{"paper_id":"3ffab11d-5fe8-49ac-b210-6a1cdbb21cc8","body_text":"J Preg Neonatal Med 2017 Volume 1 Issue 17\nhttp://www.alliedacademies.org/pregnancy-and-neonatal-medicine/Case Report\nIntroduction\nRectovaginal Endometriosis (RVE) is a severe form of \nendometriosis classified by Kirtner as stage 4 [1,2]. It is less \nfrequent than peritoneal or ovarian endometriosis affecting 3.8% \nto 37% of patients with endometriosis [3,4]. RVE infiltrates the \nrectum, vagina, and rectovaginal septum, up to obliteration of \nthe pouch of Douglas [4]. Endometriotic nodules exceeding 30 \nmm in diameter have 17.9% risk of ureteral involvement [5], \nwhile 5.3% to 12% of patients have bowel endometriosis, most \ncommonly found in the recto-sigmoid involving 74% of those \npatients [3,4].\nPreoperative diagnosis can is challenging as there is absence \nof agreed upon disease-specific laparoscopic and radiological \nfeatures, in spite of, studying several diagnostic tools as combined \nrectovaginal examination, transvaginal/transrectal ultrasounds, \nComputed Tomography (CT), Magnetic Resonance Imaging \n(MRI), colonography, colonoscopy, and, finally, laparoscopic \nremoval with histological confirmation [6-8].\nIn RVE, medical treatments are often ineffective and have \ntemporary effects in controlling symptoms. Complete surgical \nremoval provides long-term pain relief and improve the quality \nof life,  therefore  making it the treatment  of  choice  for  most   \nwomen [1,4].  Surgery  consists of  either  excision or  ablation \nthrough  transvaginal, laparotomy,  laparoscopy  or  combined\napproaches [4]. Commonly used techniques include shaving of \nIntroduction: Rectovaginal Endometriosis (RVE) is a severe form of endometriosis, less frequent \nthan peritoneal or ovarian endometriosis. Recto-vaginal endometriosis has multiple diagnostic and \nmanagement options with long-term outcomes varying according to the management strategy used.  \nCase: A 40 years old woman complained of postcoital bleeding. Detailed history revealed that \nshe suffered from persistent dysmenorrhea, dyschasia and constipation. Vaginal speculum \nexamination revealed a large fleshy polypoidal mass in the posterior vaginal fornix, which was \nexcised and biopsied. Histo-pathological examination revealed vaginal endometriosis. Four \nmonths later the mass recurred, in spite of, receiving hormonal treatment. Ultrasound and MRI \nrevealed multiple uterine fibroids, with heterogenous lesion located in the rectovaginal area, and \nCA-125 was 80 u/ml. exploratory laparotomy was done after proper bowel preparation. Total \nabdominal hysterectomy with excision of the upper vaginal portion and a part of the anterior \naspect of the recto-sigmoid was resected due to the invasion of its musculosa, short of the mucosa, \nwith primary repair. Histo-pathological examination showed advanced endometriosis including \nthe vaginal fornix and the rectal wall. The patient received two doses of Leuprolide Acetate 11.25 \nmg as an adjuvant treatment. Conclusion: All women with postcoital bleeding or pelvic pain \nshould have a detailed history taken from them and thorough examination including speculum \nexamination and visualization of posterior vaginal fornix to detect vaginal endometriosis. The \nprimary line of management for recto-vaginal endometriosis is surgery, as hormonal therapy is \nless effective in such cases, which might be explained by difference in origin from the peritoneal \ndisease.\nAbstract\nPostcoital bleeding in a case of recto-vaginal endometriosis.\nHaitham A Torky*,  Ashraf Abo-Louz  \nDepartment of Obstetrics and Gynecology, October 6th University, Giza Governorate, Egypt\nAccepted on August 21, 2017\nKeywords: Postcoital bleeding, Recto-vaginal endometriosis, Surgical treatment.\nrectal lesions, low anterior bowel resection and re-anastomosis,\nsupericial laparoscopic Anterior Discoid Resection(ADR) [1]. \nSurgical treatment of bowel endometriosis is usually lengthy and \ntechnically challenging. Associated bowel surgery increases the \nrisk of treatment complications up to 53% [4]. Bowel resection \nis usually needed in 1.7% to 28.6% of cases [4].\nRecto-vaginal endometriosis has multiple diagnostic and \nmanagement options with long-term outcomes varying according \nto the management strategy used. \nCase\n40 years old para 2 (previous 2 C.S.) complained of post coital \nbleeding. Pap smear was done which revealed non-specific \ninflammation based upon the result she received several courses \nof antibiotics but didn’t improve. Two months later she was \nreferred to our clinic for consultation. Detailed history revealed \nthat she suffered from persistent dysmenorrhea, dyschasia& \nconstipation. Vaginal speculum examination revealed a large \nfleshy polypoidal mass in the posterior vaginal fornix (Figure \n1). Combined vaginal and rectal examination revealed a very \nvascular & friable fleshy lesion, along with Left parametrial \ninduration, and the mass was felt very close to the rectum with \nintact rectal mucosa. Based upon the above findings she was \nscheduled for removal of the polypoidal mass, in addition \nto, Dilatation and Curettage. Histo-pathological examination \n\n8\nCitation: Torky HA. Postcoital bleeding in a case of recto-vaginal endometriosis. J Preg Neonatal Med. 2017;1(1):7-10.\nJ Preg Neonatal Med 2017 Volume 1 Issue 1\nrevealed vaginal endometriosis and endometrial hyperplasia, \ntherefore, she was prescribed oral progesterone (Dienogest 2 \nmg) continuous daily treatment; however, 4 months later during \nher treatment she developed dyspareunia, lower back and \npelvic pain along with marked post coital bleeding. Combined \nvaginal and rectal examination showed a newly developed \npolyp in the posterior vaginal fornix, with left parametrial \ninvolvement, and a palpable mass in the rectovaginal area, \nwith intact rectal mucosa, but inseparable from the posterior \nvaginal wall. Ultrasound and MRI revealed multiple uterine \nfibroids, with heterogenous lesion located in the rectovaginal \narea, and CA-125 was 80 u/ml so decision was taken for \nexploratory laparotomy after proper bowel preparation and the \npatient was consented for that. Total abdominal hysterectomy \nwas done for multiple fibroids with preservation of both \novaries, in addition to, excision of the upper vaginal portion. \nA part of the anterior aspect of the recto-sigmoid was resected \ndue to the invasion of its musculosa, short of the mucosa, with \nprimary repair. The postoperative period went uneventful apart \nfrom a localized hematoma in the rectovaginal space which \nwas managed conservative & subsided spontaneously. Histo-\npathological examination showed advanced endometriosis \nincluding the vaginal fornix and the rectal wall. The patient \nreceived two doses of Leuprolide Acetate 11.25 mg as an \nadjuvant treatment. \nDiscussion\nThe current case is a case of extensive recto-vaginal \nendometriosis, which is believed to be different in both \nmorphology and microscopy from peritoneal disease, and \nmost probably arise from tracts of embryological remnants of \nMüllerian tissue inside the uterosacral ligaments, anterior bowel \nwall and rectovaginal septum [9-11]. There is variation in both \nestrogen and progesterone receptors when compared to eutopic \nendometrium, pointing out to differences in both regulatory \nmechanism and origin compared to peritoneal disease. \nSymptoms include lower abdominal pain, severe backache, \nconstipation and dyschezia [9], which were found in the current \ncase. Speculum examination is useful in some cases and should \nfocus on the posterior vaginal fornix, which showed a lesion in \nthe current case. Vaginal endometriosis can present as disruption \nof the normal vaginal rugae, distortion, epithelial piling, small \nbluish cysts or a large reddish polypoid lesion as that found in \nthe current case, therefore; excision biopsy was necessary in \nthat lesion in order to confirm diagnosis. Combined rectal and \nvaginal palpation can confirm bowel involvement and in such \ncases bowel preparation should be done before surgery to allow \nfor primary repair and avoid a possible colostomy, which was \ndone before laparotomy in the current case.\nAdamyan [12] classified recto-vaginal endometriosis into 4 \nstages which are: “Stage I: Endometriosis lesions are confined \nto the rectovaginal tissue in the area of the vaginal vault Stage \nII: Endometriosis tissue invades the cervix and penetrates the \nvaginal wall, causing fibrosis and small cyst formation. Stage \nIII: Lesions spread into sacro-uterine ligaments and the rectal \nserosa. Stage IV: The rectal wall, recto-sigmoid zone and recto-\nuterine peritoneum are completely involved, and the recto-\nuterine pouch is totally obliterated”.\nHormone manipulation is not effective in most cases, despite the \npresence of estrogen and progesterone receptors and symptoms \nusually recur after its stoppage [10,11]. Vercellini et al. [13] \nin their study concluded that medications achieved temporary \nquiescence of active lesions and can be used in selected cases, \nbut surgery represented the definitive solution of such cases.\nSurgical routes include traditional laparotomy, laparoscopy \nand recently, robotic surgery. Garry et al. [9] published the \nearly analysis of the first 57 cases included in their study \nand concluded that surgery improves clinical symptoms and \nquality of life with acceptable operative morbidities. Chapron \net al. [14] did a study to assess the efficacy of laparoscopic \ntreatment of deep endometriosis involving 110 cases and \nconcluded that in the hands of a skilled laparoscopic surgeon \noperative laparoscopy is efficient in treating pain related to \ndeep endometriosis. Carvalho et al. [15] did a systemic review \nto evaluate the role of robotic surgery in the surgical treatment \nof deep endometriosis and concluded that this type of surgery is \nfeasible without conversion; however, randomized controlled \ntrials and studies assessing the long-term effects of robotic \nsurgery are needed. \nFigure 1. Showing endometriosis in the posterior vaginal fornix.\n\nTorky\n9 J Preg Neonatal Med 2017 Volume 1 Issue 1\nLaparoscopic surgery performed by a skilled surgeon is \nconsidered the gold standard. The extent of resection is \nindividualized. Most authors agree on superficial resection of \nthe nodule or full disk resection of the rectal wall in case of a \nsingle nodule less than 3 cm in diameter, if bowel involvement is \nless than half its circumference. Bowel resection is indicated if \nit is not possible to resect the nodule or in cases with Adamyan \nstage IV, between 60 and 100% of such patients show symptom \nimprovement [16]. Therefore; surgical en-bloc resection is the \nmost efficient technique for treatment of obliteration of the \ncul-de-sac regardless of the route-as the technique used during \nlaparotomy in the current case (Figures 2a and 2b) [17].\nConclusion\nAll women with postcoital bleeding or pelvic pain should have \na detailed history taken from them and thorough examination \nincluding speculum examination and visualization of posterior \nvaginal fornix to detect vaginal endometriosis.\nThe primary line of management for recto-vaginal endometriosis \nis surgery, as hormonal therapy is less effective in such cases, \nwhich might be explained by difference in origin from the \nperitoneal disease.\nReferences\n1. Moawad NS, Guido R, Ramanathan R, et al. Comparison \nof laparoscopic anterior discoid resection and laparoscopic \nlow anterior resection of deep infiltrating rectosigmoid \nendometriosis. JSLS. 2011;15(3):331-8. \n2. Roberts CP, Rock JA. The current staging system for \nendometriosis: does it help? Obstet Gynecol Clin North \nAm. 2003;30(1):115-32. \n3. Tarjanne S, Sjöberg J, Heikinheimo O. Rectovaginal \nendometriosis-characteristics of operative treatment and \nfactors predicting bowel resection. J Minim Invasive \nGynecol. 2009;16(3):302-6. \n4. Zanetti-Dällenbach R, Bartley J, Müller C, et al. Combined \nvaginal-laparoscopic-abdominal approach for the surgical \ntreatment of rectovaginal endometriosis with bowel \nresection: a comparison of this new technique with various \nestablished approaches by laparoscopy and laparotomy. \nSurg Endosc. 2008;22(4):995-1001. \n5. Kondo W, Branco AW, Trippia CH, et al. Retrocervical \ndeep infiltrating endometriotic lesions larger than thirty \nmillimeters are associated with an increased rate of ureteral \ninvolvement. J Minim Invasive Gynecol. 2013;20(1):100-3. \n6. Abrao MS, Gonçalves MO, Dias JA, et al. Comparison \nbetween clinical examination, transvaginal sonography \nand magnetic resonance imaging for the diagnosis of deep \nendometriosis. Hum Reprod. 2007;22(12):3092-7. \n7. Jelenc F, Ribič-Pucelj M, Juvan R, et al. Laparoscopic rectal \nresection of deep infiltrating endometriosis. J Laparoendosc \nAdv Surg Tech A. 2012;22(1):66-9. \n8. Sassi S, Bouassida M, Touinsi H, et al. Exceptional cause \nof bowel obstruction: rectal endometriosis mimicking \ncarcinoma of rectum–a case report. Pan Afr Med J. \n2011;10:33.\n9. Garry R, Clayton R, Hawe J. The effect of endometriosis \nand its radical laparoscopic excision on quality of life \nindicators. BJOG. 2000;107(1):44-54.\n10. Redwine DB. Mulleriosis: the single best fit model of origin \nof endometriosis. J Reprod Med 1988;33:915-20.\n11. Halme J, Hammond MG, Hulka JF, et al. Retrograde \nmenstruation in healthy women and in patients with \nendometriosis. Obstet Gynecol 1984;64(2):151-4.\n12. Adamyan L. Additional international perspectives. In: \nFigure 2a. Showing the hysterectomy specimen.\nFigure 2b. Showing the cervix and the part of the removed part of the \nposterior vaginal wall containing endometriosis.\n\n13. Vercellini P, Frontino G, Pietropaolo G, et al. Deep\nendometriosis: definition, pathogenesis, and clinical\nmanagement. J Am Assoc Gynecol Laparosc 2004;11:153.\n14. Chapron C, Dubuisson JB, Fritel X, et al. Operative\nmanagement of deep endometriosis infiltrating the\nuterosacral ligaments. J Am Assoc Gynecol Laparosc.\n1999;6:31-7.\n15. Carvalho L, Abrão MS, Deshpande A, et al. Robotics as a\nnew surgical minimally invasive approach to treatment of\nendometriosis: a systematic review. Int J Med Robot.\n16. Foti N. Rectovaginal septum endometriosis. siccr-Italian\nsociety of colo-rectal surgery. 2012;33:270-4.\n17. Redwine DB. Laparoscopic en bloc resection for treatment\nof the obliterated cul de sac in endometriosis. J Reprod\nMed 1992;37:695-8.\n \nCitation: Torky HA. Posttotal bleeding in a case of recto-vaginal endometriosis.. J Preg Neonatal Med 2017;1(1):7-10.\n10J Preg Neonatal Med 2017 Volume 1 Issue 1\nNichols DH (ed.) Gynecologic and Obstetric Surgery. St.\nLouis: Mosby Year Book. 1993;1167-82.\n*Correspondence to:\nHaitham A Torky\nDepartment of Obstetrics and Gynecology \nOctober 6th University \nEygpt\nE-mail: haithamtorky@yahoo.com","source_license":"CC0","license_restricted":false}