Undiagnosed Endometriosis: A Rare Case of Frozen Pelvis

Undiagnosed Endometriosis: A Rare Case of Frozen Pelvis Correspondence Address : Dr. Minal A Kalambe, Assistant Professor, Department of Obstetrics and Gynaecology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research, Deemed to be University (DU), Nagpur-440022, Maharashtra, India. E-mail: [email protected] A 40-year-old woman, para two live two, arrived at the emergency room complaining of dysmenorrhoea for three years and postcoital bleeding for four years. She had no previous history of any operation. Her presentation was consistent with acute pain in the abdomen, and she took treatment for that, but it was not relieved. She had no significant family history. Her vital signs, urinalysis, and complete blood count were within normal limits. Her ultrasonography report showed a bilateral ovarian cysts with a 12-week-sized uterus (Table/Fig 1). The differential diagnoses of frozen pelvis included pelvic inflammatory disease, pelvic adhesion disease, recurrent ovarian cysts, leiomyoma, adenomyosis, and hydrosalpinx. A laparotomy was performed. Upon examination, the uterus was 12 weeks in size, adhered posteriorly to the rectosigmoid colon, and had a right ovarian cyst measuring 6×5 cm and a left ovarian chocolate cyst measuring 4×3 cm (Table/Fig 2). The surgeon requested assistance during the surgery and attempted to remove the adhesion, inadvertently rupturing the wall of the left cyst. The cyst was extracted along with its contents. A salpingo-oophorectomy was conducted after aspirating the left ovarian cyst (chocolate in colour). Further dissection was not possible due to injury to the bowel and rectosigmoid region. A senior consultant confirmed the diagnosis of a frozen pelvis. The uterus, along with both ovaries, was removed and sent for histopathology, after which the abdomen was closed in layers. The uterus weighed 210 g. The patient had an uneventful postoperative recovery. During follow-up, she received a monthly subcutaneous injection of goserelin 3.5 g. She reported no further complaints of abdominal pain. The histopathology report revealed endometriosis as the cause of the frozen pelvis. Gonadotropin-releasing hormone, Laparotomy, Ovarian cyst Endometriosis occurs in 10-15% of all reproductive-age females and 70% of women with persistent pelvic pain (1). Endometriosis is estimated to affect 176 million women worldwide, with 26 million cases documented in India (2). There are three types of endometriosis: Peritoneal, ovarian, and Deep Infiltrating Endometriosis (DIE). DIE is a term for the infiltration of endometrial tissue deposits about five millimeters into surrounding tissue (3). Endometriosis can be detected by laparoscopy in between 34% and 48% of Indian women, according to several studies (1),(2). Women with endometriosis have complained of difficulty in conceiving, dysmenorrhoea, dyspareunia, dysuria, dyschezia, and abnormal or dysfunctional uterine bleeding. These patients may be asymptomatic or have non specific symptoms such as nausea, vomiting, dyspareunia, haematochezia, abdominal pain, abdominal distension, and abnormal bowel habits (diarrhoea, constipation) (3). Diagnosing a frozen pelvis due to endometriosis requires a thorough evaluation. Initial Imaging like transvaginal ultrasound, Magnetic Resonance Imaging (MRI), or Computed Tomography (CT) scans may help visualise adhesions and their impact on pelvic structures. Laparoscopy is the gold standard for diagnosing endometriosis and assessing the extent of pelvic adhesions (4). Dienogest is equally effective as Gonadotropin-releasing Hormone (GnRH) agonists at a dose of 2 mg/day but has fewer side effects (Evidence Level A) (5). GnRH agonist is one of the choices for treating pain brought on by endometriosis. Leuprolide and goserelin are the most frequently utilised GnRH agonists (6). To rule out rare cases of cancer, it is recommended that doctors should submit histopathology for ovarian endometrioma or DIE (7),(8). To minimise adhesions and related difficulties in endometriosis patients, adhesiolysis with either oxidised regenerated cellulose absorbable barrier or adhesion barrier gel could be considered in surgical treatments for endometriosis (9). Endometriosis recurrence can be reduced or delayed by using progestins, GnRH analogs, or Oral Contraceptive Pills (OCP) after surgery for at least six months (10),(11). Surgery can be abandoned due to a lack of skilled surgeons. Surgery should be executed at a location with easy access to these facilities (12). Neuropathic pain, which may be confused with endometriosis pain, can arise from nerves growing within the adhesions of highly adherent organs. To relieve the previously stated adhesions and symptoms, a frozen pelvis necessitates immediate surgery (13). The endometriosis-related frozen pelvis is a severe and challenging expression of this common gynecological disease. For those impacted, early detection, precise diagnosis, and a thorough treatment plan are crucial for symptom relief, enhancing quality of life, and addressing problems with conception. Before selecting the aggressive surgical path, patients must be informed of the shortand long-term risks associated with such significant procedures. Further research and clinical advancements are essential to refining treatment approaches. DOI: 10.7860/JCDR/2024/67962.19306 Date of Submission: Oct 09, 2023 Date of Peer Review: Dec 21, 2023 Date of Acceptance: Jan 31, 2024 Date of Publishing: Apr 01, 2024 AUTHOR DECLARATION: • Financial or Other Competing Interests: None • Was informed consent obtained from the subjects involved in the study? Yes • For any images presented appropriate consent has been obtained from the subjects. Yes PLAGIARISM CHECKING METHODS: • Plagiarism X-checker: Oct 09, 2023 • Manual Googling: Dec 25, 2023 • iThenticate Software: Jan 27, 2024 (2%) ETYMOLOGY: Author Origin EMENDATIONS: 6 - Emerging Sources Citation Index (Web of Science, thomsonreuters) - Index Copernicus ICV 2017: 134.54 - Academic Search Complete Database - Directory of Open Access Journals (DOAJ) - Embase - EBSCOhost - Google Scholar - HINARI Access to Research in Health Programme - Indian Science Abstracts (ISA) - Journal seek Database - Popline (reproductive health literature) - www.omnimedicalsearch.com