1. Perineal endometriosis in episiotomy scar with anal sphincter involvement, Report of a case
Abu Hassan Awad M.D., Mohammad matter M.D., Hosam Hamada M .D ., Essam Abu Ajwa, Tariq lubbad *Proctology Unit, Shifa Hospital *Radiology Department, Shifa Hospital * Pathology Department, Shifa Hospital

2. Case Presentation
A 29 year old female patient, who was referred to us, with history of severe perineal pain resulting in functional limitation and discomfort during her sitting and daily activities.
The pain increased with her menstrual periods.
The duration of her illness has been 6 years.
The patient’ ’s past medical history was two pregnancies with vaginal deliveries requiring episiotomies

3. Anorectal examination
Position: Examination was performed with the patient in the left lateral position without previous anorectal preparation.
Inspection: The anal region had normal appearance.
Palpation: There was a hard nodule measuring 2 x 3 cm in the right anterior perineal region, at 11-12oclock below to the scar of episiotomy.
This nodule is irregular and very painful. on examination
Anal Tones : The patient had a good sphincter squeeze tone and a good resting tone at digital rectal examination

5. Due to her suffering period of six years ,we found an abdominal C-T and pelvic MRI. The results show a cystic mass with blood products size 2 cm . Of course if we saw this patient before this expensive investigation, we could have asked for cheaper ones such as endo anal, transperineal or transvaginal U/S.

6. The surgery was performed under general anesthesia and the patient in lithotomy position.
Radial incision, including the episiotomy scar, was performed. It showed a mass 2cm/ 2cm

7. Wide excision of this mass with a small portion of superficial external anal sphincter was done . Then repair end to end of the superficial anal sphincter was done .
The divided excised specimen
showed characteristic chocolate cysts

8. The postoperative Postoperative:
The patient received antibiotics , analgesic and daily sitz bath for one week .
There was a follow up of 18 months.
There were no complications, and the patient has excellent functional results (good resting and squeeze tone).
No pain and no recurrent of disease

9. Histopathology
Histopathological examination confirmed endometriosis with endometrial glands, typical stroma, blood and hemosiderin macrophages

10. Discussion
Endometriosis seen when endometrial tissue outside the uterine cavity Endometriosis can be anywhere included pelvis, perineum, or episiotomy scar , and other regions Anal sphincter invasion of the endometrioma provides an interesting dilemma. The diagnosis may be difficult, it is necessary a careful history with symptoms related to the menstrual cycle. The physical examination will provide additional clues.

11. Discussion
history-taking and examination 1-An episiotomy during past vaginal delivery,( ask ) 2- A tender nodule or mass at the perineal region ( feel ) 3-Progressive and cyclic perineal pain ( ask ) DRE examination and Endo-anal ultrasound , *the preoperative level of serum CA125 is insensitive Computer tomography (CT) also can be used If these 3 criteria were met, the predictive value of perineal endometriosis was 100% (Zhu et al., 2009)

12. Discussion
WE and PSp is recommended as the best treatment for PEM with anal sphincter involvement
(Barisic et al., 2006; Dougherty & Hull, 2000; Kanellos et al., 2001;Martı´nez et al., 2002; Sayfan et al., 1991; Toyonaga, 2006)
In patients where the lesion was incompletely or narrowly excised, subsequent hormonal therapy is necessary to avoid symptomatic recurrence.
gonadotrophin-releasing hormone agonists- is the first choice should be administered preoperatively for 2-4 months

13. Review of the literature 1957-2016 ( 20 cases )
A PubMed search showed
only 13 cases of perineal endometriosis with anal sphincter involvement in eleven different case reports since
And Our search shows anther 7 cases report till 2016
So our case is number 21 now and first one in Gaza
(Bacher et al., 1999; Barisic et al., 2006; Beischer et al.,
1966; Dougherty & Hull, 2000; Gordon et al., 1976; Hambrick et al., 1979; Kanellos et al.,
2001; Martı´nez et al., 2002; Prince & Abrams, 1957; Sayfan et al., 1991; Toyonaga, 2006).
Lan Zhu, Na Chen and Jinghe Lang (2012). Diagnosis and Treatment of Perineal Endometriosis, Endometriosis - Basic Concepts and Current Research Trends, Prof. Koel Chaudhury (Ed.),

14. Conclusions
Perineal endometriosis with involvement of anal sphincter is rare
only 21case report ( )
The key to a definitive diagnosis is a careful history-taking
1-An episiotomy during past vaginal delivery,
2- A tender nodule or mass at the perineal lesion
3-Progressive and cyclic perineal pain
Digital rectal examination, U/S , C-T, MRI are useful
It is necessary a definitive histologic diagnosis of perineal endometriosis and to rule out the rare development of malignancy
wide excision including a part of the anal sphincter with primary sphincteroplasty is the best treatment for perineal endometriosis involving the anal sphincter

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