**5.1 Surgical management**

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 al., 2006).

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., 2009).

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 (Zhu et al., 2009).

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 sphincter important (Zhu et al., 2009).

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

Diagnosis and Treatment of Perineal Endometriosis 61

temporary relief of symptoms. No drug eradicates endometriosis or produces long-term

Beischer et al. reported that 1 patient had spontaneous regression of perineal endometriosis after a subsequent pregnancy, suggesting that the endometriosis was related to the change in hormone levels (Beischer et al., 1966). In our analysis of 36 cases with perineal endometriosis, one patient underwent hysterectomy and bilateral salpingo-oophorectomy for a recurrence of perineal endometrioma seven years after complete excision of perineal endometriosis. The patient was then followed up for 2 years; the perineal endometrioma decreased gradually and then could not be detected (Zhu et al., 2009). This also supports the

In all the masses resected from our patients who had hormone treatment before surgery, the pathologic examination of the excised specimens showed gland atrophy and interstitial hyperplasia. These cases confirmed the effectiveness of hormone treatment. However, hormone treatment provided only short-term success in alleviation of symptoms and recurrence was common after the hormone therapy was stopped, so the hormone could be used only as an adjuvant therapy. In our hospital, GnRH agonists are the first choice. We also use oral contraceptive pills, progestogens either preoperatively or postoperatively (Zhu

In our analysis of 31 cases of perineal endometriosis with anal sphincter involvement in our hospital, hormonal treatment was applied to 21 (67.7%) cases preoperatively and 14 (45.2%) cases postoperatively. For patients received hormonal therapy preoperatively, pathological examination of the resected lesions revealed responsive tissues after medical treatment. These provided evidence for the effectiveness of hormonal therapy preoperatively. As an adjuvant treatment, GnRH- agonists are the first choice in our

GnRH- agonists could effectively deplete the pituitary of endogenous gonadotropins and inhibit further synthesis, thus interrupting the menstrual cycle and resulting in a hypoestrogenic state, endometrial atrophy, and amenorrhea. In our hospital, the aim of GnRH- agonists used preoperatively for 3-4 months was to reduce the size of endometrioma, make boundaries of these lesions clearer thus to reduce intraoperative

Three typical characteristics of perineal endometriosis for women of reproductive ages include: (1) past perineal tearing of episiotomy during vaginal delivery; (2) a tender nodule or mass at the perineal lesion; and (3) progressive and cyclic perineal pain. If these 3 criteria were met, the predictive value of perineal endometriosis was 100% (Zhu et al., 2009). Based on these two studies of patients of perineal endometriosis in our hospital, Lan Zhu et al. suggests complete excision of the endometrioma is the first choice of treatment for perineal endometriosis (Zhu et al., 2009). When the perineal endometrioma invades into anal sphincter, we recommend NE and PSp with preoperative hormonal therapy as an

damage to the surrounding tissues and make the complete resection of lesions easier.

theory that endometriosis was related to the change in hormone levels.

cure.

et al., 2009).

hospital nowadays.

**6. Conclusion** 

appropriate treatment.

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 cases where NE was performed, there were no complications associated with this procedure, but, in two cases, recurrence developed requiring subsequent hormonotherapy (Prince & Abrams, 1957; Gordon et al., 1976). 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; Mart´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. In older patients closer to menopause, narrow or incomplete excision with subsequent hormonal therapy could (when endometriosis tends to regress) lessen the risk of incontinence with sphincter resection (Dougherty & Hull, 2000).

In another analysis of 31 cases of perineal endometriosis with anal sphincter involvement in our hospital, NE and PSp was carried out in 30(96.8%) patients. IE was applied in the remaining 1 (3.2%) patient because her endometrioma was too large to excise completely. Of these 31 cases, hormonotherapy was applied to 21 (67.7%) cases preoperatively. For patients who received hormonotherapy preoperatively, pathological examination of the resected lesions showed gland atrophy and interstitial hyperplasia. These provided evidence for the effectiveness of hormonotherapy. As an adjuvant treatment, hormonotherapy in PUMCH (GnRH-agonist as the first choice) should be administered preoperatively for 2-4 months when physical examinations of patients revealed lesions involved with the anal sphincter. The aim was to reduce the size of endometrioma and make boundaries of these lesions clearer, thus to make the complete excision of lesions easier and reduce damage to surrounding tissues. With no recurrence in the NE and Psp group, we suggest preoperative hormonotherapy for every PEM with anal sphincter involvement patinet. For patients (≥40 years) whose perineal lesions are too large to excise clearly, to avoid postoperative fecal incontinence and recurrence, hysterectomy and bilateral salpingo oophorectomy could be considered instead after discussing with the patient.

No recurrence or fecal incontinence was found in the NE group and 1 recurrence occurred with the IE patient during a variable follow-up period from 6 to 78 months. This may be relevant to the use of preoperative hormonotherapy in the NE group. We recommend NE and PSp with preoperative hormonotherapy as an appropriate treatment for PEM with anal sphincter involvement. Hormonotherapy immediately after surgery could be omitted, provided the lesion was resected completely.

#### **5.2 Medical management**

Medical management (including oral contraceptives, danazol, progestogens, gonadotrophin-releasing hormone agonists (GnRH- agonists and gestrinone) could produce

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 cases where NE was performed, there were no complications associated with this procedure, but, in two cases, recurrence developed requiring subsequent hormonotherapy (Prince & Abrams, 1957; Gordon et al., 1976). 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;

Some authors suggest in younger patients, wide excision with PSp may be optimal to obviate the need for additional therapy. In older patients closer to menopause, narrow or incomplete excision with subsequent hormonal therapy could (when endometriosis tends to regress) lessen the risk of incontinence with sphincter resection (Dougherty & Hull,

In another analysis of 31 cases of perineal endometriosis with anal sphincter involvement in our hospital, NE and PSp was carried out in 30(96.8%) patients. IE was applied in the remaining 1 (3.2%) patient because her endometrioma was too large to excise completely. Of these 31 cases, hormonotherapy was applied to 21 (67.7%) cases preoperatively. For patients who received hormonotherapy preoperatively, pathological examination of the resected lesions showed gland atrophy and interstitial hyperplasia. These provided evidence for the effectiveness of hormonotherapy. As an adjuvant treatment, hormonotherapy in PUMCH (GnRH-agonist as the first choice) should be administered preoperatively for 2-4 months when physical examinations of patients revealed lesions involved with the anal sphincter. The aim was to reduce the size of endometrioma and make boundaries of these lesions clearer, thus to make the complete excision of lesions easier and reduce damage to surrounding tissues. With no recurrence in the NE and Psp group, we suggest preoperative hormonotherapy for every PEM with anal sphincter involvement patinet. For patients (≥40 years) whose perineal lesions are too large to excise clearly, to avoid postoperative fecal incontinence and recurrence, hysterectomy and bilateral salpingo oophorectomy could be considered instead after discussing with the

No recurrence or fecal incontinence was found in the NE group and 1 recurrence occurred with the IE patient during a variable follow-up period from 6 to 78 months. This may be relevant to the use of preoperative hormonotherapy in the NE group. We recommend NE and PSp with preoperative hormonotherapy as an appropriate treatment for PEM with anal sphincter involvement. Hormonotherapy immediately after surgery could be omitted,

Medical management (including oral contraceptives, danazol, progestogens, gonadotrophin-releasing hormone agonists (GnRH- agonists and gestrinone) could produce

Mart´nez et al., 2002; Sayfan et al., 1991; Toyonaga, 2006).

2000).

patient.

provided the lesion was resected completely.

**5.2 Medical management** 

temporary relief of symptoms. No drug eradicates endometriosis or produces long-term cure.

Beischer et al. reported that 1 patient had spontaneous regression of perineal endometriosis after a subsequent pregnancy, suggesting that the endometriosis was related to the change in hormone levels (Beischer et al., 1966). In our analysis of 36 cases with perineal endometriosis, one patient underwent hysterectomy and bilateral salpingo-oophorectomy for a recurrence of perineal endometrioma seven years after complete excision of perineal endometriosis. The patient was then followed up for 2 years; the perineal endometrioma decreased gradually and then could not be detected (Zhu et al., 2009). This also supports the theory that endometriosis was related to the change in hormone levels.

In all the masses resected from our patients who had hormone treatment before surgery, the pathologic examination of the excised specimens showed gland atrophy and interstitial hyperplasia. These cases confirmed the effectiveness of hormone treatment. However, hormone treatment provided only short-term success in alleviation of symptoms and recurrence was common after the hormone therapy was stopped, so the hormone could be used only as an adjuvant therapy. In our hospital, GnRH agonists are the first choice. We also use oral contraceptive pills, progestogens either preoperatively or postoperatively (Zhu et al., 2009).

In our analysis of 31 cases of perineal endometriosis with anal sphincter involvement in our hospital, hormonal treatment was applied to 21 (67.7%) cases preoperatively and 14 (45.2%) cases postoperatively. For patients received hormonal therapy preoperatively, pathological examination of the resected lesions revealed responsive tissues after medical treatment. These provided evidence for the effectiveness of hormonal therapy preoperatively. As an adjuvant treatment, GnRH- agonists are the first choice in our hospital nowadays.

GnRH- agonists could effectively deplete the pituitary of endogenous gonadotropins and inhibit further synthesis, thus interrupting the menstrual cycle and resulting in a hypoestrogenic state, endometrial atrophy, and amenorrhea. In our hospital, the aim of GnRH- agonists used preoperatively for 3-4 months was to reduce the size of endometrioma, make boundaries of these lesions clearer thus to reduce intraoperative damage to the surrounding tissues and make the complete resection of lesions easier.
