{"paper_id":"6247e909-97a8-4e01-be49-f200eff6ec88","body_text":"Obstetrics and \nGynaecology Cases - Reviews\nBerger et al. Obstet Gynecol Cases Rev 2018, 5:125\nVolume 5 | Issue 3\nDOI: 10.23937/2377-9004/1410125\nISSN: 2377-9004\nOpen Access\nCitation: Berger A, Graham NW, Berry-Roberts C, Schlaff W (2018) An Atypical Presentation of Extrao-\nvarian Endometrioma. Obstet Gynecol Cases Rev 5:125. doi.org/10.23937/2377-9004/1410125\nAccepted: May 28, 2018: Published: May 30, 2018\nCopyright: © 2018 Berger A, et al. This is an open-access article distributed under the terms of the \nCreative Commons Attribution License, which permits unrestricted use, distribution, and reproduction \nin any medium, provided the original author and source are credited.\nBerger et al. Obstet Gynecol Cases Rev 2018, 5:125\n• Page 1 of 3 •\nAn Atypical Presentation of Extraovarian Endometrioma\nAlexander Berger1*, Nora Ward Graham1, Crystal Berry-Roberts1 and William Schlaff2\nmass. Presumed endometriomas may be identified by \nimaging [2], but ultimately the diagnosis of endometrio-\nsis or endometriomas is definitively made at the time of \nsurgery [3]. The gross appearance can range widely with \nthe most common being darkly pigmented lesions often \ndescribed as “powder burns”. However, endometriosis \nmay also present as vesicular lesions with or without \nneovascularity, adhesions, or endometriomas. The ma-\njority of patients are found to have ASRM stage I or II \n(minimal or mild) disease [4]. Endometriomas are more \noften associated with pelvic adhesions in patients with \nstage III or IV (moderate to severe) disease [5]. Patients \nwith an isolated ovarian endometrioma (i.e. no other \nevidence of endometriosis) are uncommon, and an iso-\nlated extraovarian endometrioma is even more rare [6]. \nHistologic confirmation of endometriosis requires evi-\ndence of endometrial glands and stroma outside of the \ncavity of the uterus. Associated findings of fibrotic gran-\nulation tissue, pigment-laden histiocytes, adhesions, \nand other signs of inflammation are common. \nCase\nThe patient was a 29 yr gravida 6 para 3 Ab 3, who \npresented to her primary care doctor with new onset of \nsharp left upper quadrant pain that radiated to the left  \ninguinal area and improved at home with non-steroidal \nanti-inflammatories. She denied nausea, vomiting, an-\norexia, dysuria, or hematuria. Her last menstrual period \nwas three and a half weeks prior and she denied any \nvaginal bleeding, discharge, or pruritis. She was afebrile, \nand her vital signs were within normal limits. She had a \nBMI of 36. On physical exam she had normoactive bow-\n*Corresponding author: Alexander Berger, MD, MPH, Department of Obstetrics and Gynecology, Thomas Jefferson \nUniversity Hospital, 834 Chestnut Street, Suite 400, Philadelphia, PA 19107, USA, Tel: (215)-955-1085, E-mail: alexan-\nderbergermd@gmail.com\nAbstract\nBackground: Patients with endometriomas typically pres-\nent with an intraovarian mass, often associated with mul-\ntiple foci of extraovarian lesions. An isolated extraovarian \nendometrioma is rare and represents a challenging diag -\nnostic dilemma.\nCase: 29 yr G6P3033 woman without history of gyneco -\nlogical malignancies presented with worsening left lower \nabdominal and pelvic pain over one month. Transvaginal \nultrasound revealed a complex cystic mass above the blad-\nder concerning for atypical hemorrhagic cyst versus neo-\nplasm. Laparoscopy revealed an isolated endometrioma on \nthe bladder peritoneum that was confirmed on histology.\nConclusion: Isolated pelvic endometriomas can occur \nin the setting of pelvic pain without peritoneal or ovarian \ninvolvement and/or adhesive disease. Clinicians should \nmaintain suspicion for endometriosis in patients with a pel-\nvic mass and pain regardless of the ultrasound appearance \nof the ovaries.\n1Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, USA\n2Division of Reproductive Endocrinology and infertility, Department of Obstetrics and Gynecology, Thomas \nJefferson University Hospital, USA\nCAse PReseNtAtioN\nCheck for\nupdates\nIntroduction\nEndometriosis is one of the most common causes of \npelvic pain in women of reproductive age [1]  and can \nbe a diagnostic challenge because of its diverse and \nnonspecific symptoms and findings. The most com-\nmon sites of endometriosis are the dependent pelvic \nstructures and include the ovaries, anterior and poste-\nrior cul-de-sac, posterior broad ligaments, uterosacral \nligaments, fallopian tubes and colon. The diagnosis of \nendometriosis is commonly suspected based on symp-\ntoms such as pelvic pain, dysmenorrhea and/or dyspa -\nreunia. Physical exam may include reduced pelvic organ \nmobility, uterosacral mass or tenderness, or a pelvic \n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410125\nBerger et al. Obstet Gynecol Cases Rev 2018, 5:125\n• Page 2 of 3 •\npain medication. In the clinic one week later the patient \nreported that her pain had moderately improved; her \nabdomen was soft, non-tender, non-distended, with -\nout rebound or guarding, and with normoactive bowel \nsounds. Her pelvic exam was notable for tenderness to \npalpation along the uterus and left adnexa, with a pal -\npable, persistent left adnexal mass.\nThe patient underwent diagnostic laparoscopy with \na preoperative differential diagnosis of atypical hem-\norrhagic cyst versus neoplasm. At surgery a 5 cm × 5 \ncm × 3 cm chocolate colored cyst was identified on the \nsurface of the bladder serosa consistent in appearance \nwith an endometrioma. The presumed endometrioma \nwas also adherent to the left round ligament and the \nfundus of the uterus but was not in any way contigu -\nous with the left ovary which was normal. The uterus, \nfallopian tubes, and right ovary were also normal in ap-\npearance, and there was no evidence of peritoneal or \nother intraabdominal endometriosis. There was no sug-\ngestion of a malignancy. During the process of resecting \nthe mass, the cyst ruptured and dark-sanguinous fluid \nel sounds and left upper quadrant tenderness without \nrebound or guarding. She did not have costovertebral \nangle tenderness nor was there hepatosplenomegaly \nor Murphy’s sign. Her urinalysis was negative. She was \nsent home with a diagnosis of non-specific abdominal \npain to be treated with acetaminophen with codeine \nand asked to return for follow up in one week.\nHer pain initially improved, however, she presented \nto the Emergency Department four days later with wors-\nening pain in the left lower quadrant and suprapubic ar-\neas. A transvaginal ultrasound at that time revealed an \n8.6 cm × 5.3 cm by 5.6 cm complex cystic mass with uni-\nform mildly thickened septations and internal echoes in \nthe left adnexa. There was no detectable internal blood \nflow, nor were there mural nodules (Figure 1 and Figure \n2). The radiologist could not confirm that the left ad-\nnexal mass was ovarian, but also could not identify the \nleft ovary independent of the mass. The right ovary and \nuterus were normal in appearance and size. The patient \nwas discharged home with a preliminary diagnosis of \na complex adnexal cystic mass concerning for atypical \nhemorrhagic cyst versus ovarian neoplasm and sched-\nuled to be seen in the gynecology clinic for a definiti ve \nplan. She was given torsion precautions and narcotic \nFigure 1: Long transvaginal ultrasound view of 8.6 cm × \n5.3 cm by 5.6 cm complex cystic mass with uniform mildly \nthickened septations and internal echoes.\nFigure 2: Coronal transvaginal ultrasound view of 8.6 cm × \n5.3 cm by 5.6 cm complex cystic mass adjacent to bladder.\nFigure 3: 20X magnification image with evidence of blood, \nstroma, containing (arrow) hemosiderin laden macrophages \n(pigmented histiocytes).\nFigure 4: 4X magnification image showing evidence of blood, \nstroma, and inflammatory response.\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410125\nBerger et al. Obstet Gynecol Cases Rev 2018, 5:125\n• Page 3 of 3 •\nthat retrograde menstrual flow led to seeding adjacent \nto the bladder surface. This case clearly emphasizes the \nimportance of maintaining a broad differential diagno -\nsis and considering endometriosis in women with pelvic \npain and a mass, even in atypical clinical contexts.\nReferences\n1. Bulun SE (2009) Endometriosis. N Engl J Med 360: 268-\n279.\n2. Chamié LP, Blasbalg R, Pereira RM, Warmbrand G, Seraf-\nini PC (2011) Findings of pelvic endometriosis at transvag-\ninal US, MR imaging, and laparoscopy. Radiographics 31: \nE77-E100.\n3. Hsu AL, Sinaii N, Segars J, Nieman LK, Stratton P (2011) \nRelating pelvic pain location to surgical findings of endome-\ntriosis. Obstet Gynecol 118: 223-230.\n4. The American Fertility Society (1985) Revised American \nFertility Society classification of endometriosis: 1985. Fertil \nSteril 43: 351-352.\n5. Jenkins S, Olive DL, Haney AF (1986) Endometriosis: \nPathogenetic implications of the anatomic distribution. Ob-\nstet Gynecol 67: 335-338.\n6. Mettler L, Schollmeyer T, Lehmann-Willenbrock E, Schup-\npler U, Schmutzler A, et al. (2003) Accuracy of Laparoscop-\nic Diagnosis of Endometriosis. JSLS 7: 15-18.\n7. Murphy AA, Green WR, Bobbie D, dela Cruz ZC, Rock JA \n(1986) Unsuspected endometriosis documented by scan-\nning electron microscopy in visually normal peritoneum. \nFertil Steril 46: 522-524.\n8. Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez \nJ (2012) Deep endometriosis: Definition, diagnosis, and \ntreatment. Fertil Steril 98: 564-571.\nwas visualized. The mass was removed, and fluid was \nevacuated. Pathological evaluation confirmed endome-\ntriotic cyst, with evidence of atrophic glands, hemosid -\nerin laden macrophages (pigmented histiocytes) (Figure \n3) and endometrial stroma with inflammatory response \n(Figure 4). The patient’s postoperative course was un -\ncomplicated and she was discharged home on the day \nof surgery on oral contraceptive pills. The patient recov-\nered well and she was without pain on follow up exam.\nComment\nThis case describes an atypical presentation of en-\ndometriosis. Despite being extraovarian, a complex pel-\nvic mass in a reproductive age female can be endome-\ntriosis. The patient’s history, complaints, and imaging \nwere concerning for a hemorrhagic cyst or malignancy; \nthere was a low suspicion for endometriosis in light of \nthe patient’s multiparity and atypical symptoms. How-\never, her exploratory laparoscopy revealed a histolog -\nically-confirmed endometrioma without peritoneal or \novarian involvement or adhesive disease. Though it is \nwell-known that endometriosis may be subclinical and \nnot visualizable at laparoscopy [7], it is nevertheless sur-\nprising that the patient had a single, isolated endome-\ntrioma without other findings of endometriosis. Even \nmore unusual was the fact that this woman had no ev -\nidence of infertility. It could be hypothesized that the \nendometrioma as seen in this patient is in some ways \ndifferent from typical deep endometriomas, which is \nfrequently multifocal [8]. However, the gross and histo-\nlogic appearance was fairly characteristic. It is possible","source_license":"CC0","license_restricted":false}