e ce Reccurent severe endometriosis ic lini Case presentation - - PDF document

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• nr. 3 / 2013 • vol 12

Revista Românæ de Urologie

Reccurent severe endometriosis – Case presentation

• I. Ioiart, H. Mureøanu

West University Vasile Goldiø, Urology, Arad, Romania

Correspondence: Dr. Horia Mureøanu Universitatea de Vest „Vasile Goldiø” Arad B-dul Revolutiei nr. 94 Tel.: 0744878655 E-mail: hmuresanu@gmail.com Abstract

Introduction and objective: Endometriosis is the presence of normal endometrial mucosa abnormally implanted in locations other than the uterine cavity, characterized by severe pain. In this paper we explore a case of endometrio- sis with urologic involvement. Material and methods: A 24 year old girl, already diagnosed with endometriosis 4 years prior, was admitted with dysuria, flank pain, and hematuria at the time of menses, pelvic pain and pelvic tenderness. Ultrasound examination revealed bilateral hydronephrosis and large right ovarian cyst. GnRh antagonist treatment was initiated, right hydronephrosis disappearing after 10 days. MRI detected rectal involvement and multiple pelvic adesions, and con- firmed the ultrasound findings. Left retrograde ureteroscopy and stenting were not possible. Results: Patient was operated for laparatomy adhesiolysis to restore normal intrapelvic organ mobility. Then right salpingo-oophorectomy and cytoreduction of visible endometriosis was performed, and the left ureteric pelvic

• bstruction was treated by ureterocystoneostomy.

Conclusions: Any postpubertal patient going to the operating room for acute or chronic pelvic / abdominal pain could have endometriosis, therefore consulting with a physician having the experience to recognize, diagnose, and treat this disease is prudent. Conservation of future fertility may be dependent on the conservative and meticulous surgical approach of an expert reproductive surgeon. Key words: endometriosis, salpingo-oophorectomy, adesions

Ca az zur ri i c cl lini ic ce e

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Revista Românæ de Urologie

• nr. 3 / 2013 • vol 12

Ca az zur ri i c cl lini ic ce e

Introduction Endometriosis is defined as the presence of normal endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity. (1) This condition is a common, poorly understood, and extremely debilitating benign gynecologic condi-

• tion. The psychologic impact of the severe pain experi-

enced by the patient is compounded by the negative impact of the disease on fertility. (2) The exact cause and pathogenesis of endometrio- sis is unclear. It is likely a combination of various factors that cause and determine the severity of this disease. (3) From our experience with 10 operated cases with urologic involvement we present our last case. Material and methods We present a case of a nulliparity 24 year old girl with recurrent severe endometriosis. Patient was admitted in hospital with dysuria, flank pain, and hematuria at the time of menses, pelvic pain and pelvic tenderness. A bluish nodule was identified in the vagina due to infiltration from the posterior vaginal wall. Ultrasound examination revealed bilateral hydronephrosis and large right ovarian cyst. She was diagnosed with endometriosis 4 years ago when left salpingo-oophorectomy for large ovarian cyst was performed. Histologic demonstration of both endometrial glands and stroma in biopsy specimens

• btained from outside the uterine cavity confirmed

the diagnosis of endometriosis. Dysmenorrhea, heavy or irregular bleeding contin- ued, associated with pelvic pain, lower abdominal or back pain, dyspareunia, dyschezia (pain on defecation)

• ften with cycles of diarrhea and constipation, inguinal

pain, pain on micturition and/or urinary frequency and pain during exercise. In 2011 coaxial retrograde stenting for 12 weeks was performed for treatment of catamenial intermit- tent left ureterohydronephosis (UHN) (Fig. 1).

Fig.1 Left UHN before stenting

Medical therapy with gonadotropin-releasing hor- mone (GnRH) analogues 3 cycles (3-5 months) every year was prescribed by the gynecologist, but symp- toms reappeared after the treatment was stopped. For rapid onset of medical castration antiandrogen treatment with GnRh antagonist was initiated. Right hydronephrosis disappeared after 10 days. Transvaginal ultrasonography identifyied right cyst

• f the ovary containing low-level homogenous inter-

nal echoes consistent with old blood.

• Fig. 2 Right ovary cyst Fig. 3 Left UHN

MRI was helpful and detected rectal involvement and multiple pelvic adesions. MRI confirmed the ultra- sound findings of the right cyst in the ovary (Fig. 2) and the left ureterohydronephrosis (Fig. 3) due to multiple pelvic adhesions. Left retrograde ureteroscopy and stenting were not possible. Result Patient was operated for laparatomy adhesiolysis to restore mobility and normal intrapelvic organ rela- tionships was performed followed by right salpingo-

• ophorectomy and cytoreduction of visible endome-
• triosis. Left ureteric pelvic obstruction was treated by

ureterocystoneostomy. Discussion Treating patients with endometriosis should be done by an experienced physician in the diagnosis and management of this condition and its complications, such as an obstetrician/gynecologist. If extensive dis- ease is present, specialists in reproductive endocrinol-

• gy, urology, colorectal surgery, and even gynecologic
• ncology may be required.

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Ca az zur ri i c cl lini ic ce e

Conclusion Any postpubertal patient going to the operating room for acute or chronic pelvic/abdominal pain could have endometriosis, therefore consulting with a physi- cian having the experience to recognize, diagnose, and treat this disease is prudent. Conservation of future fer- tility may be dependent on the conservative and meticulous surgical approach of an expert reproduc- tive surgeon. (4) References

1. Lobo RA.: Endometriosis: etiology, pathology, diagnosis, man-

• agement. In: Comprehensive Gynecology. Philadelphia, PA:

Mosby; 5th ed:2007:chap 19. 2. Shepard MK, Mancini MC, Campbell GD Jr, George R.: Right- sided hemothorax and recurrent abdominal pain in a 34-year-

• ld woman. Chest. Apr 1993;103(4):1239-40.

3. Markham SM, Carpenter SE, Rock JA.: Extrapelvic

• endometriosis. Obstet Gynecol Clin North Am. Mar

1989;16(1):193-219. 4. Jubanyik KJ, Comite F.: Extrapelvic endometriosis. Obstet Gynecol Clin North Am. Jun 1997;24(2):411-40.