Anyone asking this question has little experience with extensive disease. Extensive endometriosis usually results in severe pain that can be relieved by excision of the endometriosis. Most women with extensive cul-de-sac endometriosis have some degree of nodularity and/or tenderness of their uterosacral ligaments, anterior rectum, and posterior vagina-cervix during rectovaginal exam. The object of the surgery is to remove the painful, tender nodule. Postoperative examination after excision of the previously known lesion should confirm the absence of nodularity and tenderness, documenting that excision of the area of maximum tenderness and nodularity caused by endometriosis is the best treatment for pelvic pain caused by this condition. Unfortunately, many gynecologists fail to do an adequate rectovaginal examination to discover the lesion in the first place.
How can you remove the tender nodule without excision? I don’t know! When areas thought to be endometriosis by laparoscopic examination are subjected to treatment with laser or electrosurgery for ablation, only the "tip of the iceberg" is usually treated. The deeper components of the lesion go untreated as the surgeon under treats because of fear of late complications to the rectum and or ureter. This type of treatment can't possibly work. It usually stimulates the endometriosis lesion with resultant increase in the inflammation both inside the lesion and surrounding it. The end point of laparoscopic (and laparotomy) surgical procedures to excise endometriosis should be a normal rectovaginal exam with a mobile distensible vagina, a free rectum, and the absence of nodularity as palpated with a rectovaginal exam while probing the area visualized with the laparoscope.
Endometriosis is a discreet lesion: Endometrial glands and stroma surrounded by fibromuscular tissue, making the white and fibrotic. Symptomatic black-brown lesions are always surrounded by white fibromuscular scar.
Most endometriosis treated in the United States is not endometriosis; rather, it is old blood from retrograde menstruation or discharge from a corpus luteum (“coffee grounds or tobacco stained” tissue). The pathologist sees hemosiderin laddened macrophages. Without excisional biopsy, we have no accurate idea of the number of people with “real” endometriosis that have been treated in the past. Thus, present data regarding treatment are meaningless as they usually report on the “destructive” treatment of degenerating blood cells instead of endometriosis glands.
I ask you, if a suspected area of endometriosis is ablated without specimen taking, how can we ever know if that patient really had endometriosis to start with? We know that many things can cause pelvic pain including retrograde menstruation, physiological cysts, uterine contractions, and that some certainly are psychosomatic. Women that are told that the old blood from retrograde menstruation is endometriosis may forever feel that they are victims of this condition, no matter what future treatment is applied. This just does not represent good medicine.
I will describe the examination to diagnose endometriosis & the techniques to excise it:
The most common presentations produced by endometriosis are pelvic pain, infertility, and adnexal mass. The ovaries, the posterior leaf of the broad ligament, and the cul-de-sac of Douglas behind the uterus are the most frequent locations, and the left side is more frequently affected than the right.
Extensive endometriosis usually involves the posterior cul-de-sac of Douglas, the area surrounded posteriorly by the anterior rectum, anteriorly by the posterior vagina and cervix, and laterally by the uterosacral ligaments. These lesions can often obliterate the normal anatomy of the cul-de-sac with the rectum stuck to the posterior vagina, cervix, and uterine fundus. One or both pelvic sidewalls overlying the ureters and the rectosigmoid are often affected. In addition, less commonly involved areas include the anterior cul-de-sac (the area above the bladder and the anterior uterus), the appendix and the small bowel. Extensive bulky endometriosis may also be present in the uterine muscle itself where it is called ‘adenomyosis’.
Extensive endometriosis means bulky deep fibrotic endometriosis deposits that can often be palpated preoperatively as tender pelvic nodules. These nodules consist of endometriosis glands and stroma surrounded by fibromuscular tissue that has accumulated over many years in response to cyclic monthly activation of the endometriosis. They represent a longstanding chronic inflammatory response.
TeLinde and Scott defined the objectives of surgical treatment of endometriosis in 1952: “one should excise or fulgurate all evident endometriosis.” The surgical objectives of laparoscopic treatment are similar, i.e., to remove all evident endometriosis by excising large superficial and deep lesions and vaporising smaller deposits.(2) Hystopathological examination to document endometriosis glands and stroma is necessary to substantiate a diagnosis of the endometriosis in any suspect lesion.
Clinical Symptoms and Dignosis
The most common symptom for extensive endometriosis diagnosis is pelvic pain, and the most common sign is pelvic tenderness. This pain is usually more severe on one side and often radiates to the back and legs. The pain may be present throughout the menstrual cycle but especially during the menses (severe dysmenorrhea). Dyspareunia is common. Pain during bowel movements (dyschezia) may also be present. Pelvic pain can be severe enough that the patient is refractory to conventional medical therapy.
Deep full thickness vaginal endometriosis may present with irregular vaginal bleeding. Deep rectal endometriosis is rarely accompanied by rectal bleeding. Most rectal bleeding associated with endometriosis is from hemorrhoids caused by straining during bowel movements, which may result in some cases from a fibrotic endometriosis-related rectosigmoid stricture.
In contrast to mild endometriosis, laparoscopy may not be necessary to diagnose extensive endometriosis of the deep cul-de-sac. It is usually strongly suspected by clinical examination. Laparoscopy is then used to treat it. Yet, histopathological examination of the excised tissue is necessary to confirm the diagnosis of endometriosis: no typical endometriosis glands with surrounding stroma usually means no endometriosis. Ablation of suspected lesions with no pathological specimen always leaves doubt as to whether the lesion treated was endometriosis, fibrosis (old scar tissue), or ‘old blood’ (hemosiderin-ladened macrophages).
The rectum and vagina are readily accessible, and their examination should be the mainstay of clinical diagnosis. If the patient accepts a recto-vaginal examination, this may reveal nodularity or tenderness in the uterosacral ligaments. Cul-de-sac nodularity is pathognomonic of endometriosis. This nodularity is caused by the fibromuscular tissue surrounding endometriosis glands and stroma inside the uterosacral ligaments near their insertion into the cervix and in the angle made by anterior rectum and posterior vagina or by posterior vagina and cervix. Rectovaginal exam is diagnostic when deep cul-de-sac or recto-vaginal septum nodularity are palpated and specific tenderness in these nodules elicited. Unfortunately, most gynaecologists routinely “defer” rectal examination.
Despite the discomfort involved, a rectovaginal examination should be done routinely in patients with pelvic pain and/or a past history of endometriosis. Prior explanation does much to allay the patient’s fears, especially the fear of losing fecal control. The cervix is put on upward tension using the index finger in the vagina and the middle finger in the rectum palpates the uterosacral ligaments including their insertion and the junction of vagina with cervix and rectum. If nodules are discovered, their tenderness and mobility from the surrounding tissues is assessed as is the degree to which the rectum is tented to the lesion. The withdrawn finger is inspected for blood.
During the rectovaginal examination, a good clinician can often pinpoint the tender endometriosis nodules to be excised during surgery. These patients should not be subjected to a diagnostic laparoscopy, but should be referred to a surgeon with experience in excising cul-de-sac and rectal endometriosis.
Clinicians must be aware that a line of evidence exists suggesting that there is no relationship between extent of disease and severity of pain, and no correlation between the location of pain compared with the location of endometriosis implants. (3) This is not the case with extensive endometriosis!