全腹腔鏡下子宮全摘出後に生じた腟断端子宮内膜症の１例

抄録

　A 40-year-old G0P0 presented with uterine leiomyomas and underwent total laparoscopic hysterectomy and bilateral salpingectomy for management of worsening hypermenorrhea. Intraperitoneal findings included an endometriotic lesion (approximately 1 cm) in the peritoneum of the Douglas pouch and partial adhesion. The vaginal canal was incised, and the uterus was transected and removed after transvaginal morcellation. Histopathological examination of the resected specimen revealed uterine leiomyoma without salpingeal abnormalities or endometriotic lesions. The patient observed monthly genital bleeding, 2 and 5 months postoperatively; however, no apparent clinical abnormalities were detected. She experienced similar genital bleeding accompanied by periumbilical pain, 9 months postoperatively. Colposcopy revealed several red endometriosis-like lesions involving the vaginal stump, and the patient was diagnosed with vaginal stump endometriosis. Oral dienogest administration initiated at 11 months postoperatively was continued as maintenance therapy, and the patient's symptoms nearly resolved 5 months later.

　Preoperative diagnosis of small lesions in the Douglas pouch is challenging in patients in whom imaging does not reveal endometriosis in any other region. Endometriotic lesions may remain in the vaginal stump, even in the absence of uterine or adnexal endometriosis, and such lesions may occur even in patients with mild pelvic endometriosis. Vaginal stump endometriosis should be considered in the differential diagnosis in women with periodic genital bleeding or abdominal pain after total laparoscopic hysterectomy. Detailed patient interviews and physical evaluation within a wide area are necessary. Vaginal stump endometriosis can be histopathologically diagnosed based on biopsy specimen evaluation, and dienogest therapy is useful for symptom relief.