These bouts of tenesmus and bleeding have increased in frequency and intensity over the past three months. Intercourse has always been enjoyable to the patient and had, until recently, occurred 3-4 times weekly. For the past several months, however, the patient had noticed progressive dyspareunia. The patient's family history is significant for a history of secondary infertility in her mother following the birth of this patient. The patient's sister is four years younger than the patient and is herself infertile.
Physical examination is unremarkable with the exception of the pelvic and rectal examinations.
Bimanual pelvic examination reveals mild tenderness in the left adnexal area with apparent fixation of the left ovary to the uterus. Vaginal ultrasonography revealed a tender 3 cm left ovarian cyst. There was tenderness in the cul de sac as well as nodularity involving the left uterosacral ligament. Rectal examination was painful with marked induration approximately 3 cms from the anus. The most likely diagnosis for this patient is endometriosis , with typical symptoms of dyspareunia, dysmenorrhea as well as rectal and urinary symptomatology.