27 views

DEFINITION Endometriosis is defined as the presence of functioning endometrial glands and stroma outside the uterine cavity . PHYSICAL FINDINGS AND CLINICAL PRESENTATION ● Classic triad is dysmenorrhea, dyspareunia, and infertility. ● Presence of pelvic pain not correlated with the total area of endometriosis, type of lesion, or volume of disease, but it is correlated with the depth of infiltration. ● Other symptoms include: abnormal bleeding (premenstrual spotting, menorrhagia), cyclic abdominal pain, intermittent constipation/diarrhea, dyschezia, dysuria, hematuria, urinary frequency ● Rare manifestations: catamenial hemothorax, bloody pleural effusion, massive ascites occurring during menses ● Most severe discomfort is associated with lesions 1 cm in depth ● Bimanual examination may reveal tender uterosacral ligaments, cul-de-sac nodularity, induration of the rectovaginal septum, fixed retroversion of the uterus, adnexal mass, and generalized or localized tenderness. CAUSE ● Reflux and direct implantation theory: retrograde menstruation with implantation of viable endometrial cells to surrounding pelvic structures ● Celomic metaplasia theory: transformation of multipotential cells of the coelomic epithelium into endometrium-like cells ● Vascular dissemination theory: transport of endometrial cells to distant sites via the uterine vascular and lymphatic systems ● Autoimmune disease theory: disorder of immune surveillance allows growth of endometrial implant DIFFERENTIAL DIAGNOSIS ● Ectopic pregnancy ● Acute appendicitis ● Chronic appendicitis ● PID ● Pelvic adhesions ● Hemorrhagic cyst ● Hernia ● Psychological disorder ● Irritable bowel syndrome ● Uterine leiomyomata ● Adenomyosis ● Nerve entrapment syndrome ● Scoliosis ● Muscular/skeletal strain ● Interstitial cystitis IMAGING STUDIES ● Ultrasound: for evaluating adnexal mass; cannot reliably distinguish endometriomas from other benign or malignant ovarian conditions ● MRI: highly accurate in detecting endometriomas; limited sensitivity in detecting diffuse pelvic endometriosis ● Laparoscopy will confirm diagnosis. TREATMENT ● Expectant management (observation for 5 to 12 months) for early-stage endometriosis-associated infertility ● Nonsteroidal anti-infl ammatory drugs (NSAIDs) for symptomatic relief of dysmenorrhea ● Pharmacologic management: estrogen-progesterone, progestins, gonadotropin-releasing hormone (GnRH) agonists ● Alternative therapy for inhibition of estrogen action currently under investigation are aromatase inhibitors, raloxifene, anastrozole, letrozole. SURGICAL MANAGEMENT Conservative ● Directed at enhancing fertility or treating pain unresponsive to first-line medical treatment ● Usually accomplished through laparoscopy ● Removal or destruction of endometriotic implants by excision, electrocautery, or laser ● Cystectomy for endometrioma ● Laparoscopic uterosacral nerve ablation (LUNA) for midline pain such as dysmenorrhea or dyspareunia ● Unless pregnancy is desired, patient is usually started on GnRH agonist therapy immediately after surgery ● For those desiring pregnancy, surgery alone results in significant increase in fertility Posted in General Surgery