Surgical Procedures for Chronic Pelvic Pain: How to Perform Them, When Not to Perform Them and What to Do If They Don t Work (Didactic)

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1 Surgical Procedures for Chronic Pelvic Pain: How to Perform Them, When Not to Perform Them and What to Do If They Don t Work (Didactic) PROGRAM CHAIR Michael Hibner, MD Fred M. Howard, MD Georgine M. Lamvu, MD Sponsored by AAGL Advancing Minimally Invasive Gynecology Worldwide

2 Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

3 Table of Contents Course Description... 1 Disclosure... 3 Diagnosing Pelvic Pain G.M. Lamvu... 5 The Role of Laparoscopy in Treatment of Pelvic Pain F.M. Howard What if Surgery Fails to Cure Pain? M. Hibner Evidence for Surgical Intervention in Patients with Pelvic Pain G.M. Lamvu What if Surgery Causes Pain? M. Hibner Surgical Treatment of Endometriosis G.M. Lamvu Treatment of Less Known Conditions Causing Pelvic Pain M. Hibner CPP as We Understand It Today F.M. Howard Cultural and Linguistics Competency... 82

4 PG 112 Surgical Procedures for Chronic Pelvic Pain: How to Perform Them, When Not to Perform Them and What to Do If They Don t Work (Didactic) Michael Hibner, Chair Faculty: Fred M. Howard, Georgine M. Lamvu Course Description This course will help gynecologists advance their knowledge and skills in treatment of common and less common conditions causing pelvic pain. This will be accomplished by review of current evidence for effectiveness of surgical intervention in patients with chronic pelvic pain. The role of laparoscopy in diagnosing pathology as well as its usefulness in treatment of disorders causing pelvic pain will be discussed. Current concepts in surgical treatment of endometriosis will be presented. Less known or less common conditions such as painful bladder syndrome, pelvic floor tension myalgia, pelvic congestion syndrome, adhesions and pelvic nerve entrapment syndrome will also be discussed. Finally it will offer treatment choices in cases when surgery fails to relieve pain and when surgery produces pain. This is especially important amidst growing concerns about the risks of procedures utilizing surgical mesh. Course Objectives At the conclusion of this course, the participant will be able to: 1) Summarize key components of the diagnostic process in patients with CPP; 2) discuss evidence for performing surgery to treat pelvic pain; 3) describe the role of laparoscopy in diagnosis and treatment of CPP; 4) apply proper surgical treatment of endometriosis in patients with CPP; 5) describe treatment in patients in whom surgery fails to relieve pain; and 6) identify conditions which may cause pain after pelvic surgery. Course Outline 1:30 Welcome, Introductions and Course Overview M. Hibner 1:35 Diagnosing Pelvic Pain G.M. Lamvu 2:00 The Role of Laparoscopy in Treatment of Pelvic Pain F.M. Howard 2:25 What if Surgery Fails to Cure Pain? M. Hibner 2:50 Evidence for Surgical Intervention in Patients with Pelvic Pain G.M. Lamvu 3:15 Questions & Answers All Faculty 3:25 Break 3:40 What if Surgery Causes Pain? M. Hibner 4:05 Surgical Treatment of Endometriosis G.M. Lamvu 1

5 4:30 Treatment of Less Known Conditions Causing Pelvic Pain M. Hibner 4:55 CPP as We Understand It Today F.M. Howard 5:20 Questions & Answers All Faculty 5:30 Course Evaluation 2

6 PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties - CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium - Ethicon Endo-Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor - Intuitve Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the best available evidence from medical literature (in alphabetical order by last name). Michael Hibner* Fred M. Howard Consultant: Ethicon Women's Health & Urology Speaker's Bureau: Abbott Laboratories Georgine M. Lamvu* Frank F. Tu Consultant: Ethicon Endo-Surgery 3

7 Asterisk (*) denotes no financial relationships to disclose. 4

8 DIAGNOSING PELVIC PAIN DISORDERS Disclaimer I have no financial relationships to disclose. Georgine Lamvu, MD, MPH Director of MIS and Advanced Gynecology Fellowship Medical Director of Gynecology Florida Hospital Orlando 1 2 Objectives Review epidemiology and basic physiology of chronic pelvic pain Review the basic requirements of the initial clinical evaluation in women with chronic pelvic pain Review recommendations for evaluation Important selected references listed on the last slide 2012 IOM Report Prevalence and Costs of Chronic Pain Disorders 116 million adults affected by chronic pain disorders annually in the U.S. Estimated costs $ billion annually (poor health and low productivity) Medicare bears ¼ of medical expenditures for pain, in 2008 it was $65.3 billion Pain is a universal experience 3 4 Summary of US Prevalence 25 million women with chronic pelvic pain, prevalence ranges from 4 49% in various populations 14 million women with vaginal or vulvar pain 25 43% of the world s female population has been affected by chronic pelvic pain Dysmenorrhea: Cyclical Pelvic Pain 106 studies, 125,249 women Prevalence: 16 81%; 8.7% (Bulgaria) to 97% (Finland) P Latthe, M Latthe, Say, et al. BMC Public Health

9 Dyspareunia Noncyclical Pelvic Pain 54 Studies, 35,973 women Prevalence: 8% 21%; 1.1% (Sweeden) to 45% (US) 18 studies, 299,740 women Prevalence: 2.1% 24%; 5.2% (India) to 43.2% (Thailand) P Latthe, M Latthe, Say, et al. BMC Public Health 2006 P Latthe, M Latthe, Say, et al. BMC Public Health Main Objective Today Epidemiology of Chronic Pelvic Pain To clarify and simplify your understanding of chronic pelvic pain which is often viewed by general medical providers as a difficult, puzzling and frustrating disorder with few treatment options. LESS THAN 5% OF PATIENTS WITH CHRONIC PAIN ARE SEEN BY A PAIN SPECIALIST 9 10 The Literature Supports Our Clinical Observations PRICE J, et. al. BJOG 2006;113: SELFE SA,et al. Pain 1998;77: GRACE VM. Health Care Women Int 1995;16: Most women with CPP have negative perceptions of their interactions with providers especially gynecologists Women often feel like they Are not receiving personalized care Are not understood or taken seriously Often dismissed without reassurance or explanation for their pain CPP patients have difficulty understanding and accepting normal test results CPP patient often express disappointment with the overall quality of the consultation 11 How Do We Improve? Negative perceptions Patient care Pain relief Quality of life 12 6

10 A FEW CHRONIC (PELVIC) PAIN PRINCIPLES TO REMEMBER That are supported by research Chronic Pain is Not The Same as Acute Pain Acute Pain Symptom of injury or disease Well defined onset, recent Expected to end in days or weeks Essential biologic warning function Chronic Pain Remote onset and may change in character and severity over time Unpredictable duration No apparent biologic function Progressive or persistent May be associated diseases that exacerbate or precipitate manifestations of chronic pain Pelvic Neuro-anatomy Anxiety Depression Catastrophizing Frustration Expectations Anger Pelvic organs share neural pathways The spinal cord innervates several organs Several organs simultaneously send input into the spinal cord Bowel Bladder Uterus BRAIN Neural cross talk in the pelvis SPINAL CORD PERIPHERAL NEURON Facilitation Substance P Glutamate Serotonin Neurotensin Nerve growth factor CCK Inhibition Norepinephrine Opioids GABA Cannabinoids Adenosine 17 Measuring Levels of Pain Uni dimensional scales such as the Visual Analogue Scale (VAS) are not enough to capture many important aspects of pain such as: Multi organ co morbidity Impairment of quality of life and important functions such as sexual function Impairment of poor coping and stress associated with chronic pain Changes in function in response to treatment 18 7

11 Current Definition of Pain IASP definition: an unpleasant sensory and emotional experience associated with actual or potential damage or described in terms of such damage. Pain is both a physiologic process composed of impulse transmission along neural pathways, involving the release of neurotransmitters, and subjective and emotional experience. The 1,2,3 of the Initial Evaluation 1. Establish pattern of chronicity 2. Determine how many organs are involved 3. Physical exam to include the three M s Mood: psychological and quality of life Musculoskeletal exam (internal/external) Mucosal exam Slide courtesy of Anne Marie Fras, MD 19 Slide courtesy of Fras, MD 20 Establish a Pattern Of Chronicity Use open ended questions Timing Onset Duration Previous treatments tried Allow patient to express how pain effects Daily function Quality of life Allow patient to identify what is most distressing The quality of the initial gynecological consultation is associated with success of follow up and recovery Selfe et al. Factors influencing outcome in consultations for chronic pelvic pain. J Womens Health, 7: Establish How Many Organs Are Involved Associated gastrointestinal, urinary and musculoskeletal symptoms Alleviating or exacerbating factors Zondervan KT. Br J Obstet Gynaecol. 1999;106: Howard FM. Obstet Gynecol. 2003:101: Gastrointestinal Urologic Reproductive Musculoskeletal Physical Examination Pelvic Pain Examination Sequential examination, you may not be able to do everything in one visit! Don t get stuck on one diagnosis It may change Multiple organ systems may be involved Remember your neurobiology and think central mechanisms 23 Appearance Mood Affect Muscle Skeletal Walking Standing Strength Reflexes Sensory Motor Abdominal Sensory Contraction Relaxation Insertion points Scars Trigger points Identify location that REPLICATES pain Pain intensity and affective response Referral pattern Pelvic External Internal single digit speculum bimanual rectovaginal 24 8

12 Musculoskeletal Evaluation Identify asymmetry and pain associated with movement of the PSIS, ASIS Iliac Crest, Pubic Symphysis Greater Trochanter Musculoskeletal Examination Low Back Pain Palpate paraspinal structures With sciatica symptoms: Lasegue s test (+) test suggests L4 5 or L5 S1 disc herniation Slide courtesy of Frank Tu, MD. 25 Vroomen JC, et al, J Neurol Slide courtesy of Frank Tu, MD 26 Abdominal Examination Evaluate abdominal wall for tender muscular points (trigger points, myofascialpain) Assess both deep and superficial (brush) pain sensitivity especially around scars While the patient performs a crunch palpate p the rectus and obliques To distinguish visceral/ intr aperitoneal pain from regional somatic pain deep pelvic pain improves when the muscles are contracted Muscular pain worsens when the muscles are contracted Carnett s test Vaginal Examination Look First! External Survey Vulvar or vestibular skin lesions ulcerations, fissures Swelling or redness Vestibular hypersensitivity with Q ti touch Atrophic changes Urethral meatus Pelvic organ prolapse Slide courtesy of Frank Tu, MD Vulvar Pain: Sensory Innervation of the Perineum Vaginal Examination: Palpate Second: Internal Single Digit Voluntary contraction, strength, relaxation and pain of muscles: Introitus Levatorplate Obturator Pain of Bladder Cervix Urethral Ischeal tuberosity and alcock s canal

13 Internal Examination Speculum Examination Internal Bimanual and Rectovaginal Examination Vaginal walls Vaginal fornices or vaginal cuff Cervix Vaginal discharge ph Wet mount STI cultures Uterus Ovaries Uterosacrals Posterior cul desac Rectovaginal vault Size Location Mobility Tenderness Nodularity Masses Integrate Your Examination Findings Into a Diagnosis and Treatment Plan Therapies for CPP Disorders Musculoskeletal Somatic Myofascial syndrome Trigger points Loss of muscle function Physical therapy Muscle relaxants Trigger point injections Organ Specific Visceral Urinary Dietary changes Gastrointestinal Anti spasmotics Reproductive Cycle suppression Surgeries Mood Depression Anxiety Poor coping Sexual dysfunction Antidepressants Anxiolytics Cognitive behavioral therapy 33 Lamvu Physical Therapy Alternative Complimentary Therapy Analgesics Surgical Individualized Multidisciplinary Therapy Antidepressants Anticonvulsants Hormonal Neuropathic Blocks Cognitive Behavioral Therapy Summary Take more time with the history and physical than with anything else Try to distinguish whether multiple organs are involved Use single digit exam over global lbimanual to optimize specificity Always consider primary or secondary musculoskeletal causes Always consider the psychosocial and sexual environment Lamvu

14 THANK YOU References P Latthe, M Latthe, Say, et al. BMC Public Health 2006 PRICE J, et. al. BJOG 2006;113: SELFE SA,et al. Pain 1998;77: GRACE VM. Health Care Women Int 1995;16: Selfe et al. Factors influencing outcome in consultations for chronic pelvic pain. J Womens Health, 7: Zondervan KT. Br J Obstet Gynaecol. 1999;106: Howard FM. Obstet Gynecol. 2003:101: Vroomen JC, et al, J Neurol Institute of Medicine: Relieving Pain in America

15 The Role of Laparoscopy in the Treatment of Pelvic Pain Fred M. Howard, MS, MD Professor Emeritus of Obstetrics Gynecology University i of Rochester School of Medicine & Dentistry Rochester, New York DISCLOSURE Consultant: Ethicon Women's Health & Urology Speaker's Bureau: Abbott Laboratories OBJECTIVES Identify the disorders that may require laparoscopy for diagnosis List the important disorders in CPP that do not require laparoscopy & have negative laparoscopic findings Formulate the appropriate role for laparoscopy in women with CPP Traditional Role of Laparoscopy in CPP Routine part of the evaluation of chronic pelvic pain Abnormal exam correlates with abnormal laparoscopic findings in 70 90% of cases Normal exam in >1/2 with abnormal laparoscopic findings Laparoscopy may allow the detection of potentially treatable pathology not detected by exam Laparoscopy in Women with Prior Treatment Laparoscopy in Women with Prior Treatment % with 40 Improvement General Daily Activities Assoc Sxs McGill Gyn Laparoscopy Multidisciplinary Multidisciplinary evaluation & treatment is more likely to result in a reduction of pelvic pain than is the standard form of care. If a carefully taken history and an expert pelvic examination are negative, it is doubtful whether invasive measures such as laparoscopy have any additional information to offer. Peters AAW, et al. Obstet Gynecol 1991;77:740 Peters AAW, et al. Obstet Gynecol 1991;77:740 12

16 Evidence Based Evaluation of Diagnoses Associated with CPP Level A Evidence Diagnoses Reproductive Tract Diagnoses Endometriosis Gynecologic malignancies Ovarian retention syndrome Ovarian remnant syndrome (Pelvic congestion syndrome) Pelvic inflammatory disease Tuberculous salpingitis Level A Evidence Diagnoses Reproductive Tract Diagnoses Endometriosis Gynecologic malignancies Ovarian retention syndrome Ovarian remnant syndrome (Pelvic congestion syndrome) Pelvic inflammatory disease Tuberculous salpingitis Level A Evidence Diagnoses Urinary Tract Diagnoses Bladder malignancy Interstitial cystitis Radiation cystitis Urethral syndrome Level A Evidence Diagnoses Urinary Tract Diagnoses Bladder malignancy Interstitial cystitis Radiation cystitis Urethral syndrome Level A Evidence Diagnoses Gastrointestinal Tract Diagnoses Carcinoma of the colon Constipation Inflammatory bowel disease Irritable bowel syndrome 13

17 Level A Evidence Diagnoses Gastrointestinal Tract Diagnoses Carcinoma of the colon Constipation Inflammatory bowel disease Irritable bowel syndrome Level A Evidence Diagnoses Musculoskeletal System Diagnoses Abdominal wall myofascial pain (trigger points) Abdominal cutaneous nerve entrapment in surgical scar Chronic coccygeal or back pain Faulty or poor posture Fibromyalgia Neuralgia of iliohypogastric, ilioinguinal, and/or genitofemoral nerves Pelvic floor myalgia (levator ani or piriformis syndrome) Peripartum pelvic pain syndrome Level A Evidence Diagnoses Musculoskeletal System Diagnoses Abdominal wall myofascial pain (trigger points) Abdominal cutaneous nerve entrapment in surgical scar Chronic coccygeal or back pain Faulty or poor posture Fibromyalgia Neuralgia of iliohypogastric, ilioinguinal, and/or genitofemoral nerves Pelvic floor myalgia (levator ani or piriformis syndrome) Peripartum pelvic pain syndrome Level A Evidence Diagnoses Psychological Diagnoses Depression Catatrophizing Somatization disorder Level A Evidence Diagnoses Psychological Diagnoses Depression Catatrophizing Somatization disorder Level B Evidence Diagnoses Reproductive Tract Diagnoses Adhesions Benign cystic mesothelioma Leiomyomata Postoperative peritoneal cysts 14

18 Level B Evidence Diagnoses Reproductive Tract Diagnoses Adhesions Benign cystic mesothelioma Leiomyomata Postoperative peritoneal cysts Level B Evidence Diagnoses Urinary Tract Diagnoses Adhesions Uninhibited bladder contractions (detrusor dyssynergia) Urethral diverticulum Level B Evidence Diagnoses Urinary Tract Diagnoses Adhesions Uninhibited bladder contractions (detrusor dyssynergia) Urethral diverticulum Level B Evidence Diagnoses Gastrointestinal Tract Diagnoses Adhesions Celiac disease Porphyria Level B Evidence Diagnoses Gastrointestinal Tract Diagnoses Adhesions Celiac disease Porphyria Level B Evidence Diagnoses Musculoskeletal System Diagnoses Herniated nucleus pulposus Low back pain Neurologic dysfunction Neoplasia of spinal cord or sacral nerve Shingles 15

19 Level B Evidence Diagnoses Musculoskeletal System Diagnoses Herniated nucleus pulposus Low back pain Neurologic dysfunction Neoplasia of spinal cord or sacral nerve Shingles Level B Evidence Diagnoses Psychological Diagnoses Sleep disturbances Level B Evidence Diagnoses Psychological Diagnoses Sleep disturbances Level C Evidence Diagnoses Reproductive Tract Diagnoses Adenomyosis Atypical dysmenorrhea or ovulatory pain Adnexal cysts (nonendometriotic) Cervical stenosis Chronic ectopic pregnancy Chronic endometritis Endometrial or cervical polyps Endosalpingiosis Intrauterine contraceptive device Ovarian ovulatory pain Residual accessory ovary Symptomatic pelvic relaxation (genital prolapse) Level C Evidence Diagnoses Level C Evidence Diagnoses Reproductive Tract Diagnoses Adenomyosis Atypical dysmenorrhea or ovulatory pain Adnexal cysts (nonendometriotic) Cervical stenosis Chronic ectopic pregnancy Chronic endometritis Endometrial or cervical polyps Endosalpingiosis Intrauterine contraceptive device Ovarian ovulatory pain Residual accessory ovary Symptomatic pelvic relaxation (genital prolapse) Urinary Tract Diagnoses Chronic urinary tract infection Recurrent, acute urethritis Recurrent, acute cystitis Stone/urolithiasis Urethral caruncle 16

20 Level C Evidence Diagnoses Urinary Tract Diagnoses Chronic urinary tract infection Recurrent, acute urethritis Recurrent, acute cystitis Stone/urolithiasis Urethral caruncle Level C Evidence Diagnoses Gastrointestinal Tract Diagnoses Abdominal epilepsy Abdominal migraine Colitis Chronic intermittent bowel obstruction Diverticular disease Familial Mediterranean fever Level C Evidence Diagnoses Gastrointestinal Tract Diagnoses Abdominal epilepsy Abdominal migraine Colitis Chronic intermittent bowel obstruction Diverticular disease Familial Mediterranean fever Level C Evidence Diagnoses Musculoskeletal System Diagnoses Compression of lumbar vertebrae Degenerative joint disease Hernias: ventral, inguinal, femoral, spigelian Muscular strains and sprains Rectus tendon strain/rectus abdominis pain syndrome Spondylosis Level C Evidence Diagnoses Level C Evidence Diagnoses Musculoskeletal System Diagnoses Compression of lumbar vertebrae Degenerative joint disease Hernias: ventral, inguinal, femoral, spigelian Muscular strains and sprains Rectus tendon strain/rectus abdominis pain syndrome Spondylosis Psychological Diagnoses Bipolar personality disorders 17

21 Level C Evidence Diagnoses Diagnoses Requiring Diagnostic Laparoscopy Psychological Diagnoses Bipolar personality disorders 1. Endometriosis 2. Ovarian remnant syndrome 3. Pelvic inflammatory disease 4. Tuberculous salpingitis 5. Adhesions 6. Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10. Endosalpingiosis 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian Interim Points Abandon the idea that laparoscopy is essential in the evaluation of CPP Abandon the idea that laparoscopy is the penultimate diagnostic test in CPP Negative findings do not mean there is no organic diagnosis Interim Points Laparoscopy often has a therapeutic role in chronic pelvic pain Preferred approach to surgical treatment of manyof the disorders amenable to operative treatment Diagnoses Requiring Diagnostic Laparoscopy 1. Endometriosis 2. Ovarian remnant syndrome 3. Pelvic inflammatory disease 4. Tuberculous salpingitis 5. Adhesions 6. Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10. Endosalpingiosis 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian Diagnosis of Endometriosis Histologic diagnosis, not laparoscopic diagnosis Ectopic endometrial glands and stroma must be present Requires a tissue specimen 18

22 Visual Diagnosis Description of Lesion Confirmation of Diagnosis Black 90% Brown 78% White 76% Red 67% Clear papules 67% Glandular 67% Peritoneal defects 41% Superficial yellow-brown 40% Adhesions (ovarian) 40% Carbon 17% Adhesions (non-ovarian) 12% Cribriform peritoneal defects 9% VISUAL DIAGNOSIS Positive predictive value = 45% Negative perdictive value = 99% Sensitivity = 97% Specificity = 77% Walter et al. Am J Obstet Gynecol 2001;184:1407 Not a Visual Diagnosis Not a Visual Diagnosis Clinical Diagnosis Of 95 women clinically diagnosed with endometriosis, 81% had confirmations at the time of laparoscopy Suggests that laparoscopy is not necessary before starting medical treatment Not a Clinical Diagnosis Clinical vs Histological Diagnosis Negative Histology Positive Histology Total Endometriosis 134 (76%) 43 (24%) 177 not clinically diagnosed Endometriosis (64%) 198 clinically diagnosed Total Ling FW. Obstet & Gynecol 1999;93:51-8 Howard FM. Unpublished data 19

23 Not a Clinical Diagnosis Clinical vs Histological Diagnosis Negative Histology Positive Histology Total Endometriosis 134 (76%) not clinically diagnosed Endometriosis (64%) 198 clinically diagnosed Total NOT A VISUAL DIAGNOSIS NOT A CLINICAL DIAGNOSIS Clinical diagnosis Positive predictive value = 64% Negative predictive value = 76% Visual laparoscopic diagnosisi Positive predictive value = 45% Negative predictive value = 99% Howard FM. Unpublished data Howard FM. Unpublished data Walter et al. Am J Obstet Gynecol 2001;184:1407 Laparoscopy for Endometriosis Diagnoses Requiring Diagnostic Laparoscopy Thorough knowledge of the various appearances of endometriosis Liberal use of excisional biopsies Thorough hevaluation of the pelvis li At least a double puncture technique "Near contact" laparoscopy 1. Endometriosis 2. Ovarian remnant syndrome 3. Pelvic inflammatory disease 4. Tuberculous salpingitis 5. Adhesions 6. Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10. Endosalpingiosis 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian Ovarian Remnant Syndrome Pelvic pain or mass due to persistence of ovarian fragments unintentionally left in situ during (difficult) oophorectomy Most commonly described after a previous bilateral salpingoophorectomy and hysterectomy Occurs more commonly than generally thought Ovarian Remnant Syndrome Diagnostic Studies Vaginal ultrasound shows pelvic mass in 50 85% of cases Diagnostic accuracy improved by pretreatment with clomiphene citrate if functional follicles are present FSH levels No hormonal replacement tfor three weeks or more Pre menopausal FSH levels in 50 75% GnRH a stimulation test Baseline & 3 7 day post injection levels of estradiol 20

24 Ovarian Remnant Syndrome Medical Treatment Hormonal suppression Depot medroxyprogesterone acetate (150 mg IM each month) Danazol (600 mg per day PO) Depot leuprolide acetate (3.75 mg IM each month) Combined estrogen progestagen Radiation treatment ( cgy) Ovarian Remnant Syndrome Ovarian Remnant Ovarian Remnant Endometriosi s Ureter Diagnoses Requiring Diagnostic Laparoscopy 1. Endometriosis 2. Ovarian remnant syndrome 3. Pelvic inflammatory disease 4. Tuberculous salpingitis 5. Adhesions 6. Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10. Endosalpingiosis 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian Pelvic Inflammatory Disease 30% of women develop CPP after PID Ness RB et al. Am J of Obstet Gynecol 186:929-37, 2002 Diagnoses Requiring Diagnostic Laparoscopy 1. Endometriosis 2. Ovarian remnant syndrome 3. Pelvic inflammatory disease 4. Tuberculous salpingitis 5. Adhesions 6. Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10. Endosalpingiosis 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian Adhesions Etiology PID Endometriosis Perforated appendix Prior surgery Inflammatory bowel disease 21

25 Adhesions Physical appearance of adhesions are not specific to the underlying cause Adhesions Presently the only definitive way to diagnose adhesions is by surgical visualization Excision & histology may be important in women with endometriosis Laparoscopic Treatment of Adhesion Associated Pelvic Pain Reformed Adhesions Observational studies suggest efficacy of 60 90% RCT laparoscopic adhesiolysis showed no efficacy at 12 months Swank et al. Lancet 2003;361:1247 RCT adhesiolysis by laparotomy showed no difference at 11 months Peters AAW, et al. Br J Obstet Gynaecol 1992;99:59 RCT paracolic adhesiolysis showed improvement in pain at 4 8 weeks. Keltz et al. JSLS 2006: 10; % with Adhesions Reformed Adhesions Ovarian Laparoscopy Laparotomy Diamond M, et al. Fertil Steril 1991;55: Franklin RR, et al. Obstet Gynecol 1995;86: Laparoscopic Treatment of Adhesion Associated Pelvic Pain Prevention of recurrent adhesions Unnecessary suture material Residual blood or clots Unnecessary tissue trauma & handling Currently Interceed is only product with evidence of efficacy that can be used laparoscopically Diagnoses Requiring Diagnostic Laparoscopy 1. Endometriosis 2. Ovarian remnant syndrome 3. Pelvic inflammatory disease 4. Tuberculous salpingitis 5. Adhesions 6. Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10. Endosalpingiosis 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian 22

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