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. 2020 Jul 16;19(4):323-333.
doi: 10.1002/rmb2.12340. eCollection 2020 Oct.

Extra-pelvic endometriosis: A review

Tetsuya Hirata  1   2 , Kaori Koga  2 , Yutaka Osuga  2
Affiliations

Extra-pelvic endometriosis: A review

Tetsuya Hirata et al. Reprod Med Biol. .

Abstract

Background: Extra-pelvic endometriosis is a rare type of endometriosis, which occurs in a distant site from gynecological organs. The diagnosis of extra-pelvic endometriosis can be extremely challenging and may result in a delay in diagnosis. The main objective of this review was to characterize abdominal wall endometriosis (AWE) and thoracic endometriosis (TE).

Methods: The authors performed a literature search to provide an overview of AWE and TE, which are the major types of extra-pelvic endometriosis.

Main findings: Abdominal wall endometriosis includes scar endometriosis secondary to the surgical wound and spontaneous AWE, most of which occur in the umbilicus or groin. Surgical treatment appeared to be effective for AWE. Case reports indicated that the diagnosis and treatment of catamenial pneumothorax or endometriosis-related pneumothorax (CP/ERP) are challenging, and a combination of surgery and postoperative hormonal therapy is essential. Further, catamenial hemoptysis (CH) can be adequately managed by hormonal treatment, unlike CP/ERP.

Conclusion: Evidence-based approaches to diagnosis and treatment of extra-pelvic endometriosis remain immature given the low prevalence and limited quality of research available in the literature. To gain a better understanding of extra-pelvic endometriosis, it would be advisable to develop a registry involving a multidisciplinary collaboration with gynecologists, general surgeons, and thoracic surgeons.

Keywords: abdominal wall endometriosis; catamenial hemoptysis; catamenial pneumothorax; extra‐pelvic endometriosis; treatment.

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Conflict of interest statement

Conflict of interest: The authors report no conflict of interest. Human rights statements and informed consent/Animal studies: This article does not contain any studies with human and animal subjects performed by any of the authors.

Figures

FIGURE 1
FIGURE 1
Hypothesized pathogenesis of inguinal endometriosis. The abdominal fluid containing endometrial cells circulates clockwise in the abdominal cavity, and the sigmoid colon blocks the abdominal fluid from entering the left inguinal ring. As a result, the intraperitoneal fluid is more likely to enter the right inguinal ring than the left. Endometriosis also propagates from the pelvis to the groin via the round ligament (brown dot arrow)
FIGURE 2
FIGURE 2
Two types of inguinal endometriosis revealed by magnetic resonance imaging. Red arrowheads denote inguinal endometriosis. A, T2‐weighted axial image shows cystic lesions in the right groin. B, Fat‐saturated T1‐weighted axial image shows the hyperintense nodule in the wall of the cystic lesions. In this case, endometriosis exists and endometriotic lesion exists at the wall of a hernia sac or hydrocele of Nuck’s canal. C, T2‐weighted axial image shows the right inguinal mass (isointense with muscle). D, Fat‐saturated T1‐weighted image shows hyperintensity in the nodule. In this case, endometriotic lesions exist in the solid fibrotic mass
FIGURE 3
FIGURE 3
Hypothesized pathogenesis of catamenial pneumothorax (CP) and endometriosis‐related pneumothorax (ERP). A, The clockwise flow of peritoneal fluid containing endometrial cells reaches the right subdiaphragmatic area, while the peritoneal fluid is deviated away from the left hemidiaphragm due to obstruction by the falciform ligament of liver and sigmoid colon. Endometrial cells, which have reached the right hemidiaphragm, adhere to the surface of right hemidiaphragm or migrate into the thoracic cavity through congenital or acquired fenestration in the diaphragm. B and C, Several hypotheses have been proposed regarding how air enters the thoracic cavity. B, Transdiaphragmatic passage of air theory. In this theory, air passes from vagina and uterus into peritoneal cavity through the fallopian tubes. Subsequently, this air enters into thoracic cavity through the diaphragmatic defects, which is congenital or secondary to diaphragmatic endometriosis. C, The visceral pleural and/or superficial parenchymal endometriotic lesion causes the alveoli to rupture and air to flow from the lungs into the thoracic cavity
FIGURE 4
FIGURE 4
Comparison of hypothesized pathogenesis of catamenial pneumothorax or endometriosis‐related pneumothorax (CP/ERP) and catamenial hemoptysis (CH). A, The clockwise flow of peritoneal fluid containing endometrial cells reaches the right subdiaphragmatic area. Endometrial cells implant on the diaphragmatic surface or enter the thoracic cavity through the defects. B, Intrapulmonary endometriosis, which causes catamenial hemoptysis, is developed by lymphatic or hematogenous microembolization of endometrial cells
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