Primary Umbilical Endometriosis Coexisting with Multiple Uterine Myomas : A Rare Case Report

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Nongo, Dennis Anthony Isah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3121760/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Endometriosis and Uterine fibroids affect millions of women world-wide. Primary endometriosis is said to be very rare. The coexistence of endometriosis with uterine myomas (Ieiomyomata) has been reported in few publications. Although the aetiology and natural history of the conditions are markedly different. Symptoms can overlap and make differential diagnosis necessary, often times making use of some invasive investigative tools such as laparoscopy. The two conditions may manifest with considerable comorbities and these needs to be taken into account when treating fibroids and/or endometriosis. Yet to be fully understood are the genetic basis of these two conditions, but recent evidence suggest common underpinnings. We here by present a patient with Primary umbilical endometriosis with coexisting multiple uterine fibroids, who had radical excision (Omphalectomy) and abdominal myomectomy. To the best of our knowledge, a similar case has not been reported before. Umbilical endometriosis Multiple uterine fibroids. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Endometriosis is a benign gynaecologic condition defined by the presence of endometrial glands and stroma outside the uterus [ 1 ]. Endometriosis is said to affect roughly 10% (190 million) of women and girls in their repro-age group globally[ 2 ]. Annual incidences in specific populations varies from 0.112%[ 3 ] to 0.72%[ 4 ]. Endometriosis can be found at different sites: Superficial endometriosis found mainly on the pelvic peritoneum, cystic ovarian endometriosis (endometrioma) found in the ovaries, deep endometriosis found in the recto-vaginal septum, bladder, and bowel; and in rare cases endometriosis has also been found outside the pelvis.[ 5 , 6 ] Umbilical endometriosis represents 30–40% of the cases of endometriosis that occur on the abdominal wall and around 0.5-1.0% of all cases of endometriosis.[ 7 ] The pelvic cavity is the most common location of endometriotic implants, but about 12% of lesions are extragenital [ 8 , 9 ] and, among the extra-pelvic sites, endometriosis of the abdominal (AWE) is the most common.[ 10 ] Umbilical Endometriosis (UE) or villar’s nodule, as first described by Villar in 1886, is defined as the presence of endometrial glands and or stroma within the umbilicus. It is a rare form of endometriosis with a frequency of around 0.4–4% of extragenital lesions. [ 11 , 12 ] Umbilical Endometriosis is said to be primary or secondary. Primary Umbilical Endometriosis occurs in the absence of a surgical history, whereas secondary Umbilical Endometriosis arises on scar following abdominal procedures such as laparoscopy.[ 12 , 13 ] The classification into primary and secondary endometriosis appears to be important in the pathogenic mechanism of this disease forms. Several theories have been proposed as to the pathogenesis of primary Umbilical Endometriosis these include, migration of endometrial cells through the abdominal cavity, the lymphatic system, or embryonic remnants in the Umbilical fold (e.g the Urachus and Umbilical vessels): genetic predisposition; and immunologic defects, and after prolonged exposure to the metaplastic and environmental factors. [ 13 , 14 ] The fact still remains that the etiology of endometriosis is not fully understood, however there are risks factors which include, family history short menstrual cycle length, and previous history of pelvic surgery or laparoscopy.[ 15 ] Recent evidence from classic and genetic epidemiology points to an association of endometriosis and uterine fibroids. [ 15 , 16 ] This is a rare case of Primary Umbilical Endometriosis coexisting with multiple uterine fibroids. To the best of our knowledge, a similar case has not been reported before. Case Report She was a 46 year old, middle aged, single, nulliparous woman who presented to our gynaecology clinic with complaints of recurrent lower abdominal pains of 10 years duration, umbilical swelling and cyclical bleeding through the umbilicus both of 3 months duration. The lower abdominal pain was cramping in nature, it gets worst two days prior to the onset of her menstruation and lasts all through the duration of menstrual flow, it was non radiating, but it gets relieved by the ingestion of oral analgesic. She also had associated deep dyspareunia. Her menstrual periods were regular and were not heavy. The umbilical swelling use to get worse during her menses. The cyclical bleeding from the umbilicus starts two days before the onset of her menses and continues for the entire duration of her menstrual flow. She was not using any form of hormonal contraception. Her medical history was not significant and she never had any abdominal surgeries. On physical examination, all her vital signs were within their normal ranges. Abdominal examination revealed a 3cm x 3cm nodule at the umbilicus which was dark brown in colour, with hyph-pigmented nodules, that were non-tender on palpation ( Fig. 1 ). The uterus was 18 weeks size with nodular surface, but it was non-tender and immobile. There was no ascites. On digital vaginal examination, there were no nodules felt in the pouch of Douglas nor on the utero-sacral & cardinal ligaments. The recto-vaginal pouch was also free of nodules. She had an abdomino pelvic Ultrasound Scan (USS) ( Fig. 2 A ) , which revealed, that the umbilicus contained a lobulated mixed echogenic lesion, that measured 2.0cm x 1.5cm. Colour Doppler interrogation did not reveal abnormal vascular pattern. The uterus ( Fig. 2 B ) was lobulated, it contained multiple varying sizes of isoechoic masses within the myometrium, that completely distorted the endometrial plate. The largest of the masses was seen in the anterior myometrium. It measured 7.6cm x 5.4cm. Both ovaries were visualized and were within normal limits. There was poor soft tissue delineation in the adnexae. The cul-de-sac was preserved. The urinary bladder was compressed by the above anteriorly located masses in the myometrium. The diagnoses from the abdomino-pelvic ultrasound scan were that of multiple uterine fibroids and umbilical endometriosis. Abdominopelvic computed tomography scan (CT-Scan) ( Fig. 3 B ) revealed that the uterus was grossly enlarged and distorted with a lobulated outline. It demonstrated multiple (about 3), soft tissues masses (HU 47), that involved predominantly the posterior inferior aspect of the uterus with relative sparing of the fundus and anterior surfaces as well as the cervical mass. This masses demonstrated central non-enhancing hypodense areas that were likely due to cystic degeneration. The largest, which was seen posteriorly measured 7.5cm x 5.3cm x 5.7cm in size. The masses appeared to have caused significant mass effect on the urinary bladder, the bowel loops, sigmoid colon and also displacement of the endometrial plate. There was an irregular enhanced soft tissue dense lesion that was seen at the umbilical region, it measured 2.4 x 2.4cm. ( Fig. 3 A ) .The liver, spleen, gall bladder, and pancreas were all morphologically normal. The lung windows showed normal broncho vascular markings. The bone marrow window demonstrated normal bones and joints. The diagnosis from the CT scan of the abdomen and pelvis, were that of multiple uterine fibroids and umbilical endometriosis. Chest x-ray-posterior/anterior view (CXR-PA), revealed a heart that was normal in size and outline with a cardiothoracic ratio of 0.48. Both lung fields were clear and the recesses were free. The bony thorax was normal. The conclusion from the chest x-ray was that of a normal study. Laboratory investigations which included Full Blood Count (FBC), serum electrolyte, urea and creatinine (s/e/u/cr) and serology screening were all normal. Her blood group was O Rhesus negative, two pints of compatible O Rh negative blood were cross-matched and made available on the day of surgery. The following diagnoses were made, primary Umbilical endometriosis coexisting with multiple uterine leiomyomas. She had abdominal myomectomy, intra-peritoneal adhesiolysis, and radical excision of the primary umbilical endometriosis. Histopathological analysis of the samples that were taken confirmed umbilical endometriosis and leiomyomata uteri. ( Fig. 4 ) Discussion Endometriosis is a disease in which endometrial glands and stroma implant and grow in areas outside the uterus. Endometriosis thus commonly cause significant morbidity among women of reproductive age group.[ 17 , 18 ] Endometriosis is diagnosed in women who are of 12–80 years in age, and the average age at diagnosis is said to be approximately 28.[ 19 ] Our patient was 46 years. Women who are caucasians appear to be more likely to suffer from endometriosis than African Americans or Asians.[ 20 ] There are several types of endometriosis, these include Ovarian, peritoneal, deep infiltrating (DIE) and endometriosis of other locations, which is where umbilical endometriosis belongs.[ 21 ] Endometriosis occurring outside the pelvis is a rare phenomenon. Literature data provide information on respiratory endometriosis, pericardial endometriosis and endometriosis in a scar after surgery with laparotomy access. [ 22 , 23 ] The commonest locations of endometriosis are the ovaries (up to 88% of all cases), followed by the appendix, intestine, cervix, omentum and skin.[ 24 ] 70% of cutaneous endometriosis, more frequently are secondary, which follow previous abdominopelvic surgery, but can appear spontaneously (30%), when they occur in the absence of prior surgery.[ 24 ] When there is primary endometriosis, it appears most commonly on the umbilicus, followed by the inguinal region [ 24 , 25 , 26 ] and these are cases in which the lateral abdominal wall is involved.[ 27 , 28 ] Our patient had primary umbilical endometriosis because she did not have any prior abdominal surgery. The pathogenic mechanism of cutaneous endometriosis is still in the realm of speculation. It has been thought to arise from iatrogenic implantation for example following previous surgeries or from haematogenous or lymphatic metastasis of endometrial tissues[ 24 , 29 ]. In the case of our patient, the umbilical endometriosis may have arisen most likely from haematogenous or lymphogenous metastasis of endometrial tissue. Spontaneous endometriosis is said to be associated with more severe pelvic disease than scar endometriosis. There were moderate pelvic adhesion seen in our patient which made the exteriorization of the uterus and the passage of a Foley catheter tourniquet at the Cervico- isthmic junction and at the base of the broad ligament impossible. Umbilical endometriosis could present with symptoms such as swelling at the umbilicus,Umbilical swelling that correlates with the menstrual cycle, and bleeding from the umbilicus which is usually cycle, but some patients are asymptomatic. [ 24 , 29 , 30 ] Our patient presented with a growth at the umbilicus and cyclical bleeding at the umbilicus. More often than not Umbilical endometriosis is associated with pelvic endometriosis with complaint of dysmenorrhea, dyspaurenia, or pain while defaecating.[ 24 ] Our patient had pelvic endometriosis as was evidenced by the finding of moderate pelvic adhesion at surgery, as such she also presented with symptoms of dysmenorrhea and deep dyspaurenia. On examination of the abdomen, umbilical endometriosis presents as a rubbery or firm nodule, and it’s size may vary from several millimeters to 6cm. [ 24 , 29 , 30 ] Our patient had a 3cm x 3cm nodule at the umbilicus which was dark brown in colour, with hyperpigmented areas, it was non-tender. Even though umbilical endometriosis can be suspected based on the clinical presentation, but confirming the diagnosis by histopathologic analysis is good clinical practice.[ 31 ] It is also vital to differentiate umbilical endometriosis from the other metastatic tumours of the umbilicus which are well known as sister Mary Joseph nodule (SMJN).[ 26 ] The golden standard for the diagnosis of umbilical endometriosis is histopathological examination, however diagnostic tools such as ultrasound, Magnetic Resonance Imaging (MRI) or CT Scan can be helpful. [ 31 ] Our patient had an abdominal pelvic ultrasound scan which diagnosed umbilical endometriosis and multiple uterine fibroids. She also had an abdominal CT Scan which diagnosed umbilical endometriosis and multiple leiomyomas. We do not have an MRI in our hospital and it’s also quite expensive in other facilities that has it within our locality as such it was not done. Transcutaneous ultrasound scan ,MRI or CT Scan can be helpful in investigating the relationship of the nodule with the surrounding tissue and also helps to differentiate between other umbilical lesions such as umbilical hernia.[ 32 , 33 , 34 ] Fine needle aspiration cytology can be supplementary, but results have been reported to be inconclusive in as high as 75% of cases.[ 35 ] A high level of tumour makers such as CEA and CA 125 may raise the suspicion of concomitant pelvic endometriosis.[ 8 ] In our case, the typical presentation along with an USS and CT Scan revealing no invasion in the underlying structures was found sufficient to establish a tentative diagnosis in order to initiate treatment. When considering a diagnosis of umbilical endometriosis, the following differentials should be taken into account, melanocyte naevus, endosalpingiosis presenting as periumbilical papules, pyogenic/foreign body granuloma, umbilical polyp, seborrheic keratosis, epithelial inclusion cyst, desmoid tumour, haemangioma, keloid, omphalltis, umbilical hernia and granular cell tumour.[ 32 ] The following should also be ruled out, primary or secondary neoplasms, such as melanoma or sister Mary Joseph’s nodule. [ 32 , 33 , 36 , 37 , 38 ] The risk of malignancy in cases of umbilical endometriosis is quite low, only three cases have been reported to be associated with malignancy. Umbilical endometriosis can be managed surgically or medically but surgical management is the preferred. Our patient had radical Omphalectomy at the same that she had a midline abdominal incision for abdominal myomectomy. At the time of the radical omphalectomy, the margin of 1cm was respected, she also had a repair of the underlying fascia. The literature reports a 13–15% incidence of simultaneous pelvic endometriosis presence.[ 39 ] At the time of the laparotomy to perform abdominal myomectomy there were no obvious pelvic endometriotic deposits, however the finding of moderate pelvic adhesions and some red cell pigments that were lying freely in her pelvis, suggests that she also had pelvic endometriosis. Medical treatment is still a subject of debate. Medical treatment is intended to ameliorate the symptoms by reducing the size of the umbilical nodule, thereby limiting the amount of specimen to be excised and reducing angiogenesis. The overall results from medical treatment of umbilical endometriosis is said to be poor due to the relatively low levels of oestrogen receptors found in cutaneous endometriotic lesions. [ 34 , 40 , 41 ] The following medical agents have been used to treat umbilical endometriosis: Danazol or GnRH analogues, progesterone and oral contraceptives. Our patient was not offered medical treatment; this was because she had multiple uterine fibroids, which were also an indication for abdominal myomectomy. The prognosis of umbilical endometriosis is good if an optimal and complete surgical excision is achieved, like in our case. Our case was uncommon in that it was in association with an enlarged uterus of about 16 week’s equivalent of gestational age, due to multiple uterine fibroids (a total of 13 uterine fibroid nodules were enucleated at surgery). The correlation of the pathogenesis between the endometriosis and the uterine fibroids was unclear. The genetic foundations of both uterine fibroids and endometriosis are yet to be fully and clearly understood, but recent evidence seems to suggest common underpinings.[ 42 ] Recent evidence from classic and genetic epidemiology also points to an association of both conditions. [ 15 , 16 ] Our patient had umbilical endometriosis coexisting with multiple uterine fibroids. Surgery is a treatment option for both umbilical endometriosis and uterine fibroids. The aim of the surgical modality of treatment for umbilical endometriosis is to relieve pain and the cyclical bleeding during menstruation. This is achieved by removing all visible lesions or signs of the disease. [ 43 ] The symptoms of uterine fibroids such as heavy menstrual bleeding, pain, pressure and reduced fertility can also be improved by surgery. 44 Our patient had radical omphalectomy and abdominal myomectomy and her symptoms were proven to have been relieved during her follow-up visits. Conclusions The most common gynaeocological diseases that affect women’s quality of life are uterine fibroids and endometriosis. Recent data is showing a common pathogenesis between endometriosis and uterine fibroid, this is from genetic studies and partly because they both have an oestrogen related pathophysiology. This common pathogenesis implies that women with endometriosis are also at risk of having uterine fibroids and vice versa. This has an important implication for treatment of either condition. Thus, it is more beneficial when contemplating surgery in a woman who presents with these two conditions to have surgery for both endometriosis and uterine fibroids at the same time. Experience with our patient has shown that surgery for these two conditions leads to a good outcome and an improvement in the quality of life for the patient. Declarations Ethical Approval and consent to participate: Ethical approval was obtained from the Human and research ethical committee of University of Abuja Teaching Hospital. Consent to Publication: informed consent for publication was obtained from the participant. Data Availability statement: Not applicable for that section. Conflict of interest: No conflict of interest Funding: No funding Acknowledgment: I wish to acknowledged Chief Medical Director, Department of Obstetrics and Gynaecology and the Department of Pathology of University of Abuja Teaching Hospital for their continuous support. Author contribution: Dr. BH Nongo and DA Isah were the consultant who managed the patient and did the case report. All authors have read and approved the manuscript. References Theunissen CI, Ijpma FF. Primary Umbilical endometriosis: a Cause of a painful nodule. J Surg case Rep. 2015; (3) 1–3. Zonderoan KT, Becker CM, Missmer SA, Endometriosis. N Engl J Med. 2020;382:1244–56. 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Clinical practice, Endometriosis. N Engl J Med. 2010;362:2389–98. Stewart EA, Laughlin. Tommaso SK, Catherino WH, Lalitkumar S, Gupta D, Vollenhoven B. Uterine fibroids. Nat Rev Dis Prim. 2016;2:16643. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3121760","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":217160378,"identity":"9fc31a79-c822-499a-959a-12d90c01213f","order_by":0,"name":"Benjain H. Nongo","email":"","orcid":"","institution":"University of Abuja Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Benjain","middleName":"H.","lastName":"Nongo","suffix":""},{"id":217160379,"identity":"025deace-b7f4-4e5f-8311-931bde5a2aa4","order_by":1,"name":"Dennis Anthony Isah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYDCCA2DEwGAAIhKAiJ+BgY0oLRJwLZINRGhhgGsB6TI4QEAL3/Hegwd/1NypM2fvPSbx4I9dnvGN5GcPPlQwyPOLHcCqRfLMuYTDPMeeSVj2nEuTSGxLLja7kWZuOOMMg+HM2QlYtRjcyDE4zMB2WALIMJNIbGBO3HYjwUyatw3owts4tNx/Y3Dwxz+oloQ/9YmbZ6R/w6/lBo/BAd42mBa2w4kbJHLw2yJ5Bugw3r7DkhvOnDG2SGw7njjjzJsyyRlnJHD6he/4GeOPP74d5jc43mN488ef6sT+9vRtEh8qbOT5pbFrQQYsEmBKAKxSgqByEGD+AKb4DxClehSMglEwCkYOAABaoGnt+X12wwAAAABJRU5ErkJggg==","orcid":"","institution":"University of Abuja Teaching Hospital","correspondingAuthor":true,"prefix":"","firstName":"Dennis","middleName":"Anthony","lastName":"Isah","suffix":""}],"badges":[],"createdAt":"2023-06-28 19:14:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3121760/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3121760/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":39925295,"identity":"8e3d3e9f-2625-4368-a46d-cfd52f074341","added_by":"auto","created_at":"2023-07-12 14:53:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":358327,"visible":true,"origin":"","legend":"\u003cp\u003eShows the Villar’s nodules\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3121760/v1/cb61ebb66d867a753eb2953c.png"},{"id":39925287,"identity":"659dedd0-ca08-487b-b623-839f2f181613","added_by":"auto","created_at":"2023-07-12 14:53:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":515172,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA: \u003c/strong\u003eShows USS of the Umbilical lesion which revealed a lobulated mixed echogenic lesion. No abnormal vasculature on coloured dopper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB: \u003c/strong\u003eShows abdominopelvic USS image that revealed multiple uterine fibroids.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3121760/v1/c3bda11fb4426e136aab889c.png"},{"id":39925280,"identity":"6fc0b17a-4167-47aa-8b73-8c9b879837a8","added_by":"auto","created_at":"2023-07-12 14:53:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":362676,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA: \u003c/strong\u003eShows the CT Scan image of the primary umbilical endometriotic nodules\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB: \u003c/strong\u003eShows the CT Scan image of the multiple uterine fibroids\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3121760/v1/280a48375980a720507687d0.png"},{"id":39925292,"identity":"b9ff75dd-df3f-4e6c-a9d5-2e84de52ac1d","added_by":"auto","created_at":"2023-07-12 14:53:47","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1249748,"visible":true,"origin":"","legend":"\u003cp\u003eShows the micrograph of the umbilical endometriosis\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3121760/v1/93f0d545b6d847ab2026df41.png"},{"id":49835439,"identity":"5aa895fd-a090-4388-a1a4-6e63999f415a","added_by":"auto","created_at":"2024-01-18 18:22:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2445884,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3121760/v1/fb9b627e-a5d9-4906-b288-a8b481ed9127.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Primary Umbilical Endometriosis Coexisting with Multiple Uterine Myomas : A Rare Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometriosis is a benign gynaecologic condition defined by the presence of endometrial glands and stroma outside the uterus [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Endometriosis is said to affect roughly 10% (190\u0026nbsp;million) of women and girls in their repro-age group globally[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Annual incidences in specific populations varies from 0.112%[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] to 0.72%[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Endometriosis can be found at different sites: Superficial endometriosis found mainly on the pelvic peritoneum, cystic ovarian endometriosis (endometrioma) found in the ovaries, deep endometriosis found in the recto-vaginal septum, bladder, and bowel; and in rare cases endometriosis has also been found outside the pelvis.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Umbilical endometriosis represents 30\u0026ndash;40% of the cases of endometriosis that occur on the abdominal wall and around 0.5-1.0% of all cases of endometriosis.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] The pelvic cavity is the most common location of endometriotic implants, but about 12% of lesions are extragenital [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and, among the extra-pelvic sites, endometriosis of the abdominal (AWE) is the most common.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Umbilical Endometriosis (UE) or villar\u0026rsquo;s nodule, as first described by Villar in 1886, is defined as the presence of endometrial glands and or stroma within the umbilicus. It is a rare form of endometriosis with a frequency of around 0.4\u0026ndash;4% of extragenital lesions. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Umbilical Endometriosis is said to be primary or secondary. Primary Umbilical Endometriosis occurs in the absence of a surgical history, whereas secondary Umbilical Endometriosis arises on scar following abdominal procedures such as laparoscopy.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] The classification into primary and secondary endometriosis appears to be important in the pathogenic mechanism of this disease forms.\u003c/p\u003e \u003cp\u003eSeveral theories have been proposed as to the pathogenesis of primary Umbilical Endometriosis these include, migration of endometrial cells through the abdominal cavity, the lymphatic system, or embryonic remnants in the Umbilical fold (e.g the Urachus and Umbilical vessels): genetic predisposition; and immunologic defects, and after prolonged exposure to the metaplastic and environmental factors. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] The fact still remains that the etiology of endometriosis is not fully understood, however there are risks factors which include, family history short menstrual cycle length, and previous history of pelvic surgery or laparoscopy.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Recent evidence from classic and genetic epidemiology points to an association of endometriosis and uterine fibroids. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] This is a rare case of Primary Umbilical Endometriosis coexisting with multiple uterine fibroids. To the best of our knowledge, a similar case has not been reported before.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eShe was a 46 year old, middle aged, single, nulliparous woman who presented to our gynaecology clinic with complaints of recurrent lower abdominal pains of 10 years duration, umbilical swelling and cyclical bleeding through the umbilicus both of 3 months duration. The lower abdominal pain was cramping in nature, it gets worst two days prior to the onset of her menstruation and lasts all through the duration of menstrual flow, it was non radiating, but it gets relieved by the ingestion of oral analgesic. She also had associated deep dyspareunia. Her menstrual periods were regular and were not heavy. The umbilical swelling use to get worse during her menses. The cyclical bleeding from the umbilicus starts two days before the onset of her menses and continues for the entire duration of her menstrual flow. She was not using any form of hormonal contraception. Her medical history was not significant and she never had any abdominal surgeries. On physical examination, all her vital signs were within their normal ranges. Abdominal examination revealed a 3cm x 3cm nodule at the umbilicus which was dark brown in colour, with hyph-pigmented nodules, that were non-tender on palpation \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e The uterus was 18 weeks size with nodular surface, but it was non-tender and immobile. There was no ascites.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOn digital vaginal examination, there were no nodules felt in the pouch of Douglas nor on the utero-sacral \u0026amp; cardinal ligaments. The recto-vaginal pouch was also free of nodules. She had an abdomino pelvic Ultrasound Scan (USS) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eA\u003cb\u003e)\u003c/b\u003e, which revealed, that the umbilicus contained a lobulated mixed echogenic lesion, that measured 2.0cm x 1.5cm. Colour Doppler interrogation did not reveal abnormal vascular pattern. The uterus \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eB\u003cb\u003e)\u003c/b\u003e was lobulated, it contained multiple varying sizes of isoechoic masses within the myometrium, that completely distorted the endometrial plate. The largest of the masses was seen in the anterior myometrium. It measured 7.6cm x 5.4cm. Both ovaries were visualized and were within normal limits. There was poor soft tissue delineation in the adnexae. The cul-de-sac was preserved. The urinary bladder was compressed by the above anteriorly located masses in the myometrium. The diagnoses from the abdomino-pelvic ultrasound scan were that of multiple uterine fibroids and umbilical endometriosis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAbdominopelvic computed tomography scan (CT-Scan) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003eB\u003cb\u003e)\u003c/b\u003e revealed that the uterus was grossly enlarged and distorted with a lobulated outline. It demonstrated multiple (about 3), soft tissues masses (HU 47), that involved predominantly the posterior inferior aspect of the uterus with relative sparing of the fundus and anterior surfaces as well as the cervical mass. This masses demonstrated central non-enhancing hypodense areas that were likely due to cystic degeneration. The largest, which was seen posteriorly measured 7.5cm x 5.3cm x 5.7cm in size. The masses appeared to have caused significant mass effect on the urinary bladder, the bowel loops, sigmoid colon and also displacement of the endometrial plate. There was an irregular enhanced soft tissue dense lesion that was seen at the umbilical region, it measured 2.4 x 2.4cm.\u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003eA\u003cb\u003e)\u003c/b\u003e .The liver, spleen, gall bladder, and pancreas were all morphologically normal. The lung windows showed normal broncho vascular markings. The bone marrow window demonstrated normal bones and joints. The diagnosis from the CT scan of the abdomen and pelvis, were that of multiple uterine fibroids and umbilical endometriosis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eChest x-ray-posterior/anterior view (CXR-PA), revealed a heart that was normal in size and outline with a cardiothoracic ratio of 0.48. Both lung fields were clear and the recesses were free. The bony thorax was normal. The conclusion from the chest x-ray was that of a normal study. Laboratory investigations which included Full Blood Count (FBC), serum electrolyte, urea and creatinine (s/e/u/cr) and serology screening were all normal. Her blood group was O Rhesus negative, two pints of compatible O Rh negative blood were cross-matched and made available on the day of surgery.\u003c/p\u003e \u003cp\u003eThe following diagnoses were made, primary Umbilical endometriosis coexisting with multiple uterine leiomyomas. She had abdominal myomectomy, intra-peritoneal adhesiolysis, and radical excision of the primary umbilical endometriosis. Histopathological analysis of the\u003c/p\u003e \u003cp\u003esamples that were taken confirmed umbilical endometriosis and leiomyomata uteri.\u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEndometriosis is a disease in which endometrial glands and stroma implant and grow in areas outside the uterus. Endometriosis thus commonly cause significant morbidity among women of reproductive age group.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Endometriosis is diagnosed in women who are of 12\u0026ndash;80 years in age, and the average age at diagnosis is said to be approximately 28.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Our patient was 46 years. Women who are caucasians appear to be more likely to suffer from endometriosis than African Americans or Asians.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] There are several types of endometriosis, these include Ovarian, peritoneal, deep infiltrating (DIE) and endometriosis of other locations, which is where umbilical endometriosis belongs.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Endometriosis occurring outside the pelvis is a rare phenomenon. Literature data provide information on respiratory endometriosis, pericardial endometriosis and endometriosis in a scar after surgery with laparotomy access. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe commonest locations of endometriosis are the ovaries (up to 88% of all cases), followed by the appendix, intestine, cervix, omentum and skin.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] 70% of cutaneous endometriosis, more frequently are secondary, which follow previous abdominopelvic surgery, but can appear spontaneously (30%), when they occur in the absence of prior surgery.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] When there is primary endometriosis, it appears most commonly on the umbilicus, followed by the inguinal region [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and these are cases in which the lateral abdominal wall is involved.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] Our patient had primary umbilical endometriosis because she did not have any prior abdominal surgery.\u003c/p\u003e \u003cp\u003eThe pathogenic mechanism of cutaneous endometriosis is still in the realm of speculation. It has been thought to arise from iatrogenic implantation for example following previous surgeries or from haematogenous or lymphatic metastasis of endometrial tissues[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In the case of our patient, the umbilical endometriosis may have arisen most likely from haematogenous or lymphogenous metastasis of endometrial tissue. Spontaneous endometriosis is said to be associated with more severe pelvic disease than scar endometriosis. There were moderate pelvic adhesion seen in our patient which made the exteriorization of the uterus and the passage of a Foley catheter tourniquet at the Cervico- isthmic junction and at the base of the broad ligament impossible. Umbilical endometriosis could present with symptoms such as swelling at the umbilicus,Umbilical swelling that correlates with the menstrual cycle, and bleeding from the umbilicus which is usually cycle, but some patients are asymptomatic. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Our patient presented with a growth at the umbilicus and cyclical bleeding at the umbilicus. More often than not Umbilical endometriosis is associated with pelvic endometriosis with complaint of dysmenorrhea, dyspaurenia, or pain while defaecating.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Our patient had pelvic endometriosis as was evidenced by the finding of moderate pelvic adhesion at surgery, as such she also presented with symptoms of dysmenorrhea and deep dyspaurenia. On examination of the abdomen, umbilical endometriosis presents as a rubbery or firm nodule, and it\u0026rsquo;s size may vary from several millimeters to 6cm. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Our patient had a 3cm x 3cm nodule at the umbilicus which was dark brown in colour, with hyperpigmented areas, it was non-tender. Even though umbilical endometriosis can be suspected based on the clinical presentation, but confirming the diagnosis by histopathologic analysis is good clinical practice.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] It is also vital to differentiate umbilical endometriosis from the other metastatic tumours of the umbilicus which are well known as sister Mary Joseph nodule (SMJN).[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe golden standard for the diagnosis of umbilical endometriosis is histopathological examination, however diagnostic tools such as ultrasound, Magnetic Resonance Imaging (MRI) or CT Scan can be helpful. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] Our patient had an abdominal pelvic ultrasound scan which diagnosed umbilical endometriosis and multiple uterine fibroids. She also had an abdominal CT Scan which diagnosed umbilical endometriosis and multiple leiomyomas. We do not have an MRI in our hospital and it\u0026rsquo;s also quite expensive in other facilities that has it within our locality as such it was not done. Transcutaneous ultrasound scan ,MRI or CT Scan can be helpful in investigating the relationship of the nodule with the surrounding tissue and also helps to differentiate between other umbilical lesions such as umbilical hernia.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] Fine needle aspiration cytology can be supplementary, but results have been reported to be inconclusive in as high as 75% of cases.[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] A high level of tumour makers such as CEA and CA 125 may raise the suspicion of concomitant pelvic endometriosis.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] In our case, the typical presentation along with an USS and CT Scan revealing no invasion in the underlying structures was found sufficient to establish a tentative diagnosis in order to initiate treatment.\u003c/p\u003e \u003cp\u003eWhen considering a diagnosis of umbilical endometriosis, the following differentials should be taken into account, melanocyte naevus, endosalpingiosis presenting as periumbilical papules, pyogenic/foreign body granuloma, umbilical polyp, seborrheic keratosis, epithelial inclusion cyst, desmoid tumour, haemangioma, keloid, omphalltis, umbilical hernia and granular cell tumour.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] The following should also be ruled out, primary or secondary neoplasms, such as melanoma or sister Mary Joseph\u0026rsquo;s nodule. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] The risk of malignancy in cases of umbilical endometriosis is quite low, only three cases have been reported to be associated with malignancy.\u003c/p\u003e \u003cp\u003eUmbilical endometriosis can be managed surgically or medically but surgical management is the preferred. Our patient had radical Omphalectomy at the same that she had a midline abdominal incision for abdominal myomectomy. At the time of the radical omphalectomy, the margin of 1cm was respected, she also had a repair of the underlying fascia. The literature reports a 13\u0026ndash;15% incidence of simultaneous pelvic endometriosis presence.[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] At the time of the laparotomy to perform abdominal myomectomy there were no obvious pelvic endometriotic deposits, however the finding of moderate pelvic adhesions and some red cell pigments that were lying freely in her pelvis, suggests that she also had pelvic endometriosis.\u003c/p\u003e \u003cp\u003eMedical treatment is still a subject of debate. Medical treatment is intended to ameliorate the symptoms by reducing the size of the umbilical nodule, thereby limiting the amount of specimen to be excised and reducing angiogenesis. The overall results from medical treatment of umbilical endometriosis is said to be poor due to the relatively low levels of oestrogen receptors found in cutaneous endometriotic lesions. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] The following medical agents have been used to treat umbilical endometriosis: Danazol or GnRH analogues, progesterone and oral contraceptives. Our patient was not offered medical treatment; this was because she had multiple uterine fibroids, which were also an indication for abdominal myomectomy. The prognosis of umbilical endometriosis is good if an optimal and complete surgical excision is achieved, like in our case. Our case was uncommon in that it was in association with an enlarged uterus of about 16 week\u0026rsquo;s equivalent of gestational age, due to multiple uterine fibroids (a total of 13 uterine fibroid nodules were enucleated at surgery). The correlation of the pathogenesis between the endometriosis and the uterine fibroids was unclear. The genetic foundations of both uterine fibroids and endometriosis are yet to be fully and clearly understood, but recent evidence seems to suggest common underpinings.[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] Recent evidence from classic and genetic epidemiology also points to an association of both conditions. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Our patient had umbilical endometriosis coexisting with multiple uterine fibroids. Surgery is a treatment option for both umbilical endometriosis and uterine fibroids. The aim of the surgical modality of treatment for umbilical endometriosis is to relieve pain and the cyclical bleeding during menstruation. This is achieved by removing all visible lesions or signs of the disease. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] The symptoms of uterine fibroids such as heavy menstrual bleeding, pain, pressure and reduced fertility can also be improved by surgery. \u003csup\u003e44\u003c/sup\u003e Our patient had radical omphalectomy and abdominal myomectomy and her symptoms were proven to have been relieved during her follow-up visits.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe most common gynaeocological diseases that affect women\u0026rsquo;s quality of life are uterine fibroids and endometriosis. Recent data is showing a common pathogenesis between endometriosis and uterine fibroid, this is from genetic studies and partly because they both have an oestrogen related pathophysiology. This common pathogenesis implies that women with endometriosis are also at risk of having uterine fibroids and vice versa. This has an important implication for treatment of either condition. Thus, it is more beneficial when contemplating surgery in a woman who presents with these two conditions to have surgery for both endometriosis and uterine fibroids at the same time. Experience with our patient has shown that surgery for these two conditions leads to a good outcome and an improvement in the quality of life for the patient.\u003c/p\u003e"},{"header":"Declarations","content":"\u003col style=\"list-style-type: lower-roman;\"\u003e\n \u003cli\u003eEthical Approval and consent to participate: Ethical approval was obtained from the Human and research ethical committee of University of Abuja Teaching Hospital.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eConsent to Publication:\u0026nbsp;informed consent for publication was obtained from the participant.\u003c/li\u003e\n \u003cli\u003eData Availability statement: \u003cstrong\u003eNot applicable for that section.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Conflict of interest: No conflict of interest\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Funding: No funding\u003c/li\u003e\n \u003cli\u003eAcknowledgment: I wish to acknowledged Chief Medical Director, Department of Obstetrics and Gynaecology and the Department of Pathology of University of Abuja Teaching Hospital for their continuous support.\u003c/li\u003e\n \u003cli\u003eAuthor contribution: Dr. BH Nongo and DA Isah were the consultant who managed the patient and did the case report. \u003cstrong\u003eAll authors have read and approved the manuscript.\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eTheunissen CI, Ijpma FF. 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Tommaso SK, Catherino WH, Lalitkumar S, Gupta D, Vollenhoven B. Uterine fibroids. Nat Rev Dis Prim. 2016;2:16643.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Umbilical endometriosis, Multiple uterine fibroids.","lastPublishedDoi":"10.21203/rs.3.rs-3121760/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3121760/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEndometriosis and Uterine fibroids affect millions of women world-wide. Primary endometriosis is said to be very rare. The coexistence of endometriosis with uterine myomas (Ieiomyomata) has been reported in few publications. Although the aetiology and natural history of the conditions are markedly different. Symptoms can overlap and make differential diagnosis necessary, often times making use of some invasive investigative tools such as laparoscopy. The two conditions may manifest with considerable comorbities and these needs to be taken into account when treating fibroids and/or endometriosis. Yet to be fully understood are the genetic basis of these two conditions, but recent evidence suggest common underpinnings. We here by present a patient with Primary umbilical endometriosis with coexisting multiple uterine fibroids, who had radical excision (Omphalectomy) and abdominal myomectomy. To the best of our knowledge, a similar case has not been reported before.\u003c/p\u003e","manuscriptTitle":"Primary Umbilical Endometriosis Coexisting with Multiple Uterine Myomas : A Rare Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-12 14:53:42","doi":"10.21203/rs.3.rs-3121760/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b456bcf6-6e36-49b2-b352-e1c457706258","owner":[],"postedDate":"July 12th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-18T18:14:16+00:00","versionOfRecord":[],"versionCreatedAt":"2023-07-12 14:53:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3121760","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3121760","identity":"rs-3121760","version":["v1"]},"buildId":"2u56kwukJI3zHK-uzyFNs","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}