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Large bowel-to-pelvic sidewall adhesions associated with chronic pelvic pain
November 1995, Vol. 3, No. 1 TheJournal of the American Association of Gynecologic Laparoscopists
Large Bowel-to-Pelvic Sidewall Adhesions Associated With Chronic Pelvic Pain Martin D. Keltz, M.D., Lanford Peck, M.D., Susan Liu, M.D., Alexis H. Kim, M.D., Aydin Arici, M.D., and David L. Olive, M.D.
Abstract
Study Objectives. To assess retrospectively the prevalence of colon-to-pelvic sidewall adhesions associated with pelvic pain or pelvic endometriosis, and to evaluate prospectively their prevalence compared with controls. Design. A retrospective review of all patients undergoing laparoscopy for chronic pelvic pain between August 1992 and September 1993; and based on a power analysis, a prospective comparison of women undergoing taparoscopy for chronic pelvic pain with those undergoing laparoscopy for tubal sterilization between October 1994 and December 1995. Setting. A university-associated teaching hospital. Patients. Fifty women in the retrospective portion, and 30 women (15 in each group) in the prospective portion. Measurements and Main Results. Of the 50 women undergoing laparoscopy for pelvic pain, 47 (94%) had either right- or left-sided colon-to-sidewall adhesions, and these adhesions were more common than any other type of intraabdominal adhesion, 94% versus 58%. Thirty-eight (76%) of these women had visual and 25 (50%) histologic evidence of endometriosis. The prospective study revealed that women with pelvic pain had a higher rate of colon-to-sidewall adhesions than controls (93.3% vs 13.3%) and a correspondingly higher rate of visualized endometriosis (73.3% vs 6.7%). Right-sided paracolic adhesions were both more common than left-sided adhesions (87.7% vs 46.7%) and were more often extensive than minimal (46.7% vs 6.7%). Conclusions. Colon-to-sidewall adhesions occur in the majority of patients with chronic pain, whereas they are an uncommon finding in the general population. The lateral gutters are dependent regions of the abdominal cavity that are susceptible to the spread of peritoneal endometriosis or other inflammatory processes, and should be evaluated at diagnostic laparoscopy for chronic pelvic pain.
From the Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Yale University School of Medicine, New Haven, Connecticut (all authors). 24th annual meeting of the American Association of Gynecologic Laparoscopists, Orlando, Florida, November 8-12, 1995. Second Place, Postgraduate Prize Paper Competition. Address reprint requests to Martin D. Keltz, M.D., Department of Obstetrics and Gynecology, St. Luke's/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, 1000 Tenth Avenue, New York, NY 10019; fax 212 523 8066.
55
Colon-to-Sidewall Adhesions Keltz et al
performed at each laparoscopy employing a stepwise approach: the anterior and posterior cul-de-sacs, ovarian fossae, right ascending colon, perihepatic region, and left descending colon. The colon was manipulated to reveal the lateral gutters and any adhesions that might be present. The size of our prospective cohort was determined by Statistical Power Analysis (Lawrence Erlbaum Assoc., Hillsdale, N J) based on the frequency ofparacolic adhesions in our retrospective study. Beginning in December 1994, 15 consecutive women undergoing laparoscopy for chronic pelvic pain, viewed by at least two of the authors, made up the patients. Fifteen consecutive women with no history of pelvic pain, endometriosis, or pelvic infection; undergoing tubal sterilization or diagnostic laparoscopy; and viewed by at least two of the authors were the controls. A diagrammatic record of the operative findings was made by the authors during or immediately after the procedure in the prospective portion. Pathologic adhesions were defined as attaching the ascending or descending colon anteriorly or anterolaterally to the pelvic sidewall, generally with visual evidence of neovascularity. Lysis of colon-to-sidewall adhesions was performed, and when the adhesions were sufficiently extensive, a specimen was evaluated histologically. Both physical examinations and laparoscopies were performed randomly throughout the menstrual cycle. Statistical analysis was by two-tailed Fisher's exact test (Systat, Evanston, IL).
The association between intraperitoneal adhesions and chronic pelvic pain has generated considerable controversy as to whether adhesiolysis will ameliorate the pain. A number of conditions that likely cause adhesion formation are clearly associated with acute and chronic pelvic pain, such as endometriosis, pelvic inflammatory disease, previous abdominal and pelvic surgery, and several other intraabdominal inflammatory processes. When assessing adhesive disease and pelvic pain, most of the literature focuses on adhesions of the reproductive organs, notably, the adnexae. In a retrospective study on adhesions and pelvic pain all four categories of adhesions involved the adnexaeJ Another group defined adhesions as only those between the viscera and reproductive organs? One investigation of the anatomic distribution of endometriosis did not include the ascending or descending colon or the abdominopelvic sidewalls as possible sites) Other adhesions are reported in women with pelvic and abdominal pain, including omental and perihepatic adhesions; however, adhesions between the large bowel and the pelvic sidewall have been disregarded or presumed to be physiologic. When visualizing the paracolic gutters from the pelvis to the hepatic and splenic flexures during laparoscopy for chronic pelvic pain, we have frequently noted colon-to-sidewall adhesions. They tend to be translucent, carrying tortuous, cascading vessels running anterolaterally from the surface of the colon to the abdominopelvic sidewall. The retrospective portion of this study was initiated to determine the prevalence of these adhesions and assess their association with endometriosis in women with chronic pelvic pain. We then prospectively compared patients with pelvic pain with controls to verify the association of adhesions and the pain.
Results
Retrospective Study Of the 50 women, 47 (94%) had at least unilateral sidewall adhesions. There was no difference in the numbers with left- and fight-sided adhesions. Patients with unilateral right colon-to-sidewall adhesions reported right-sided pelvic pain significantly more often than left-sided pain (85.7% vs 0.0%; Table 1). Among all 50 women, colon-to-sidewall adhesions were significantly more common than all other intraabdominal adhesions combined (94% vs 58.0%, p <0.001). Of the 47 women with sidewall adhesions, 36 (76.5%) had visualized endometriosis and 23 (48.9%) had histologic evidence of endometriosis. In addition to endometriosis, endosalpingiosis was diagnosed in six patients. All had sidewall adhesions and four also had endometriosis.
Materials and Methods
Our retrospective evaluation included all 50 women who underwent laparoscopy for chronic pelvic pain by one surgeon at Yale-New Haven Hospital between August 1, 1992, and September 30, 1993. Their charts were reviewed with respect to preoperative pain history and physical examination, operative findings as noted in the chart and operative dictation, and any pathology report. The operative findings in both the retrospective and prospective studies were based on a thorough evaluation of the abdominal cavity
56
November ] 995, Vol. 3, No. ]
The Journal of the American Association o~ Gynecologic Laparoscopists
TABLE 1. Colon-to-Sidewall Adhesions Associated With Endometriosis and Pain (retrospective study)
All patients Visualized endometriosis Right lower quadrant tenderness Left lower quadrant tenderness ap <0.05.
Bilateral (%)
Right Only (%)
Left Only (%)
None (%)
30 (60.0) 25/30 (83.3) 16/30 13/30
7 (14.0) 4/7 (57.1) 6/7 a 0/7 a
10 (20.0) 7/10 (70.0) 4/10 4/10
3 (6.0) 2/3 (66.7) 1/3 1/3
Prospective Study
ceptives (3), medroxyprogesterone depot (3), and Norplant (1). Among the patients, histologic evaluation of sidewall adhesions revealed fibrovascular tissue consistent with adhesions (5) and endosalpingiosis (1). Endometriosis was diagnosed histologically in six (40%) of these women and endosalpingiosis in t w o (13.3%), including the one with sidewall adhesions. No biopsies were performed on controls.
Patients with pelvic pain were more likely to have colon-to-sidewall adhesions than controls, including any adhesions, and right- and left-sided adhesions. They also were more likely than controls to have visualized endometriosis (Table 2). Among the patients, right-sided adhesions were more frequent than left-sided adhesions (86.7% vs 46.7%), and these women were more likely than controls to have extensive (covering >50% of the length of the ascending or descending colon) right-sided than left-sided adhesions (46.6% vs 6.6%). Six of the seven patients with extensive right-sided adhesions had right lower quadrant tenderness on physical examination, and the one with extensive left-sided adhesions had left lower quadrant tenderness on examination. Among the patients, colon-to-sidewall adhesions were again more common than all other intraabdominal adhesions, 93.3% versus 46.6%. In all 30 women, patients and controls, a thin avascular attachment was present between the junction of the descending and sigmoid colon and the pelvic sidewall at or below the internal inguinal canal, which was presumed to be a physiologic attachment. No menstrual cycle-specific differences were noted at laparoscopy with regard to sidewall adhesions among patients undergoing laparoscopy in the follicular (4) or secretory phase (5), or among those taking oral contraceptives (5) or depot leuprolide (1). Similarly, controls had laparoscopies during the follicular (5) and secretory phases (3), and while taking oral contra-
Discussion
This study demonstrates the nearly universal finding (93%) of at least unilateral ascending or descending colon-to-sidewall adhesions in patients with chronic pelvic pain, and the infrequent finding of those adhesions in controls. The adhesions generally appeared translucent, with numerous vessels running parallel within them from the anterolateral surface of the colon to the anterior pelvic and abdominal sidewalls (Figure 1). Although our retrospective study found no difference in the rate of right- and left-sided paracolic adhesions, the prospective evaluation confirmed our anecdotal impression that fight-sided adhesions are more frequent as well as generally more extensive. Colon-to-sidewall adhesions in patients with pelvic pain appeared to be associated with endometriosis. In our retrospective analysis, 76.6% of women with adhesions had visual evidence of endometriosis; in our prospective analysis the figure was 75%, including 11 of 14 patients and 1 of 2 controls. All women with visualized endometriosis, both patients and controls, had
TABLE 2. Colon-to-Sidewall Adhesions and Endometriosis (prospective study) Group
Sidewall Adhesions (%)
Patients 14/15 (93.3) Controls 2/I 5 (13.3) For all comparisons, p <0.05.
Right-Sided Adhesions (%)
Left-Sided Adhesions (%)
Visualized Endometriosis (%)
13/15 (86.7) 2/15 (13.3)
7/15 (46.7) t/15 (6.7)
11/15 (73.3) 1/15 (6.7)
57
Colon-to-Sidewall Adhesions Keltz el al
adhesions had lower quadrant tenderness on the corresponding side; however, in the absence of sidewall adhesions, lateralized lower quadrant tenderness was also often present on examination. In the retrospective study, women with only right-sided adhesions preoperatively had fight-sided tenderness more often than left-sided tenderness. Others also found that, in general, the history and physical examination were not accurate in predicting laparoscopic findings of adhesions; however, they did report that a right adnexal mass or right adnexal tenderness on examination was significantly correlated with right lower quadrant adhesions2 Other groups also demonstrated an association between pelvic pain and adhesions. For example, 51% of patients with chronic pelvic pain had some pelvic adhesions versus 14% of controls. 6 In another report, 65.1% of women reported improvement in pain for at least 6 months after lysis of adhesions. 7 Some authors, however, noted that very few infertile patients with adhesions have pelvic pain) It also was suggested that a causal relationship between adhesions and pelvic pain is a myth perpetuated by surgeons and patients hoping for success in treating the pain) This study provides what is believed to be the first indication that colon-to-sidewall adhesions can be found almost universally in patients with chronic pelvic pain and are quite infrequent in pain-free women. The finding of these adhesion in dependent regions of the abdominal cavity, and in association with endometriosis and pelvic inflammatory disease, suggests that they are induced by inflammatory processes transported by peritoneal fluid. We recommend evaluating the paracolic gutters at laparoscopy for chronic pelvic pain, as the finding of colon-to-sidewall adhesions may suggest other intraperitoneal pathology such as endometriosis. When extensive paracolic adhesions are present, adhesiolysis may be indicated, but this issue requires further study.
FIGURE 1. Extensive adhesions with cascading vessels from the cecum and ascending colon to the right pelvic
sidewall.
colon-to-sidewall adhesions. Among the three patients with sidewall adhesions and no endometriosis visualized, one had a history of pelvic inflammatory disease and another had prior laparoscopic evidence of endometriosis. These adhesions appeared to be associated with intraperitoneal inflammatory processes such as endometriosis, endosalpingiosis, and pelvic inflammatory disease. Histologic evaluation confirmed that they were fibrovascular, often mesothelially lined tissues consistent with adhesions, with one specimen containing endosalpingiosis. Colon-to-sidewall adhesions are more common and more extensive along the right paracolic gutter than the left. This is not surprising, given the circular spread of peritoneal fluid, which, while moving cephalad in both paracolic gutters, tends to carry both inflammatory and neoplastic processes primarily up the fight sidewall. Pelvic inflammatory disease tends to track up the right paracolic gutter, causing perihepatic adhesions. Studies of the spread of ovarian cancer demonstrated greater involvement of the right sidewall and hemidiaphragm than the left. 4 Given the spread of peritoneal processes to the lateral gutters and the concomitant finding of endometriosis and pelvic inflammation with these adhesions, it seems likely that endometriosis or other inflammatory processes induce the formation ofparacolic adhesions. The role of paracolic adhesions in inducing pelvic pain is unclear. Nearly all patients in the prospective study with pelvic pain with extensive right- or left-sided
References
1. Rapkin A J: Adhesions and pelvic pain: A retrospective study. Obstet Gynecol 68:13-15, 1986 2. Lundberg WI, Wall JE, Mathers J: Laparoscopy in evaluation of pelvic pain. Obstet Gyneco142:872-876, 1973 3. Jenkins S, Olive D, Haney A: Endometriosis: Pathogenetic implications of the anatomic distribution. Obstet Gynecol 67:335-338, 1986
58
November 1995, Vol. 3, No. 1
The Journal of the American Association of Gynecologic Laparoscopists
4. Morrow P, Townsend D, eds: Synopsis of Gynecologic Oncology. New York, John Wiley & Sons, 1981, p 217
7. Chan C, Wood C: Pelvic adheiolysis--The assessment of symptom relief by 100 patients. Aust NZ J Obstet Gynaecol 25:295-298, 1985
5. Stovall T, Elder R, Ling F: Predictors of pelvic adhesions. J Reprod Med 34:345-348, 1989
8. Alexander-Williams J: Do adhesions cause pain? Br Med J 294:659, 1987
6. Kresch AJ, Seifer D, Sachs LB, et al: Laparoscopy in 100 women with chronic pelvic pain. Obstet Gynecol 64:672-674, 1984
59
Large Bowel-to-Pelvic Sidewall Adhesions Associated With Chronic Pelvic Pain Martin D. Keltz, M.D., Lanford Peck, M.D., Susan Liu, M.D., Alexis H. Kim, M.D., Aydin Arici, M.D., and David L. Olive, M.D.
Abstract
Study Objectives. To assess retrospectively the prevalence of colon-to-pelvic sidewall adhesions associated with pelvic pain or pelvic endometriosis, and to evaluate prospectively their prevalence compared with controls. Design. A retrospective review of all patients undergoing laparoscopy for chronic pelvic pain between August 1992 and September 1993; and based on a power analysis, a prospective comparison of women undergoing taparoscopy for chronic pelvic pain with those undergoing laparoscopy for tubal sterilization between October 1994 and December 1995. Setting. A university-associated teaching hospital. Patients. Fifty women in the retrospective portion, and 30 women (15 in each group) in the prospective portion. Measurements and Main Results. Of the 50 women undergoing laparoscopy for pelvic pain, 47 (94%) had either right- or left-sided colon-to-sidewall adhesions, and these adhesions were more common than any other type of intraabdominal adhesion, 94% versus 58%. Thirty-eight (76%) of these women had visual and 25 (50%) histologic evidence of endometriosis. The prospective study revealed that women with pelvic pain had a higher rate of colon-to-sidewall adhesions than controls (93.3% vs 13.3%) and a correspondingly higher rate of visualized endometriosis (73.3% vs 6.7%). Right-sided paracolic adhesions were both more common than left-sided adhesions (87.7% vs 46.7%) and were more often extensive than minimal (46.7% vs 6.7%). Conclusions. Colon-to-sidewall adhesions occur in the majority of patients with chronic pain, whereas they are an uncommon finding in the general population. The lateral gutters are dependent regions of the abdominal cavity that are susceptible to the spread of peritoneal endometriosis or other inflammatory processes, and should be evaluated at diagnostic laparoscopy for chronic pelvic pain.
From the Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Yale University School of Medicine, New Haven, Connecticut (all authors). 24th annual meeting of the American Association of Gynecologic Laparoscopists, Orlando, Florida, November 8-12, 1995. Second Place, Postgraduate Prize Paper Competition. Address reprint requests to Martin D. Keltz, M.D., Department of Obstetrics and Gynecology, St. Luke's/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, 1000 Tenth Avenue, New York, NY 10019; fax 212 523 8066.
55
Colon-to-Sidewall Adhesions Keltz et al
performed at each laparoscopy employing a stepwise approach: the anterior and posterior cul-de-sacs, ovarian fossae, right ascending colon, perihepatic region, and left descending colon. The colon was manipulated to reveal the lateral gutters and any adhesions that might be present. The size of our prospective cohort was determined by Statistical Power Analysis (Lawrence Erlbaum Assoc., Hillsdale, N J) based on the frequency ofparacolic adhesions in our retrospective study. Beginning in December 1994, 15 consecutive women undergoing laparoscopy for chronic pelvic pain, viewed by at least two of the authors, made up the patients. Fifteen consecutive women with no history of pelvic pain, endometriosis, or pelvic infection; undergoing tubal sterilization or diagnostic laparoscopy; and viewed by at least two of the authors were the controls. A diagrammatic record of the operative findings was made by the authors during or immediately after the procedure in the prospective portion. Pathologic adhesions were defined as attaching the ascending or descending colon anteriorly or anterolaterally to the pelvic sidewall, generally with visual evidence of neovascularity. Lysis of colon-to-sidewall adhesions was performed, and when the adhesions were sufficiently extensive, a specimen was evaluated histologically. Both physical examinations and laparoscopies were performed randomly throughout the menstrual cycle. Statistical analysis was by two-tailed Fisher's exact test (Systat, Evanston, IL).
The association between intraperitoneal adhesions and chronic pelvic pain has generated considerable controversy as to whether adhesiolysis will ameliorate the pain. A number of conditions that likely cause adhesion formation are clearly associated with acute and chronic pelvic pain, such as endometriosis, pelvic inflammatory disease, previous abdominal and pelvic surgery, and several other intraabdominal inflammatory processes. When assessing adhesive disease and pelvic pain, most of the literature focuses on adhesions of the reproductive organs, notably, the adnexae. In a retrospective study on adhesions and pelvic pain all four categories of adhesions involved the adnexaeJ Another group defined adhesions as only those between the viscera and reproductive organs? One investigation of the anatomic distribution of endometriosis did not include the ascending or descending colon or the abdominopelvic sidewalls as possible sites) Other adhesions are reported in women with pelvic and abdominal pain, including omental and perihepatic adhesions; however, adhesions between the large bowel and the pelvic sidewall have been disregarded or presumed to be physiologic. When visualizing the paracolic gutters from the pelvis to the hepatic and splenic flexures during laparoscopy for chronic pelvic pain, we have frequently noted colon-to-sidewall adhesions. They tend to be translucent, carrying tortuous, cascading vessels running anterolaterally from the surface of the colon to the abdominopelvic sidewall. The retrospective portion of this study was initiated to determine the prevalence of these adhesions and assess their association with endometriosis in women with chronic pelvic pain. We then prospectively compared patients with pelvic pain with controls to verify the association of adhesions and the pain.
Results
Retrospective Study Of the 50 women, 47 (94%) had at least unilateral sidewall adhesions. There was no difference in the numbers with left- and fight-sided adhesions. Patients with unilateral right colon-to-sidewall adhesions reported right-sided pelvic pain significantly more often than left-sided pain (85.7% vs 0.0%; Table 1). Among all 50 women, colon-to-sidewall adhesions were significantly more common than all other intraabdominal adhesions combined (94% vs 58.0%, p <0.001). Of the 47 women with sidewall adhesions, 36 (76.5%) had visualized endometriosis and 23 (48.9%) had histologic evidence of endometriosis. In addition to endometriosis, endosalpingiosis was diagnosed in six patients. All had sidewall adhesions and four also had endometriosis.
Materials and Methods
Our retrospective evaluation included all 50 women who underwent laparoscopy for chronic pelvic pain by one surgeon at Yale-New Haven Hospital between August 1, 1992, and September 30, 1993. Their charts were reviewed with respect to preoperative pain history and physical examination, operative findings as noted in the chart and operative dictation, and any pathology report. The operative findings in both the retrospective and prospective studies were based on a thorough evaluation of the abdominal cavity
56
November ] 995, Vol. 3, No. ]
The Journal of the American Association o~ Gynecologic Laparoscopists
TABLE 1. Colon-to-Sidewall Adhesions Associated With Endometriosis and Pain (retrospective study)
All patients Visualized endometriosis Right lower quadrant tenderness Left lower quadrant tenderness ap <0.05.
Bilateral (%)
Right Only (%)
Left Only (%)
None (%)
30 (60.0) 25/30 (83.3) 16/30 13/30
7 (14.0) 4/7 (57.1) 6/7 a 0/7 a
10 (20.0) 7/10 (70.0) 4/10 4/10
3 (6.0) 2/3 (66.7) 1/3 1/3
Prospective Study
ceptives (3), medroxyprogesterone depot (3), and Norplant (1). Among the patients, histologic evaluation of sidewall adhesions revealed fibrovascular tissue consistent with adhesions (5) and endosalpingiosis (1). Endometriosis was diagnosed histologically in six (40%) of these women and endosalpingiosis in t w o (13.3%), including the one with sidewall adhesions. No biopsies were performed on controls.
Patients with pelvic pain were more likely to have colon-to-sidewall adhesions than controls, including any adhesions, and right- and left-sided adhesions. They also were more likely than controls to have visualized endometriosis (Table 2). Among the patients, right-sided adhesions were more frequent than left-sided adhesions (86.7% vs 46.7%), and these women were more likely than controls to have extensive (covering >50% of the length of the ascending or descending colon) right-sided than left-sided adhesions (46.6% vs 6.6%). Six of the seven patients with extensive right-sided adhesions had right lower quadrant tenderness on physical examination, and the one with extensive left-sided adhesions had left lower quadrant tenderness on examination. Among the patients, colon-to-sidewall adhesions were again more common than all other intraabdominal adhesions, 93.3% versus 46.6%. In all 30 women, patients and controls, a thin avascular attachment was present between the junction of the descending and sigmoid colon and the pelvic sidewall at or below the internal inguinal canal, which was presumed to be a physiologic attachment. No menstrual cycle-specific differences were noted at laparoscopy with regard to sidewall adhesions among patients undergoing laparoscopy in the follicular (4) or secretory phase (5), or among those taking oral contraceptives (5) or depot leuprolide (1). Similarly, controls had laparoscopies during the follicular (5) and secretory phases (3), and while taking oral contra-
Discussion
This study demonstrates the nearly universal finding (93%) of at least unilateral ascending or descending colon-to-sidewall adhesions in patients with chronic pelvic pain, and the infrequent finding of those adhesions in controls. The adhesions generally appeared translucent, with numerous vessels running parallel within them from the anterolateral surface of the colon to the anterior pelvic and abdominal sidewalls (Figure 1). Although our retrospective study found no difference in the rate of right- and left-sided paracolic adhesions, the prospective evaluation confirmed our anecdotal impression that fight-sided adhesions are more frequent as well as generally more extensive. Colon-to-sidewall adhesions in patients with pelvic pain appeared to be associated with endometriosis. In our retrospective analysis, 76.6% of women with adhesions had visual evidence of endometriosis; in our prospective analysis the figure was 75%, including 11 of 14 patients and 1 of 2 controls. All women with visualized endometriosis, both patients and controls, had
TABLE 2. Colon-to-Sidewall Adhesions and Endometriosis (prospective study) Group
Sidewall Adhesions (%)
Patients 14/15 (93.3) Controls 2/I 5 (13.3) For all comparisons, p <0.05.
Right-Sided Adhesions (%)
Left-Sided Adhesions (%)
Visualized Endometriosis (%)
13/15 (86.7) 2/15 (13.3)
7/15 (46.7) t/15 (6.7)
11/15 (73.3) 1/15 (6.7)
57
Colon-to-Sidewall Adhesions Keltz el al
adhesions had lower quadrant tenderness on the corresponding side; however, in the absence of sidewall adhesions, lateralized lower quadrant tenderness was also often present on examination. In the retrospective study, women with only right-sided adhesions preoperatively had fight-sided tenderness more often than left-sided tenderness. Others also found that, in general, the history and physical examination were not accurate in predicting laparoscopic findings of adhesions; however, they did report that a right adnexal mass or right adnexal tenderness on examination was significantly correlated with right lower quadrant adhesions2 Other groups also demonstrated an association between pelvic pain and adhesions. For example, 51% of patients with chronic pelvic pain had some pelvic adhesions versus 14% of controls. 6 In another report, 65.1% of women reported improvement in pain for at least 6 months after lysis of adhesions. 7 Some authors, however, noted that very few infertile patients with adhesions have pelvic pain) It also was suggested that a causal relationship between adhesions and pelvic pain is a myth perpetuated by surgeons and patients hoping for success in treating the pain) This study provides what is believed to be the first indication that colon-to-sidewall adhesions can be found almost universally in patients with chronic pelvic pain and are quite infrequent in pain-free women. The finding of these adhesion in dependent regions of the abdominal cavity, and in association with endometriosis and pelvic inflammatory disease, suggests that they are induced by inflammatory processes transported by peritoneal fluid. We recommend evaluating the paracolic gutters at laparoscopy for chronic pelvic pain, as the finding of colon-to-sidewall adhesions may suggest other intraperitoneal pathology such as endometriosis. When extensive paracolic adhesions are present, adhesiolysis may be indicated, but this issue requires further study.
FIGURE 1. Extensive adhesions with cascading vessels from the cecum and ascending colon to the right pelvic
sidewall.
colon-to-sidewall adhesions. Among the three patients with sidewall adhesions and no endometriosis visualized, one had a history of pelvic inflammatory disease and another had prior laparoscopic evidence of endometriosis. These adhesions appeared to be associated with intraperitoneal inflammatory processes such as endometriosis, endosalpingiosis, and pelvic inflammatory disease. Histologic evaluation confirmed that they were fibrovascular, often mesothelially lined tissues consistent with adhesions, with one specimen containing endosalpingiosis. Colon-to-sidewall adhesions are more common and more extensive along the right paracolic gutter than the left. This is not surprising, given the circular spread of peritoneal fluid, which, while moving cephalad in both paracolic gutters, tends to carry both inflammatory and neoplastic processes primarily up the fight sidewall. Pelvic inflammatory disease tends to track up the right paracolic gutter, causing perihepatic adhesions. Studies of the spread of ovarian cancer demonstrated greater involvement of the right sidewall and hemidiaphragm than the left. 4 Given the spread of peritoneal processes to the lateral gutters and the concomitant finding of endometriosis and pelvic inflammation with these adhesions, it seems likely that endometriosis or other inflammatory processes induce the formation ofparacolic adhesions. The role of paracolic adhesions in inducing pelvic pain is unclear. Nearly all patients in the prospective study with pelvic pain with extensive right- or left-sided
References
1. Rapkin A J: Adhesions and pelvic pain: A retrospective study. Obstet Gynecol 68:13-15, 1986 2. Lundberg WI, Wall JE, Mathers J: Laparoscopy in evaluation of pelvic pain. Obstet Gyneco142:872-876, 1973 3. Jenkins S, Olive D, Haney A: Endometriosis: Pathogenetic implications of the anatomic distribution. Obstet Gynecol 67:335-338, 1986
58
November 1995, Vol. 3, No. 1
The Journal of the American Association of Gynecologic Laparoscopists
4. Morrow P, Townsend D, eds: Synopsis of Gynecologic Oncology. New York, John Wiley & Sons, 1981, p 217
7. Chan C, Wood C: Pelvic adheiolysis--The assessment of symptom relief by 100 patients. Aust NZ J Obstet Gynaecol 25:295-298, 1985
5. Stovall T, Elder R, Ling F: Predictors of pelvic adhesions. J Reprod Med 34:345-348, 1989
8. Alexander-Williams J: Do adhesions cause pain? Br Med J 294:659, 1987
6. Kresch AJ, Seifer D, Sachs LB, et al: Laparoscopy in 100 women with chronic pelvic pain. Obstet Gynecol 64:672-674, 1984
59