AMERICAN JOURNAL OF SURGERY CASE REPORTS Available online at online.naturelibrary.org Nature Library Ltd. * Correspondence to: Elvis Vargas Castillo, Coloproctology Unit, Domingo Luciani Hospital, Caracas, Venezuela; E-mail: elvisvargasc@hotmail.com © 2020 Elvis Vargas Castillo. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hosting by Nature Library Ltd. All rights reserved. http://dx.doi.org/10.47496/nl.AJSCR.2020.01.03 Research Article Perineal Endometriosis: What to Do in These Cases - Analysis of 13 Patients Elvis Vargas Castillo 1* , Ingrid Melo Amaral 1 , Sthephania López 1 , Mariangela Pérez Paz 1 , Daniel Chiantera 1 , Jenils Coacuto 1 , Bonilla Eliana 1 and María Pérez 2 1 Coloproctology Unit, Domingo Luciani Hospital, Caracas, Venezuela 2 Obstetric-Gynecology Department, Domingo Luciani Hospital, Caracas, Venezuela A R T I C L E I N F O Article history: Received: 1 September, 2020 Accepted: 16 September, 2020 Published: 29 September, 2020 Keywords: perineal endometriosis, clinical features, endoanal ultrasonography, hormonal therapy, sphincteroplasty A B S T R A C T Objective: To analyse the clinical features of perineal endometriosis (PEM), its treatment and outcome. Methods: Prospective, single-centre study with 13 patients with PEM who were treated between 2011-2018 at Domingo Luciani Hospital and mean followed up for 58.4 months. Results: Mean age was 32,2 years. All cases had a history of vaginal delivery with an episiotomy. All complained of perineal pain related to the menstrual cycle; the perineal mass progressively increased in size and was tender during menstrual periods. Mean VAS was 7. 69,2% with rectal bleeding. The mean size of the lesion was 3.42 cm. CA125 levels were measured in all patients, 3 (23,1%) with abnormal range; all patients were subjected to transvaginal, endoanal ultrasonography (EUS) and FNAB before surgery. Anal sphincter (AS) involvement was demonstrated by EUS in 46.2% (6). Mean EUS pre-treatment volume 18.98 ml. First, these 6 patients received hormonal therapy based on GnRH and evaluated response. Mean EUS post-treatment volume 10.21 ml p < 0.05. Complete local excision was performed on all cases. Mean CCFIS preoperative was 2.46 and postoperative 3.01 p=0.01. No major complications or recurrences were noted. Conclusion: PEM presents with typical clinical features when it involves the AS, it could benefit from first a hormonal therapy before surgery. EUS is a useful preoperative tool to decide what we should do. The main idea at the time of surgery is performed a complete local excision with non-touch AS, and in cases where these aren’t possible, a sphincteroplasty is mandatory with good continence results, minor complications and no recurrences. © 2020 Elvis Vargas Castillo. Published by Nature Library Ltd. All rights reserved 1. Introduction Endometriosis, which is defined as the presence of endometrial tissues outside of the uterine cavity, is one of the most common diseases in women of reproductive age, affecting 3-10% of these. In general, endometriosis can be divided into pelvic and extrapelvic sites. Endometriosis is commonest in the pelvis. The areas of the pelvis most frequently affected are the peritoneum, the ovaries, the pouch of Douglas, and the uterosacral ligament. It is very occasionally found in extrapelvic sites such as the gastrointestinal tract, pulmonary structures, the urinary system, abdominal wall, perineum or vagina, skin, and even the central nervous system. A widely accepted theory on the pathogenesis is that endometrial tissue is transplanted outside the endometrial cavity either by retrograde menstrual flow, or lymphatic or hematogenic transport [1]. Perineal endometriosis is the occurrence in the perineum of endometrial glands and stroma that respond to the hormone variations in the cycle, and when islands of endometrial tissues invade the sphincteric muscular tissue, perineal endometriosis with anal sphincter involvement occurs. Endometriosis of perineum and vulva, accounting for less than 1% of cases of surgically treated endometriosis, has been reported in the literature with the most common site being episiotomy scars [2, 3]. Similarly, seeding of endometrial tissue into wounds may be responsible for endometriosis developing in perineal scars. Since 1923, case studies of perineal endometriosis with anal sphincter involvement, a condition that has a low prevalence, have been published in the obstetric and gynecologic literature [4]. Using PubMed and ScienceDirect to search about this condition, we realized it was relatively rare disease; the diagnosis and treatment of the disease need to be further studied. This prospective study shows 13 cases of perineal endometriosis that received surgical treatment with or without pre/post hormonal therapy between January 2011 and July 2018 in Domingo Luciani Hospital. Through the following analysis of the clinical features, diagnosis, medical or surgical treatment, and prognosis of the 13 cases, we put forward our understanding of the diagnosis and treatment of the disease.