{"paper_id":"07d84248-6475-4eae-a169-94975e282588","body_text":"J. Obstetrics Gynecology and Reproductive Sciences                                                                                                                                       Copy rights @ Elie Anastasiadis, \nAuctores Publishing LLC – Volume 10(1)-293 www.auctoresonline.com \nISSN: 2578-8965   Page 1 of 5 \n \n \nIntra-Operative Discovery of A 150mm Anterior Vaginal Wall \nEndometrioma During Repair of a Stage 4 Cystocele \nNicolas Anastasiadis 1, Rita Ajoury 2, Elie Anastasiadis 2*, Sergio Sbeih 2 \n1Saint Joseph University, Faculty of Medicine, Lebanon. \n2Department of Obstetrics and Gynecology, University of Balamand, Lebanon. \n*All authors contributed equally to the manuscript \n*Corresponding Author: Elie Anastasiadis, Department of Obstetrics and Gynecology, University of Balamand, Lebanon. \nReceived date: November 11, 2025; Accepted date: December 08, 2025; Published date: January 07, 2026. \nCitation: Nicolas Anastasiadis, Rita Ajoury, Elie Anastasiadis, Sergio Sbeih , (2026), Intra-Operative Discovery of A 150mm Anterior Vaginal Wall \nEndometrioma During Repair of a Stage 4 Cystocele, J. Obstetrics Gynecology and Reproductive Sciences, 10(1) DOI:10.31579/2578-8965/293 \nCopyright: © 2026, Elie Anastasiadis. This is an open -access article distributed under the terms of The Creative Commons Attribution License, \nwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. \nAbstract: \nIntroduction: The involvement of the anterior vaginal wall by endometriosis is exceedingly rare and may present as an anterior \ncompartment mass simulating a cystocele or urethral diverticulum. Due to its atypical location and broad clinical spectrum, the \ndiagnosis may be difficult and is usually incidentally established during surgery. \nCase Presentation: A 36-year-old woman, with one previous vaginal delivery, with no significant medical or surgical history, \npresented for repair of a stage IV cystocele. Intra-operatively, a large cystic lesion of about 150 mm in size was noted between \nthe bladder and the a nterior vaginal wall. The mass was completely excised. Leakage of chocolate colored liquid confirmed \nthe presence of endometriosis. The postoperative course was uneventful, and the patient remained asymptomatic at follow-up. \nDiscussion: Literature review showed only a few cases of anterior vaginal wall endometrioma, the majority of which were \ndiagnosed preoperatively on magnetic resonance imaging. Our case is remarkable for its extraordinary size and incidental \nintraoperative finding. This underscores that a wide differential diagnosis must be maintained when assessing anterior vaginal \nwall protrusions. \nConclusion: Anterior vaginal wall endometrioma is an infrequent presentation of endometriosis that may present as pelvic \norgan prolapse. Preoperative imaging in atypical or unusually large anterior -compartment lesions may help in avoiding \nunexpected intraoperative findings. \nKeywords: endometrioma; anterior vaginal wall; cystocele \nIntroduction \nEndometriosis, an estrogen dependent disease, is a condition characterized \nby the abnormal presence of endometrial tissue and glands outside the uterus \n[1]. Classical locations include the ovaries, ovarian fossa, pouch of douglas, \nuterosacral ligaments or even rectovaginal septum[2]. However, atypical \nlocations like the anterior vaginal wall, bladder and vesicovaginal septum \ncan be seen in up to 1% of all reported cases of  extra -pelvic endometriosis \nnowadays[3,4]. Because of these uncommon locations and th eir broad \nsymptoms, anterior -wall endometriotic lesions are most commonly \nincidentally found intra-operatively during unrelated procedures [4,5].  \nPatients with anterior vaginal wall endometriosis may experience symptoms \nranging from urinary frequency, to a visible bulge that can mimic organ \nprolapse [6]. Pelvic organ prolapse, more specifically cystocele, affects \napproximately 40% of women [7]. The development of a mass between the \nbladder and the anterior vaginal wall, clinical examination might favor \ncystocele, but the diagnosis may be challenging [8]. \nTo date and to the best of our knowledge, few cases of anterior vaginal wall \nendometriomas were documented. Here, we present the case of an individual \nwho presented with stage 4 cystocele and was found to have a large \nendometrioma in the anterior vaginal wall. \nCase presentation: \nWe report the case of a 36 -year-old female patient, gravida 1 parity 1 who \npresented to the gynecologic clinic complaining of worsening symptoms of \na protruding mass from the vulva. Her obstetrical history included one \nnormal vaginal delivery 9 years ago. Her menarche was at 13 years of age, \nwith regular cycles and no menorrhagia and no dysmenorrhea. The patient \nwas previously healthy and had only a laminectomy as past surgical history.  \nThere was a loss of follow -up for 7 years, with no clinic visit. She then \npresented complaining of a mass protruding from her vagina, which was \n  Open Access  \n Research Article \n   Journal of Obstetrics Gynecology and Reproductive Sciences \n                                                                                                                              Elie Anastasiadis * \nAUCTORES \nGlobalize your   Research \n\nJ. Obstetrics Gynecology and Reproductive Sciences                                                                                                                                       Copy rights @ Elie Anastasiadis, \nAuctores Publishing LLC – Volume 10(1)-293 www.auctoresonline.com \nISSN: 2578-8965   Page 2 of 5 \ndescribed as a Stage 2 cystocele, with no symptoms of urinary incontinence. \nThe PAP smear done at that moment showed ASC-US, with negative HPV.  \nTwo years later, in a follow -up visit, the patient reported worsening of her \nprevious symptoms, alongside new onset urinary incontinence and \nsuperficial dyspareunia. On physical examination, the vulva was normal in \nappearance. A 150 mm mass was seen on the  anterior vaginal wall, going \nfrom below the urethral meatus and out of the vulva, with a POP -Q of Aa \n+2.  The total vaginal length TVL was normal. There were no uterine or \ncervical prolapse, and the posterior vaginal wall was normal in appearance. \nThe clinical presentation was compliant with a Stage 4 cystocele.  \nThe patient was scheduled for an anterior repair in the operating room. \nDissection ranged from the urethrovesiular junction until the anterior part of \nthe cervix. Upon the midline incision on the anterior vaginal mucosa, a \nchocolate fluid leaked out (image  1), consistent with endometrioma. After \nremoval, the cyst cavity was irrigated with normal serum (Image 2) and \nclosed with vicryl sutures (Image 3).  \nFew months later, the patient returned for follow -up, feeling healthy and \nreported complete resolution of her symptoms.  \n \nImage 1: Intraoperative view showing a cystic mass between the anterior vaginal wall and bladder, consistent with endometrioma. \n \nImage 2: Cavity irrigated and cleaned with normal serum. \n\n\nJ. Obstetrics Gynecology and Reproductive Sciences                                                                                                                                       Copy rights @ Elie Anastasiadis, \nAuctores Publishing LLC – Volume 10(1)-293 www.auctoresonline.com \nISSN: 2578-8965   Page 3 of 5 \n \nImage 3: Closure of the anterior vaginal wall with continuous vicryl sutures. \nDiscussion: \nAnterior vaginal wall endometrioma is an atypical location of \nendometriomas and a rare complication of this benign gynecologic disease. \nIts presence often causes a diagnostic challenge to physicians, thus raising \nthe importance of imaging in the pre-operative planning. This pathology may \nmimic common gynecologic diseases such as cystocele, urethral \ndiverticulum or even Mullerian cysts. In our case, this 150mm endometrioma \nwas found incidentally while undergoing a planned anterior repair for stage \n4 cystocele, underlining the burden of endometriosis.  \nTo this day, and to the best of our knowledge, there has been only 5 cases \nreporting the atypical finding of endometriosis in the anterior vaginal wall \n(Table 1). Most cases reported patients aging from 23 years old to 46 years \nold. The largest two lesions  documented till this day were 100mm9 and 80 \nmm10 . Patients across all cases, reported one of two symptoms; vaginal \nbulge 3,8 or urinary problems10. Such cases were intially mis -diagnosed \nwith cystocele or pelvic organ prolapse 8.  \nIn contrast to our case, a 45 years old patient known to have endometriosis, \nwith many past urogynecologic surgeries, was found to have a 15mm \nanterior vaginal wall endometrioma3. A rationale explanation of the finding, \nwas the dissimenation of endometrios is after repeated urogynecologic \nsurgeries3.  \nIn the case described by Dilday et Al., a 23 years old patient, known to have \na vaginal cyst, diagnosed at a prior institution, was then found to be of \nendometriotic origin4. The authors reported an incidental finding of anterior \nvaginal wall endometrioma, during a planned excision of Gartner cyst4. Our \npatient had no prior history of cysts, or any gynecologic problem and was \nadmitted for a stage 4 cystocele repair. \nBenkaddour et Al. described the case of 41 years old patient presenting with \ndysuria and dyspareunia. However, in contrast to our case, the pre-operative \ndiagnosis of endometrioma was made using magnetic resonnace imaging \n(MRI)10. Our patient was not complaining of typical symptoms of \nendometriosis.  \nNelson et al. reported the case of a 43 -year-old female patient with an \nanterior vaginal wall mass associated with urinary frequency and pelvic \npressure, which was initially thought to be due to pelvic organ prolapse6. \nPre-operative MRI studies showed a we ll-defined cystic lesion, and \nhistopathology confirmed endometriosis6. Özbilgeç et al. also reported a 46-\nyear-old woman with a 100mm anterior wall cyst of the vagina, which was \nlocated just below the urethral meatus and was confused with a cystocele \nuntil imaging studies demonstrated a cystic mass located between the bladder \nand the vaginal wall9. Both these cases underscore the fact that anterior wall \nvaginal endometriomas may closely resemble cystocele and thus easily lead \nto diagnostic confusion. Contra sting with those findings, our patient had a \nmuch larger lesion (150 mm) found incidentally during cystocele repair, \nwhich further supports the view that even extensive endometriotic cysts may \nbe clinically silent until surgical exploration.  \nThe absence of typical endometriosis symptoms, such as dysmenorrhea \nmade the clinical pre-operative diagnosis nearly impossible. This highlights \nthe importance of having a wide differential diagnosis while dealing with \npatients presenting for large anterior wall protrusions.  \nWhile physical exam remains the gold standard in diagnosis pelvic organ \nprolapse11, imaging such as transperineal  ultrasound or even magnetic \nresonance imaging (MRI), can help narrow down the differential diagnosis \nbefore heading into surgery[12]. This said, imaging is not routinely done \nbefore anterior organ prolapse repair, and more research and \nrecommendations on this subject are needed in order to minimize the rate of \nincidental operational finding of such conditions. \n\n\nJ. Obstetrics Gynecology and Reproductive Sciences                                                                                                                                       Copy rights @ Elie Anastasiadis, \nAuctores Publishing LLC – Volume 10(1)-293 www.auctoresonline.com \nISSN: 2578-8965   Page 4 of 5 \nTable 1: Reported cases of anterior vaginal wall or vesico-vaginal septum endometriomas. \nConclusion: \nThe anterior vaginal wall endometrioma is a rare presentation of \nendometriosis, closely simulating pelvic organ prolapse. In our case, a very \nlarge 150mm lesion was found incidentally during cystocele repair, which \nunderlines the diagnostic challenge prese nted by atypical anterior -\ncompartment disease. While physical examination remains the cornerstone \nof prolapse evaluation, preoperative imaging, such as MRI or transperineal \nultrasound, should be considered in cases with atypical or unusually large \nanterior vaginal wall protrusions in order to avoid surprising intraoperative \nfindings. \nAuthors contribution: \nNicolas Anastasiadis, Rita Ajoury, Sergio Sbeih wrote the first draft and \ncontributed to data collection and investigation. \nElie Anastasiadis and Sergio Sbeih edited the first draft and supervised the \nwork. \nElie Anastasiadis performed the surgical procedure and provided clinical \ndata. \nDisclosures:  \nThe authors declare that they have no conflicts of interest to disclose. \nFunding: \nNo funding was received for this work \nEthical approvment and consent: \nWritten informed consent was obtained from the patient \nReferences: \n1. Bulun, S. E. (2009). Endometriosis. The New England Journal \nof Medicine, 360(3), 268–279.  \n2. Burney RO, Giudice LC. (2012). Pathogenesis and \npathophysiology of endometriosis. Fertil Steril. 98(3):511-519.  \n3. Christensen AE, Kjer JJ, Hartwell D, Perlman S. (2021). \nAtypical vaginal location of endometriosis following repeated \nurogynaecological surgery. BMJ Case Rep. 14(8):e244186.  \n4. Dilday EA, Lewis MS, Vahidi K, Memarzadeh S. (2020). An \nasymptomatic anterior vaginal wall endometrioma, a rare \nmanifestation of endometriosis: A case report. Case Rep \nWomens Health. 27:e00210.  \n5. Roman H, Vassilieff M, Gourcerol G, et al. (2011). Surgical \nmanagement of deep infiltrating endometriosis of the rectum: \npleading for a symptom -guided approach. Hum Reprod.  \n26(2):274-281.  \n6. Nelson P. (2018). Endometriosis presenting as a vaginal mass. \nBMJ Case Rep. 2018:bcr-2017-222431.  \n7. Wu M. Global burden and trends of pelvic organ prolapse \nassociated with aging women: An observational trend study \nfrom 1990 to 2019. Front Public Health. \n8. Benlghazi A, Belouad M, Bouhtouri Y, Benali S, El Hassani \nMM, et al. (2023). Anterior vaginal cyst mimicking pelvic organ \nprolapse: Case report and literature review. Int J Surg Case Rep. \n111:108868.  \n9. Özbi̇Lgeç S, Türen Demi̇R E, Taşci AE, Çi̇Çek Ş, Çalişkan H. et \nal. (2022).Anterior Vaginal Wall Endometrioma: Case Report. \nGenel Tip Derg. 32(6):793-795.  \n10. Ait Benkaddour Y, El Farji A, Soummani A. (2020). \nEndometriosis of the vesico-vaginal septum: a rare and unusual \nlocalization (case report). BMC Womens Health. 20(1):179.  \n11. Swift SE, Tate SB, Nicholas J. (2003). Correlation of symptoms \nwith degree of pelvic organ support in a general population of \nwomen: what is pelvic organ prolapse? Am J Obstet Gynecol . \n189(2):372-377.  \n12. Bazot M, Daraï  E. (2017). Diagnosis of deep endometriosis: \nclinical examination, ultrasonography, magnetic resonance \nimaging, and other techniques. Fertil Steril. 108(6):886-894.  \n \n \n \n \n \n \n \n \n \n \n \nAuthor Age Symptoms Size  Pathology Location Imaging \nBenkaddour et Al. \n(2020)10 \n41 years old Dysuria, acute \nurinary retention \n80mm  Endometrioma Vesico-vaginal \nseptum \nMRI \nChristensen et Al. \n(2021)3 \n45 years old Lump in vaginal \nwall \n15mm  Endometrioma Anterior vaginal \nwall \nMRI \nDilday et Al. (2020)4 23 ye Asymptomatic 20mm Endometrioma Anterior vaginal \nwall \n- \nOzbilgec et Al. (2022)9 46  Enlargement in the \nvagina \n100mm Endometrioma Anterior vaginal \nwall \nMRI \nNelson et Al. (2018)6 43 Vaginal lump 20mm  Endometrioma Anterior vaginal \nwall  \nMRI \n\nJ. Obstetrics Gynecology and Reproductive Sciences                                                                                                                                       Copy rights @ Elie Anastasiadis, \nAuctores Publishing LLC – Volume 10(1)-293 www.auctoresonline.com \nISSN: 2578-8965   Page 5 of 5 \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n This work is licensed under Creative    \n   Commons Attribution 4.0 License \n \n \nTo Submit Your Article, Click Here: Submit Manuscript \n \nDOI:10.31579/2578-8965/293 \n \n \n \n \n \n  \nReady to submit your research? 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