Endoanal ultrasonography in the diagnosis and operative management of perianal endometriosis: report of two cases

Abstract

We report two cases of perianal endometriosis in which we were greatly assisted by endoanal ultrasonography. Patient 1 was a 43-year-old woman with perianal pain. Endosonography showed a hypoechoic mass in the anterior perianal region without involvement of the anal sphincter. Local excision was performed under spinal anesthesia without damage to the anal sphincter. Patient 2 was a 30-year-old woman with perianal pain coinciding with her menstrual period. Endosonography showed a heterogeneous mass containing cystic anechoic areas in the right anterior perianal region and involving the external anal sphincter. Wide excision, including the episiotomy scar and part of the external anal sphincter, and primary sphincteroplasty were performed under spinal anesthesia. According to our experience, preoperative endosonography is a reliable technique for visualizing perianal endometriosis and for diagnosing anal sphincter involvement. Operative management should be determined on the basis of preoperative and intraoperative ultrasonographic assessment.

Diagnosis and Treatment of Perineal Endometriosis

“…Besides, endoanal ultrasonography can also help in the differential diagnosis of perianal lesions: ultrasonography of perianal abscess shows homogeneous hypoechoic lesions; ultrasonography of perianal fistula shows hypoechoic fistula passes through the longitudinal muscle tissues; ultrasonography of anal carcinoma and melanoma show solid lesions. As 16.7% of patients with PEM are concomitant with pelvic endometriosis, pelvic examination and pelvic ultrasonography should be taken to exclude pelvic endometriosis (Bacher et al, 1999;Toyonaga, 2006;Watanabe et al, 2003). Fig.…”

“…Linear (a) and radial (b) ultrasound showed a heterogeneous mass containing cystic anechoic areas (black arrow) in the right anterior perianal region;the mass seemed to involve the external anal sphincter (white arrowhead) and not to involve the internal anal sphincter (black arrowhead). (Toyonaga, 2006) Computer tomography (CT) also can be used in the diagnosis of perineal endometriosis by some authors. The value of CT however remains to be determined as it is both expensive and uses ionizing radiation.…”

“…Preoperative endoanal ultrasonography is a reliable technique for visualizing perianal endometriosis and for diagnosing anal sphincter involvement. Preoperative endoanal ultrasonography enables the surgeon to determine the operative approach and to explain the possible complications of sphincteroplasty to the patient (Bacher et al, 1999;Toyonaga, 2006;Watanabe et al, 2003).…”

“…This may necessitate primary sphincteroplasty to lesson the risk of fecal incontinence. A PubMed search showed only 13 cases of perineal endometriosis with anal sphincter involvement in eleven different case reports since 1957 (Bacher et al, 1999;Barisic et al, 2006;Beischer et al, 1966;Dougherty & Hull, 2000;Gordon et al, 1976;Hambrick et al, 1979;Kanellos et al, 2001;Martı´nez et al, 2002;Prince & Abrams, 1957;Sayfan et al, 1991;Toyonaga, 2006). In the 13 cases of PEM with anal sphincter involvement, the wide excision (WE) and primary sphincteroplasty (PSp) were performed in 6 cases, narrow excision (NE) and PSp in 5 cases, and incomplete excision (IE) in 1 case, and spontaneous regression after a subsequent delivery was registered in 1 case.…”

“…In the group where WE was performed, there were no complications, no incontinence or recurrence during variable follow-up (minimal 3 months, maximal 36 months). Based on these studies, WE and PSp is recommended as the best treatment for PEM with anal sphincter involvement (Barisic et al, 2006;Dougherty & Hull, 2000;Kanellos et al, 2001;Martı´nez et al, 2002;Sayfan et al, 1991;Toyonaga, 2006). Some authors suggest in younger patients, wide excision with PSp may be optimal to obviate the need for additional therapy.…”