{"paper_id":"88bc4ca7-bbc1-44b4-9bbd-8edf5ecd4886","body_text":"22166\nCopyright@ Thiago Sampaio Busato | Biomed J Sci & Tech Res | BJSTR. MS.ID.004752.\nISSN: 2574 -1241\nAbdominal Wall Endometrioma Mimicking  \nPubalgia: A Case Report\n      DOI: 10.26717/BJSTR.2020.29.004752\nThiago Sampaio Busato1, Juliana Maranho2, William Kondo3, Marcelo Morozowski4, Gladyston \nR Matioski Fo4, Lucas Dias Godoi4 and Juan R V Capriotti5\n1Chair of Hip Surgery Fellowship Programme, Brazil\n2Fellow of Hip Surgery Fellowship Programme, Brazil\n3Gynecologist of VITA Batel and Hospital das Nações, Brazil\n4Staff of Hip Surgery Unit at C.R.I.Ar, Brazil\n5Chair of Hip Surgery Unit at C.R.I.Ar, Brazil\n*Corresponding author: Thiago S Busato, Chair of Hip Surgery Fellowship Programme, Brazil\nCase Report\nIntroduction\nPubalgia is a painful inflammatory syndrome of variable \netiology that involves the pubic symphysis and its neighboring \nstructures [1]. Among the main factors involved in its pathogenesis, \nsports that involve microtrauma in the pubic region stand out. Less \noften, it is secondary to infectious causes or gynecological and \nurological surgery [2]. The clinical condition starts with pain in the \npubic region. It can occur irradiation to the perineum and the inner \nthigh region and worsens on exertion [1,3,4]. It is usually a self-  \n \nlimited condition, but in athletes who maintain physical activity in \nthe presence of the disease, the pain can worsen, becoming limiting \n[1,2]. The diagnosis is initially clinical, but should always be based \non imaging tests. Irritating maneuvers (squeeze test, Grava test) \ncan cause pain. Imaging exams may show mechanical overload in \nthe region, for example, due to the presence of pubic symphysis \narthrosis on radiographs and T2 bone edema on Magnetic \nResonance Imaging (MRI), in addition to possible tendonitis of the \nARTICLE INFO AbsTRACT\nReceived: \n   July 11, 2020\nPublished: \n   July 24, 2020\nCitation: Thiago Sampaio B, Juliana M, Wil-\nliam K, Marcelo M, Gladyston R Matioski \nF, et al., Abdominal Wall Endometrioma \nMimicking Pubalgia: A Case Report . Bi -\nomed J Sci & Tech Res 29(1)-2020. BJSTR. \nMS.ID.004752.\nKeywords: Pubis; Endometrioma\n \nThe authors present a case of endometrioma of the rectus abdominis muscle that \nmimicked a clinical condition of pubalgia in a female patient. There was a previous \nhistory of two cesarean deliveries and an abdominoplasty. The patient underwent \nprior unsuccessful physiotherapy for pubalgia in another service until an MRI scan \nfinally clarified the correct etiological diagnosis. The initial pelvic radiographs \npresented, curiously, an image compatible with the pubic symphysis’s osteoarthritis, \nprobably inducing the initial diagnosis of the assistant colleague for a mechanical \netiology, given that the patient was also quite active. After the new diagnosis, we \nreferred the patient to a gynecological surgery team specialized in the treatment of \nendometriosis. The patient achieved complete resolution of symptoms after tumor \nresection, which was histologically compatible with an endometrioma. Endometriosis \nof the rectus abdominis muscle, as described in this clinical case, is rare, with about \nonly 20 cases found in the literature. In the knowledge of the authors, this is it’s first \nreport as a differential diagnosis of pubalgia. When it forms a circumscribed mass, \nendometriosis is called an endometrioma. One of the most common sites for the \nappearance of endometrioma is in the lower abdominal wall, especially if there is a \nlocal scar (by cesarean section or other surgery). This case report calls for rare but \nrelevant differential diagnoses of pubalgia. It should always be considered in women \nwith suspicious symptoms and a history of previous abdominal surgery, especially \ncesarean. For the definitive diagnosis, in addition to complete semiology, a radiological \ninvestigation that includes nuclear magnetic resonance is routinely necessary.\n\n\nCopyright@ Thiago Sampaio Busato | Biomed J Sci & Tech Res | BJSTR. MS.ID.004752.\nVolume 29- Issue 1\nDOI: 10.26717/BJSTR.2020.29.004752\n22167\nadductor muscles or abdominal rectum. The treatment is initially \nconservative, with physiotherapy, rest, and anti-inflammatory \ndrugs. On the rare occasions when the painful condition persists \neven after conservative treatment, surgical treatment, indicated \non a case-by-case basis, may be required, including debridement \nof the pubic symphysis, partial pubectomy, adductor, and rectus \nabdominis tenotomy, or arthrodesis with use bone graft [5]. There \nis a multitude of differential diagnoses for pubalgia. Among them \nare intra-articular pathologies of the hip, urological diseases, \nabdominal wall dysfunctions, and gynecological diseases [6-9]. We \nhighlighted the abdominal wall endometrioma, with few reports of \noccurrence in the world literature [8-10]. In the previous literature, \nwe did not find a description of an abdominal wall endometrioma \nmimicking a pubalgia condition, as described in this report. The \npatient fully consented that her medical data and clinical (and \nradiological) images would be used for this case report. The authors \ndeclare that there are no conflicts of interest in this report.\nCase Report\n39-year-old female patient. Housewife, a practitioner of \nfitness and weight training in the gym. She sought our service for a \nsecond opinion with a previous diagnosis of pubalgia, as reported. \nComplained of chronic pain in the pubic region for approximately \na year, with gradual worsening. She reported pain worsening after \nphysical exercise and at night. When questioned, she reported \ncyclic worsening related to menstrual cycles and history of two \ncesarean deliveries and an abdominoplasty. She also reported \ntemporary pain improvement after the intramuscular application \nof corticosteroids, relapsing days later. She had been followed up in \nanother service and physiotherapy for six months, without favorable \nresults. Physical examination showed a normal gait. A typical \ntransverse scar from an abdominoplasty in the lower abdomen \nwas noted. Upon palpation, there was pain in the rectus abdominis \nmuscle topography at the right side of the lower abdominal \nregion (without a palpable mass). The range of motion of the \nhips was normal. There was no crural pain, the femoroacetabular \nimpingement maneuvers were negative, as well as the irritative \nsacroiliac maneuvers. The squeeze test was negative, and although \nshe presented mild pain to Grava’s test, she was still able to flex \nthe trunk. She had a radiograph in anteroposterior view of the \npelvis that showed discrete osteoarthritis of the pubic symphysis \nand bilateral morphology of pincer-type acetabular impingement \n(asymptomatic) (Figure 1).\nFigure 1: Radiograph of the pelvis in anteroposterior view. White arrow demonstrates osteoarthritis of the pubic symphysis.\nNew radiographs were requested, including the “flamingo” \nseries for pubalgia, and a MRI. These showed the presence of \na Morfological pincer-type impingement and confirmed the \nprevious findings of pubic symphysis arthrosis, in addition to mild \nsclerosis of the sacroiliac. The flamingo series did not present \nsignificant unevenness to alternating monopodial support. MRI \nof the pelvis demonstrated an oval lesion, with a fusiform aspect, \npoorly delimited, predominantly hypointense in T1 and with an \nintermediate signal in T2 / STIR, measuring about 40 mm in the \nlongest axis of the muscle right abdominal rectum, about 12 mm \nfrom the insertion in the pub, with diffuse enhancement by the \ncontrast. There was no tendonitis or bone edema. Therefore, \nabdominal wall endometriosis was suspected (Figures 2 & 3). Based \non the imaging findings and the endometrioma suspect, the patient \nwas referred to a gynecological team specialized in endometriosis. \nSurgical removal of the lesion was indicated. For this, the surgeon \nmade a 5cm incision on the previous scar, dissecting the planes up \nto the fascia of the rectus abdominis muscle. The lesion was just \ncranial to the pubic symphysis and was removed entirely. A nodule \nwith a typically endometriotic aspect was observed (Figures 4 & 5). \nThe patient evolved uneventfully in the postoperative period, with \ntotal improvement in pain symptoms at 4 weeks after surgery. The \nanatomopathological examination confirmed the initial hypothesis \nof endometrioma. After a year of follow-up, the patient remains \nasymptomatic and has resumed her physical activities.\n\nVolume 29- Issue 1\nDOI: 10.26717/BJSTR.2020.29.004752\n22168\nCopyright@ Thiago Sampaio Busato | Biomed J Sci & Tech Res | BJSTR. MS.ID.004752.\nFigure 2: Magnetic Resonance Imaging of the pelvis, axial section. White arrows demonstrate the tumor.\nFigure 3: Magnetic Resonance Imaging of the pelvis, sagittal section. White arrows demonstrate the tumor.\nFigure 4: Intraoperative image. The tumor is dissected from the right rectus abdominis muscle belly.\n\n\nCopyright@ Thiago Sampaio Busato | Biomed J Sci & Tech Res | BJSTR. MS.ID.004752.\nVolume 29- Issue 1\nDOI: 10.26717/BJSTR.2020.29.004752\n22169\nFigure 5: Image of the specimen (#15 scalpel blade for reference). Source: authors’ files.\nDiscussion\nSeveral terms are used as synonyms for pubalgia, such as pubic \nosteitis (used when there is an inflammatory cause), athlete’s \npubalgia, among others [4]. It is common to complain about the \npresence of pain in the pubic symphysis region, which can irradiate to \nthe abdomen, perineum, and inner thigh. Pain tipically progressively \nworsens with movement and improves with rest [2,3,4]. Treatment \nis eminently non-surgical, with physiotherapy, withdrawal from \nsports, systemic or local corticosteroids, and non-hormonal \nanti-inflammatory drugs. Among the differential diagnoses of \npubalgia are intra-articular pathologies of the hip, sacroiliitis, \nurological diseases, inguinal hernias, and gynecological diseases \n[6-9]. In this last group, there are ovarian cysts and abdominal wall \nendometriosis. Endometriosis is defined as the presence of tissue \nfrom the endometrium located outside the uterus. The prevalence \nranges from 8 to 15% of women of childbearing age 10 and can be \neither pelvic or extra-pelvic. Endometriosis of the rectus abdominis \nmuscle, as described in this clinical case, is rare, with only about 20 \ncases found in the literature [8-10]. When it forms a circumscribed \nmass, endometriosis is called an endometrioma [8]. One of the most \ncommon sites for the appearance of endometrioma is in the lower \nabdominal wall, especially if there is a local scar (by cesarean section \nor other surgery). The incidence of abdominal wall endometrioma \nafter the cesarean section varies from 0.03 to 0.8% of cases [8,9]. \nAlthough the number of women affected by pubalgia is still lower \nthan in men, the incidence tends to increase, with the increasing \nparticipation of women in high-impact sports related to the genesis \nof the disease (running, football, hockey, etc.). One of the factors \ncited as causative of the lower incidence of pubalgia in women \ncould be the shape of the female pelvis. The gynaecoid pelvis has a \nlarger area of insertion of the abdominal muscles, which increases \nthe area of distribution of forces and could prevent the disease \n[9]. Even so, it is necessary to value situations that can confuse the \ndiagnosis of pubalgia in women. This is due to a large number of \ndifferential diagnoses, such as gynecological pathologies, which can \nmimic the symptoms of the disease in the case presented here.\nIn this report, a patient with chronic pain was shown to have \na failure similar to that of her pubic pain. This case was first \ndiagnosed as pubalgia of mechanical etiology due to the location \nof the pain and presenting local alteration in the pubic symphysis \non the radiograph, which was compatible with the condition \ninitially suspected by the other colleagues. Besides, the presence \nof femoroacetabular impingement-although asymptomatic in this \ncase - could also lead to diagnostic error. However, the failure in the \nprevious treatment and the incomplete radiological investigation \nled us to consider other differential diagnoses. In this case, previous \ngynecological surgeries and localized pain in the abdominal wall’s \nmusculature alerted us to the possibility of some local alteration. \nMRI is essential as a diagnostic tool in the suspicion of pubalgia, \nbeing considered a gold-standard diagnostic test [1]. Therefore, \nwe must pay attention to the possibility of gynecological etiology \nin patients who present symptoms of pubalgia, but mainly in those \nwho are not part of the most familiar profile to the disease or who \ndo not respond adequately to the initial treatment.\nConclusion   \nThis case report calls attention for a rare but important \ndifferential diagnosis of pubalgia. It should always be considered \nin women with suspicious symptoms and a history of previous \nabdominal surgery, especially cesarean. For the definitive diagnosis, \nin addition to the complete semiology, a radiological investigation \nthat includes nuclear magnetic resonance is routinely necessary.\nReferences\n1. Gomes LSM (2015) Cirurgia Preservadora do Quadril Adulto. Atheneu \npp. 359-361. \n\nVolume 29- Issue 1\nDOI: 10.26717/BJSTR.2020.29.004752\n22170\nCopyright@ Thiago Sampaio Busato | Biomed J Sci & Tech Res | BJSTR. MS.ID.004752.\n2. Grava de Sousa JP , Fallopa F, Siqueira Jr D, Santa Cruz ARS (2005) \nTratamento cirurgico da pubalgia em jogadores de futebol profissional. \nRev Bras Ortop 40(10): 601-607.\n3. Schuroff A, Pedroni M, Deeke M, Valerio J, Vargas M, et al. (2012) Pubalgia \ncomo uma das causas de dispareunia. Rev Port Ortop Traum 20(1). \n4. Reis FA, Rosenfeld A, Ikawa MH, Silva FD, Costa JD, et al. (2008) A \nimportância dos exames de imagem no diagn óstico da pubalgia no \natleta. Rev Bras Reumatol 48(4).\n5. Matikainen M, Hermunen H, Paajanen H (2017) Athletic pubalgia in \nfemales: predictive value of MRI in outcomes of endoscopic surgery. \nOrthop J Sports Med 5(8): 2325967117720171.\n6. Oliveira AL, Andreoli CV, Ejnisman B, Queiroz RD, Pires OGN, et al. \n(2016) Perfil epidemiológico dos pacientes com diagnóstico de pubalgia \ndo atleta. Rev bras ortop 51(6).\n7. Branco RC, Fontenelle CRC, Miranda LM, Ching San Jr YA, Vianna EM \n(2010) Estudo comparativo por resson ância magnética de p úbis entre \natletas e sedentários assintomáticos. Rev bras ortop 45(6).\n8. Ozkan OF, Cikman O, Kiraz HA, Roach EC, Karacaer MA, et al. (2014) \nEndometrioma localized in the rectus abdominis muscle: A case report \nand review of literature. ABCD arq bras cir dig 27(3).\n9. Accetta I, Accetta P , Accetta AF, Maia FJS, Oliveira APFA (2011) \nEndometrioma de parede abdominal. ABCD arq bras cir dig 24(1).\n10. Gachabayov M, Horta R, Afanasyev D, Gilyazov T (2016) Abdominal wall \nendometrioma: Our experience in Vladimir, Russia. Niger Med J 57(6): \n329-333.\nSubmission Link: https://biomedres.us/submit-manuscript.php\nAssets of Publishing with us\n• Global archiving of articles\n• Immediate, unrestricted online access\n• Rigorous Peer Review Process\n• Authors Retain Copyrights\n• Unique DOI for all articles\nhttps://biomedres.us/\nThis work is licensed under Creative\nCommons Attribution 4.0 License\nISSN: 2574-1241\nDOI: 10.26717/BJSTR.2020.29.004752\nThiago Sampaio Busato. Biomed J Sci & Tech Res","source_license":"CC0","license_restricted":false}