she noticed was gradually enlarging. She had undergone surgical excision of a mass in the episiotomy scar 9 year ago and resequently histological type of endometriosis. Physical examination revealed a 10 × 5 cm soft, purple scar which is closely related to the apex of the episiotomy.We underwent a local excision of the mass for a biopsy . The second surgery performed after one cycle of paclitaxel and cisplatin (TP) to permit clearance of tumor while preserving normal vaginal function.Pathological result was clear cell adenocarcinoma. Two cycles of TP adjuvant chemotherapy were administrated after surgery.ConclusionsWe report a case of primary clear cell carcinoma developing within a previous episiotomy scar in a patient with a history of endometriosis, along with a review of the literature. Accumulation of management data on these rare tumors and Long-term follow-up of such patients is therefore important.

Anterior Abdominal Wall Scar Endometriosis: An Enigma.

The presence of functioning endometrium outside the uterine cavity is called endometriosis. It is a major gynecological problem which affects 8–10 % of women of reproductive age. In 30 % of the women, the condition is associated with primary or secondary infertility [1]. Endometriosis is common in the pelvic organs like ovaries, pouch of Douglas, broad ligament, uterosacral ligament, fallopian tubes, rectosigmoid colon, bladder, and uterovesicle space, and also on other genital organs like episiotomy scars and bartholin glands [2]. Extra pelvic endometriosis is a rare entity occurring in the following possible sites—in the order of their frequency: the peritoneum, the abdominal wall, and bladder. Rare are the umbilicus, kidney, lungs, pleura, and the extremities. Scar endometriosis is a rare disease with an incidence of 0.03–0.15 %. They present with varied clinical manifestations like pain, painful palpable nodules, bleeding from scar, cramps, and bloating sensation during menses. Anterior abdominal wall endometrioma is well documented in the literature, but it may cause diagnostic dilemma due to unfamiliarity and rarity. This case report helps to highlight the fact that extra pelvic endometriosis still remains an enigma—difficult to diagnose clinical condition requiring high index of clinical suspicion—especially when it is recurrent and deep seated in fascia as occurred in our case.

Endometriosis of episiotomy scar: a case report

Endometriosis is characterized by the presence of histologically normal endometrial glands and stroma outside the uterine cavity. Endometriosis predominantly locates on peritoneal surfaces, but it also affects the vagina, vulva, and perineum, usually secondary to surgical or obstetric trauma. Endometriosis in an episiotomy scar is a fairly rare phenomenon. The authors present a case of endometriosis in an episiotomy scar.

Scar endometriosis is a gynecological complication that general surgeons have to deal with

Scar endometriosis is the presence of functional endometrium tissue in surgical incisions. It is a complication that develops after obstetrical or gynecological surgical procedures. As it presents with a mass adjacent to surgical incisions, general surgeons usually deal with it. The authors' aim was to review and discuss the differential diagnosis, treatment methods, recurrence rate, and follow up of scar endometriosis.Data of patients diagnosed with incisional scar endometriosis between 2005 and 2012 were recorded retrospectively. Their initial symptoms, previous surgery histories, onset of symptoms after surgery, duration of symptoms, diagnostic modalities, treatment methods, pathological evaluations, and rate of recurrences were documented and analyzed.Seventeen patients were diagnosed to have scar endometriosis. Former surgical histories were one hysterectomy, one vaginal birth with episiotomy, and 15 cesarean sections. Sixteen of the scar endometrioses were demonstrated on pfannenstiel incision and one on episiotomy scar. Only one recurrence was seen during follow up.Scar endometriosis should be taken into account in the surgical practice of incisional site masses of the abdominal wall. They should be excised totally for a proper treatment. Patients must be warned about malignancy risk.

Diagnosis and treatment of perineal endometriosis: review of 17 cases.

To demonstrate the appropriate diagnosis and treatment of perineal endometriosis. Seventeen patients who presented with a tender perineal mass coinciding with the menstrual cycle on the scar of a previous vaginally procedure were examined retrospectively. Their clinical features and treatment were analyzed. All patients presented with a palpable painful lesion. All of them had had vaginal delivery with episiotomy. The mean age of the patients was 34.35 years. The mean latent period was 46.82 months. The mean size was 2.38 cm. Thirteen patients presented with one subcutaneous nodule and four had multiple nodules. Color Doppler ultrasound revealed a subcutaneous nodule with an irregular outline and echo-complex density underlying the episiotomy scar. Only one patient suffered from perineal endometriosis combined with pelvic endometriosis. All endometriotic masses in perineum were completely excised and cured, and confirmed by the microscopic examination. A detailed history and thorough pelvic examination are essential in diagnosing perineal endometriosis. Surgical intervention is the first choice of treatment.

The implantation of cervical neoplasia at postpartum episiotomy scar: the clinical evidence.

Cervical cancer recurrence in episiotomy scars after vaginal deliveries is a rather rare event. We present a review of the current literature data on the field. A systematic search was performed in PubMed and Scopus. 10 case reports and 3 case series with total 18 patients were included. The mean age of the patients was 33.3 years. One of them was diagnosed 1 year before her pregnancy, two of them were diagnosed during pregnancy, six of them during labor and eight patients at postpartum follow-up appointments from 1 week to 8 months postpartum. Twelve cases were squamous cell carcinoma, five cases adenocarcinoma and one case adenosquamous carcinoma with the majority of them staged as Ib1-2. The interval time from initial diagnosis to detection of recurrence had a wide range from 5 weeks to 5.5 years. The diameter of the recurrence was also ranging (5-60 mm). The management of such a recurrence included different extent of wide local excision or chemotherapy or radiotherapy or combinations of them. Clinicians should be aware about the importance of carefully examining not only the cervix at the time of labor, but also the episiotomy scar in women following a pregnancy complicated by cervical cancer.

Trigonometric characteristics of episiotomy and risks for obstetric anal sphincter injuries in operative vaginal delivery

The objective of this study was to investigate the association between the trigonometric properties of episiotomy in operative vaginal delivery (OVD) and obstetric anal sphincter injuries (OASIS). The study included 72 primiparous women who had an OVD and episiotomy. Cases (n = 36) had sustained OASIS at birth, while controls (n = 36) had not. The groups were matched for instrumental delivery. The episiotomy scar was identified and its trigonometric characteristics were measured at 8-12 weeks postpartum. Data were analysed using conditional logistic analysis. The angle of episiotomy behaves as a factor associated with anal sphincter injury, so women with a mediolateral episiotomy and an angle greater than 20° have an 87% less risk of having an OASIS (odds ratio 0.13, 95% confidence interval 0.03-0.58). The study showed that scarred episiotomies at 8-12 weeks after OVD with an angle ≤ 20°, depth and distance between the episiotomy and anus ≤ 15 mm, total upper triangle perimeter ≤ 75 mm, para-anal triangle perimeter ≤ 15 mm and areas between scar and midline ≤ 250 mm(2) were significantly associated with higher risk of OASIS. When a mediolateral episiotomy is performed in OVD the technique has a strong effect on the occurrence of OASIS. Additional research is needed to determine if the optimal technique for mediolateral episiotomies produces less OASIS than deferring the performance of episiotomy.

Chronic non-healing sinus manifesting in episiotomy scar: hidden fistula-in-ano

A non-healing sinus manifesting in an episiotomy scar after it has healed is rare. We report one such woman. There were no underlying risk factors like third- or fourth-degree tear or inflammatory bowel disease. In spite of previous attempted exploration the problem had persisted. Examination of the case under anaesthesia revealed it to be a low fistula-in-ano. The methodical evaluation and management of the case is detailed. Fistulectomy completely cured the patient. Most of these patients present to obstetricians and gynaecologists. Awareness and a high index of suspicion of communication with the anorectal canal are important. A team approach with the colorectal surgeon would help in better preoperative counselling, planned evaluation and definitive procedure to completely cure the patient.

A Case of Endometriosis in Episiotomy Scar with Anal Sphincter Involvement and Extension into Ischiorectal Fossa

ABSTRACT Episiotomy scar endometriosis is characterized by presence of endometrial tissue (glands and stroma) and is a rare condition. It may also extend and involve the anal sphincter. The ideal treatment is wide excision to prevent recurrence but it may cause fecal incontinence, if the anal sphincter is involved. We describe here a case with much deeper extension into ischiorectal fossa. She was treated with wide local excision and primary sphincteroplasty. She has remained free of recurrence up to 12 months follow-up. How to cite this article Jain S, Ghoshal S, Kumar M, Jain M. A Case of Endometriosis in Episiotomy Scar with Anal Sphincter Involvement and Extension into Ischiorectal Fossa. J South Asian Feder Obst Gyne 2014;6(2):123-125.

Endometriosis of the perineum

Endometriosis of the perineum and vulva is extremely rare, with the most common site being episiotomy scars. We report here a case of spontaneously developing perineal endometriosis successfully treated with local excision. A 39-year-old woman was admitted complaining of a painful vulvar lump with cyclic swelling. She had first noticed the mass 7 years before, and it had gradually increased in size. Gynecological examination showed a walnut-size, painful, subcutaneous mass in the left perineum. Magnetic resonance imaging revealed a multilobular cystic mass with inner hemorrhage, suggesting vulvar endometriosis. The patient was treated by local excision of the vulvar mass, and complete excision was achieved. The pathological diagnosis of the excised tissue was endometriosis. The patient is well without evidence of disease 5 months following the local excision. Spontaneous perineal and vulvar endometriosis is extremely rare. However, any lesion that evolves in response to the menstrual cycle should be considered endometriosis.

Giant recurrent perineal endometriosis in an episiotomy scar – a case report

The occurrence of perineal endometriotic lesions can be explained by mechanical dissemination and transplantation of endometrial cells. Viable decidual endometrial cells are likely to be transplanted into the episiotomy wounds or perineal tears during normal vaginal delivery and subsequent growth may occur A case of a 33-year old woman with a medical history of recurrent perineal endometriosis was described. An endometriotic giant mass (8 centimeter in diameter) was wide-excised, together with the episiotomy scar. The recovery was uneventful. Three years after the surgery, the patient is symptom-free and with no signs of recurrence or discomfort. According to the literature and our own experience, a complete excision of endometriotic tissue is the treatment of choice. We can conclude that a wide excision is mandatory as it is the only way to prevent tumor recurrence.

Perineal Endometriosis in an Episiotomy Scar: Case Report and Review of Literature

Purpose Perineal endometriosis is a rare disease characterized by the presence of ectopic endometrial stroma and glands in the perineum. Most commonly observed in the episiotomy scar after normal vaginal deliveries, perineal endometriosis is not often considered in the differential diagnosis of perineal masses. This could lead to unnecessary investigations and inadequate patient treatments. Case Report A 41-year-old woman complains of a tender perineal mass, which becomes hard and more painful during menses. Her symptoms started five years prior in the same area where a midline episiotomy was performed during a normal vaginal delivery. Complete surgical excision of the perineal mass was performed and the pathology report confirmed perineal endometriosis. No recurrence was noted on the postoperative course. Conclusion A comprehensive history and meticulous pelvic examination are essential in diagnosing perineal endometriosis. Surgical intervention is the best approach for treatment and permanent cure is usually achieved after complete excision of the perineal endometriosis.

Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case‐control study

ObjectivesTo investigate the association between the geometrical properties of episiotomy and obstetric anal sphincter injuries (OASIS) because episiotomies angled at 40–60° are associated with fewer OASIS than episiotomies with more acute angles.DesignCase–control study.SettingUniversity Hospital of North Norway, Tromsø and Nordland Hospital, Bodø, Norway.SampleSeventy-four women who had one vaginal birth and episiotomy. Cases (n = 37) have sustained OASIS at birth, while controls (n = 37) had not. The groups were matched for instrumental delivery.MethodsTwo groups of women with history of only one vaginal birth were compared. Episiotomy scar was identified and photographed and relevant measures were taken. Data were analysed using conditional logistic analysis.Main outcome measuresMean episiotomy angle, length, depth, incision point.ResultsThe risk of sustaining OASIS decreased by 70% (odds ratio [OR] 0.30; 95% CI 0.14–0.66) for each 5.5-mm increase in episiotomy depth, decreased by 56% (OR 0.44; 95% CI 0.23–0.86) for each 4.5-mm increase in the distance from the midline to the incision point of the episiotomy, and decreased by 75% (OR 0.25; 95% CI 0.10–0.61) for each 5.5-mm increase in episiotomy length. Lastly, there was no difference in mean angle between groups but there was a “U-shaped” association between angle and OASIS (OR 2.09; 95% CI 1.02–4.28) with an increased risk (OR 9.00; 95% CI 1.1–71.0) of OASIS when the angle was either smaller than 15°or >60°.ConclusionThe present study showed that scarred episiotomies with depth > 16 mm, length > 17 mm, incision point > 9 mm lateral of midpoint and angle range 30–60° are significantly associated with less risk of OASIS. Shrinkage of tissue must be considered.

Extrapelvic Endometriosis: A Study of 17 Cases

ABSTRACT Endometriosis is defined as the presence of tissue, histologically similar to endometrium outside the uterine cavity. Endometriosis at unusual sites is a diagnostic and therapeutic challenge for the clinician. Materials and methods This is a study of 17 cases presented in last 15 years at our institute with extrapelvic location and unusual symptomatology. Observation and discussion Extrapelvic endometriosis can affect unusual sites, like abdominal scars, episiotomy scars, umbilicus, bladder, GI tract and on rare occasions may be found at undersurface of diaphragm. The clinical presentation in each case is different and often misleading. Diagnosis can be reached by high degree of clinical suspicion. Histopathology of tissue is most reliable for diagnosis. CT and MRI offer higher diagnostic accuracy compared to ultrasonography. Complete excision of the tissue is ideal treatment however medical methods, like progesterone/danazol, can be tried with varied success in difficult cases. Conclusion High degree of clinical suspicion along with energetic treatment of extrapelvic endometriosis is the goal of this uncommon but challenging pathology. How to cite this article Patel BS, Tripathi JB, Patel FB, Rawal SA, Patel S, Gupta M. Extrapelvic Endometriosis: A Study of 17 Cases. J South Asian Feder Obst Gynae 2012; 4(1):32-34.