Unusual presentation of a case of endometriosis diagnosed without laparoscopy

Because of the varied symptoms and clinical presentation, it is important to keep endometriosis in the differential diagnosis of women of child bearing age with chronic pelvic pain. Despite the fact that laparoscopy is key to the definitive diagnosis of endometriosis; due to its invasive nature, the successful diagnosis is largely contingent upon appropriate clinical acumen and judgment. One of the major shortcomings and resultant patient complaints of current clinical practice and management is the delay in diagnosis due to the difficulty in efficiently applying the current diagnostic criteria. To that end, it is important that we continually work to expand our knowledge of all potential markers of the condition so that the diagnosis can be made in a quicker timeframe going forward. In the case of this patient, there were two relatively unique symptoms exhibited. The first was post-coital nausea and vomiting and the second was bilateral lower limb pain. Due to the direct connection between the pelvis and peritoneal cavity in women, the theory of retrograde menstruation posits that endometriosis can spread to the peritoneal space. It is possible that due to excess physical stimulation during intercourse, irritation of inflamed ectopic endometrial sites could trigger feelings of nausea and cause vomiting. In the case of the second symptom; ectopic endometrial tissue in the lower extremities could contribute to bilateral lower limb pain; similarly to how it can cause pelvic and abdominal pain.

In this patient with a four year history of endometriosis, several non-laparoscopic symptoms were crucial to arriving at her ultimate diagnosis. She had some very classical clinical symptoms such as dyspareunia, progressively worsening pelvic pain, pelvic fullness, and lower back pain that began leading up to the menstrual cycle and resolved shortly after menstrual flow. On CT scan, she had what is known as the “kissing ovaries” sign and an endometrioma, which are well known to be associated with endometriosis. In addition to the more typical signs above, she also had two uncommon findings: post-coital symptoms and bilateral lower limb pain. Future work from a diagnostic and data-gathering standpoint could focus on identifying how common these signs are in other patients with a diagnosis of endometriosis. Overall, identification of the wider array of symptoms, laboratory values, and imaging findings associated with endometriosis is important to making the diagnostic process more efficient and helping patients with the condition get appropriate care sooner than they currently do.

Endometrioma, Endometriosis, Kissing ovaries, Pelvic pain How to cite this article Horvath D, Pandey U. Unusual presentation of a case of endometriosis diagnosed without laparoscopy. J Case Rep Images Obstet Gynecol 2023;9(1):28–30. Article ID: 100140Z08DH2023 ********* Figure 2: Axial CT with contrast showing multicystic, juxtaposed ovaries in the pouch of Douglas (“kissing sign”). Although difficult to discern, part of the endometrioma is tangent to the anterior rectal wall. Figure 3: Coronal CT with contrast showing multiloculated ovaries. Inferomedial to the ovaries is a homogenous appearing cyst likely to represent an endometrioma. Journal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 28–30. ISSN: 2582-0249 J Case Rep Images Obstet Gynecol 2023;9(1):28–30. www.ijcriog.com Horvath et al. 30 doi: 10.5348/100140Z08DH2023CI

1. Ajayi A, Ajayi V, Oyetunji I, Biobaku O, Aikhuele H, Afolabi BM. Abdominal scar endometriosis and hemothorax in a Nigerian woman: A case report. Gynecol Obstet (Sunnyvale) 2017;7(2):430. ********* Author Contributions David Horvath – Conception of the work, Acquisition of data, Analysis of data, Interpretation of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved Utkarsh Pandey – Design of the work, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved Guarantor of Submission The corresponding author is the guarantor of submission. Source of Support None. Consent Statement Written informed consent was obtained from the patient for publication of this article. Conflict of Interest Authors declare no conflict of interest. Data Availability All relevant data are within the paper and its Supporting Information files. Copyright © 2023 David Horvath et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information. Access full text article on other devices Access PDF of article on other devices Submit your manuscripts at www.edoriumjournals.com