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Routine Clinical Examination Is Not Sufficient for Diagnosing and Locating Deeply Infiltrating Endometriosis
May 2002, Vol. 9, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
Routine Clinical Examination Is Not Sufficient for Diagnosing and Locating Deeply Infiltrating Endometriosis Charles Chapron, M.D., Jean-Bernard Dubuisson, M.D., Valeiria Pansini, M.D., Marco Vieira, M.D., Arnaud Fauconnier, M.D., Habib Barakat, M.D., and Bertrand Dousset, M.D.
Abstract Study Objective. To determine whether routine clinical examination is sufficient for the diagnosis and establishing the location of deeply infiltrating endometriosis (DIE). Design. Retrospective analysis (Canadian Task Force classification II-2). Setting. University-affiliated hospital. Patients. One hundred sixty women with histologically proved deeply infiltrating endometriosis. Measurements and Main Results. Speculum examination allowed endometriotic lesions to be viewed in only 14.4% (23) of patients, and a classic, painful, spheric nodule was palpated in only 43.1% (69). Results of routine clinical examination varied significantly with location of DIE. Whereas a nodule was found in 80.0% (24) of patients with vaginal endometriosis, this rate dropped to only 35.3% (6) and 33.3% (34) in those with DIE of the digestive tract and uterosacral ligaments, respectively (p <0.0001). Conclusion. High locations of DIE lesions at the level of uterosacral ligaments, bottom of the pouch of Douglas, and upper one-third of the posterior vaginal wall explain why results of routine clinical examination are so poor. The term “deep endometriosis infiltrating the rectovaginal septum” is generally incorrect in the true anatomic sense. (J Am Assoc Gynecol Laparosc 9(2):115–119, 2002)
Deep endometriosis is defined as penetration of endometriotic lesions into the retroperitoneal space to a depth of at least 5 mm.1 The gold standard for treatment of deeply infiltrating endometriosis (DIE) is surgical excision.2–7 Its success depends on how extensive surgical excision is.8 The preoperative work-up should thus allow the location and extent of lesions to be established as clearly as possible.8, 9 It was reported that tenderness on preoperative examination that reproduced any of a patient’s pain symptoms predicted reduction of symptoms after surgery.10
Materials and Methods We attempted to establish whether routine clinical examination is sufficient for diagnosing and pinpointing the location of DIE lesions with a retrospective analysis of a continuous series of 160 patients. On the basis of previous reports we classified endometriosis into four stages: bladder, when lesions infiltrate the bladder muscularis propria,11 uterosacral, when lesions infiltrate only uterosacral ligaments,12 vaginal, when lesions infiltrate the anterior rectovaginal pouch,
From Assistance Publique, Hopitaux de Paris, Service de Chirurgie Gynécologique (Drs. Chapron, Dubuisson, Pansini, Vieira, Fauconnier, and Barakat), and Service de Chirurgie Digestive (Dr. Houssin), CHU Cochin, Paris, France. Address reprint requests to Charles Chapron, M.D., Service de Chirurgie Gynécologique, Clinique Universitaire Baudelocque, C.H.U. Cochin PortRoyal, 123 Bld Port-Royal, 75014 Paris, France; fax 33 1 58 41 18 70. Accepted for publication January 14, 2002.
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Diagnosing and Locating Deeply Infiltrating Endometriosis Chapron et al
posterior vaginal fornix, and retroperitoneal area between the anterior rectovaginal pouch and posterior vaginal fornix,7, 13 and intestinal, when lesions involve the digestive tract. In parallel, and again by definition, we classified lesions into two groups: anterior DIE, which corresponds to bladder endometriosis, and posterior DIE, which corresponds to uterosacral, vaginal, and intestinal disease. When a woman had multiple lesions we classified her in the stage corresponding to the worst one. We classified lesions in the following order from least to worst: uterosacral, vaginal, bladder, and intestinal. For each patient we recorded general characteristics (age, parity, gravidity, height, weight, body mass index), infertility, pelvic pain (dysmenorrhea, deep dyspareunia, noncyclic chronic pelvic pain), and history of medical or surgical treatment for endometriosis. During the surgical procedure (laparotomy, operative laparoscopy) a complete investigation of the endometriotic lesions was carried out and scored (score, stage) according to the revised American Fertility Society classification.14 For every patient routine clinical examination consisted of two phases. First was inspection with the speculum, the results of which were considered positive if bluish lesions were seen that were typical of endometriosis, and if red, hypertrophic lesions were seen that bled easily on contact. Second was vaginal touch, which was considered positive if palpation of a painful spheric nodule and/or palpation of a painful induration reproduced pain identical to that of which the patient was complaining. Statistical analyses were performed with χ2 and Fisher’s exact tests. Significance was set at probability below 0.05.
TABLE 1. Patient Characteristics Variable
Result
Age (yrs) 31.2 ± 5.6 (19.2–51.1) Parity 0.3 ± 0.6 (0–4) Gravidity 0.7 ± 0.9 (0–4) Height (cm) 164.0 ± 6.3 (142–180) Weight (kg) 56.6 ± 8.8 (35–96) Body mass index (kg/m2) 21.1 ± 3.2 (13.7–33.3) Previous treatment for endometriosis Hormone treatment 126 (78.7) Laparoscopy 129 (80.6) Infertility 75 (46.9) Noncyclic chronic pelvic pain 41 (26.6) Dysmenorrhea 130 (81.2) Deep dyspareunia 114 (71.5) Mean rAFS14 score 20.0 ± 19.9 (2–88) rAFS stage 1 23 (14.4) 2 70 (43.7) 3 27 (16.9) 4 40(25.0) rAFS = revised American Fertility Society classification. Data are presented as mean ± SD or as number (%).
Results of routine clinical examination did not differ significantly whether DIE lesions were located in the anterior or posterior part of the pelvis (Table 2). In cases of posterior DIE, clinical examination results differed significantly according to the location of lesions (Table 3). Whereas lesions were seen by speculum inspection in half the patients with vaginal DIE (16, 53.3%), this rate dropped to only 23.5% (4) and 2.9% (3, p <0.0001), respectively, for intestinal and uterosacral DIE. Vaginal touch was always positive in women with vaginal endometriosis, but was considered
Results TABLE 2. Results of Routine Clinical Examination for Women with DIE
Patient characteristics are shown in Table 1. For women with noncyclic chronic pelvic pain, dysmenorrhea, and deep dyspareunia, mean preoperative pain scores (scale of 0–10) were 1.9 ± 3.3, 6.2 ± 3.4, and 4.8 ± 3.6, respectively. Locations of DIE lesions were uterosacral ligaments (102, 63.8%), vaginal (30, 18.7%), bladder (11, 6.9%), and intestinal (17, 10.6%). Inspection with the speculum was positive in 14.4% (23) of patients. Although vaginal touch was positive in 89.9% (139) of patients, a classic painful spheric nodule was palpated in only 43.1% (69). In 43.7% (70) of women an irregular, painful induration was found during vaginal touch.
DIE Examination Positive speculum inspection Positive vaginal touch Painful nodules Painful induration
Anterior (n = 11)
Posterior (n = 149)
p
0 (0.0)
23 (15.4)
0.33
8 (72.7) 5 (45.4) 3 (27.3)
131 (87.9) 64 (42.9) 67 (44.9)
0.33 0.87 0.40
DIE = deeply infiltrating endometriosis. Values are number (%).
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TABLE 3. Results of Routine Clinical Examination for women with Posterior DIE Posterior DIE Examination
USL (n = 102)
Vaginal (n = 30)
Intestinal (n = 17)
p
Positive speculum inspection Positive vaginal touch Painful nodules Painful induration
3 (2.9) 85 (83.3) 34 (33.3) 51 (50.0)
16 (53.3) 30 (100.0) 24 (80.0) 6 (20.0)
4 (23.5) 16 (94.1) 6 (35.3) 10 (58.8)
<0.0001 0.03 <0.0001 0.005
USL = uterosacral ligaments; DIE = deeply infiltrating endometriosis. Values are number (%).
nodule had been diagnosed on clinical examination during menstruation.15 Histologic results established the existence of deep endometriosis lesions in 87.5% of these women. When there is any doubt as to the diagnosis during routine clinical examination, these results lead us to recommend performing the examination during menstruation if during questioning functional symptoms suggest DIE. The fact that we did not systematically perform clinical examination during menses could indicate that our results may underestimate the true frequency of DIE recognized clinically. For the same reasons, notably for small lesions, it is preferable to perform the operation during the menstrual period. The results of routine clinical examination varied according to DIE lesions’ locations. Whereas at speculum examination lesions suggestive of endometriosis were observed in half the women with infiltration of the upper part of the posterior vaginal wall, this rate was significantly far lower for disease of the digestive tract or uterosacral ligaments. Similarly, palpation of a painful spheric nodule or painful induration during vaginal touch was significantly more frequent in those with vaginal involvement than when lesions were located higher at uterosacral ligament level. These clinical results agree with several reports20–22 that used different procedures to study the anatomy of this region. The conclusions of these studies are in line with findings of anatomic studies.23–26 Normally, peritoneum of the pouch of Douglas descends to the middle one-third of the posterior surface of the vagina before reflecting over the anterior surface of the rectum. This limit, represented by the bottom of the pouch of Douglas, is also the upper edge of the rectovaginal septum (RVS). In our experience, when DIE lesions are palpated during vaginal touch they are almost always felt in the upper one-third
normal (or negative) in 16.7% (17) with uterosacral and 5.9% (1) with intestinal DIE (p = 0.03). Painful spheric nodules were palpated in 80% (24) of patients with vaginal DIE; rates were 33.3% (34) and 35.3% (6), respectively, for those with uterosacral and intestinal DIE (p <0.0001). Discussion Routine clinical examination is not sufficient to diagnose DIE. Examination with the speculum was very unreliable (14.4%, 23 patients). In practice, if the diagnosis were to be made solely when bluish lesions are seen with the speculum, nearly 85% of lesions would be missed. A lesion was palpated during vaginal touch in only 87% of women. In other words, a normal clinical examination does not in any way eliminate the diagnosis of DIE. In our experience the reliability of routine clinical examination is far higher than that reported by others. In a retrospective series of 140 patients, pelvic nodules were felt in only 36% of women on routine clinical examination during the follicular or luteal phase.15 The diagnostic reliability of the examination depends on the types of lesions (infiltration, retraction, adenomyosis externa)16 together with the depth to which they penetrate and their volume.15 In our study, when the examination was positive, an isolated, painful, spheric nodule was observed in only half of patients. In the other women we found painful induration, in agreement with observations of others.15 The reliability of clinical examination can be increased significantly by examining the patient during menstruation.17–19 In a group of 16 women with severe pelvic pain, normal clinical examination, normal ultrasonography, and no suggestion of adhesions, laparoscopy was performed solely because a painful
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Diagnosing and Locating Deeply Infiltrating Endometriosis Chapron et al
of the posterior vaginal wall. They are most often located not in the RVS but above it, infiltrating the uterosacral ligaments and bottom of the pouch of Douglas (63.7%, 102/160 in our experience), and in certain cases infiltrating the digestive tract. Today the term “deep endometriosis of the rectovaginal septum” no longer appears to be exact from the anatomic point of view.13 It would be more accurate to talk of infiltration of the upper one-third of the posterior vaginal wall. These high locations of DIE lesions explain the poor reliability of clinical examination and its variability depending on the location of lesions. Because it is impossible to be sure that a diagnosis of DIE can be made during clinical examination whether during menstruation or not, it is necessary to carry out additional investigations when DIE is suspected. In this context rectal endoscopic ultrasonography27–29 and magnetic resonance imaging30–33 seem to be of interest. Further studies are essential to determine the preliminary results of these two examinations and specify their respective indications.
7. Chapron C, Jacob S, Dubuisson JB, et al: Laparoscopically assisted vaginal management of deep endometriosis infiltrating the rectovaginal septum. Acta Obstet Gynecol Scand 80:349–354, 2001 8. Garry R: Laparoscopic excision of endometriosis: The treatment of choice. Br J Obstet Gynaecol 104:513–515, 1997 9. Chapron C, Dubuisson JB: Management of deep endometriosis. Ann NY Acad Sci 943:276–280, 2001 10. Redwine DB, Wright JT: Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: Long-term follow-up of en bloc resection. Fertil Steril 76:358–365, 2001 11. Chapron C, Dubuisson JB: Laparoscopic management of bladder endometriosis. Acta Obstet Gynecol Scand 78:887–890, 1999 12. Chapron C, Dubuisson JB, Fritel X, et al: Operative management of deep endometriosis infiltrating the uterosacral ligaments. J Am Assoc Gynecol Laparosc 6:31–37, 1999 13. Martin DC, Batt RE: Retrocervical, rectovaginal pouch, and rectovaginal septum endometriosis. J Am Assoc Gynecol Laparosc 8:12–17, 2001
References 1. Koninckx PR, Meuleman C, Demeyere S, et al: Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 55:759–765, 1991
14. American Fertility Society: Revised American Fertility Society classification for endometriosis. Fertil Steril 43:351–352, 1985 15. Koninckx P, Meuleman C, Oosterlynck D, et al: Diagnosis of deep endometriosis by clinical examination during menstruation and plasma CA-125 concentration. Fertil Steril 65:280–287, 1996
2. Chapron C, Dubuisson JB: Laparoscopic treatment of deep endometriosis located on the uterosacral ligaments. Hum Reprod 11:868–873, 1996
16. Koninckx PR, Martin DC: Deep endometriosis: A consequence of infiltration or retraction or possibly adenomyosis externa? Fertil Steril 58:924–928, 1992
3. Donnez J, Nisolle M, Casanas-Roux F, et al: Rectovaginal septum, endometriosis or adenomyosis: Laparoscopic management in a series of 231 patients. Hum Reprod 10:630–635, 1995
17. Counsellor VS: Endometriosis: A clinical and surgical review. Am J Obstet Gynecol 36:877–888, 1938
4. Redwine DB: Laparoscopic en bloc resection for treatment of the obliterated cul-de-sac in endometriosis. J Reprod Med 37:695–698, 1992
18. Fallon J, Brosnan JT, Moran WG: Endometriosis: 200 cases considered from the viewpoint of the practitioner. N Engl J Med 235:669–673, 1946
5. Reich H, McGlynn F, Salvat J: Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis. J Reprod Med 36:516–522, 1991
19. Kistner RW: Management of endometriosis in the infertile patient. Fertil Steril 26:1151–1166, 1975 20. Baessler K, Schuessler B: The depth of the pouch of Douglas in nulliparous and parous women without genital prolapse and in patients with genital prolapse. Am J Obstet Gynecol 182:540–544, 2000
6. Koninckx PR, Martin D: Treatment of deeply infiltrating endometriosis. Curr Opin Obstet Gynecol 6:231–241, 1994
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21. Kuhn RJP, Hollyock VE: Observations on the anatomy of the rectovaginal pouch and septum. Obstet Gynecol 59:445–447, 1982
28. Fedele L, Bianchi S, Portuese A, et al: Transrectal ultrasonography in the assessment of rectovaginal endometriosis. Obstet Gynecol 91:444–448, 1998
22. Vercellini P, Aimi G, Panazza S, et al: Deep endometriosis conundrum: Evidence in favor of a peritoneal origin. Fertil Steril 73:1043–1046, 2000
29. Schröder J, Löhnert M, Doniec JM, et al: Endoluminal ultrasound diagnosis and operative management of rectal endometriosis. Dis Colon Rectum 40:614–617, 1997
23. Cunéo B, Veau V: De la signification morphologique des aponévroses périviscérales. Journal de l’anatomie et de la physiologie normales et pathologiques de l’homme et des animaux 35:235–245, 1899
30. Kinkel K, Chapron C, Balleyguier C, et al: Magnetic resonance imaging characteristics of deep endometriosis. Hum Reprod 14:1080–1086, 1999
24. Uhlenhuth E, Wolfe WM, Smith EM, et al: The rectovaginal septum. Surg Gynecol Obstet 76:148–163, 1948
31. Siegelman ES, Outwater E, Wang T, et al: Solid pelvic mass caused by endometriosis: MR imaging features. AJR 163:357–361, 1994
25. Milley PS, Nichols DH: A correlative investigation of the human rectovaginal septum. Anat Rec 163:443–452, 1969
32. Tanaka YO, Itai Y, Anno I, et al: MR staging of pelvic endometriosis: Role of fat-suppression T1-weighted images. Radiat Med 14:111–116, 1996
26. Tobin CE, Benjamin JA: Anatomical and surgical restudy of Denonvilliers’ fascia. Surg Gynecol Obstet 80:373–388, 1945
33. Balleyguier C, Chapron C, Dubuisson JB, et al: Comparison of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis of bladder endometriosis. J Am Assoc Gynecol Laparosc 9(1): 15–22, 2002
27. Chapron C, Dumontier I, Dousset B, et al: Results and role of rectal endoscopic ultrasonography for patients with deep pelvic endometriosis. Hum Reprod 13:2266–2270, 1998
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The Journal of the American Association of Gynecologic Laparoscopists
Routine Clinical Examination Is Not Sufficient for Diagnosing and Locating Deeply Infiltrating Endometriosis Charles Chapron, M.D., Jean-Bernard Dubuisson, M.D., Valeiria Pansini, M.D., Marco Vieira, M.D., Arnaud Fauconnier, M.D., Habib Barakat, M.D., and Bertrand Dousset, M.D.
Abstract Study Objective. To determine whether routine clinical examination is sufficient for the diagnosis and establishing the location of deeply infiltrating endometriosis (DIE). Design. Retrospective analysis (Canadian Task Force classification II-2). Setting. University-affiliated hospital. Patients. One hundred sixty women with histologically proved deeply infiltrating endometriosis. Measurements and Main Results. Speculum examination allowed endometriotic lesions to be viewed in only 14.4% (23) of patients, and a classic, painful, spheric nodule was palpated in only 43.1% (69). Results of routine clinical examination varied significantly with location of DIE. Whereas a nodule was found in 80.0% (24) of patients with vaginal endometriosis, this rate dropped to only 35.3% (6) and 33.3% (34) in those with DIE of the digestive tract and uterosacral ligaments, respectively (p <0.0001). Conclusion. High locations of DIE lesions at the level of uterosacral ligaments, bottom of the pouch of Douglas, and upper one-third of the posterior vaginal wall explain why results of routine clinical examination are so poor. The term “deep endometriosis infiltrating the rectovaginal septum” is generally incorrect in the true anatomic sense. (J Am Assoc Gynecol Laparosc 9(2):115–119, 2002)
Deep endometriosis is defined as penetration of endometriotic lesions into the retroperitoneal space to a depth of at least 5 mm.1 The gold standard for treatment of deeply infiltrating endometriosis (DIE) is surgical excision.2–7 Its success depends on how extensive surgical excision is.8 The preoperative work-up should thus allow the location and extent of lesions to be established as clearly as possible.8, 9 It was reported that tenderness on preoperative examination that reproduced any of a patient’s pain symptoms predicted reduction of symptoms after surgery.10
Materials and Methods We attempted to establish whether routine clinical examination is sufficient for diagnosing and pinpointing the location of DIE lesions with a retrospective analysis of a continuous series of 160 patients. On the basis of previous reports we classified endometriosis into four stages: bladder, when lesions infiltrate the bladder muscularis propria,11 uterosacral, when lesions infiltrate only uterosacral ligaments,12 vaginal, when lesions infiltrate the anterior rectovaginal pouch,
From Assistance Publique, Hopitaux de Paris, Service de Chirurgie Gynécologique (Drs. Chapron, Dubuisson, Pansini, Vieira, Fauconnier, and Barakat), and Service de Chirurgie Digestive (Dr. Houssin), CHU Cochin, Paris, France. Address reprint requests to Charles Chapron, M.D., Service de Chirurgie Gynécologique, Clinique Universitaire Baudelocque, C.H.U. Cochin PortRoyal, 123 Bld Port-Royal, 75014 Paris, France; fax 33 1 58 41 18 70. Accepted for publication January 14, 2002.
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Diagnosing and Locating Deeply Infiltrating Endometriosis Chapron et al
posterior vaginal fornix, and retroperitoneal area between the anterior rectovaginal pouch and posterior vaginal fornix,7, 13 and intestinal, when lesions involve the digestive tract. In parallel, and again by definition, we classified lesions into two groups: anterior DIE, which corresponds to bladder endometriosis, and posterior DIE, which corresponds to uterosacral, vaginal, and intestinal disease. When a woman had multiple lesions we classified her in the stage corresponding to the worst one. We classified lesions in the following order from least to worst: uterosacral, vaginal, bladder, and intestinal. For each patient we recorded general characteristics (age, parity, gravidity, height, weight, body mass index), infertility, pelvic pain (dysmenorrhea, deep dyspareunia, noncyclic chronic pelvic pain), and history of medical or surgical treatment for endometriosis. During the surgical procedure (laparotomy, operative laparoscopy) a complete investigation of the endometriotic lesions was carried out and scored (score, stage) according to the revised American Fertility Society classification.14 For every patient routine clinical examination consisted of two phases. First was inspection with the speculum, the results of which were considered positive if bluish lesions were seen that were typical of endometriosis, and if red, hypertrophic lesions were seen that bled easily on contact. Second was vaginal touch, which was considered positive if palpation of a painful spheric nodule and/or palpation of a painful induration reproduced pain identical to that of which the patient was complaining. Statistical analyses were performed with χ2 and Fisher’s exact tests. Significance was set at probability below 0.05.
TABLE 1. Patient Characteristics Variable
Result
Age (yrs) 31.2 ± 5.6 (19.2–51.1) Parity 0.3 ± 0.6 (0–4) Gravidity 0.7 ± 0.9 (0–4) Height (cm) 164.0 ± 6.3 (142–180) Weight (kg) 56.6 ± 8.8 (35–96) Body mass index (kg/m2) 21.1 ± 3.2 (13.7–33.3) Previous treatment for endometriosis Hormone treatment 126 (78.7) Laparoscopy 129 (80.6) Infertility 75 (46.9) Noncyclic chronic pelvic pain 41 (26.6) Dysmenorrhea 130 (81.2) Deep dyspareunia 114 (71.5) Mean rAFS14 score 20.0 ± 19.9 (2–88) rAFS stage 1 23 (14.4) 2 70 (43.7) 3 27 (16.9) 4 40(25.0) rAFS = revised American Fertility Society classification. Data are presented as mean ± SD or as number (%).
Results of routine clinical examination did not differ significantly whether DIE lesions were located in the anterior or posterior part of the pelvis (Table 2). In cases of posterior DIE, clinical examination results differed significantly according to the location of lesions (Table 3). Whereas lesions were seen by speculum inspection in half the patients with vaginal DIE (16, 53.3%), this rate dropped to only 23.5% (4) and 2.9% (3, p <0.0001), respectively, for intestinal and uterosacral DIE. Vaginal touch was always positive in women with vaginal endometriosis, but was considered
Results TABLE 2. Results of Routine Clinical Examination for Women with DIE
Patient characteristics are shown in Table 1. For women with noncyclic chronic pelvic pain, dysmenorrhea, and deep dyspareunia, mean preoperative pain scores (scale of 0–10) were 1.9 ± 3.3, 6.2 ± 3.4, and 4.8 ± 3.6, respectively. Locations of DIE lesions were uterosacral ligaments (102, 63.8%), vaginal (30, 18.7%), bladder (11, 6.9%), and intestinal (17, 10.6%). Inspection with the speculum was positive in 14.4% (23) of patients. Although vaginal touch was positive in 89.9% (139) of patients, a classic painful spheric nodule was palpated in only 43.1% (69). In 43.7% (70) of women an irregular, painful induration was found during vaginal touch.
DIE Examination Positive speculum inspection Positive vaginal touch Painful nodules Painful induration
Anterior (n = 11)
Posterior (n = 149)
p
0 (0.0)
23 (15.4)
0.33
8 (72.7) 5 (45.4) 3 (27.3)
131 (87.9) 64 (42.9) 67 (44.9)
0.33 0.87 0.40
DIE = deeply infiltrating endometriosis. Values are number (%).
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TABLE 3. Results of Routine Clinical Examination for women with Posterior DIE Posterior DIE Examination
USL (n = 102)
Vaginal (n = 30)
Intestinal (n = 17)
p
Positive speculum inspection Positive vaginal touch Painful nodules Painful induration
3 (2.9) 85 (83.3) 34 (33.3) 51 (50.0)
16 (53.3) 30 (100.0) 24 (80.0) 6 (20.0)
4 (23.5) 16 (94.1) 6 (35.3) 10 (58.8)
<0.0001 0.03 <0.0001 0.005
USL = uterosacral ligaments; DIE = deeply infiltrating endometriosis. Values are number (%).
nodule had been diagnosed on clinical examination during menstruation.15 Histologic results established the existence of deep endometriosis lesions in 87.5% of these women. When there is any doubt as to the diagnosis during routine clinical examination, these results lead us to recommend performing the examination during menstruation if during questioning functional symptoms suggest DIE. The fact that we did not systematically perform clinical examination during menses could indicate that our results may underestimate the true frequency of DIE recognized clinically. For the same reasons, notably for small lesions, it is preferable to perform the operation during the menstrual period. The results of routine clinical examination varied according to DIE lesions’ locations. Whereas at speculum examination lesions suggestive of endometriosis were observed in half the women with infiltration of the upper part of the posterior vaginal wall, this rate was significantly far lower for disease of the digestive tract or uterosacral ligaments. Similarly, palpation of a painful spheric nodule or painful induration during vaginal touch was significantly more frequent in those with vaginal involvement than when lesions were located higher at uterosacral ligament level. These clinical results agree with several reports20–22 that used different procedures to study the anatomy of this region. The conclusions of these studies are in line with findings of anatomic studies.23–26 Normally, peritoneum of the pouch of Douglas descends to the middle one-third of the posterior surface of the vagina before reflecting over the anterior surface of the rectum. This limit, represented by the bottom of the pouch of Douglas, is also the upper edge of the rectovaginal septum (RVS). In our experience, when DIE lesions are palpated during vaginal touch they are almost always felt in the upper one-third
normal (or negative) in 16.7% (17) with uterosacral and 5.9% (1) with intestinal DIE (p = 0.03). Painful spheric nodules were palpated in 80% (24) of patients with vaginal DIE; rates were 33.3% (34) and 35.3% (6), respectively, for those with uterosacral and intestinal DIE (p <0.0001). Discussion Routine clinical examination is not sufficient to diagnose DIE. Examination with the speculum was very unreliable (14.4%, 23 patients). In practice, if the diagnosis were to be made solely when bluish lesions are seen with the speculum, nearly 85% of lesions would be missed. A lesion was palpated during vaginal touch in only 87% of women. In other words, a normal clinical examination does not in any way eliminate the diagnosis of DIE. In our experience the reliability of routine clinical examination is far higher than that reported by others. In a retrospective series of 140 patients, pelvic nodules were felt in only 36% of women on routine clinical examination during the follicular or luteal phase.15 The diagnostic reliability of the examination depends on the types of lesions (infiltration, retraction, adenomyosis externa)16 together with the depth to which they penetrate and their volume.15 In our study, when the examination was positive, an isolated, painful, spheric nodule was observed in only half of patients. In the other women we found painful induration, in agreement with observations of others.15 The reliability of clinical examination can be increased significantly by examining the patient during menstruation.17–19 In a group of 16 women with severe pelvic pain, normal clinical examination, normal ultrasonography, and no suggestion of adhesions, laparoscopy was performed solely because a painful
117
Diagnosing and Locating Deeply Infiltrating Endometriosis Chapron et al
of the posterior vaginal wall. They are most often located not in the RVS but above it, infiltrating the uterosacral ligaments and bottom of the pouch of Douglas (63.7%, 102/160 in our experience), and in certain cases infiltrating the digestive tract. Today the term “deep endometriosis of the rectovaginal septum” no longer appears to be exact from the anatomic point of view.13 It would be more accurate to talk of infiltration of the upper one-third of the posterior vaginal wall. These high locations of DIE lesions explain the poor reliability of clinical examination and its variability depending on the location of lesions. Because it is impossible to be sure that a diagnosis of DIE can be made during clinical examination whether during menstruation or not, it is necessary to carry out additional investigations when DIE is suspected. In this context rectal endoscopic ultrasonography27–29 and magnetic resonance imaging30–33 seem to be of interest. Further studies are essential to determine the preliminary results of these two examinations and specify their respective indications.
7. Chapron C, Jacob S, Dubuisson JB, et al: Laparoscopically assisted vaginal management of deep endometriosis infiltrating the rectovaginal septum. Acta Obstet Gynecol Scand 80:349–354, 2001 8. Garry R: Laparoscopic excision of endometriosis: The treatment of choice. Br J Obstet Gynaecol 104:513–515, 1997 9. Chapron C, Dubuisson JB: Management of deep endometriosis. Ann NY Acad Sci 943:276–280, 2001 10. Redwine DB, Wright JT: Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: Long-term follow-up of en bloc resection. Fertil Steril 76:358–365, 2001 11. Chapron C, Dubuisson JB: Laparoscopic management of bladder endometriosis. Acta Obstet Gynecol Scand 78:887–890, 1999 12. Chapron C, Dubuisson JB, Fritel X, et al: Operative management of deep endometriosis infiltrating the uterosacral ligaments. J Am Assoc Gynecol Laparosc 6:31–37, 1999 13. Martin DC, Batt RE: Retrocervical, rectovaginal pouch, and rectovaginal septum endometriosis. J Am Assoc Gynecol Laparosc 8:12–17, 2001
References 1. Koninckx PR, Meuleman C, Demeyere S, et al: Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 55:759–765, 1991
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