The Rare Case of Prepubertal Endometriosis without Müllerian Outflow Obstruction

Abstract

Prepubertal endometriosis is an exceptionally rare clinical entity, particularly in the absence of congenital outflow obstruction or hormonal stimulation associated with puberty. Its atypical presentation often leads to delayed recognition and prolonged discomfort in affected children. We describe the case of an eight-year-old girl who presented with recurrent lower abdominal pain that persisted for nearly one year and was initially treated as constipation and functional abdominal pain. Despite multiple evaluations, her symptoms worsened, prompting referral for specialized pediatric assessment. Physical examination was largely unremarkable except for vague suprapubic tenderness. Laboratory tests were normal, and imaging showed a small, ill-defined adnexal lesion without evidence of hydrometrocolpos or Müllerian anomaly. Persistent symptoms warranted diagnostic laparoscopy, which revealed isolated endometriotic implants scattered over the left uterosacral region and peritoneum. Histopathology confirmed endometrial glands and stroma consistent with endometriosis. The absence of structural genital tract obstruction suggested extra pelvic seeding or embryonic Müllerian cell rests as a potential mechanism. The patient received conservative surgical excision and postoperative non-hormonal analgesic management. Her symptoms improved significantly, and follow-up showed resolution of chronic pain with no recurrence over twelve months. This case highlights the importance of considering endometriosis in prepubertal girls presenting with unexplained abdominal pain, even without typical risk factors. Early recognition can reduce morbidity, prevent repeated misdiagnosis, and support family education regarding long-term monitoring. Our report contributes to the limited literature on this rare pediatric condition and underscores the diagnostic value of laparoscopy when noninvasive testing remains inconclusive.