Unusual Complications and Causes of Endometriosis

William G. Karow, M.D.
Associate Clinical Professor, Department of Obstetrics and Gynecology, U.C.L.A.

Endometriosis, Aspects and Proceedings of a Symposium
Saint John's Hospital and Health Center, Santa Monica, California
Editor: J.J. Marik

We assume that endometriosis can occur in any part of the body. Retrograde flow of menstrual blood accounts for the majority of cases, but the unusual sites require other theories of spread such as hematologic, lymphatic or celomic metaplasia.

Table ) reflects the first reported case and the number of reported cases in each of these unusual sites; there are of course many unreported cases.

Congenital Tract Anomalies

There have been 41 cases of endometriosis associated with congenital anomalies of the vagina, cervix or uterus with obstruction to the outflow of menstrual blood and retrograde flow (Table 2). Of these, 33 occurred under the age of 21 with the average age of 17, while fourteen were under the age of
16. Early diagnosis and proper treatment are mandatory since delay can necessitate radical surgery including hysterectomy. In this group of patients, in no way does it require 5 years after ovulatory menses to develop. Any teenager with uterine retroflexion or uterosacral modularity who has acquired progressive dysmenorrhea which is refractory to standard methods of therapy is recommended for endoscopy.

Ruptured Endometrioma in Pregnancy

It is rare for an endometrial cyst to rupture suddenly, particularly so in pregnancy. Generally, these cysts should decrease in size. However, the enlarging uterus may cause gradually increasing tension and/or pressure in these cysts, and the descent of the head or any sudden strain or pressure might rupture one of them.

Differential diagnosis includes the pre-operative diagnosis (Table 3) plus any other G.I. catastrophe and is related to the trimester in which the rupture occurs. In this group of patients, although 5 had living children (Table 4), each had some span of time since her last pregnancy. In all patients but one, pain was acute and medical attention was sought fairly rapidly; endometriosis was known to be present in two.

Treatment is dictated by the findings, but with the new drug regimens available, conservative surgery with preservation of child-bearing ability is usually indicated.

Pulmonary Endometriosis

The distinct differences of etiology and symptomology of endometriosis of the lung and pleura are reflected in Tables 5 and 6. In lesions of the lung, the chief complaint is steadily progressive hemoptysis which after a few months seems to correlate with the menstrual period. There was a definite history of endometrial trauma (D&C, abortion, C-section or abnormal delivery) which most likely was the source of hematogenous spread.

In contrast, pleural endometriosis usually presents, due to symptoms of pleural effusion, secondary to direct extension through the diaphragm from abdominal endometriosis. Barnes and Nicholson state that blood removed at thoracentesis has no fibrin layer, fails to clot, and is thus menstrual blood. Treatment, whether hormonal suppression, surgical or x-ray castration, gives good results.

The syndrome of recurrent catamenial pneumothorax, first described by Mauer in 1958, is summarized in Table 7.

  

Ureteral Endometriosis
Of the 86 cases reported in Table 8, 26 were primary or intrinsic with the ureter, the site of invasive disease (which may penetrate the mucosa) and frequently the only site.

The secondary or extrinsic form (60 cases) causes ureteral obstruction by external pressure without invading the ureter. Some of the primary cases represent further invasion of the secondary type.
One case of ureteral endometriosis of the ureter undergoing malignant change has been reported by Ferrera and Clayton in 1958.

The patient's history, as seen in Table 9, frequently reveals that she has had several pelvic operations before signs and symptoms of urinary tract involvement develop, suggesting long-standing disease and an aggressive process. Symptoms tend to be cyclic. Frequently dysuria, hematuria, and suprapubic pain are exaggerated just before and during the menstrual period. Pain frequently radiates to the groin and medial aspects of the thigh. An enlarged endometriotic ureteral node might easily account for cyclic urinary-tract symptoms by compression of the terminal ureter. Should secondary complications develop, such as a hydroureter, hydronephrosis or pyelonephritis, symptoms should be the same as those associated with these urologic problems of obstructive diseases from other causes.

Of the 86 cases, ages ranged from 21 to 63 with an average of 40.5. A number of these patients were postmenopausal, and therefore the damage caused at this point is due to subsequent fibrosis and for this reason castration or suppression may not always be effective.

If endometriosis is sufficiently severe to require surgical intervention, an IVP is indicated. Of the 73 cases in which treatment was described, 15
showed loss of a functioning kidney and 43 required castration, thus reflecting long-standing disease, a very serious aspect of endometriosis.

Obstructive Endometriosis of the Rectosigmoid

In this disease, symptoms are usually cyclic with progressive constipation, and must be differentiated from diverticulitis and carcinoma.

In patients with unusual symptoms, by entertaining the suspected diagnosis of endometrosis, pre-operative preparation may allow the optimal surgical procedure, and unnecessary surgical procedures sometimes more dangerous than the disease may be avoided.

Bibliography

Barnes, J. (1953): J. Obstet. Gynec. Brit. Emp. 60:823.
Bungler, W. et al. (1939): Arch. Chir. Clin. Exper. 3:169. Collins, D. C. (1951): Arch. Surg. (Chicago) 63:617.
Cullen, T. S. (1917): Bull. Johns Hopkins Hospital 28:34. de Jong, J. (1913): Virchows Arch. Path. Anat. 211:141.
Felson, H. et al. (1960): Am. J. Med. 29:1072.
Ferrcira, H. P. et al. (1951): J. Obstet. Gynecol. Brit. Emp. 65:41. Froesch, F. J. (1936): Am. J. Obstet. Gynec. 32:490.
Goodall, J. R. (1944): Annl. Sting. 20:891.
Hauffler, F. (1931): Virchows Arch. Path. Anat. 280:822.
Hobbs, J. E. et al. (1940): Am. J. Obstet. Gynec. 40:832.
Judd, E. S. (1921): Surg. Clin. N. Arner. 1:1271.
Kerr, W. S., Jr. (1966):Clin. Obstet. Gynec. 9:331.
Marshall, V. F. (1943): J. Urol. 50:652.
Mauer, C. R. et al. (1958): JA MA /68:2013.
Meyer, R. (1909): Virchows Arch. Path. Anat. /95:487.
Nicholson, H. (1951): Thorax 6:75.
Sampson, J. A. (1925): Arch.10:1
Sutton, L. A. (1941): Nets, York State J. Med. 4/:1343.
von Rokitansky, C. (1860): Ztsch. K. Gesselsch. Aerate (Wien) !6:577 (cited in Collins).

Back to Table of Contents