A 28-year-old woman comes to the office due to discomfort during urination for the past 3 months. Antibiotics for a urinary tract infection were prescribed at an urgent care center a few weeks ago, but her symptoms have persisted despite treatment. The patient has also noticed increasing pain with the passage of stool for the last year, particularly during menses. Bowel movements occur daily and are soft and not watery. Examination shows suprapubic tenderness and an immobile, retroverted uterus. Rectovaginal examination reveals nodularity in the posterior cul-de-sac. Urinalysis and urine culture are normal. Surgical biopsy of the pelvic nodules would most likely show which of the following?

Question

A 28-year-old woman comes to the office due to discomfort during urination for the past 3 months.  Antibiotics for a urinary tract infection were prescribed at an urgent care center a few weeks ago, but her symptoms have persisted despite treatment.  The patient has also noticed increasing pain with the passage of stool for the last year, particularly during menses.  Bowel movements occur daily and are soft and not watery.  Examination shows suprapubic tenderness and an immobile, retroverted uterus.  Rectovaginal examination reveals nodularity in the posterior cul-de-sac.  Urinalysis and urine culture are normal.  Surgical biopsy of the pelvic nodules would most likely show which of the following?

Quizplus · Accepted Answer

11ec160b_391e_9735_9249_ab3db4e43011_MD0001_00 Endometriosis affects women of reproductive age and is characterized by the ectopic implantation of endometrial glands and stroma, causing chronic pelvic pain. Symptoms and examination findings vary, depending on the specific location of endometriosis implants. Dysuria or suprapubic tenderness and dyschezia (pain with defecation) can be caused by implants on the bladder and rectovaginal septum, respectively. Bowel symptoms commonly worsen with menses. Rectovaginal nodularity is highly characteristic of endometrial implants and fibrosis of the posterior cul-de-sac. The uterus is often immobile and fixed in a retroverted position due to scarring from continued cyclic shedding of ectopic endometrial tissue that has no outlet. Other common clinical features include an adnexal mass (endometrioma) and cervical motion tenderness. Definitive diagnosis is by direct visualization with biopsy during surgical exploration. (Choice A) Colorectal hamartomas, typically benign colonic tumors, may cause abdominal pain due to mass effect; however, hamartomas do not worsen with menses or cause pelvic inflammation (eg, immobile uterus). (Choice C) Endometrial intraepithelial neoplasia, atypical overgrowth of the intrauterine endometrial lining, typically occurs in women with risk factors (eg, obesity, chronic anovulation). Patients typically have abnormal uterine bleeding or postmenopausal bleeding. (Choice D) Invasive urothelial carcinoma can cause dysuria, but patients typically have painless hematuria; this patient's urinalysis is normal, making this diagnosis unlikely. (Choice E) Serous epithelial ovarian carcinoma can cause abdominal pain, but the typical presentation is bloating or ascites in a postmenopausal patient with an adnexal mass. (Choice F) Leiomyoma (ie, fibroids), benign tumors of uterine myometrium, may cause abdominal pain and urinary or bowel symptoms due to mass effect; however, symptomatic patients typically have an irregularly enlarged uterus, making this diagnosis less likely. Educational objective: Endometriosis causes chronic pelvic pain due to ectopic implantation of endometrial glands and stroma in the abdominopelvic cavity. Bladder implants may also result in dysuria while rectovaginal implants may cause dyschezia, rectovaginal nodularity, and pelvic fibrosis (eg, immobile uterus).

A 28-Year-Old Woman Comes to the Office Due to Discomfort