Anatomical Distribution of Deep Infiltrating Endometriosis and Its Relationship to Pelvic Pain

Abstract

Background: Deeply infiltrative endometriosis (DIE) is found in many anatomical locations in the pelvis and causes chronic pelvic pain (CPP). Objective: The goal of this research was to investigate the relationship between several types of pelvic pain with anatomical locations of DIE lesions. Materials and Methods: This was a retrospective observational study that included 59 women who underwent surgical exeresis of DIE. Clinical and surgical data were collected on the anatomical locations of lesions (uterosacral ligaments, retrocervical, rectovaginal septum, vagina, bowel, bladder, and others), and pelvic adhesions. Multivariate analysis and logistic regression were used to study the relationship between the types of pelvic pain and sites of DIE as well as the locations/extents of pelvic adhesions. Results: Most women presented with more than one type of pelvic pain (46; 78%) and multifocal DIE (36; 61%). DIE was more frequently encountered in the bowel (40; 34.2%) and uterosacral ligaments (31; 26.5%). Deep dyspareunia was associated with vaginal DIE (odds ratio [OR]: 3.17; 95% confidence interval [CI]: 0.9–10.7) and rectovaginal septum DIE (OR: 4.42; 95% CI: 1.0–19.3). Pelvic adhesions in the cul-de-sac were associated with dyschezia (OR: 7.58; 95% CI: 0.9–66.3) and intestinal DIE (OR: 10.2; 95% CI: 2.79–37.3). Conclusions: Deep dyspareunia was associated with DIE in the vagina and rectovaginal septum. Dyschezia was related to cul-de-sac adhesions, whereas intestinal endometriosis was associated with cul-de-sac obliteration. Specific types of pelvic pain may be predictive of DIE locations and can be used to help plan surgical interventions. (J GYNECOL SURG 32:99)

Introduction

Endometriosis is a progressive and benign estrogen-dependent disease defined by the presence of endometrial tissue (glands and stroma) outside the uterine cavity.¹ This condition occurs in reproductive-age women and often leads to pelvic pain and/or infertility in women while others remain asymptomatic.^2,3 Deep infiltrating endometriosis (DIE) is regarded as a specific entity that has been arbitrarily defined in histologic terms as endometriotic lesions extending more than 5 mm underneath the peritoneum.⁴ DIE accounts for painful symptoms⁵ with severity that appears to be correlated with the depth of the DIE lesions.^6,7 A relationship between an increase in pain intensity and a decrease in quality of life (QoL) has been reported in women with DIE.^7,8

The most frequent symptoms of pelvic endometriosis are dysmenorrhea, dyspareunia, chronic pelvic pain (CPP), and infertility.^5–8 DIE may be found in many anatomical locations in the pelvis and may present with distinct types of pelvic pain. These symptoms, however, appear to have poor correlations with the stages or anatomical locations of endometriosis.^7–10 Apparently, the symptoms of endometriosis are related to the number and/or location of endometrial implants and the number and/or location of adhesions, but published studies do not seem to agree entirely on these factors.^9–15 As proper diagnosis regarding the presence, location, and extent of lesions is a fundamental step in preoperative evaluation and defining the surgical approach for endometriosis, the current study was designed to investigate the relationships between these types of pelvic pain with anatomical location of DIE lesions.

Materials and Methods

This was a retrospective observational study that included 399 women who underwent surgical exeresis of DIE because of CPP and who were operated on by a multidisciplinary surgical team from July 1997 to September 2007. All surgeries were laparoscopies performed by the same gynecologist (I.A.) and coloproctologist (L.M.P.C.). Only cases with histologic confirmation of endometriosis were included.

All of the patients in this study underwent gynecologic examination, and pelvic transvaginal and abdominal ultrasonography to evaluate the presence of pelvic endometriosis prior to surgery. Other diagnostic tests were performed when indicated, as previously described in the literature.^3,7 All of the study patients who were scheduled for laparoscopic management of DIE gave informed written consent to surgical treatment and the possible use of their anonymous data for research purposes. The study protocol was approved a local ethics committee.

The surgical strategy was complete laparoscopic excision of all visually suspected endometriotic lesions and the laparoscopic procedures were performed by the same surgeon (I.A.) and coloproctologist (L.M.P.C.). Although the surgical team had an extensive background in laparoscopic treatment of patients with DIE, only 1 surgeon's involvement was studied in order to have uniform criteria for all of the treated cases. Laparoscopic resection of endometriosis was performed as previously described in the literature.¹⁶ Surgical staging was performed in accordance with the American Society of Reproductive Medicine criteria (ASRM, 1996).¹⁷

In addition, urinary, gastrointestinal (GI), and coital symptoms were analyzed for their relationship to the presence of DIE lesions in specific anatomical locations. Patients were included in this analysis only after histologic confirmation of diagnosis. DIE was confirmed when any lesion penetrated >5 mm under the peritoneal surface.

Data were collected on each patient's age at surgery, disease stage, lesions, and presence of any of six types of pelvic pain (CPP, dysmenorrhea, severe dysmenorrhea, deep dyspareunia, dyschezia, and dysuria) as well as the anatomical localization of DIE lesions (uterosacral ligaments, retrocervical space, rectovaginal septum, vagina, bowel, bladder, and others) and pelvic adhesions. All of the collected data were recorded on an Excel spreadsheet. Multivariate analysis and logistic regression were used to study the relationship between the six types of pelvic pain and 9 sites of DIE as well as the locations and extents of the pelvic adhesions

A χ² test and Fisher's exact test were used to assess the association between the anatomical locations of endometriosis and types of pelvic pain. For this analysis, the association was considered to exist when p < 0.10, according to Fauconnier et al.⁸ The variables that reached statistical significance were submitted further to univariate logistic regression. Statistical analysis was performed using Statistical Package for the Social Sciences.

Results

Fifty-nine cases (15%) met the study's inclusion criteria and were analyzed. The mean patient age was 35 years, and most patients were white (n = 49; 83%) and nulliparous (n = 41, 71%), with only 23 (39%) being infertile. In addition, 46% of these patients had undergone previous treatment for endometriosis. Pelvic pain was the main surgical indication (n = 44; 75%), followed by pelvic mass (n = 6; 10%) and infertility (n = 4; 7%). Dysmenorrhea was found in 48 (81%) women, deep dyspareunia in 27 women (46%), dyschezia in 27 women (46%), and dysuria in 5 women (8%). Forty-six women (78%) presented with more than one type of pelvic pain.

Most of the surgeries performed were laparoscopies (n = 54; 92%), and 80% of women with DIE were classified as being at stage IV (n = 47) while 7 women (12%) were at stage III, and 5 women (8%) were at stage II. Ovarian endometriomas were found in 51% (n = 30) of women. Surgical complications occurred in 4 cases (7%): 3 rectovaginal fistulas and 1 deep vein thrombosis and urinary bladder lesion.

There were 117 endometriotic implants available for analysis. The majority were intestinal lesions (n = 40; 34.2%) mainly located in the rectosigmoid area, followed by the uterosacral ligaments (n = 31; 26,5%), vagina (n = 19; 17.1%), and retrocervical area (n = 12; 10.2%). In addition, 71% of cases also presented with posterior cul-de-sac adhesions

The majority of women presented with more than one type of concomitant pelvic pain (46; 78%), and, in most cases, DIE was multifocal (36; 61%). DIE was more frequently encountered in the bowel (40; 34.2%) and uterosacral ligaments (31; 26.5%). Deep dyspareunia was associated with vaginal DIE (odds ratio [OR]: 3.17; 95% confidence interval [CI]: 0.9–10.7) and rectovaginal septum DIE (OR: 4.42; 95% CI: 1.0–19.3). Pelvic adhesions in the cul-de-sac were associated with dyschezia (OR: 7.58; 95% CI: 0.9–66.3) and intestinal DIE (OR: 10.2; 95% CI: 2.79–37.3).

Results shown in Table 1 revealed that:

(1) Vaginal DIE increased the chances of deep dyspareunia 3.169 times.

(2) Rectovagnal DIE increased the chances of deep dyspareunia 4.424 times.

(3) Adhesions in the cul-de-sac increased the chances of dyschezia 7.583 times.

Table 1.

Pelvic Pain Related to Anatomical Location and Pelvic Adhesions

Symptom	Variable	p-Value	Adjusted OR	95% CI
Deep dyspareunia	DIE vagina = No	0.063	1	–
	DIE vagina = Yes		3.169	0.9–10.7
	DIE rectovaginal septum = No	0.048	1	–
	DIE rectovaginal septum = Yes		4.424	1.0–19.3
Dyschezia	Adhesions pCS = No	0.067	1	–
	Adhesions pCS = Yes		7.583	0.9–66.3

OR, odds ratio; CI, confidence interval; DIE, deep infiltrating endometriosis; pCS, posterior cul-de-sac.

The association between adhesions obliterating the posterior cul-de-sac and the presence of intestinal DIE was also evaluated and the result showed that the presence of such lesions increased the chances of having intestinal lesions by >10 times (Table 2).

Table 2.

Association Between Intestinal DIE and Posterior Cul-de-Sac Adhesions

Association	p-Value	OR (95% CI)
Intestinal DIE × pCS adhesions	0.427	–
Intestinal DIE × pCS adhesions	0.000	10.2 (2.79–37.3)

OR, odds ratio; DIE, deep infiltrating endometriosis; CI, confidence interval; pCS, posterior cul-de-sac.

Discussion

The current study showed that specific types of pelvic pain might be related to the anatomical locations of lesions in women with DIE. Analysis of the anatomical locations of the lesions revealed a multifocal pattern, as 61% of the woman in this study had >1 simultaneous site affected, which is in accordance with previously published data.^18,19 The majority of women also presented with more than one type of pelvic pain (dysmenorrhea, dyspareunia, dyschezia, and dysuria). Such a multifocal distribution pattern observed in women with DIE made it more difficult to study possible relationships between pain and anatomical locations. Thus, logistic regression analysis was used in an attempt to overcome such barriers, given that this topic is still a matter of debate in current literature.

The current study's results showed that anatomical location influenced deep dyspareunia as vaginal and rectovaginal DIE significantly increased the chances of presenting with such a symptom. Adhesions in the posterior cul-de-sac increased the chances of dyschezia 7.583 times. The association between adhesions obliterating the posterior cul-de-sac and the presence of intestinal DIE was also evaluated and the presence of such lesions increased the chances of having intestinal lesions by >10 times.

To date, only a few studies on the subject have been published, and these studies have had conflicting results. Porpora et al.⁵ found that deep dyspareunia predicted deep endometriosis and an ovarian endometrioma with periovarian adhesions simultaneously. Dai et al.¹⁹ found that DIE in the left uterosacral ligament increased the odds of deep dyspareunia and dyschezia. Another study, however, involving a total of 469 women, encountered no clear-cut association between stage, site or morphological characteristics of pelvic endometriosis and pain.²⁰

Although dysmenorrhea was a frequent symptom, no associations with DIE anatomical locations or with pelvic adhesions were identified. Dysmenorrhea has been related to DIE or pelvic adhesions inconsistently.^9–11 The relationship between the severity of dysmenorrhea in women with posterior DIE and indicators of the extent of their disease was evaluated by Chapron et al.¹¹ The presence of a rectal or vaginal infiltration by posterior DIE and extensiveness of adnexal adhesion were the only factors that remained related to severity of dysmenorrhea. Chopin et al.²¹ showed that, after multiple regression analysis, rectal infiltration and the American Fertility Society reviewed scores of implants were the only factors that remained related to dysmenorrhea severity

Deep dyspareunia was found in 46% of the current study's population and was associated with vaginal and rectovaginal DIE (p = 0.063 and p = 0.048 respectively). Such findings may be compromised by the large CI (95% CI 0.9–10.7 in vaginal DIE and 1.0–19.3 in rectovaginal DIE), which may reflect the small sample evaluated. The association between rectovaginal DIE and deep dyspareunia may be explained by the invasive behavior of the disease.^{22, 23}

The available published literature to date reports different findings with regard to anatomical location and pelvic pain. The most frequent symptoms of pelvic endometriosis are dysmenorrhea, dyspareunia, CPP, and infertility.²⁴ These symptoms, however, appear to have poor correlations with stages or anatomical locations of endometriosis.¹³

In a retrospective study, Fauconnier et al.⁸ evaluated 255 women to determine if specific types of pelvic pain (dysmenorrhea, dyspareunia, dyschezia, GI symptoms, and noncyclical pelvic pain) were correlated with the anatomical locations of DIE. Apparently, the different types of pelvic pain were associated with specific locations of DIE. Deep dyspareunia was correlated with involvement of the uterosacral ligament, painful defecation with the vagina, noncyclic pelvic pain with the bowel, lower urinary-tract symptoms with the bladder, and GI symptoms with the bowel and vagina. Severe dysmenorrhea was not correlated with any DIE location, but was correlated with adhesions in the Douglas pouch. Seracchioli et al.²⁵ evaluated the relationship between anatomical locations and diameter of endometriotic lesions with severity of perimenstrual dyschezia. In that study, it appeared that severity of dyschezia was correlated significantly with posterior DIE and lesion diameter.

Vercellini et al.¹³ however, studied 1054 consecutive women with endometriosis undergoing first-line conservative or definitive surgery. The association between endometriosis stage and severity of pelvic symptoms was marginal and inconsistent and could be demonstrated only with a major increase in study power. Chêne et al.¹⁴ also failed to find relationships among severity of symptoms, QoL, and the extent of endometriotic lesions at surgery.

The current study had limitations related to its retrospective nature as well as the difficulty in retrieving data. A visual analogue scale was not used to assess pain, but, as pain intensity and relief were not sought outcomes, the lack of such information did not affect the results. One strength was that only women with histologic diagnoses were included. Another point to consider is that all laparoscopic procedures were performed by the same surgeon (I.A.) and coloproctologist (L.M.P.C.). Despite the extensive expertise of the entire surgical team, a decision was made to evaluate the work of only 1 surgeon to have uniform criteria for all cases; This reduced the number of cases that were included in the study.

DIE lesions are multifocal in a large number of patients. This observation is in agreement with results reported by Redwine and Wright²⁶ for patients presenting with complete obliteration of the pouch of Douglas associated with endometriosis. As the efficiency of surgical treatment depends on the how radical the exeresis is,^8,27 the location of DIE lesions must dictate the choice of operating technique. In multifocal cases, several surgical procedures must be applied. Multifocality is a major characteristic of DIE lesions. It is essential to take this parameter into account when deciding on a surgical strategy, as complete exeresis is essential if functional improvement is to be obtained.^11,27

The association between endometriosis stage and severity of pelvic symptoms remains inconsistent. However, a comprehensive clinical history is useful for identifying patients at risk for endometriosis and for defining those who would benefit from referral for diagnostic laparoscopy. Early diagnosis of endometriosis would enable the use of effective medical and surgical treatments to control symptoms and improve the long-term outcomes for patients as well as reducing costs.^28,29

Conclusions

Deep dyspareunia was associated with DIE in the vagina and rectovaginal septum. Dyschezia was related to cul-de-sac adhesions, whereas intestinal endometriosis was associated with cul-de-sac obliteration by adhesions. Specific types of pelvic pain may be predictive of DIE location and can be used to help plan surgical interventions.

Footnotes

Disclosure Statement

The authors declare that they have nothing to disclose.

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