{"paper_id":"9c34271c-e960-4124-9217-1784c061f659","body_text":"Okoye et al. Obstet Gynecol Cases Rev 2021, 8:209\nVolume 8 | Issue 5\nDOI: 10.23937/2377-9004/1410209\nCitation: Okoye IM, Omiwole O, Adeoye OM (2021) Primary Umbilical Endometriotic Nodule with an \nUltrasound Incidental Finding of Ovarian Endometrioma and a Solitary Intramural Uterine Myoma: A \nCase Report. Obstet Gynecol Cases Rev 8:209. doi.org/10.23937/2377-9004/1410209\nAccepted: September 13, 2021: Published: September 15, 2021\nCopyright: © 2021 Okoye IM, 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.\n• Page 1 of 5 •\nOkoye et al. Obstet Gynecol Cases Rev 2021, 8:209\nOpen Access\nISSN: 2377-9004\nObstetrics and\nGynaecology Cases - Reviews\nPrimary Umbilical Endometriotic Nodule with an Ultrasound \nIncidental Finding of Ovarian Endometrioma and a Solitary \nIntramural Uterine Myoma: A Case Report\nIfeanyi Martin Okoye1*, Olufemi Omiwole2 and Oluwatoyosi Mary Adeoye3\n1Department of Obstetrics and Gynaecology, Westcare Specialist Hospital, Lagos, Nigeria\n2Department of Family Medicine, Westcare Specialist Hospital, Lagos, Nigeria\n3All Saints University School of Medicine, Dominica\nCAse RepORt \nAbstract\nEndometriosis is the presence of endometrial stroma \noutside the uterine cavity. Endometrioma (chocolate cyst) is \nthe most common form of endometriosis. Primary umbilical \nendometriosis (PUE) is rare, with a prevalence of < 1% of \nendometriosis cases. Our case is a 25-year-old nulliparous \nfemale with a three-year history of infertility presenting with \nprimary umbilical endometriosis and an abdomino-pelvic \nultrasonography finding of a right endometrioma, and a \nsolitary intramural uterine myoma. These three findings in \na patient are a rare occurrence. Abdominopelvic ultrasound \nand excision biopsy was performed to arrive at a diagnosis.\nKeywords\nEndometrioma, Primary umbilical endometriotic nodule, \nIntramural uterine myoma, Ultrasoundscan, MRI, \nLaparoscopy\nCheck for\nupdates\nchronic pelvic pain in patients with dysmenorrhea [5]. \nOn average, there is a 7 to 10 years delay in diagnosis \n[7]. Subcutaneous endometriosis describes the types \nof endometriosis found in the skin and subcutaneous \ntissues. It accounts for 0.03 to 0.15% of cases [1]. It \npresents in two forms: Primary and secondary umbilical \nendometriosis. Primary umbilical endometriosis, also \nknown as villar’s nodules (villar first described the \nscenario in 1886), arises spontaneously with unclear \npathogenetic physiology, and it constitutes 75% of \ncases of all umbilical endometriosis. The secondary type \nresults from surgical procedures (laparoscopic and open \nsurgeries) involving the umbilicus [8].\nCase Description\nA 25-year-old nulliparous female with a medical \nhistory of infertility for three years presented with a \ncomplaint of cyclic dull aching umbilical pain that has \nbeen present for seven years and does not radiate. \nThe pain worsens during menstrual flow and is relieved \nwith analgesics. The patient also complained of \ndysmenorrhoea and deep dyspareunia.\nOn physical examination, the vital signs were normal. \nA hyperpigmented supraumbilical nodule was noted. \nThe nodule was warm, tender, and measured 2-3 cm in \nsize (Figure 1).\nThe rest of the exam was unremarkable. A differential \n*Corresponding author: Ifeanyi Martin Okoye, Department of Obstetrics and Gynaecology, Westcare Specialist Hospital, \nLagos, Nigeria\nIntroduction\nEndometriosis is a benign disease characterized by \nthe presence of endometrial tissue outside the uterus \n[1,2]. Endometriosis can occur in nearly every tissue \nand organ, including lungs, urinary tracts [3, 4] and the \novaries [4]. It was first described in 1690 by a German \nphysician Daniel Schroen [1]. Endometriosis affects \nroughly 10% (190 million) of reproductive-age women \nglobally [5]. Infertility is a common complication found \nin four out of ten women who have endometriosis \n[6]. In addition, endometriosis is implicated in 70% of \n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410209\nOkoye et al. Obstet Gynecol Cases Rev 2021, 8:209\n• Page 2 of 5 •\nnoticed. The endometrial cavity was well demonstrated. \nIn addition to the endometriotic nodule, A small solitary \nisoechoic mass was found in the anterior myometrium \nmeasuring 1.2 cm × 2.2 cm in size suggestive of an \nintramural uterine myoma seedling. Furthermore, a \nright-sided unilocular cyst measuring 6.8 × 6.9 cm, with \nan acoustic enhancement and a homogenous ground-\nglass echotexture was found suggestive of a possible \nendometrioma (Figure 3 and Figure 4).\nAn Excision biopsy of the supraumbilical nodule was \nperformed under general anesthesia to confirm the \ndiagnosis of a Sister Mary Joseph node was made to rule \nout a possible endometriotic nodule. An abdominopelvic \nultrasound report showed a supraumbilical mass with \nhomogeneous echotexture measuring 2 cm × 3 cm \n(Figure 2). The mass was attached to the underlying \nrectus sheath. Sonodiagnosis of the pelvis revealed an \nanteverted, non-gravid uterus measuring 5.8 × 4.5 mm \nin length and Anteriorposterior diameter, respectively, \nin addition the uterus showed a heterogeneous \nmyometrial echo pattern (Figure 3).\nNo intrauterine or extrauterine gestational sac was \n         \nFigure 1: Picture of the endometrotic nodule before excision.\n         \nFigure 2: Picture of the ultrasonogram of the umbilical nodule.\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410209\nOkoye et al. Obstet Gynecol Cases Rev 2021, 8:209\n• Page 3 of 5 •\n         \nFigure 3: Picture of the abdomino-pelvic sonogram of the endometroma, solitarymyoma (indicated by a blue arrow) and \nthe uterus.\n         \nFigure 4: Picture of the zoomed picture of the sonogram of the endometrioma.\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410209\nOkoye et al. Obstet Gynecol Cases Rev 2021, 8:209\n• Page 4 of 5 •\nfor the diagnosis is histological confirmation [1,8]. Other \ndiagnostically helpful tools include ultrasonography, \nwhich is usually the first choice of evaluation, computed \ntomography, magnetic resonance imaging, and Doppler \nultrasonography [14].\nThe differential diagnosis of cutaneous umbilical \nendometriosis includes lipoma, keloid, hypertrophic \nscars, granuloma, hernia, cutaneous metastasis of \ncancers, among others which were all considered. \nHowever, these lesions do not present with cyclical pain \nand discoloration of the mass as seen in this patient \n[1,14].\nThe treatment for cutaneous umbilical endometriosis \nis generally surgical excision, preferably performed at \nthe end of the menstrual cycle when the lesion is small \nto clear all the margins to prevent recurrence [1, 14]. \nOur patient had surgical excision of the mass, which was \neventually sent for histology but no surgery was done \nregarding the uterine myoma and endometrioma due \nto financial constraints.\nIt can also be treated with hormonal therapy, such \nas combining oral contraceptive pills and gonadotropin-\nreleasing hormone agonists like danazol, which were \nnot considered in the index patient as there was a \nhistory of infertility [1].\nRegarding the prognosis, recurrence is the \ncommonest problem encountered with endometriosis \nfollowing surgical treatment, Primary umbilical \nendometriosis will recur more than endometrioma [15].\nConclusion\nSince umbilical Endometriosis is a rare finding, a \nhigh index of suspicion is needed to make the diagnosis. \nAny young lady of reproductive-age with a complaint \nof a swollen painful umbilical nodule without any \nsurgical history should point towards this diagnosis. \nAs a result any patient suspected of primary umbilical \nendometriosis should undergo detailed history, \nexaminations with investigations in order to confirm \nand as well as look out for possible endometriosis in \nother parts of the body.\nThe management and treatment in poor resource \ncountries can be a daunting task since the procedures \nneeded to confirm and manage the condition is not \neasily accessible and when available, the price will be a \nmajor turnoff for patients.\nAcknowledgement\nWe hereby acknowledge the patient who gave us \nthe go ahead to write the case report and all the staff  \nof Westcare Hospital Ejigbo, Lagos Nigeria for the roles \nthey played in the management of the patient.\nConflict of Interest\nThe authors declare no conflict of interest.\ndiagnosis of the primary umbilical endometriosis.\nThe umbilical specimen was sent for a histology \nreview, and the histology examination showed a \nspecimen consisting of 2 pieces of amorphous greyish \nwhite tissue both measuring 2.0 × 1.0 × 0.5 cm. Cut \nsections are greyish white. Microscopic examination: \nOf histologic sections of skin tissue showed islands \nof unremarkable endometrial glands and stroma, \nsurrounded by hemosiderin-laden macrophages \nsuggestive of primary umbilical endometriosis. Further \nworkup to confirm the endometrioma with Magnetic \nresonance imaging (MRI) and laparoscopy was \nrequested for the patient, but no further workup was \ndone due to financial limitations.\nDiscussion\nEndometriosis is a common condition among women \nof a reproductive age group that negatively impacts their \nquality of life [9]. Histopathologically, it is defined by the \npresence of endometrial stroma and glands outside the \nendometrium [2,9].\nWhile ovarian endometriosis is the commonest \nform of endometriosis with a prevalence of 88% of all \ncases of endometriosis [10], Cutaneous endometriosis \nis a rare spread of endometriosis found on the anterior \nabdominal wall, including those that arise from a \nsurgical incision or spontaneously [5,11].\nIt is identified by the presence of endometrial stroma \nand glands in the skin [2]. This constitutes less than 1% \nof all cases [2].\nCutaneous endometriosis can be primary or \nsecondary. Primary, also known as spontaneous \ncutaneous endometriosis, is found in the absence of \nsurgery and usually located in the umbilicus, as seen in the \nindex patient [1]. The pathogenesis of endometriosis is \nstill not fully understood with Multiple etiopathogenesis \nincluding genetic susceptibility, hormonal, immune and \nenvironmental factors has also been discussed [12]. \nThe presence of both endometrioma and extrapelvic \n(umbilical) endometriosis can be explained by these \nmultifactorial etiopathogenesis [10].\nClinical features of endometriosis include cyclical \npain, chronic pelvic pain, dyspareunia, swelling, and \neven bleeding that correlates with their menstrual cycle \n[13,14]. It is important to note that it is an important \ncause of infertility [14]. Primary umbilical endometrosis \nwith an endometrioma coexisting with uterine myoma \nhas been reported in some publications [10].\nThe index patient experienced cyclical pain, \ndyspareunia, and discoloration in the umbilical swelling \naround her menstrual cycle. She also had a history \nof 3 years of infertility. While it is not every patient \nthat presents with all these symptoms, some can be \nasymptomatic [1]. While cutaneous endometriosis \ncould be suspected clinically, the current gold standard \n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410209\nOkoye et al. Obstet Gynecol Cases Rev 2021, 8:209\n• Page 5 of 5 •\n9. Hunt G, Allaire C, Yong PJ, Dunne C (2021) Endometriosis: \nAn update on diagnosis and medical management. BC Med \nJ 63: 158-163.\n10. Yunusa DM, Umar UH, Dahiru AMC (2019) Umbilical and \novarian endometriosis coexisting with multiple uterine \nmyomas: A rare case report. Indian J Case Reports 5: 44-\n46.\n11. Saliba C, Jaafoury H, El Hajj M, Nicolas G, Ahmad HH, \net al. (2019) Abdominal wall endometriosis: A Case report. \nCureus 11: e4061.\n12. Sourial S, Tempest N, Hapangama DK (2014) Theories on \nthe pathogenesis of endometriosis. Int J Reprod Med 2014: \n179515.\n13. Alimi Y, Iwanaga J, Loukas M, Tubbs RS (2018) The clinical \nanatomy of endometriosis: A review. Cureus 10: e3361. \n14. Matei A-M, Draghici Ionescu A-M, Cioplea M, Zurac S, \nBoda D, et al. (2021) Skin endometriosis: A case report and \nreview of the literature. Exp Ther Med 21: 1-5.\n15. Konstantinos N, Ma L, McKinnon B, Mueller MD (2020) \nRecurrence patterns after surgery in patients with different \nendometriosis subtypes: A long-term hospital-based cohort \nstudy. J Clin Med 9: 496.\nReferences\n1. Ade-Ojo IP, Ipinnimo OM (2021) Menstruating primary \numbilicus cutaneous endometriosis: A case report and \nreview of the literature. Clin J Obstet Gynecol 4: 69-71.\n2. Seung-Hee L, Lew B-L, Sim W-Y (2017) Primary cutaneous \nendometriosis of umbilicus. Ann Dermatol 29: 621-625.\n3. Dimitra C, Koukoura O, Ntavela IG, Chintziou F, Gkorila \nG, et al. (2018) Gastrointestinal and urinary tract \nendometriosis: A review of the commonest locations of \nextrapelvic endometriosis. Adv Med.\n4. Hyun JL, Park YM, Jee BC, Kim B, Suh CS, et al. \n(2015) Various anatomic locations of surgically proven \nendometriosis: A single-center experience. Obstet Gynecol \nSci 58: 53-58.\n5. Parasar P, Ozcan P, KLT (2018) Endometriosis: \nEpidemiology. Curr Obs Gynecol Rep 6: 34-41.\n6. Bulletti C, Coccia ME, Battistoni S, Borini A (2010) \nEndometriosis and Infertility. J Assist Reprod Genet 27: \n441-447.\n7. Johnston Jennifer L, Reid H, Hunter D (2015) Diagnosing \nendometriosis in primary care. British Journal of General \nPractice 65: 101-102.\n8. Lorenzo C, Sciascia V, Loiaco G, Guida G, Iarrobino F, et \nal. (2020) Primary subcutaneous umbilical endometriosis: \nCase report and review of the literature. Case Rep Surg \n2020: 8899618.","source_license":"CC0","license_restricted":false}