Patients present with one, or usually more of the following signs and symptoms: pelvic pain, lower abdominal and/or back pain [8], dysmenorrhea, dyspareunia, dyschezia, heavy bleeding during and between periods, irregular menstruation and urinary frequency. They may also complain of nausea, bloating and pain during or after exercise. Sometimes the presentation may appear similar to be that of a genito-reproductive tract tumor, in which case a detailed work up can help differentiate the disease from cancer.

• Pain

  […] could be; a score of 1–50 was considered mild pain, 51–80 moderate pain and 81–100 severe pain. [dx.doi.org]

  […] include: Painful, even debilitating, menstrual cramps, which may get worse over time Pain during or after sex Pain in the intestine or lower abdomen Painful bowel movements or painful urination during menstrual periods Heavy menstrual periods Premenstrual [nichd.nih.gov]

  VAS is the most frequently used pain scale and, together with NRS, seems the best adapted for endometriosis pain measurement. [ncbi.nlm.nih.gov]

  Treatments for Pain from Endometriosis Treatments for endometriosis pain fall into three general categories: Pain medications Hormone therapy Surgical treatment Pain Medications Pain medications may work well if your pain or other symptoms are mild. [web.archive.org]

• Infertility

  RESULTS: In the mid-follicular eutopic endometrium, we observed a significant increase in HSD3B2 transcript levels in all infertile women with endometriosis (p 0.003), in infertile women with stage I/II endometriosis (p 0.008) and in infertile women with [ncbi.nlm.nih.gov]

  However, this has not been confirmed with regard to infertility ( Guzick et al ., 1997 ). [dx.doi.org]

• Inguinal Pain

  pain Pain on micturition and/or urinary frequency Pain during exercise Because most endometriotic implants are found on the uterus, ovaries, and posterior peritoneum, the patient usually presents with a history of progressively increasing pelvic pain [emedicine.medscape.com]

  […] typically reflect the area of involvement: Dysmenorrhea Heavy or irregular bleeding Pelvic pain Lower abdominal or back pain [2] Dyspareunia Dyschezia (pain on defecation) - Often with cycles of diarrhea and constipation Bloating, nausea, and vomiting Inguinal [emedicine.com]

• Perineal Pain

  Pelvic and perineal pain Micrograph showing endometriosis (H&E stain), a common cause of chronic pelvic pain in women. Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. [en.wikipedia.org]

• Nasal Irritation

  start treatment on day 2 to 4 of menstrual cycle Estrogen deficiency, bone density changes, nasal irritation 431 TABLE 2 Medical Treatment of Endometriosis Drug Dosage Adverse effects Cost* Danazol (Danocrine) 800 mg per day in 2 divided doses Estrogen [aafp.org]

  start treatment on day 2 to 4 of menstrual cycle Estrogen deficiency, bone density changes, nasal irritation 431 IM intramuscularly; SC subcutaneously. [web.archive.org]

• Abdominal Pain

  Keywords: Abdominal pain, endometriosis, male, metaplasia, Mullerian agenesis How to cite this article: Jabr FI, Mani V. An unusual cause of abdominal pain in a male patient: Endometriosis. [avicennajmed.com]

  This was associated with cyclical lower abdominal pains, abdominal swelling, and weight loss. Examination revealed hyperactive bowel sounds with scant fecal matter on rectal examination. [ncbi.nlm.nih.gov]

  Year Age Symptoms Previous history Episode time Hemoperitoneum Uncu et al [ 25 ] 2008 45 Abdominal pain and nausea Not described The second day of menstruation Yes Akbulut et al [ 26 ] 2009 40 Lower right quadrant pain Lower right abdominal pain before [wjgnet.com]

• Constipation

  Despite long-term continuous medical treatment, the patient presented 4 years later with impaired digestion consisting in constipation alternating with diarrhea, bloating, dyschesia, and pelvic pain. [ncbi.nlm.nih.gov]

  They are manifested as cramps, flatulence, painful tenesmus, hyper-peristaltis, progressive constipation or diarrhea alternating with constipation. A bowel obstruction complicates sigmoid endometriosis in approximately 10% of cases [ 4 ]. [panafrican-med-journal.com]

• Nausea

  They may also complain of nausea, bloating and pain during or after exercise. [symptoma.com]

  Clinical case: A 28-year-old female patient with abdominal pain in the right iliac fossa and pelvic cavity, fever and nausea, exploratory laparotomy is performed with the discovery of sigmoid perforation of the colon, requiring resection of the lesion [medigraphic.com]

  Nausea is a new symptom for me. “I now can’t physically sit in a car for two hours because the pain is too unbearable and the pain medication that I once used has now been taken off pharmacy shelves. [news.com.au]

  […] menstrual cramping, lower back or abdominal pain, painful bowel movements or painful urination Pain during or after sex Excessive bleeding: heavy periods or bleeding or spotting between periods Gastrointestinal symptoms: diarrhea, constipation, bloating, or nausea [health.ucsd.edu]

  Case presentation A 31-year-old Caucasian woman with increasing abdominal distension, pain and nausea was referred to our department by gastroenterologists at the ED. [jmedicalcasereports.biomedcentral.com]

• Dyschezia

  Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility. [ncbi.nlm.nih.gov]

• Pelvic Mass

  A fetal pelvic mass was diagnosed at 35 weeks’ gestation and removed on day of life 2, revealing endometriosis. [fertstertdialog.com]

  Following removal of the pelvic masses with laparotomy, the histological exam revealed an endometriosis. [ncbi.nlm.nih.gov]

  […] et al. (1991) 201 Various No (stage: frequency of pain symptoms) Marana et al. (1991) 206 Infertility, pain, pelvic mass No (stage, type and site of lesions: severity of pain) Ripps and Martin (1991) 59 Infertility, pain, pelvic mass Yes (deep lesions [dx.doi.org]

• Low Back Pain

  It can cause dyspareunia, dysmenorrhea, low back pain and infertility. A definitive diagnosis can be made only by means of laparoscopy. [ncbi.nlm.nih.gov]

  back pain, and/or fatigue. [medicine.umich.edu]

  Long-term pelvic or low back pain that may occur at any time and last for 6 months or more. [nlm.nih.gov]

• Leg Pain

  Ultimately, once diagnosed with endometriosis of the retroperitoneal spinal and neural elements, her back and leg pain responded completely to hormonal therapy and then to a hysterectomy and a bilateral salpingo-oophorectomy. [ncbi.nlm.nih.gov]

  pain Pelvic pain Loss of 'old' or 'dark blood' before period Pain before or after passing urine or opening bowel All of the symptoms above may have other causes and may not necessarily be endometriosis symptoms. [endometriosis-uk.org]

  Subfertility/infertility, excruciating pain during sexual intercourse, silent kidney loss, searing lower back, hip and leg pain, and severe bowel and bladder dysfunction are among other symptoms experienced by women with endometriosis. [nezhat.org]

  Lower back pain or leg pain, especially around the time of menses. Fatigue Infertility Testing Endometriosis can only be diagnosed through laparoscopy and confirmation of the disease can be achieved through pathological biopsy. [resolve.org]

• Pelvic-Girdle Pain

  Susannah provides assessment and treatment for pelvic pain conditions such as pelvic floor dysfunction, pelvic girdle pain, vulvar and vaginal pain, bladder and bowel dysfunction, and chronic pelvic pain and endometriosis. [bcwomens.ca]

  girdle pain (SPD or DSP) Pudendal nerve entrapment Gynecologic Dysmenorrhea—pain during the menstrual period Endometriosis—pain caused by uterine tissue that is outside the uterus. [en.wikipedia.org]

• Pelvic Pain

  […] in non-menstrual pelvic pain, deep dyspareunia or dyschezia. [ncbi.nlm.nih.gov]

  Median (interquartile range) age at onset of symptoms, at reporting symptoms to a doctor, and at diagnosis in women presenting for pelvic pain and infertility Pelvic pain ( n 180) Infertility ( n 20) Age at onset of symptoms (years) 20.5 (14.0–27.5) 23.5 [humrep.oxfordjournals.org]

  Morphologic appearance in women with chronic pelvic pain. J Reprod Med 36:533–536 PubMed Google Scholar 5. [dx.doi.org]

• Chronic Pelvic Pain

  A cognitive behavioural based assessment of women with chronic pelvic pain. J Psychosom Obstet Gynaecol. 2009; 30 (4):262–268. [ PubMed ] [ Google Scholar ] 10. Howard FM. Chronic pelvic pain. [ncbi.nlm.nih.gov]

  Chronic Pelvic Pain in Endometriosis: An Overview Abstract Chronic pelvic pain (CPP) could be considered nowadays a deep health problem that challenges physicians all over the world. [dx.doi.org]

  pelvic pain ( Propst and Laufer, 1999 ). [humrep.oxfordjournals.org]

• Dysmenorrhea

  Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility. [ncbi.nlm.nih.gov]

  Decreasing dyspareunia and dysmenorrhea in women with endometriosis via a manual physical therapy: Results from two independent studies Journal of Endometriosis 2011; 3(4): 188 - 196 Article Type: ORIGINAL ARTICLE DOI:10.5301/JE.2012.9088 Authors Belinda [web.archive.org]

• Dyspareunia

  […] on the Mankoski Pain Scale for analyzing the effect on dysmenorrhea and dyspareunia (n 18), respectively. [web.archive.org]

  Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility. [ncbi.nlm.nih.gov]

  Assessment of deep dyspareunia was not available or not reliable in 309 cases. [dx.doi.org]

  The most common types of pain are dysmenorrhea, dyspareunia and chronic pelvic pain. Endometriosis can also reduce fertility. [sbu.se]

• Adnexal Mass

  Oral CHM may have a better overall treatment effect than danazol; it may be more effective in relieving dysmenorrhoea and shrinking adnexal masses when used in conjunction with a CHM enema. [ncbi.nlm.nih.gov]

  A set of 38 patients with surgically evaluated adnexal masses, but no hydrosalpinx, were randomly chosen as control subjects. [dx.doi.org]

Work up includes a detailed history, physical examination and tests.

Laboratory tests

• Complete blood count
• Urinalysis
• Blood cultures (to rule out STDs)
• Serum cancer antigen test (Ca-125)
• Antibody testing against Thomsen-Friedenreich (T) antigen (Gal beta1-3GalNAc) bearing proteins

Imaging 

The following imaging studies may be performed:

• Transvaginal ultrasound
• Endorectal ultrasound
• CT scan and MRI

Other tests

• Biopsy
• Pelvic laparoscopy (It is the primary modality for assessing and diagnosing endometriosis).

Test results

Diagnosis is based on physical findings and test results. Imaging studies in particular play an important role in disease identification.

• Ovarian Mass

  We at the Institute, however, council women that if their ovarian masses prove benign, radical surgery would be unnecessary. Often times, during surgery, we find the presence of an endometrioma (Endometriosis of the ovary). [alternativesurgery.com]

  CONCLUSION: MR imaging is superior to Doppler US and CT in diagnosis of malignant ovarian masses. There is little variation among conventional US, CT, and MR imaging as regards staging. References 1. [dx.doi.org]

  Jeong YY, Outwater EK, Kang HK: Imaging evaluation of ovarian masses. Radiographics 2000 Sep-Oct; 20(5): 1445-70 [Medline]. [web.archive.org]

• Torsades De Pointes

  Adult Dose 40 mg PO qd Pediatric Dose Not recommended Contraindications Documented hypersensitivity Interactions Elevated dofetilide plasma concentrations may occur (with increased risk of ventricular arrhythmias, including torsades de pointes) if coadministered [web.archive.org]

Conservative management

It includes the use of analgesics to relieve pelvic and abdominal pain and the use of hormone therapy like the use of Danazol or progesterone. Oral contraceptives have proved to be effective in slowing disease progression. In many women, menopause (natural or surgical) will abate the process [9].

Surgical intervention

If the disease cannot be satisfactorily managed conservatively, it may be treated surgically. Surgical intervention is of two types. The first is called conservative or semi conservative surgical intervention in which reproductive organs are spared. The second type, called radical surgery, involves a total hysterectomy and bilateral oophorectomy as well as adhesiolysis. This type is usually only performed in women past the child bearing age or in women with very serious, grade IV endometriosis.

It is a progressive disease with a high rate of recurrence even after treatment. However, endometriosis has been found to resolve spontaneously in one third of women who are not actively treated [7]. Prognosis depends upon the stage of the disease. It has 4 stages.

• Stage I: Only superficial lesions and adhesions are present.
• Stage II: Some superficial as well as deep lesions are present
• Stage III: Presence of superficial and deep lesions as well as presence of endometriomas in the ovaries
• Stage IV: All the above findings plus large endometriomas and extensive adhesions.

The exact cause of endometriosis is unknown. Several factors have been implicated in its development. The two main theories; metastatic and metaplastic theories have been explained in a later section. Humoral antibodies to endometrial tissue have also been found in sera of women with endometriosis [2]. Some women may also be genetically predisposed to this condition. Overall it is thought to be a collection of several factors, not just one, that ultimately cause this disease. As for why some women may be prone to this disease as opposed to those who are not, studies reveal that it varies on individual-based responses.

Incidence

Endometriosis is not a common occurrence. Approximately, endometriosis occurs in roughly 4–10% of women [3]. It has a prevalence of 7-10% in the United States.

Age

It is principally a disease of women in their active reproductive life. So it is common in women aged between mid-twenties and early-forties.

Race

There does not appear to be any predilection to a particular race or ethnicity.

The most common site of ectopic endometrial tissue is the ovary. The next most common sites, in decreasing order of frequency are: Uterine ligaments, rectovaginal septum, cul de sac, pelvic peritoneum, large and small bowel, appendix, cervical mucosa, vagina, fallopian tubes and laparotomy scars. Two major theories for the development of endometriosis have been proposed [4], they are:

• Metastatic theory

According to this theory, there is lymphatic or hematogenous ‘metastasis’ of endometrial tissue to abnormal locations. Retrograde menstruation may be the cause of peritoneal endometriosis, for example.

• Metaplastic theory

According to this theory, endometrial tissue may itself arise directly from coelomic epithelium at extrauterine sites. This coelomic epithelium is from which the mullerian ducts and ultimately the endometrium itself originates during embryonic development. Under the influence of factors that are still unclear, there may be abnormal production of endometrial gland and stromal cells in sites other than the uterus.

Specific abnormalities that distinguish normal endometrium from endometriotic tissue are highlighted below [5].

1. Profound activation of inflammatory cascade, characterized by high levels of prostaglandin E2, IL-1B, IL-6 and TNF. 
2. Marked upregulation of estrogen production mainly due to high levels of the key steroidogenic enzyme aromatase [6].

Endometriosis may be prevented or at least slowed by use of birth control pills [10]. Birth control pills act to decrease the production of hormones by the body which are necessary to support the endometrial tissue’s growth and division.

Endometriosis is defined as ectopic production or occurrence of endometrial tissue in extrauterine sites [1]. Endometrium is the innermost layer lining the uterus. Due to some reasons, as discussed in detail in later sections, this tissue may occur abnormally in extrauterine sites. Commonly, the ectopic tissue consists of both the endometrial glands and the stroma. It may occur anywhere in the body but typically remains within the abdominal and pelvic cavities. It may be confused with cancer so a thorough knowledge of the disease and its manifestation is imperative for proper diagnosis and treatment.

Definition

Endometriosis can be defined as abnormal presence of endometrial tissue (cells of the inner lining of the uterus), outside of the uterus. For example, endometrial tissue may abnormally occur in the ovaries, uterine ligaments, fallopian tubes, peritoneum, as well as other sites.

Cause

There is no known specific cause of endometriosis. It may be genetic or due to some immune dysfunction or it may simply be due to displacement and/or abnormal growth of uterine tissue in sites other than the uterus.

Symptoms

It may be asymptomatic but in symptomatic patients, it presents with painful menstruation, pelvic pain and in severe cases, infertility. Other symptoms include pain during urination or defecation, heavy menstrual bleeding, mid-cycle bleeding, nausea and vomiting and lower back pain.

Treatment

Treatment involves the use of contraceptive pills and painkillers. Surgical intervention may be needed in severe cases.

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