+ Fakultas

Kedokteran
Universitas
Tarumanagara
Laporan Kasus
2019

Endometriosis
Disusun oleh : Pembimbing :

Dila Nur Fitriani dr. Andriana, Sp.OG

406172113

Kepaniteraan Klinik Obstetrik & Ginekologi

RS Sumber Waras Jakarta

Periode 31 Desember 2018 – 1 Maret 2019

+ Identitas Pasien
Nama : Ny. R

Usia : 35 Tahun

Jenis kelamin : Perempuan

Alamat : Jl. Terete 7 No.159

Status pernikahan : Menikah

Agama : Islam

Pendidikan : SMP

Pekerjaan : Ibu rumah tangga

Masuk RS : 11 Maret 2019

No. RM : 663489
+
ANAMNESA

Tgl masuk RS : 11 Maret 2019

Tgl pemeriksaan : 11 Maret 2019

Diperoleh dari : Autoanamnesis

Keluhan utama : Perut membesar

+
Riwayat Penyakit Sekarang
Perut bawah semakin membesar sejak 7 bulan yang
lalu, terasa mengganggu dan nyeri jika ditekan.
Selain itu perut bawah terasa nyeri yang hilang
timbul, muncul tidak menentu, nyeri tidak menjalar
Nyeri terutama memberat saat menstruasi. Saat
menstruasi perdarahan tidak berlebihan, dalam satu
hari pembalut diganti 3-4x. Keluhan nyeri saat
berhubungan disangkal. Tidak ada keluhan saat
berkemih. Demam disangkal. Tidak ada gejala-
gejala konstitusional keganansan seperti penurunan
berat badan, kelelahan. Saat ini pasien sudah
memiliki 2 orang anak.
+
Riwayat Keluarga
Riwayat Penyakit Dahulu
Tidak ada keluarga pasien
Pasien tidak pernah yang mengalami keluhan
mengalami keluhan serupa. Riwayat HT, DM,
serupa ataupun sakit yang jantung disangkal
berat sebelumnya. Riwayat
peny. Ginekologi
Riwayat Kebiasaan
disangkal. Hipertensi (-),
DM (-), jantung (-)
Pasien tidak merokok,
Riwayat Alergi tidak mengonsumsi
alkohol atau obat-obat
Pasien maupun tertentu
keluarganya tidak ada
alergi terhadap obat atau Riwayat Kontrasepsi
makanan.
Tidak menggunakan alat
kontrasepsi
+ Riwayat Pernikahan Riwayat Menstruasi

Menikah 1x, usia menarche usia 12 th, siklus 28 hari,

pernikahan 29 th, kawin lama haid 7 hari, haid teratur. Sehari
di usia 19 th ganti pembalut sekitar 4x,
dysmenorrhea. HPHT : 13/02/19

Riwayat Kehamilan, Persalinan

N Th Tempat Jenis Penol Penyulit JK BB PB Keadaan
o partus persalin ong anak
an sekarang
1. 14/09/ Prakte Spontan Bidan - L 3 kg - Baik
2003 k
bidan
2. 29/03/ Prakte spontan Bidan - P 3 kg - Baik
2008 k
bidan
+ Tanda Vital

KU : Tampak sakit sedang, CM Data Antopometri

TD : 116/79 mmHg
Suhu : 36,5oC BB : 70 kg
Nadi :79x/menit TB :155 cm
RR : 20x/menit IMT : 29,2 (Obes I)

Pemeriksaan Sistem

• Kepala : Bentuk normal, tidak ada kelainan kulit kepala, jejas (-)
• Mata : konjungtiva tidak anemis, sklera tidak ikterik, pupil bulat,
isokor, diameter pupil 2 mm, refleks cahaya langsung +/+.
• Hidung : Bentuk hidung luar normal, kavum nasi dextra et
sinistra lapang, tidak ada deviasi septum nasi, sekret -/-, mukosa
hidung tidak hiperemis.
• Telinga : Bentuk normal, liang telinga dextra et sinistra lapang,
tidak hiperemis, sekret -/-, serumen +/+.
+
Mulut : mukosa bibir lembab, mukosa mulut lembab, tonsil T1/T1, faring tidak
hiperemis.

Leher : Trakea di tengah, kelenjar getah bening submandibula, cervical, supra-

infraclavicular tidak membesar.

Thorax :
Dada bagian belakang
Inspeksi : Bentuk dada normal, letak dan bentuk columna vertebralis normal.
Palpasi : tidak teraba benjolan, stem fremitus kiri pada lapangan paru atas,
tengah dan bawah lebih kuat daripada kanan.
Perkusi : Redup pada paru kiri lapangan bawah.
Auskultasi : Suara vesikuler menurun pada paru kiri lapangan bawah, ronkhi
pada paru kiri lapangan atas, tengah dan bawah.

Dada bagian depan

Inspeksi : Bentuk dada simetris, iga-iga tidak mendatar
Palpasi : suara fremitus kiri pada lapangan paru atas, tengah dan bawah lebih
kuat daripada paru kanan.
Perkusi : Redup pada paru kiri lapangan bawah.
Auskultasi : Suara vesikuler menurun pada paru kiri lapangan bawah, ronkhi
pada paru kiri lapangan atas, tengah dan bawah.
+
• Abdomen
Inspeksi : Tampak cembung, distensi (-)
Palpasi : Supel, teraba massa di regio iliac dextra et sinistra,
nyeri tekan regio iliac dextra et sinistra, tidak teraba
hepatosplenomegali
Perkusi : timpani di seluruh kuadran.
Auskultasi : Bising usus (+)

• Ekstremitas : CRT < 2 detik, akral hangat, tidak edema

+ USG (11/03/19)

 Uterus antefleksi, normal

 Ovarium kiri : Tampak cyst ovary 5,9 x 3,5 cm
 Ovarium kanan : Tampak cyst ovary 11,9 x 8,5 x 11,3 cm dengan
filling defect

Kesan : Cyst ovary bilateral, susp. endometrioma

+
Diagnosis

 Working Diagnosis : Kista ovarium bilateral susp.

Endometrioma dan Adenomiosis
 Post op diagnosis : Endometrioma bilateral dan
adenomiosis
 DD : CA ovarium, Mioma uteri

Tatalaksana

 Salpingoooforokistektomi dextra + kistektomi

sinistra
 Ketorolac 3 x 30 mg i.v
 Ceftriaxone 2 x 1 g i.v
 Cefadroxil 3 x 500 mg PO
 As.mefenamat 3 x 500 mg PO
+ Endometriosis

Definition Prevalence & Epidemiology

The presence of  Predominantly in women of

endometrial glands and reproductive age
stroma outside of the  Women with unexplained
normal location subfertility with or without
pain (regular cycle, partner
 commonly found on the with normal sperm) 
pelvic peritoneum  prevalence of endometriosis
also on the ovaries, 50%
rectovaginal septum  Asian women are at higher
risk and African-American
women have a lower risk for
developing endometriosis
+
Endometriosis

Etiology Risk Factors

 Retrograde Menstruation  Familial clustering

 Lymphatic or vascular  Anatomic defects
spread  Environmental toxins
 Coelomic metaplasia
 Induction theory
+
+
+
+
Symptoms

 Pain
Pelvic pain  cyclic or chronic

 Dysmenorrhea
endometriosis-associated dysmenorrhea precedes menses by
24 to 48 hours and is less responsive to nonsteroidal antiin
ammatory drugs (NSAIDs) and combination oral
contraceptives (COCs)

 Dyspareunia
Most often related to rectovaginal septum or uterosacral
ligament disease. endometriosis-associated dyspareunia is
suspected if pain develops after years of pain free intercourse
+
Symptoms

 Dysuria
May be suspected if these symptoms are concurrent with
negative urine culture results

 Noncyclic pain
The most common symptom associated with endometriosis.
focus of chronic pain may vary (ex : rectovaginal septum or
uterosacral ligaments  pain may radiate to the rectum or
lower back)

 Infertility
Adhesions that are caused by endometriosis may impair
normal oocyte pick-up and transport by the fallopian tube
+ Physical Examination

In many women no abnormality is detected during clinical

examination. Other signs of possible endometriosis :
 Uterosacral or culdesac nodularity
 Lateral or cervical displacement caused by uterosacral
scarring
 Painful swelling of the rectovaginal septum
 Unilateral ovarian cystic enlargement
 Uterus often fixed retroversion, and mobility of the ovaries &
fallopian tubes is reduced

 Visual inspection
abnormalities during visual inspection are often lacking

 Speculum examination
Examination of the vagina and cervix often reveals no signs of
endometriosis. The presence of a narrow pinpoint cervical
ostium can be a risk factor for endometriosis

 Bimanual examination
ovarian endometrioma  enlarged, cystic adnexal mass, may
be mobile or adhered to other pelvic structures
+

Laboratory testing

 to exclude other
causes of pelvic pain
 (CBC), urinalysis and
urine cultures, vaginal
cultures
 Serum CA 125  a
better test in
diagnosing stage III
and IV endometriosis
+ Diagnostic Imaging

Sonography
 TVS is the mainstay in evaluating symptoms
associated with endometriosis.
 Small endometriotic plaques or nodules may
occasionally be seen, but these ndings are
inconsistent
 adequate sensitivity  if 20 mm in diameter or
greater
 Endometriomas  cystic structures with low-
level internal echoes

CT Scan
 suggested for the diagnosis and evaluation of
the extent of bowel endometriosis
MRI
 endometrioma appears as a high-signal-
intensity mass (on T1-weighted sequences), low
intensity (on T2-weighted sequences)
+
+
 Diagostic Laparoscopy

 Primary method used for

diagnosing endometriosis
 Lesion Lesions are variable
colors, which may include red
(red, red-pink, or clear), white
(white or yellow-brown), and
black (black or black-blue)
 can appear as smooth blebs on
peritoneal surfaces, as holes or
defects within the peritoneum,
or as at stellate lesions whose
points are formed by
surrounding scar tissue
 Pathologic Analysis

 current guidelines do not

require biopsy and histologic
evaluation for the diagnosis
 Histologic diagnosis requires
both endometrial glands and
stroma found outside the
uterine cavity
 hemosiderin deposition and
bromuscular metaplasia are
frequently noted
+
Combination Oral Contraceptives

 act by inhibiting gonadotropin release, decreasing menstrual flow, and

decidualizing implants
 reduce nerve fiber density and nerve growth factor expression in
endometriotic lesions

Progestins

 antagonize estrogenic effects on the endometrium, causing initial

decidualization and subsequent endometrial atrophy
 reduce nerve fiber density and nerve growth factor expression in
endometriotic lesions
 Ex : oral progestins, depot medroxyprogesterone acetate (DMPA)
(Depo-Provera), levonorgestrel-releasing intrauterine device (IUD), the
newer selective progesterone-receptor modulators (SPRMs)
 Surgical Treatment of Endometriosis-Related Pain

 Lesion removal and adhesiolysis

 Endometrioma resection
 Presacral Neurectomy
 Laparoscopic Uterine Nerve Ablation (LUNA)

Hysterectomy with bilateral salpingo-oophorectomy

 the definitive and most effective therapy for women with
endometriosis who do not wish to retain their reproductive function
 Limitations : surgical risks, pain recurrence, and hypoestrogenism
effects
+