Clinical Information > Gynaecological > Endometriosis

For recent research abstracts see Pelvic Pain- Research under the heading - Endometriosis

Gynecologie, Obstetrique & Fertilite 36 (February 2008)

Debate

Yes, it is necessary to operate on patients with deeply infiltrating endometriosis ! “prefer optimistic will to pessimistic intelligence”

M Canis, S Matsuzaki, K Jardon, C Rivoire, B Cotte, S Tamburro, R Botchorischvilli, B Rabischong, J-L Pouly, G Mage. Department of Gynaecology, Obstetrics and Reproductive Medicine, CHU Polyclinique, Clermont-Ferrand, France            

Surgery for infiltrating endometriosis is often complex and difficult and can cause major complications such as ureteral or rectovaginal fistulas. Besides this surgery is not always effective and some patients have minimal pain and/or easily achieve the pregnancies they want.

For all of these reasons, it is necessary to ask the question about the reason for this surgical intervention. The decision to operate is rarely based on objective reasons, and probably more often rests upon the experience/aptitude of  the surgeon  in carrying out the surgical procedure and on the patient’s concerns following information about potential complications.

1. CONDITIONS OF THIS SURGERY

Several notions are important.

Excision is the only treatment; vaporization or coagulation are always insufficient in the treatment of these infiltrating lesions of more than 5mm. The initial treatment must be as complete as possible. In fact, all incomplete surgical procedures complicate definitive treatment, as it is difficult to distinguish the fibrosis introduced by the procedure from that which surrounds the lesions.

Infiltrating lesions are not more than 3 or 4 cm in diameter. Many lesions are less than 2 cm, do not infiltrate the intestine and their surgical treatment is quite simple. In these circumstances , the question is rather : why not operate on all of these symptomatic patients who consult for pain and/or infertility in as far as the lesions are often associated with adnexal lesions ?

For the larger lesions which involve organs such as the rectum or the ureter, the surgery must be carried out in specialist centres where the competences of gynaecological, colo-rectal and urological surgeons are combined.(1). But the gynaecological surgeon must remain in charge : his knowledge of the disease allows him to decide what is best, recognizing the  consequences of his actions. Bringing together a team of this type is not always easy. For this,  collaboration must be established in a clear manner before the appearance of complications which require recourse to a specialist surgeon.

This surgical intervention poses serious complications. In the course of our experience we have had several recto-vaginal fistulas (2). Darai et al. report a serious complication rate of 12,6% including six rectovaginal fistulas (3). In the literature, the complication rate depends very much on the patients included in the study. The rates are much lower (4) if all infiltrating lesions are included and not only the lesions that infiltrate more than half of the digestive tract. Serious complications are similarly reported by teams that  perform laparotomies.(5) But the digestive or urinary tract procedures required to treat complications are temporary. Similar complication rates are seen by digestive surgeons in colo-rectal surgery (6); if the lesion infiltrates the vagina and the rectum , a temporary diversion of the digestive tract is necessary because the vagina which needs to be extensively excised , does not heal well. Finally,one needs to take account of the years of intense pain for these patients and the many months necessary to treat the complications that arise.

The only remaining question is to know what is the spontaneous fertility and the rate following assisted medical conception of the patients who have had a serious complication.   

The answer can only be obtained in the context of a multi-centre survey.

1. EVALUATION OF THE PATIENTS

The indication to operate cannot be asked without correct assessment of these patients. The lesions, often suspected during routine questioning and identified by vaginal examination, must be assessed precisely. The patients about which it is claimed “they don’t have pain “ are often the patients in whom the questioning has not been thorough. Certain questions regarding the intensity of dysmenorrhoea, the disturbance linked with dyspareunia or the presence of digestive or urinary signs must be asked systematically, in particular amongst infertile patients who often consider these unimportant in the context.

The recommendations of the French National College of Obstetricians and Gynaecologists (CNGOF) emphasize the importance of specific questionnaires and an assessment of quality of life (7). This approach enables us to appreciate the importance of symptoms and to choose the right treatment. Under-estimating the pain can delay the diagnosis, leading to “neglecting certain patients “ where the feeling of frustration aggravates the retention of the painful signs.

Finally, it is necessary to question the notion of the asymptomatic patient when one knows that ureteral and renal lesions are for the most part clinically silent or with few symptoms due to the very progressive nature of ureteral obstruction !

1. IS IT NECESSARY TO OPERATE IN THE CONTEXT OF INFERTILITY ?

Several studies have shown that the observed fertility, after surgical treatment of infiltrating endometriosis, is similar to that observed following treatment of other severe forms of the disease (8). But one single study has compared conservative surgery by laparotomy to surgical abstention in the case of infiltrating lesions of the posterior cul-de-sac. It did not find any difference between the two groups. It was not a randomized study, but it was based on a comparison of the patients with whom the therapeutic treatment was decided following discussion with them of the advantages and the risks of surgery (9) In as far as the clinical signs correlate with the severity of the lesions, one could think that the patients who have the more severe lesions chose to have surgery due to the severity of their pain. The lesions associated with an ovarian cyst or a ureteral lesion have been excluded. This study confirms my approach to surgical treatment of nodules to treat chronic pain in the context of infertility.  

Therefore, at this point, one could ask the following questions. Are there patients who have infiltrating lesions and who don’t have any pain ?  Doesn’t the pain that some patients tolerate, limit their fertility to the extent where their chronic pain, and in particular dyspareunia, probably limits the frequency of sexual intercourse and therefore spontaneous conception ? Have we not deprived some patients who had less severe lesions of a pregnancy which might have occurred after the operation ? Who are the patients who have no pain and no adnexal lesion and who must not have surgery ?   Are they numerous ? In order to respond to this question, shouldn’t one randomize during laparoscopy after treatment of the associated adnexal lesions ?

Amongst patients with pain and infertility , the only true alternative is the use of medical treatment between IVF attempts which is not acceptable to all couples and which does not seem desirable, given the results of surgery in the treatment of infertility.(8)

1. IS IT NECESSARY TO OPERATE IN THE CONTEXT OF PAIN ?

The effectiveness of surgical treatment in chronic pelvic pain has been demonstrated by two prospective randomized controlled trials (10,11). The study by Abbott et al. included patients who presented with infiltrating lesions (11). The review of the recent literature carried out for the National College recommendations confirms the importance of surgical treatment of lesions which infiltrate the vagina and/or the digestive tract (12). Medical treatment may help functional signs but its limits are known. It is little or not effective for dyspareunia, which, when it exists, is triggered by direct trauma to the lesions. Similarly, it has little effect on functional signs ( digestive or urinary ), as they have lost their cyclical character and the hyperalgesia triggered by a clinical examination (13) Finally, these lesions do not disappear, which explains why the cyclical signs reappear on stopping treatment or a few weeks later.

For all of these reasons, surgical treatment is the only definitive treatment for infiltrating lesions, and it is one of numerous clinical situations where surgery is unavoidable, claimed by the patients who consider it, despite the risks of complication, as the light at the end of the tunnel of pain.

1. IS INFILTRATING ENDOMETRIOSIS A PROGRESSIVE DISEASE ?

In a series of 88 asymptomatic patients, Fedele et al observed an increase in size or the appearance of clinical signs linked to a nodule of the septum in six patients (14). But, in this series of patients there are several questions. What is the significance of the term asymptomatic where 24 patients had already been operated on for pain and endometriosis ? The authors assume that only dyspareunia, dychezia and dysmenorrhoea with anal irradiation are due to infiltrating endometriosis. The signs are typical, but are not reported by all of the patients who consult for lesions of this type. What contraception have these patients used ? In fact, if 22 patients consulted for infertility, only 24 used an oral contraception, which is low for women whose average age is 31 and who have been followed for a period of 68 months. No patient used a specific medical treatment for endometriosis, but oral contraception is a medical treatment for endometriosis, for which the effectiveness is similar to that of GnRH analogies. Finally, during the study period, certain patients were reoperated on for pain attributed to ovarian lesions. The functional result of these surgeries is not reported.

Likewise, Vercellini did not see an increase in the size of the lesions in the group that did not undergo surgery (9).

We studied the average delay between the beginning of clinical signs and the first surgical treatment of patients operated on for infiltrating endometriosis. The average delay is approximately two years for lesions of less than 1 cm and nine years for lesions of 1 to 3 cm or more in diameter (15). The result suggests that infiltrating endometriosis is a progressive disease, probably slowly progressive. We note that we do not know to what extent the contraception used by the majority of women today interferes with the speed of this development.

Given the very long delay observed in patients in whom the lesion exceeds 1 cm in diameter, it seems that the duration of follow up reported by Fedele and Vercellini, could be too short to determine whether these lesions are not progressive. For Vercellini, this slow evolution or non increase in size is explained by the fibrosis which surrounds the lesions buried in the retroperitoneal area. But , one also knows that these lesions, in the great majority, are not only surrounded by fibrosis but are composed of smooth muscle hypertrophy due to the infiltration of the vaginal or rectal muscularis. In this respect one can comment that the lesions that develop in the rectus abdominus of the abdomen do not self-limit themselves (16) and that their treatment by GnRH analogues are not effective. It is not logical to think that the spontaneous development on contact with a smooth muscle is different from that observed in a striated muscle.    

1. CONCLUSIONS

If these lesions have a spontaneous tendency to become more severe , if they are responsible for severe pain, all the more intense because they have not been recognized/ taken account of at an early stage, if surgical treatment is effective, why not operate on these patients ? why wait until the lesions increase in size and involve the rectum or the ureter more frequently ? why wait until the patients have experienced pain for such a very long  time and their treatment is more complex, whilst one knows that the pain experienced is also an apprenticeship ?  why allow patients who consult for infertilty to suffer, why suggest IVF when one knows that spontaneous fertility following surgery for these lesions, is similar to that observed following treatment of other severe forms of the disease ? only the thought of complications can justify this attitude. But the complications are more frequent if one operates on large lesions which infiltrate neighbouring organs, if one allows the lesions to develop for too long !

Therefore , we must favour “optimistic will rather than pessismistic intelligence” It is necessary to operate on these patients.

In our experience, 20-30% of patients refuse surgery be it because they are little symptomatic or more often because they are relieved by amenorrhoea obtained with medical treatment. In this situation, strict clinical monitoring is essential. It is necessary to see and examine these women once or twice a year. It is necessary to request a renal ultrasound at least once a year. Renal obstruction due to endometriosis is slow and progressive and generally asymptomatic. Surgical abstention also has serious complications. !!!

REFERENCES

• Golfier F, Sabra M. Surgical management of endometriosis. J Gynecol Obstet Biol Reprod 2007;36:162-72
• Mage G, et al. Chirurgie Coelioscopique en Gynecologie. Masson; 2007
• Darai E, Ackerman G, Bazot M, Rouzier R, Dubernard G. Laparoscopic segmental colorectal resection for endometriosis: limits and complications. Surg Endosc 2007;21:1572-7
• Slack A, Child T, Lindsey I, Kennedy S, Cunningham C Mortensen N, et al. Urological and colorectal complications following surgery for rectovaginal endometriosis. BJOG 2007;114:1278-82
• Leconte M, Chapron C, Dousset B. Surgical treatment of rectal endometriosis. J Chir 2007;144:5-10
• Ret davalos ML, De Cicco C, D’Hoore A, De Decker B, Koninckx PR. Outcome after rectum or sigmoid resection: a review for gynecologists. J Minim Invasive Gynecol 2007;14:33-8
• Panel P, Renouvel F. Management of endometriosis: clinical and biological assessment. J Gynecol Obstet Biol Reprod 2007;36:119-28
• Darai E, Bazot M, Rouzier R, Houry S Dubernard G. Outcome of laparoscopic colorectal resection for endometriosis. Curr Opin Obstet Gynecol 2007;19:308-13
• Vercellini P, Pietropaolo G, De Giorgi O, Daguati R, Pasin R, Crosignani PG. Reproductive performance in infertile women with rectovaginal endometriosis: is surgery worthwhile ? Am J Obstet Gynecol 2006;195:1303-10
• Sutton CJ, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertile Steril 1994;62:696-700   
• Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R. Laparoscopic excision of endometriosis: a randomized, placebo controlled trial. Fertil Steril 2004;82:878-84
• Roman H. Guidelines for the management of painful endometriosis. J Gynecol Obstet Bio Reprod 2007;36:141-50
• Anaf V, Simon P, El Nakadi I, Fayt I, Simonart T, Buxant F, Noel JC. Hyperalgesia, nerve infiltration and nerve growth factor expression in deep adenomyotic nodules, peritoneal and ovarian endometriosis. Hum Reprod 2002;17:1895-900
• Fedele L, Bianchi S, Zanconato G, Raffaelli R, Berlanda N. is rectovaginal endometriosis a progressive disease ? Am J Obstet Gynecol 2004;191:1539-42
• Matsuzaki S, Canis M, Pouly JL, Rabischong  B, Botchorishvilli R, Mage G   Relationship between delay of surgical diagnosis and severity of disease in patients with symptomatic deep infiltrating endometriosis. Fertil Steril 2006;86:1314-6
• Rivlin ME, DAS SK, Patel RB, Meeks GR. Leuprolide acetate in the management of caesarean scar endometriosis. Obstet Gynecol 1995;85:838-9                                                              

Journal of Gynaecology-Obstetrics and Reproductive Biology 36 (2007) 106-7

Guidelines for clinical practice: Endometriosis

Endometriosis is simple!

To preside over the guidelines for clinical practice in endometriosis is both an honour and a challenge. A challenge, because the existing literature remains too fragmented and incomplete for each recommendation, whether it is based on randomized studies or meta analyses.

But, thanks to the talent, effort and competence of the “experts” who participated in the development of the clinical guidelines, it seems to me that the challenge has been resolved. In fact many of the questions that we meet in practice receive logical answers. The answers are sometimes far from the norms in practice and the “superstitions” have been raised to the status of a dogma. Nevertheless, the scientifically validated answers are close to those suggested by common sense. This is why I wanted to introduce this article by describing endometriosis as a simple disease. What we do not understand is not necessarily complicated or complex!

The working group concluded that biopsy is recommended in order to make the diagnosis of endometriosis, which is logical for a disease for which the definition is histological. The heavy psychological impact of a diagnosis of endometriosis in the life of a woman, the possible confusions between a functional cyst with chocolate content and endometriosis or between obvious bladder endometriosis and small peritoneal granulations encountered in the context of a primitive peritoneal carcinoma justifies the decision.

Several recent works have underlined that the delay in diagnosis is a major problem in endometriosis. Analysis of the literature underlines the interest of questionnaires and pain evaluation scores and quality of life. Likewise the importance of careful examination of the posterior cul-de-sac of the vagina is clear. Never forget that pain inscribes itself in a life, in a personal history and that there is not always a correlation between the severity of the disease and the gravity of the complaint. Listening to the patient and their history must be given as much attention as that of the pain and of the disease. For this reason and due to associated problems, the pain often requires multidisciplinary care.

The recommendations underline the importance of referral centres where this care (pain specialists, rheumatologists, psychologists, urologists, gastronterologists ….   ) can be organized. This multidisciplinarity also concerns surgery for the infiltrating forms of the disease.  The gynaecological surgeon may need the competences of a urologist or a bowel surgeon, but he should remain the conductor. It is he who knows the pathology and who puts forward the indications, taking account of the technical constraints and the possible complications.

 In order to know the indications, the gynaecological surgeon needs as precise a diagnosis as possible. For this, the laparoscopy must follow a sequence of precise procedures. All of the areas of the pelvis and the abdomen must be assessed, then described in the operative report. Alongside this analytical description, a resume using one of the classifications simplifies the dialogue.

But the laparoscopic “gold standard” has its limits. Ultrasound and MRI must evolve thanks to the efforts of radiologists, whose high performing methods of diagnosis guide the surgeons. Unfortunately these examinations are dependent upon the operator and competence in this area is too rare. This competence can only be acquired in the context of close collaboration. Radiographers need to see the surgical images in order to learn, in order to help us and to guide us.  In the case of infiltrating lesions, the surgeon only obtains the information that imagery obtains, after two or three hours of operating. The contribution of radiography will be considerable, but a huge amount of information and training remains to be done!

As Brosens emphasized, menstruation is key (1), whatever the role of menstrual reflux may be in the etiology of the disease. This signifies that the catamenial character of a clinical sign, even the most unexpected, should lead one to think of endometriosis, and that the majority of patients are relieved of pain by obtaining therapeutic amenorrhea.

Medical treatment has its limits, as you know. The intra-uterine endometrium does not disappear during treatment with GNrH analogues or during progestogen treatment. Therefore why should that which does not occur within the uterus, occur outside of the uterus? In fact, we know from the work of Schweppe and Evers that medical treatment has a suppressive effect (2), (3). These conclusions have been repeated recently in the Afssaps guidelines concerning the medical treatment of endometriosis(4).

In the same way, the antigonadotrophins have no effect on fibrosis. Then why should these treatments used alone be an effective treatment for ovarian endometriomas in which the wall consists of partial fibrosis? Therapeutic amenorrhea relieves the pain in practically all patients, but it does not resolve fibrotic lesions or soft tissue fibres. This evidence, suggested by common sense – is sometimes poorly accepted, because there is an exception: superficial peritoneal lesions.

Just as the seeding of a grain of corn depends on the soil where it is sown, the growth and development of ectopic endometrium depends on the tissue on which it develops. The peritoneum is a hostile environment capable of encasing cysts and expelling elements which are foreign to it. It excludes and surrounds the ectopic endometrial implants. For this reason, the very young endometriotic lesions situated on the surface of the peritoneum may disappear completely during medical treatment. But this situation is an exception. The guidelines remind us all that medical treatment does not allow effective treatment of the implants situated in scar tissue in the abdominal wall or in other well vascularized tissues.

Surgery of infiltrating lesions is effective if it is complete. The quality of the surgery carried out is more important than the technique, an incomplete procedure is often followed by recurrence. It is necessary to explain to our patients that this surgery carries a non negligible risk of severe complications. These complications are more frequent during treatment of large lesions. A diagnosis and early treatment are the best method of preventing complications.

Cystectomy is the treatment of preference of endometriomas. But this cystectomy is sometimes impossible or too difficult and it may be necessary, following a biopsy, to rearrange the therapeutic surgery following several weeks of medical treatment. However, this cystectomy is not a simple cystectomy, there is always the moment where the plane of cleavage is difficult to follow and it is necessary to approach the cyst by coagulating the summit of the red triangles of fibrosis where one sees the surface of the cyst.(5) These triangles are like arrows that the patient is using to guide us, follow them!  Surgeons must, like the radiographers, learn the specificities of the surgical treatment of endometriosis.

Again common sense!  if one tells you that the menopause does not improve fertility, you conclude that the postoperative medical treatment of endometriosis is of no interest in the context of infertility. The meta-analyses confirm that such a prescription is useless, apart from amongst patients who need an immediate postoperative PMA.

When the treatment of endometriosis seems too complex, resort to common sense reminding ourselves that we are treating a patient who is consulting for infertility or pain and not for endometriosis. For example, one often asks : is it necessary to use a postoperative medical treatment in a patient who does not wish to become pregnant ? In practice this question hardly exists. If the patient does not want a child, she generally wants to avoid pregnancy and needs contraception. Therapeutic amenorrhoea  of which we have spoken above may be a contraception ( monophasic oestro-progestative, macroprogestative ) administered continuously. The response to this question is simple, even if we do not know whether this treatment reduces the risk of recurrence.

Yes, endometriosis is mysterious but in spite of that, it is a simple disease.

1. Brosens IA. Endometriosis: a disease because it is characterized by bleeding . Am J Obstet Gynecol 1997: 176;263-7

2. Schweppe KW, Dmowski WP, Wynn RM. Ultrastructural changes in endometriotic tissue during danazol treatment. Fertil Steril 1981;36:20-6

3. Evers JL. The second-look laparoscopy for evaluation of the result of medical treatment of endometriosis should not be performed during ovarian suppression. Fertil Steril 1987;47:502-4

4. Afssaps. Recommendation de bonne pratique. Les traitments medicamentaux de l’endometriose genitale http://agmed.sante.gouv.fr/pdf/5/rbp/endomet_reco.pdf.

5. Canis M, Pouly JL, Tamburro S, Mage G, Wattiez A, Bruhat MA. Ovarian response during IVF-embryo transfer cycles after laparoscopic ovarian cystectomy for endometriotic cysts of > 3 cm in diameter. Hum Reprod 2001;16:2583-6.     

M. Canis

Department of gynecology-obstetrics and reproductive medicine, Polyclinique Hotel-Dieu,

CHU Clermont-Ferrand, France                                                      

 Gynecologie, Obstetrique & Fertilite 34 (2006) 1-2

                       Editorial

    Surgeons ! Pity patients who suffer from endometriosis !  

Endometriosis is a pathology that is frequently encountered by surgeons. The surgical diagnosis, easy in the vast majority of cases, is generally arrived at during a laparoscopy. Endoscopic treatment of mild forms or small ovarian cysts (moderate stage) is simple and can be carried out in good conditions by all gynaecologic surgeons.

Unfortunately, the operator is frequently confronted by severe or extensive lesions much more serious than expected based on the preoperative examination and information. The procedure which began as a laparoscopy is difficult, that is very difficult. There are uterosacral ligament lesions, large ovarian cysts, dense adhesions of which the cleavage is  haemorraghic, a complete obliteration of the Pouch of Douglas, intestinal infiltration……….

In view of the severity of the lesions and the technical limits of laparoscopy, the conclusion is simple: a laparotomy is indispensable and inevitable. Unfortunately the Pfannenstiel is not the solution: the procedure remains difficult, albeit very difficult. It is often incomplete leaving in place part of the cysts, the main part of the infiltrating lesions of the uterosacral ligaments or the rectovaginal septum. In addition, the incomplete procedure often includes drainage and radical non indispensable procedures : oophorectomy, annexectomy (more frequently on the right) ………

This salvatory surgery, often carried out in an urgent or semi- urgent context, justified by the severity of the lesions, does not resolve anything. A few weeks, months or years later, following the wish of the patient to conceive or the duration of medical treatment that has been prescribed postoperatively, the disease that has not been treated, inevitably recurs. The ineffectiveness of medical treatment on large cysts and infiltrating rectovaginal lesions has been known for a long time.

The patient is therefore referred to a specialist centre for surgical treatment. The procedure is generally complex and often very much more difficult amongst patients who have already had a laparotomy. In fact, in addition to the adhesions caused by the disease, for which the cleavage gradually becomes practically impossible over the course of repeated procedures, there are  the adhesions induced by the surgeon, which make laparoscopic access to the pelvis problematic. The treatment of ovarian cysts on the annexes which have become solitary, expose an increased risk of definitive ovarian insufficiency. Finally, the fibrosis introduced around the nodules by an incomplete treatment cannot be distinguished from the fibrosis which often surrounds the infiltrating endometriotic lesions. In order to carry out a complete treatment, the surgeon, who has difficulty in finding the plane of cleavage, is forced to carry out a wider excision which increases the risk of serious complications, ( lesions of the ureter, the rectum, fistulas etc. ) of incomplete treatment and recurrences.

Therefore, what should be done at the initial surgery ? an immediate laparotomy is not obligatory: only small bowel obstruction and the suspicion of ovarian cancer are indications for urgent laparotomy in the context of endometriosis. In all other situations encountered in patients with severe or extensive endometriosis, the operator must, if he is not used to treating this endoscopically, make a difficult decision for a surgeon: stop the surgical  procedure having confirmed the diagnosis by a biopsy for anatomopathological examination and draining the ovarian cysts. The procedure is concluded by a careful vaginal and rectal examination to define the significance of the infiltrating lesions and an operative report which is as detailed as possible in order to guide future procedures.

Surgical abstention followed by postoperative progestogens or GnRH agonists is the best solution. Sometimes specialists may need to defer a surgical procedure due to medical treatment, that they judge too difficult from the first few minutes of the procedure. The lesions are much less impressive when the functional cysts have disappeared, when the endometriomas have decreased in volume and when the operative procedure has been organized under good conditions in a specialist centre where it is possible to treat intestinal and/or urological lesions which have been planned for. Even under these conditions complications are not unusual, but at least the patient has been offered the best chances of effective and safe surgical treatment.

The patient will not reproach you for a delay in treatment and you will not witness postoperative complications that you wanted to avoid by performing a laparotomy and that you feared at the discovery of widespread lesions.

Abstention is not natural for surgeons who are more inclined to act, but it is this approach that surgeons must learn…………. for the benefit of their endometriosis patients.

G  Mage

M Canis

CHU Clermont-ferrand

Dept of Gynecology- Obstetrics & Reproductive Medicine

Deeply infiltrating endometriosis: a plea for listening to patients and vaginal examination!

Editorial: Gynecologie, Obstetrique, Fertilite 2003 Nov 31 (11) 893-4

How can all this be avoided? This is the question that one asks oneself on seeing again in consultation a patient in whom bowel involvement is reestablished 3 months after the development of scarring of a rectovaginal fistula and more than 6 months after the initial surgery. This patient had a large lesion due to a severe gynecological and intestinal symptomatology, for which medical treatment only brought incomplete improvement. The surgery carried out by a team familiar with such lesions (1,2) had been complex, difficult dissection, vaginal resection and rectal resection with transanal anastomosis. This surgery poses a risk of rectovaginal fistula, an infrequent complication but difficult to accept in a young woman wishing to retain her fertility and causing major functional problems for several months.

(1) How can this be avoided?
The first response “operate correctly!” any complication is the surgeon's fault, but if the surgery is very complex, even the most competent may have a complication.

The second response “don't operate!!” But we don't operate on asymptomatic patients, nor on patients who are satisfactorily relieved by a medical treatment and who are resorting to assisted reproduction techniques to treat their infertility. The surgery is reserved for patients who have incapacitating pain (dyspareunia, chronic pelvic pain) in spite of an effective medical treatment.

The third response “ prolonged medical treatment with GnRH analogues with add back therapy in between assisted reproduction attempts.” But the long term results are unknown in the context of large nodules. How many of these patients are operated on despite everything ? Among young patients, treatment is envisaged for more than 10 years. After all, this treatment is not always effective with patients who have daily pain, in particular those with permanent intestinal involvement.

The fourth response : “performing an incomplete surgery of debulking which leaves the rectal lesions in place and only treats the vaginal lesions” (3). This approach appears satisfactory amongst patients who have superficial rectal involvement without deep infiltration of the muscularis. But there is a risk of complication with large lesions and before deciding on a partial surgery, it is necessary to remember the complexity of reoperating. When the postoperative fibrosis combines with the fibrosis induced by the endometriotic nodule, it is more difficult, quasi impossible to know where to fix the limits of the excision necessary in order to treat the pain effectively.

If abstending is not satisfactory, if the medical treatment and the debulking surgery have reached their limits, if radical surgery becomes too difficult to carry out without a 5% risk of serious complications, what should be done?

(2) Preventing a possible inextricable situation !!!
We have no means of preventing endometriosis. But serious lesions do not develop in 3 months, nor even in 1 year!

We follow patients who have infiltrating endometriotic lesions who have not been operated on and the evolution observed suggests that the worsening of these lesions is generally slow. A rapid development may lead one to doubt the diagnosis of endometriosis and the benign nature of the lesion.

So, when one is confronted with the clinical history of these patients; when one “discovers” frequently a rectovaginal nodule previously unrecognized ; when one “hears” this long complaint of severe and incapacitating dysmenorrhea, ignored or badly taken into account; when it is frequently known that dyspareunia is absent due to its ballistic characteristic: one asks oneself how it is possible not to see or detect such large and obvious lesions. The screening instruments for deep lesions and the prevention of complications are available. These instruments are present in all gynecology departments.

Yes, all gynecologists have two ears to listen to the severe dysmenorrhea, the anal pain, pain on defecation. All gynecologists have two fingers to examine the vaginal cul-de-sac and in particular the posterior cul-de-sac and to find the obvious nodule as soon as its diameter exceeds 1 cm!!

No, severe dysmenorrhoea must not on the face of it be considered as insignificant even among very young girls, even if it is isolated… the questioning will search for bowel or bladder signs which suggest infiltration of the neighbouring organs…

No, the absence of dyspareunia does not rule out the diagnosis. If it is absent on questioning, palpation of a nodule often triggers pain that the patient recognizes as having felt in certain positions that she since avoids.

Yes, vaginal examination remains essential while increasingly accurate ultrasound tends to replace the clinical exam. Yes, the posterior vaginal cul-de-sac must be inspected gently to search for blue lesions or an area of retraction. Yes, it is necessary to examine the posterior cul-de-sac gently but thoroughly in all patients, even if this part of the examination is uncomfortable or disagreeable. The explained inconvenience is more easily accepted than neglected severe endometriosis. And, the anterior cul-de-sac should not be forgotton even if it is rarely affected. !
If the clinical exam is carried out correctly, how is it possible not to see or detect these lesions ?

Rarely are infiltrating lesions situated so high that the clinical exam cannot detect them and rarely do they need to be sought on MRI or ultrasound in a patient who has very severe symptoms.

Yes, vaginal exam may reveal lesions which have not been detected in a previous examination, because the lesions have increased in volume or because the patient with increased confidence allows herself to be examined more easily.

Yes, it is necessary to carefully repeat a clinical exam which was negative several months previously or which was negative several years before/ago.

Yes, it is necessary to doubt the diagnosis of primary dysmenorrhoea which had been made so far.

No, a normal MRI does not rule out the diagnosis, because the lesions are difficult to see if they are less than 5mm in diameter or if the radiologist is not familiar with deep endometriosis.

Yes, it is necessary to doubt the conclusions of a negative laparoscopy, if it was carried out several years previously and, if the operative report does not describe a vaginal exam under endoscopic control which is indispensable to the visualization of sub-peritoneal lesions which are sometimes difficult to see via the abdominal route.

Yes, it may be useful to carry out the clinical exam during menstruation as suggested by Koninckx et al. (4).

The doubt of a negative clinical exam or non contributive paraclinical investigations is easier if one takes account of what the patients say. If one only considers that everything has already been investigated and that the pain is of imaginary origin ... such pain has a psychological effect...!

If to detect these lesions at a time when their surgical removal is simple and without risk, it is sufficient to listen to the patient, to place the speculum and to palpate the vaginal cul-de-sac why is it still necessary to do complex high risk surgery ?

Is it necessary to educate patients that they shouldn't consider dysmenorrhea as physiological or that dyspareunia is embarrassing ?

Is it necessary to remind general practitioners and gynecologists of the advantage and rules of clinical examination ?

Is it necessary to remind medical lecturers that they must insist on the advantage of vaginal examination and not to allow their students to think that the vagina only serves for the placing of the speculum, the fingers or the ultrasound probe which examines the upper genital system ?

After early diagnosis, surgical treatment is the logical approach. It generally easily allows complete treatment of the lesion. If a medical treatment is used, it will be prescribed with full knowledge of the facts and with careful monitoring to detect an increase in size or a lateral extension of the nodule, changes which pose an indication for surgery before the procedure becomes too complex.

References

(1) Canis M, Slim K, Tamburo S, Botchorishvili R, Wattiez A, Mage G et al. Traitement chirurgicale de l'endometriose infiltrant. In Endometriose J Belaish Ed Masson

(2) Canis M, Botchorishvili R, Slim K, Pezet D, Pouly JL, Wattiez A et al. Bowel endometriosis. Eight cases of colorectal resection. J. Gynecol Obstet Biol Reprod 1996; 25;699-709

(3) Donnez J,Nisolle M,Gillerot S, Smets M,Bassil S, Casanas-Roux F. Rectovaginal septum adenomyotic nodules: a series of 500 cases. Br J Obstet Gynaecol 1997; 104:1014-8

(4) Koninckx PR,Meuleman C, OosterlynckD,Cornillie FJ Diagnosis of deep endometriosis by clinical examination during menstruation and plasma CA-125 concentration. Fertil Steril 1996; 65:280-287

M. Canis
Department of Gynecology-Obstetrics and Reproductive Medicine, Clermont- Ferrand, France