Review Question - QID 221285

This patient with dyspareunia, chronic pelvic pain, and dyschezia, most likely has endometriosis. The presence of a mass on the ovary is consistent with an endometrioma.

Endometriosis is thought to occur due to ectopic implantation of the endometrial tissue from retrograde menstruation. It can present with a wide array of symptoms depending on the location of the implanted tissue. Dyspareunia can be caused by ectopic implants surrounding the vagina, while dysuria can be caused by implants on the bladder or that compress the ureter. Dyschezia is usually caused by endometriosis involving the rectovaginal space. An implant on the ovary, known as an endometrioma, may be the only presenting finding of endometriosis. Patients with endometriosis are at increased risk of future infertility. Conservative treatment includes oral contraceptives and non-steroidal anti-inflammatory medications, while surgical excision of visible lesions can be conducted in refractory cases unresponsive to medical therapy.

Nisenblat et al. review imaging modalities for the non-invasive diagnosis of endometriosis. They found that transvaginal ultrasonography has a sensitivity of 93% and specificity of 96%. They recommend the use of either MRI or ultrasound in the diagnostic evaluation of patients with suspected endometriosis.

Figure/Illustration A is an ultrasound of the ovary demonstrating a homogenous mass (red circle). This appearance is consistent with a diagnosis of an endometrioma.

Incorrect Answers:
Answer 1: Adenomyosis is the presence of endometrial tissue within the myometrium of the uterus and can also present with pelvic pain. Adenomyosis tends to cause heavy menstrual bleeding, which is absent in this patient. Adenomyosis would not explain the ultrasound findings of a mass on the ovary. Adenomyosis is heavily correlated with endometriosis.

Answer 3: Leiomyomas, also known as fibroids, can present with chronic pelvic pain and pelvic pressure that is worsened with activity and vaginal bleeding. These benign tumors arise from the smooth muscle cells of the uterine myometrium and not the ovary.

Answer 4: Mature teratoma can cause pelvic pain, but ultrasound findings typically reveal calcified, heterogenous nodules. This patient has a homogenous nodule on her ovary that is more consistent with an endometrioma.

Answer 5: Pelvic inflammatory disease can present with pelvic pain in a patient with a history of an inadequately treated sexually transmitted infection. This disease would likely have bilateral involvement of the ovaries and no cystic findings on ultrasound.

Bullet Summary:
Endometriosis can present with dyspareunia, dyschezia, and dysuria.