What is the best course of treatment for a 49-year-old female with perineal endometriosis, a new lump on the posterior wall, and symptoms of feeling raw in the anal area, who has previously been treated with birth control (hormonal contraception) and has a history of perineal cysts and multiple births with episiotomies or tears?

Management of Perineal Endometriosis with New Lump and Anal Symptoms

This 49-year-old woman requires urgent surgical referral for wide local excision of the new perineal lump, as surgical excision is the definitive treatment for perineal endometriosis and provides the best chance of cure with excellent functional results. 1, 2, 3

Immediate Diagnostic Workup

Obtain pelvic MRI before surgical referral to map the extent of disease, identify deep infiltrating lesions, and assess for involvement of adjacent structures including the rectum and anal sphincter. 4, 2 Transvaginal and endorectal ultrasound can serve as complementary modalities if MRI is not immediately available. 2

The "raw" anal sensation with slight bleeding suggests possible deep infiltrating endometriosis extending toward the rectovaginal septum or anal canal, which requires preoperative imaging to plan the surgical approach and determine if colorectal surgery consultation is needed. 4, 5

Why Surgery is the Primary Treatment Here

Perineal endometriosis, particularly in episiotomy scars, requires surgical excision as the definitive treatment. 1, 2, 3 Medical management with hormonal suppression has a controversial role and typically fails in extrapelvic endometriosis involving fibrotic lesions. 3

Key surgical principles for perineal endometriosis:

• Wide excision of the endometriotic mass together with the episiotomy scar tissue provides the best cure rates with satisfactory functional and aesthetic results. 2, 3
• All six patients in one case series were cured following complete surgical excision of perineal endometriomas. 3
• Recovery is typically uneventful with excellent functional outcomes when complete excision is achieved. 1, 2

Role of Hormonal Therapy

Discontinue current birth control and do not restart hormonal suppression until after surgical excision. 3 Here's why:

• Hormonal medications induce disease remission but do not cure endometriosis, and symptom relapse occurs when drugs are discontinued. 5
• For fibrotic infiltrating perineal lesions, surgery is more successful than medical management. 5
• After complete surgical excision, consider postoperative hormonal suppression to prevent the 10% per year cumulative recurrence rate. 5

If the patient declines surgery or surgery must be delayed, combined oral contraceptives or progestin-only therapy can temporize symptoms, though this is not definitive treatment for perineal endometriosis. 6, 7

Addressing the Anal Symptoms

The "raw" sensation and bleeding in the anal area requires specific evaluation:

• Perform anoscopy or proctoscopy to rule out anal fissures versus endometriotic involvement of the anal canal. 2
• If endometriosis extends to involve the rectum or anal sphincter, multidisciplinary surgical planning with a colorectal surgeon is essential to minimize morbidity. 4, 5
• Deep infiltrating lesions causing bowel symptoms may require bowel resection when necessary to achieve complete disease removal. 4

Specialist Referral

Refer to a gynecologic surgeon with expertise in extrapelvic endometriosis rather than a general OBGYN. 7, 4 The patient's history of multiple episiotomies/tears with all three births places her at risk for episiotomy scar endometriosis, which requires specialized surgical expertise. 1, 2

Look for surgeons who:

• Have experience with perineal and extrapelvic endometriosis excision 2, 3
• Work in multidisciplinary teams including colorectal surgeons if deep disease is suspected 4, 5
• Can perform complete excision with attention to functional and aesthetic outcomes 2

Critical Pitfalls to Avoid

Do not biopsy the perineal mass in the office setting. 2, 3 While fine needle aspiration cytology has been described, definitive diagnosis and treatment should occur together during surgical excision to ensure complete removal. 3

Do not assume hormonal therapy alone will be adequate. 3 The literature consistently shows that perineal endometriosis requires surgical excision, and hormonal suppression typically fails for these extrapelvic, fibrotic lesions. 5, 3

Do not delay evaluation of the new lump. 1 Any perineal lesion that evolves in response to the menstrual cycle should be considered endometriosis and warrants prompt surgical evaluation. 1

Expected Outcomes

Following complete surgical excision:

• Patients are typically asymptomatic within 3-6 months postoperatively 1, 2
• Cure rates approach 100% when complete excision is achieved 3
• Functional and aesthetic results are excellent 2
• However, up to 44% of women with endometriosis experience symptom recurrence within one year, highlighting the importance of postoperative hormonal suppression 8, 7

Postoperative Management

After successful excision:

• Initiate continuous combined oral contraceptives or progestin-only therapy to prevent recurrence 6, 5
• Follow-up at 3-month intervals initially to monitor for recurrence 3
• Continue hormonal suppression long-term, as discontinuation leads to 25-34% recurrence of pelvic pain within 12 months 6