e ce Reccurent severe endometriosis ic lini – Case presentation cl i c ri zur az I. Ioiart, H. Mureøanu Ca West University Vasile Goldiø, Urology, Arad, Romania Abstract Introduction and objective: Endometriosis is the presence of normal endometrial mucosa abnormally implanted in locations other than the uterine cavity, characterized by severe pain. In this paper we explore a case of endometrio- sis with urologic involvement. Material and methods: A 24 year old girl, already diagnosed with endometriosis 4 years prior, was admitted with dysuria, flank pain, and hematuria at the time of menses, pelvic pain and pelvic tenderness. Ultrasound examination revealed bilateral hydronephrosis and large right ovarian cyst. GnRh antagonist treatment was initiated, right hydronephrosis disappearing after 10 days. MRI detected rectal involvement and multiple pelvic adesions, and con- firmed the ultrasound findings. Left retrograde ureteroscopy and stenting were not possible. Results: Patient was operated for laparatomy adhesiolysis to restore normal intrapelvic organ mobility. Then right salpingo-oophorectomy and cytoreduction of visible endometriosis was performed, and the left ureteric pelvic obstruction was treated by ureterocystoneostomy. Conclusions: Any postpubertal patient going to the operating room for acute or chronic pelvic / abdominal pain could have endometriosis, therefore consulting with a physician having the experience to recognize, diagnose, and treat this disease is prudent. Conservation of future fertility may be dependent on the conservative and meticulous surgical approach of an expert reproductive surgeon. Key words: endometriosis, salpingo-oophorectomy, adesions Correspondence: Dr. Horia Mureøanu Universitatea de Vest „Vasile Goldiø” Arad B-dul Revolutiei nr. 94 Tel.: 0744878655 E-mail: hmuresanu@gmail.com 3 9 3 9 nr. 3 / 2013 • vol 12 Revista Românæ de Urologie
ce e Introduction Medical therapy with gonadotropin-releasing hor- ic Endometriosis is defined as the presence of normal mone (GnRH) analogues 3 cycles (3-5 months) every lini endometrial mucosa (glands and stroma) abnormally year was prescribed by the gynecologist, but symp- implanted in locations other than the uterine cavity. (1) toms reappeared after the treatment was stopped. cl This condition is a common, poorly understood, For rapid onset of medical castration antiandrogen i c and extremely debilitating benign gynecologic condi- treatment with GnRh antagonist was initiated. Right ri tion. The psychologic impact of the severe pain experi- hydronephrosis disappeared after 10 days. zur enced by the patient is compounded by the negative Transvaginal ultrasonography identifyied right cyst impact of the disease on fertility. (2) of the ovary containing low-level homogenous inter- az The exact cause and pathogenesis of endometrio- nal echoes consistent with old blood. Ca sis is unclear. It is likely a combination of various factors that cause and determine the severity of this disease. (3) From our experience with 10 operated cases with urologic involvement we present our last case. Material and methods We present a case of a nulliparity 24 year old girl Fig. 2 Right ovary cyst Fig. 3 Left UHN with recurrent severe endometriosis. Patient was admitted in hospital with dysuria, flank MRI was helpful and detected rectal involvement pain, and hematuria at the time of menses, pelvic pain and multiple pelvic adesions. MRI confirmed the ultra- and pelvic tenderness. sound findings of the right cyst in the ovary (Fig. 2) and A bluish nodule was identified in the vagina due to the left ureterohydronephrosis (Fig. 3) due to multiple infiltration from the posterior vaginal wall. pelvic adhesions. Ultrasound examination revealed bilateral Left retrograde ureteroscopy and stenting were not hydronephrosis and large right ovarian cyst. possible. She was diagnosed with endometriosis 4 years ago when left salpingo-oophorectomy for large ovarian cyst was performed. Histologic demonstration of both Result endometrial glands and stroma in biopsy specimens Patient was operated for laparatomy adhesiolysis obtained from outside the uterine cavity confirmed to restore mobility and normal intrapelvic organ rela- the diagnosis of endometriosis. tionships was performed followed by right salpingo- Dysmenorrhea, heavy or irregular bleeding contin- oophorectomy and cytoreduction of visible endome- ued, associated with pelvic pain, lower abdominal or triosis. Left ureteric pelvic obstruction was treated by back pain, dyspareunia, dyschezia (pain on defecation) ureterocystoneostomy. often with cycles of diarrhea and constipation, inguinal pain, pain on micturition and/or urinary frequency and pain during exercise. Discussion In 2011 coaxial retrograde stenting for 12 weeks Treating patients with endometriosis should be was performed for treatment of catamenial intermit- done by an experienced physician in the diagnosis and tent left ureterohydronephosis (UHN) (Fig. 1). management of this condition and its complications, such as an obstetrician/gynecologist. If extensive dis- ease is present, specialists in reproductive endocrinol- ogy, urology, colorectal surgery, and even gynecologic oncology may be required. Fig.1 Left UHN before stenting 4 0 4 0 Revista Românæ de Urologie nr. 3 / 2013 • vol 12
ce e Conclusion References ic Any postpubertal patient going to the operating 1. Lobo RA.: Endometriosis: etiology, pathology, diagnosis, man- lini agement. In: Comprehensive Gynecology. Philadelphia, PA: room for acute or chronic pelvic/abdominal pain could Mosby; 5th ed:2007:chap 19. have endometriosis, therefore consulting with a physi- 2. Shepard MK, Mancini MC, Campbell GD Jr, George R.: Right- cl cian having the experience to recognize, diagnose, and i c sided hemothorax and recurrent abdominal pain in a 34-year- treat this disease is prudent. Conservation of future fer- old woman. Chest. Apr 1993;103(4):1239-40. ri tility may be dependent on the conservative and 3. Markham SM, Carpenter SE, Rock JA.: Extrapelvic zur meticulous surgical approach of an expert reproduc- endometriosis. Obstet Gynecol Clin North Am. Mar 1989;16(1):193-219. tive surgeon. (4) az 4. Jubanyik KJ, Comite F.: Extrapelvic endometriosis. Obstet Ca Gynecol Clin North Am. Jun 1997;24(2):411-40. 4 1 4 1 nr. 3 / 2013 • vol 12 Revista Românæ de Urologie
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