Infiltrative endometriosis without endometrioma

The patient in the journal Radiology Case Reports was a 40-year-old woman, gravida 1, para 1, with a history of hysterectomy who presented with chronic abdominal pain and severe hematuria.¹

Magnetic resonance imaging (MRI) detected an infiltrative pelvic mass that mimicked a bladder malignancy for a neoplasm that showed subtle hyperintense components on T1-weighted images.

The diagnosis of infiltrative endometriosis was validated after cystoscopy and tissue sampling.

Afterward, the patient began hormonal therapy. Over the next 3 years, symptoms of pelvic pain and hematuria decreased in frequency and severity and quality of life also improved.

However, more recently the patient presented to the emergency department with large volume hematuria. She is currently being evaluated by gynecological oncology and urology services for potential mass resection and bladder reconstruction.

Increasing cancer antigen 125 (CA-125) levels can be used to monitor progression/recurrence of endometriosis, according to the authors, but it is not a serologic marker that should be deemed pathognomonic for endometriosis or reliable before surgical resection.

CA-125 measurements of at least 30 units/mL are suspect for recurrence of endometriosis in symptomatic patients but are not diagnostic. The patient for the case study had an elevated CA-125 of 93.9 IU/mL.

In addition, the patient had a 1- to 2-year history of painful hematuria and intermittently passes large clots. The pain, which was worse at night, induced nausea/vomiting with intermittent constipation.

The patient also reported severe dyspareunia, but no constitutional symptoms like weight loss or fever. Menarche started at age 12 and was painful throughout her reproductive life. Moreover, her single pregnancy was complicated by preeclampsia.

The patient’s hysterectomy was performed 10 years prior and current medical history includes morbid obesity.

Physical examination revealed that the patient's abdomen was tender to deep palpation in the lower quadrants. Conversely, external female genitalia was normal with an intact urethra and Skene ducts; however, speculum placement in the vagina produced significant pain. The cervix was also visualized and rectovaginal examination attempted, but manipulation of the area produced severe pain.

The overall suboptimal pelvic examination was secondary to guarding, discomfort, and patient's body habitus.

Nonetheless, the case report stresses the importance of pelvic examinations and imaging to begin exploring the etiology of chronic pelvic pain, even after a total hysterectomy.

“A differential diagnosis that could be considered for this case includes recurrence or metastasis from a primary gynecological tumor, metastasis from gastrointestinal tumor, urachal adenocarcinoma, as well as pseudosarcomatous fibromyxoid tumors,” wrote the authors.

A primary gynecological tumor recurrence is likely, given the patient’s history of prior surgery and unknown final pathology (due to care being provided in another country).

Symptomatic treatment of endometriosis may entail modulating hormone levels with medications, such as estrogen/progesterone oral contraceptives or gonadotropin-releasing hormone agonists, that target the various types of pain linked to endometriosis.

Surgical removal of the mass or masses is often definitive treatment, but can be complicated. Surgeons from multiple specialties, like gastrointestinal for colon, are needed to increase success.

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Reference

1. Dominguez JL, Mattinson TJ, Wang SS, et al. Infiltrative endometriosis without endometrioma: a case report and imaging findings mimicking a bladder malignancy. Radiol Case Rep. 2021. Oct 29;17(1):41-45. doi:10.1016/j.radcr.2021.09.059