Deep Endometriosis

Endometriosis is a state observed in 30-60% of infertile female population and approximately 10% of pre-menopause women and affecting life quality. Chocolate cysts exist in approximately 17-44% of endometriosis patients. Endometriosis may lead to intra-abdominal adhesions and infections, cystic formations and tube obstructions by deforming anatomy of uterus, tube or ovary.

Endometriosis sub-groups can be classified as peritoneum endometriosis, endometriosis in ovaries, deep endometriosis (in urinary tracts, gastrointestinal system and in the region between vagina and backside) and endometriosis out of peritoneum.

Deep infiltrative endometriosis (DIE) is defined as entry of endometriosis focuses into the walls of organs at bottom abdominal region. Deep infiltrative endometriosis is a special class. The endometriosis focuses of 1-2 cm not showing any finding under normal conditions lead to severe pains when they settle in deep regions and diagnosis is generally skipped in this patient group.

It is shown that in DIE patients, the intrauterine-like cells are at the depth of >5 mm of peritoneum and these cells are very active and lead to increasing pubic pain, pain during sexual act, backside pain, backside bleeding and urinary tract symptoms.

Form of pubic pain varies according to settlement of deep infiltrative endometriosis. Complaints of menstrual pain, backside pain and urinary tract pains may be very severe. In some cases, diarrhea, backside bleeding and constipation may be observed.

In endometriosis between vagina and backside, the nodule may be extremely inflammatory. It may be very difficult to separate these nodules from surrounding organs. These nodules may also lead to obstructions in intestine and urinary tracts.

Deep endometriosis may not be noticed if it is not very severe and extensive. In 1990s, DIE diagnoses were substantially made with laparoscopy. Difficulties in diagnosis are still continuing.

Hormonal treatment (progestins or GnRHa) is effective in decreasing pain. Pain recurrence is high when the treatment is given up. The main treatment for endometriosis between vagina and backside is surgical.

Preoperative methods assisting DIE diagnosis: rectovaginal examination during menstrual cycle, ultrasonography, pelvic MRI, double contrast enema, rectosigmoidoscopy, IVP and tm markers (Ca 125). An intestinal cleaning is essential before laparoscopic treatment. The patient should be informed about surgical operation and postoperative period.

In patients with endometriosis between vagina and backside, surgical extraction of all nodules is a preferred treatment method. Use of menstruation stopping injections during 2-3 months before the operation facilitates the surgery as well as decreasing the rate of disease recurrence. Drug treatment is insufficient alone due to high recurrence rates. When selecting method of surgery, it should be aimed to give minimum harm to the patient. The surgeon should use the method for which he/she is the most experienced.

The aim of surgery is to make lesion visible, to extract it completely, and to take measures which will prevent adhesions.

In conclusion, vagina-backside or DIE nodule excision is one of the most sensitive laparoscopic surgical operations. The operator should be experienced in advanced laparoscopic surgery, intestine surgery and repair of urinary tracts; therefore, such operations may require team work. Success of surgery, decrease of symptoms and increase of life quality are closely associated with experience of surgical team and complete excision of lesions.
Whatsapp ile ulaşabilirsiniz