Patient Information > Gynaecological > Adhesions

                                                        ADHESIONS

 (the word adhesions comes from the verb "to adhere")

What are adhesions?

Adhesions are deposits of fibrous strands/scar tissue which can connect organs together. Organs in the peritoneal cavity (pelvic/abdominal space ) normally slide freely against each other and adhesions can hinder this movement leading to such comlications as pain, infertility and bowel obstruction. Adhesions are usually the result of injury to the peritoneum (lining of the abdomen and pelvis) and are part of the normal wound healing process. They do not always lead to problems but when they do cause difficulties, these can be wisespread and severe.

What are the causes of adhesions?

• Endometriosis
• Infection- any type of infection can lead to adhesions if it is not treated quickly and effectively eg pelvic inflammatory disease, abcess
• Inflammation- pelvic inflammatory disease, inflammatory bowel diseases (Crohns disease, ulcerative colitis) or a ruptured appendix.
• Surgery- there is an increased risk of adhesions after abdominal and pelvic surgery. Some  types of surgery carry a higher risk of resulting in the development of adhesions. This includes ovarian, endometriosis, tubal, myomectomy (removal of fibroids) and adhesiolysis (removal of adhesions).  

Prolonged exposure to air during surgery can lead to drying of tissues which may contribute to new adhesion formation at sites away from the operative procedure. Stitches during surgery can result in adhesions. Adhesions can begin to form immediately after surgery and certainly are formed within the first 5 days following surgery. 

What are the problems caused by adhesions?

• Pain. It appears that some adhesions cause pain by restricting mobility. Furthermore, nerve endings may become entrapped within developing adhesions. The pain can be local or deep in the pelvis
• Dyspareunia- pain during sexual intercourse. This can be caused when the ovaries become stuck down and by local trauma during deep penetration.
• Bowel obstruction- dense adhesions can cause kinking and stricture of the bowel. Hysterectomy is a common cause of postoperative intestinal obstruction.
• Bladder problems- adhesions can reduce the capacity and proper emptying of the bladder causing pain and frequency- can be mistaken for cystitis.
• Infertility- can be produced by adhesions in different ways depending on their site. Adhesions around the ovary can interfere with ovulation. If they are around the ends of the fallopian tubes there can be problems with picking up the egg following release from the ovary. If adhesions are around the fallopian tubes, transport of the egg through the tube may be restricted. Adhesions around the uterus (womb) can cause it to be bound down. The uterus can become attached to the bowel. This may be described as fixed or immobile. ( A retroverted uterus is when it is tilted backwards. An anteverted uterus is when it is pulled forward attaching  to the bladder.)

What can be done for adhesions?

Laparoscopic procedures appear to reduce incisional and new adhesion formation. Research is currently ongoing in this area. Peritoneal injury may be minimized by using filtered, heated and hydrated gas instead of the frequently used dry gas.

Good surgical technique:

• Preserving good blood flow.

• The least possible tissue handling of tissues.
• Use of microsurgical instruments.
• Powder free and even starch free gloves should be used because of the association with adhesions.
• Meticulous care with stopping bleeding. (Careful haemostasis). 
• Use of fine stitching material.
• Control of infection.

All diseased tissue should be excised. Because endometriosis can hide beneath adhesions, it is vital to completely excise the scar tissue to be certain no endometriosis is left behind. 

Use of adhesion prevention products:

Some adhesion prevention products have been removed from the market in recent years. There are two main categories of products:

 a) physical barriers, films and gels (these are site specific ie for localized use)

 b)solutions ( broad coverage within the abdominal cavity)   

Several of these agents are currently under study. 

ANY TECHNIQUE IS ONLY AS GOOD AS THE SURGEON USING IT.!!

As a patient:

• Ask your surgeon what precautions and strategies they take to prevent adhesions. 
• Exercise may help to make the adhesions flexible and help to reduce pain.

The future of adhesion prevention.

Further advances are likely to occur over the next few years. 

Chronic pelvic pain affects nearly 15% of women between 18 and 50. The treatment of chronic pelvic pain is emerging as a multidisciplinary speciality. This means a team of pain specialists, anaesthesiologists, neurologists, urologists, general surgeons, physical therapists, gynecologists and nurses working in a coordinated manner to achieve maximum benefit for the patient.

Do your homework before you are referred – you can request to be referred to a specific surgeon. Be sure to ask your surgeon what precautions they take to prevent adhesion formation. If your surgeon is not open to discussing this, you can seek a surgeon who does or request a second opinion. The Pelvic Pain Support Network has a more detailed information leaflet about adhesions which patients find helpful as well as a suggested list of questions you may wish to ask (available on request – contact us ).

References:

Royal College of Obstetricians and Gynaecologists consensus in adhesion reduction management 2004

We are currently carrying out a survey about adhesions:  Click here

For further information about adhesions see the message board:

http://www.pelvicpain.org.uk/forum/index.php