Endometriosis & Chronic Pelvic Pain

Endometriosis & Chronic Pelvic Pain

Endometriosis is the modern epidemic of gynecology. A woman normally sheds the inner lining of the uterus (endometrium) at the end of each menstrual cycle. This manifests in the form of menstrual bleeding. Some of this blood containing living endometrial cells can also reach the abdominal cavity through her Fallopian tubes, blood vessels or lymphatics. In a small percentage of women, these cells can implant (stick) on the various organs of the pelvis (ovaries, intestines, Fallopian tubes and surface of the uterus) and grow & bleed inside the abdomen. This causes irritation of the abdominal cavity and causes the various organs (intestines, ovaries, Fallopian tubes and uterus) to stick to one another (adhesions). The important structures passing through the pelvis such as the pelvic nerves, blood vessels and ureters (tubes carrying urine from the kidneys to the bladder) can become encased and constricted in these adhesions.

Symptoms

Endometriosis can lead to the following symptoms:

  • Severe chronic pelvic pain worsening during menstruation
  • Pain with feeling of passing stools (tenesmus) & blood in feces (hematochesia) and occasionally intestinal obstruction.
  • Infertility by blocking the ovaries and Fallopian tubes due to adhesions and inflammation which can damage the sperms and eggs
  • Occasionally, endometriosis involving the urinary bladder can cause painful passage of urine (dysuria) and passage of blood in urine (hematuria)
  • Compression of ureters can lead to dilatation of the ureters (hydronephrosis) causing pain and, rarely, renal failure.
Hysteroscopy can be performed for the following indications:

Adenomyosis is a variant of endometriosis where the the lining of the uterus (endometrium) invades and grows into the muscle of the uterus (myometrium). This condition can cause severe pain especially during menstruation (dysmenorrhea) and heavy menstrual bleeding (menorrhagia).

Rectovaginal adenomyosis is another entity which is characterized by the presence of uterus like tissue (endometrium and muscle) in the pelvic. This gives rise to symptoms similar to endometriosis. Sometimes, in a woman with chronic pain, no pathology can be found except dilated blood vessels around the uterus. This is called as pelvic congestion syndrome.

The mainstay of management of endometriosis and its associated pathologies is surgery followed by treatment for fertility (getting pregnant) and medication. Laparoscopic surgery has become the gold standard for management of endometriosis.

Treatment

The following surgeries can be performed for endometriosis:

Adhesiolysis and excision of endometriosis implants: The adhesions which involve the pelvic organs are cut and any localized nodules of endometriosis excised. This is an extremely complex surgery involving releasing the intestines from the adhesions, releasing the ureters from the endometriosis and separating the ovaries from the adhesions. The ovaries can be lifted and tied lightly away to the round ligament (cord like structure arising from the uterus) to prevent recurrence of adhesions around the ovary (ovariopexy). The goal of the surgery is to restore anatomy to as normal as possible and improve chances of pregnancy.

Hysterectomy with removal of both ovaries and Fallopian tubes (salpingo-ophorectomy): In women not wishing further pregnancies and those with severe symptoms, the uterus and both ovaries along with the Fallopian tubes can be removed. This removes the hormones which support growth of endometriosis and reduce the possibility of recurrence of endometriosis. This is also a major surgery involving separation of the intestines and ureters from the uterus and ovaries.

Ovarian cystectomy: In a large number of cases of endometriosis, the endometriosis implants on the ovaries leading to formation of large cysts containing thick chocolate coloured bloody fluid (chocolate cysts or endometriomas). These cysts can usually be removed completely leaving behind adequate amount of normal ovary (cystectomy). Rarely, the entire ovary may have to be exised (ovariotomy).

Excision of rectovaginal adenomyosis: Excision of these implants often involves excising part of vagina and superficial aspect of the rectum and intestine. However, complete excision is necessary since this prevents recurrence and offers a complete cure to the woman.

Adenomyomectomy: Adenomyomectomy involves excision of the adenomyoma out of the uterine wall and stitching up the uterine wall. This procedure is similar to removal of fibroids.

Laparoscopic uterine nerve ablation (LUNA): This is indicated for women with severe menstrual pain. It involves excision of the which pass along the uteosacral ligaments (cord like structures at the back of the uterus). It is important to keep the ureters away from the field of surgery since they may get damaged accidentally.

Presacral neurectomy: In women with severe endometriosis and pelvic congestion, the nerves which enter the pelvis over the sacral bone and passing to the pelvic organs (uterus, rectum and bladder) are cauterized and cut. This is more complicated procedure since it involves dissection around major blood vessels entering the pelvis.

The advantages of laparoscopy in surgery for endometriosis includes:

  • Better visualization of important structures during surgery with possibility of more complete surgery.
  • Better post-operative recovery with reduced pain.
  • Better cosmesis.
  • Reduced post-operative adhesions between important pelvic organs.
  • Improved chances of pregnancy.
  • Improved long terms results for chronic pelvic pain and other symptoms.