**4.3 Lab examination**

Our study of 36 patients with Perineal Endometriosis (PEM) between 1983 and 2007 in PUMCH revealed serum CA125 was elevated in 2 (6.7%) of 30 patients (CA125 levels were measured in 30 patients of these 36 patients) (Zhu et al., 2009). In 31 cases of perineal endometriosis with anal sphincter involvement, level of serum CA125 was elevated (>35U/ml) in 2 (6.5%) cases because of simple PEM with anal sphincter involvement. An analysis Of 101 patients with abdominal wall endometriosis (AWE) between 1992 and 2005 in PUMCH showed level of serum CA125 was abnormal (>35U/ml) in 20.5% of them (Cheng et al., 2007). These studies indicate the preoperative level of serum CA125 is insensitive for the diagnosis of AWE, PEM or PEM with anal sphincter involvement.

Ultrasound is an easy and non-invasive examination that could be prescribed in general practice. Perineal ultrasonography shows irregular hypoechoic mass in the perineal region with rounded or oval anechoic areas in it. With some patients of PEM, the examination shows a heterogeneous mass containing cystic anechoic and hyperechoic areas. Perineal ultrasonography can help in the diagnosis of the lesion, but it fails in

A thorough physical examination, which included a bimanual gynecologic examination, a trimanual gynecologic examination and a digital rectal examination (DRE), was performed on each case. The exam revealed a hard perineal nodule corresponded to the episiotomy scar or perineal laceration scar. In a patient with PEM and anal sphincter involvement, the nodule was also associated with part of the anal sphincter. In nearly half of all patients with PEM at PUMCH, the endometrioma eroded into the anal sphincter. Thus, it is imperative that further examination (including DRE and endoanal ultrasonography) should be used to confirm whether the anal sphincter is involved in a patient with PEM. Physical examination (including DRE) could provide extremely important additional clues. The mass is generally hard, frequently adjacent to an existing episiotomy scar or previous site of tearing or injury. For some patients, the skin color over the perineal lesions may be brownish on examination.

Fig. 1. Preoperative status with firm nodule in the episiotomy scar (Odobasic et al., 2010)

Our study of 36 patients with Perineal Endometriosis (PEM) between 1983 and 2007 in PUMCH revealed serum CA125 was elevated in 2 (6.7%) of 30 patients (CA125 levels were measured in 30 patients of these 36 patients) (Zhu et al., 2009). In 31 cases of perineal endometriosis with anal sphincter involvement, level of serum CA125 was elevated (>35U/ml) in 2 (6.5%) cases because of simple PEM with anal sphincter involvement. An analysis Of 101 patients with abdominal wall endometriosis (AWE) between 1992 and 2005 in PUMCH showed level of serum CA125 was abnormal (>35U/ml) in 20.5% of them (Cheng et al., 2007). These studies indicate the preoperative level of serum CA125 is insensitive for

Ultrasound is an easy and non-invasive examination that could be prescribed in general practice. Perineal ultrasonography shows irregular hypoechoic mass in the perineal region with rounded or oval anechoic areas in it. With some patients of PEM, the examination shows a heterogeneous mass containing cystic anechoic and hyperechoic areas. Perineal ultrasonography can help in the diagnosis of the lesion, but it fails in

the diagnosis of AWE, PEM or PEM with anal sphincter involvement.

Some may have cyclic ulceration or bleeding from the perineal mass.

**4.2 Physical examination** 

**4.3 Lab examination** 

revealing the involvement of anal sphincter. Preoperative endoanal ultrasonography, on the contrary, is a reliable technique for visualizing perianal endometriosis and for diagnosing anal sphincter involvement. The ultrasonographic features of the lesion are similar to those mentioned above. Its advantage over perineal ultrasonography is that it can reveal the involvement of anal sphincter clearly. 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. 2a,b. A 30-year-old woman with a mass in the right anterior perineal region adjacent to an episiotomy scar. 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. (Amato& Levitt, 1984). Fine needle aspiration cytology of the

Diagnosis and Treatment of Perineal Endometriosis 59

The pathology result of the excised lesions (endometrial glands and stroma in hyperplastic

Management of perineal endometriosis can be classified into surgical management and

Surgical excision of endometrioma is recommended in all perineal endometriotic cases, in spite of a case of spontaneous regression of endometrioma after subsequent pregnancy reported in the literature. Wide excision of the endometrial tissues with a good healthy margin is important even if this necessitates primary sphincteroplasty when the anal sphincter is involved. It has the best chance of cure and is recommended in all cases where such an excision does not compromise function of adjacent structures and organs (Barisic et

In our analysis of 36 cases of perineal endometriosis in 2007, 10 patients with no anal sphincter involvement had complete excision of the endometrial tissue and did not receive hormonal treatment before or after surgery. None of these 10 patients had recurrence or fecal incontinence at the follow-up between 4 and 11 years. There were no postoperative complications after surgical excision. Surgical intervention with complete excision of the mass included a resection margin of 0.5–1 cm of surrounding healthy tissue (Zhu et al.,

Of the 26 patients with perineal endometriosis and anal sphincter involvement, 18 cases received complete excision and had no recurrence or fecal incontinence during follow-up between 4 and 11 year. Of these 18 patients, 7 patients had no hormonal treatment and remaining patients had hormonal treatment after surgery. Of the remaining 8 patients with anal sphincter involvement, disease recurred after incomplete excision in 7 of them and complete excision in 1 of them. After a second complete wide surgical excision of perineal endometriomas, there were no recurrence during follow-up between 6 months to 5 years

Based on this analysis, Lan Zhu et al. suggest surgical excision is the first choice of treatment for perineal endometriosis. The relevance between the recurrence rate of perineal endometriosis and anal sphincter involvement makes preoperative evaluation of anal

Anal sphincter invasion of the endometrioma provides an interesting dilemma. The goal is to excise the endometrioma completely, which may compromise the anal sphincter. 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; Mart´nez et al., 2002; Prince & Abrams, 1957; Sayfan et al., 1991; Toyonaga, 2006). In

connective tissues) confirmed the diagnosis.

**5. Management** 

al., 2006).

2009).

(Zhu et al., 2009).

sphincter important (Zhu et al., 2009).

medical management.

**5.1 Surgical management** 

lesion to demonstrate histological evidence of endometriosis is recommended for an accurate diagnosis (Griffin & Betsill, 1985).
