Unusual Presentation of Rectovaginal Septum Endometriosis: Cystic Endometrioma

Study Objective

To report and to illustrate with video a rare case of endometriosis of the rectovaginal septum presented as a cystic endometrioma.

Design

Case report.

Setting

Private hospital.

Patients or Participants

We present the case of a 39-year-old woman diagnosed with endometriosis in 2016. At the time, diagnose was due to anal pain during menstrual period, however, we do not have access to old imaging exams.

Since then, symptoms diminished using continuous dienogest, and she had been amenorrhea for 4 years.

In physical examination she had a painful bulging retrocervical nodule occupying the posterior vaginal fornix up to 4 cm to vaginal introitus.

Transvaginal sonography with bowel preparation shows normal uterus and adnexa, an endometriotic nodule in rectosigmoid measuring 4.3cm, at 10cm from anal verge affecting 20% of its circumference. Also, a cystic endometrioma in rectovaginal septum measuring 6.3 × 4.7 × 4.5 cm.

Interventions

In February 2021, the patient was scheduled for a laparoscopic surgery to treat deep endometriosis. We performed the exeresis of a 6 cm cystic endometrioma of rectovaginal septum, rectosigmoidectomy with end-to-end anastomosis at 2 cm from anal verge and protective loop ileostomy, colporrhaphy and exeresis of peritoneal endometriosis.

Measurements and Primary Results

Surgery duration time was 3h30min, estimated blood loss was about 50 ml. The patient was discharged in the second postoperative day. And the final pathological report confirmed endometriosis of all specimens.

Conclusion

Endometriosis of the rectovaginal septum is quite rare. Due to the distal topography, a precise imaging report is necessary. Once the anastomosis was at 2 cm from anal verge and we opened the vagina, we opted for the protective loop ileostomy to reduce the anastomotic leak rates.