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Perianal endometriosis: A rare case report

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Author Details : Vidya Kuchanur*, Vardendra Kulkarni, Seema Bijjaragi, H R Chandrasekhar, Rajashekar K S

Volume : 4, Issue : 1, Year : 2019

Article Page : 99-101

https://doi.org/10.18231/2456-9267.2019.0017

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Abstract

Abstract

Endometriosis is defined as the presence of endometrial tissue outside the endometrium and myometrium. Endometriosis is a relatively less common disease. Perianal endometriosis is a very rare entity. The lesion is usually localised in the episiotomy scars and uncommonly associated with cyclical pain. Here a case of perianal endometriosis in a 30 year old female patient having painful perianal swelling, who had a history of episiotomy is being reported. Clinically diagnosed as perianal abscess, the lesion was treated surgically by wide margin excision. Histopathological examination revealed presence of endometriotic tissue, composing of endometrial glands surrounded by endometrial stromal cells. Presence of endometrial stromal cells is confirmed by CD10 marker during IHC. Thus the histomorphological and IHC findings were consistent with the diagnosis of perianal endometriosis.

Keywords: Endometriosis, Perineum, Pain, Abscess, CD10.

Introduction

Scar endometriosis usually follows previous abdominal surgery, especially early hysterectomy and caesarean section. Minaglia et al. who analysed 30 years of incisional endometriosis after caesarean section found the incidence of scar endometriosis to be 0.08%.^[5] Ectopic pregnancies, salpingectomy puerperal sterilization, laparoscopy, amniocentesis, appendectomy, episiotomy, vaginal hysterectomies, and hernia repair are the other surgical factors for scar endometriosis.^[6],^[7],^[8]

There are various theories concerning the scar endometriosis. One of them is the direct implantation of the endometrial tissue in scars during the operation.^[9] Under proper hormonal stimulus, these cells may proliferate (cellular transport theory) or the neighbourhood tissue may undergo metaplasia, which leads to scar endometriosis (coelomic metaplasia theory). By lymphatic or vascular pathways, the endometrial tissue may reach the surgical scar and then generate to scar endometriosis. Direct mechanical
implantation seems to be the most plausible theory for explaining scar endometriosis.^[10]

Perianal endometriosis is a rare entity (0.2% of ectopic endometriosis) with only few cases reported.^[11],^[12]Perineum
is an unusual location for endometriosis, where it is
frequently confined to episiotomy scar, as a result of tissue implantation taking place during episiotomy procedure.^[12] In this case swelling was present at episiotomy scar site.

Perianal swelling with cyclical pain and bleeding during menstruation may help in diagnosis of perianal endometriosis. It is rarely considered as one of the differential diagnosis of perianal problems by the clinicians as the characteristic cyclical pain is uncommon in perianal region.^[2]

 A recurrent painful perianal swelling with no pus, observed on drainage should arouse the suspicion of endometriosis. Fine needle aspiration cytology has shown to be beneficial in diagnosis, although biopsy of unusual lesion in patient with recurrent perianal pain is considered confirmative diagnosis.^[2],^[13]Histopathological examination shows presence of endometrial glands surrounded by endometrial stromal cells along with hemosiderin laden macrophages.^[1],^[2],^[3]Immunohistochemically, CD10 is a sensitive and specific marker for endometrial stromal cells.^[3],^[4]CD10, also called common acute lymphoblastic leukaemia antigen (CALLA), is a neutral peptidase typically used in phenotyping of leukaemia and lymphoma. However CD10 is also being used in identifying normal, ectopic and neoplastic endometrial stromal cells,^[3][4]as demonstrated in our case too. Thus it is very helpful in the confirmation of diagnosis.

Wide local excision is the surgical intervention of choice.^[2]Same was done in our patient, sparing anal sphincter. The patient has shown no signs of recurrence even after lapse of 10 months following surgery at the time of writing this manuscript.

Conclusion

Endometriosis should be considered in differential diagnosis of painful perianal swellings in females particularly with a history of episiotomy. Biopsy is helpful in diagnosis. CD10 staining is of value in establishing a definitive diagnosis of endometriosis.

Conflicts of Interest: None.

References

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How to cite : Kuchanur V, Kulkarni V, Bijjaragi S, Chandrasekhar H R, Rajashekar K S, Perianal endometriosis: A rare case report. IP Arch Cytol Histopathol Res 2019;4(1):99-101

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