Ischiorectal endometriosis is rare and can be associated with vaginal delivery and birth trauma. In this video, we present the case of a 34-year-old patient who presents with progressively worsening perineal pain after childbirth. An MRI confirms an endometriosis nodule in the ischiorectal fossa. We have described an approach to resection using a trans-ischiorectal fossa approach and subsequent reconstruction with a Martius flap. Rotational grafts such as the Martius flap have been used for fistula repair and are less invasive when compared to gluteal or gracilis flaps. We describe a two-step approach as a feasible strategy to avoid an invasive rotational flap. This video aims to provide a step-by-step approach to both resection and reconstruction while providing an overview of perineal anatomy.