Endometrioma of the Vulva after Episiotomy - a Case Report

Background

Endometriosis is a chronic disease characterized by endometrial glands and stroma located outside the uterine cavity. It is an estrogen-dependent inflammatory disease that affects 5-10% of women of reproductive age in the United States [1,2]. The term endometriomas is used for a collection of endometriosis that can be seen macroscopically.

Case Presentation

A 24 years old female presented for evaluation of cyclical perinea pain and dyparuenia that has been present and progressively debilitating following a vaginal delivery five years prior. She had a mediolateral episiotomy at delivery, which was complicated by infection and an abscess formation. She had undergone several courses of antibiotic therapies after attempts of incision and drainage procedures and neurogenic medications such as Gabapentin after being evaluated by various specialists.

The pain corresponded with the onset of menses and examination demonstrated extensive Vulva scarring. A clinical impression of Vulva endometriomas was made and a wide local excision was done. Pathology results were consistent with an endometriomas.

Discussion

The etiology of endometriosis remains enigmatic and without consensus [3]. The most common site for an endometriomas is the ovary. Only 1 in 500 endometriomas implants are found in the vulva [4]. Endometriomas have been clinically confused with abscess, lipoma, hematoma, sebaceous cyst, suture granuloma, incisional hernia, tumors or primary and metastatic cancer.5 However, fine needle biopsy can aid the diagnosis.

Diagnostic modalities include the use of ultrasound and magnetic resonance imaging (MRI). Characteristic sonographic features of endometriomas are diffuse low-level internal echoes, multilocularity and hyper echoic foci in the wall [6] although ultrasound does demonstrate lower sensitivities than MRI.

Conclusion

Endometrioma of the vulva does clinically present with an undulating mass with cyclic pain which may vary in intensity. A high index of suspicion and correlation with prior vulva injury such as an episiotomy or significant vulva laceration is necessary.

It is important that though rare, endometriomas do and can occur in the vulva and care needs to be taken to keep this possibility at the top of the differential diagnosis.

References

1. Giudice LC, Kao LC. Endometriosis. Lancet. 2004; 364: 1789-1799.
2. Bulun SE. Endometriosis. N Engl J Med. 2009; 360: 268-279.
3. Stenchever MA, et al. Comprehensive Gynecology. 4th edition. Endometriosis and Adenomyosis. 531-564.
4. Netter's Obstetrics, Gynecology and Women's Health. Smith RP, Netter FH. Icon Learning Systems LLC. 1st edition. Endometriosis. 246-247.
5. Blanco RG, Parithivel VS, Shah AK, Gumbs MA, Schein M, Gerst PH. Abdominal wall endometriomas. Am J Surg. 2003; 185: 596-598.
6. Kinkel K, Frei KA, Balleyguier C, Chapron C. Diagnosis of endometriosis with imaging: a review. Eur Radiol. 2006; 16: 285-298.