Diagnosis and Surgical Treatment of Endometriosis

Limitations and Opportunities in the Diagnosis and Surgical Treatment of Endometriosis

From first symptoms to diagnosis can take 5-10 years. The woman affected by the disease consults not only the gynecologist, but also doctors of other specialties, gastroenterologist, urologist, internal medicine doctors.

Why does it take so long to diagnose endometriosis?

Despite efforts to raise awareness, endometriosis is still under-diagnosed, not because women do not go to the doctor, as the symptoms are often very “noisy”, meaning pain, infertility, physical and emotional trauma, but because the real reason for under-diagnosis and incorrect therapeutic approach is a lack of knowledge of the pathology and its peculiarities.

  • Insufficient knowledge of the pathology and its specific features.

Based on the idea that “in medicine you only see what you know and look for what you know”, in the diagnosis of endometriosis it is necessary to have a perfect knowledge and correlation between the data provided by the clinical examination and those provided by the imaging examination, transvaginal ultrasound and/or MRI with endometriosis protocol, and it is the gynecologist who evaluates and manages this synergy, in order to provide the complete picture of the pathology, a diagnosis of certainty and an optimal and personalized therapeutic pathway for each case.

  • A primary reason for the delay in diagnosis is that endometriosis lesions are also located elsewhere than in the ovary. They can appear on the ligaments of the uterus, intestines, bladder, peritoneum, not being so obvious on clinical or ultrasound examination.

Knowing and developing over time a thorough knowledge of the pathology, gaining experience in surgery of complex cases of deep infiltrating endometriosis/DIE – bowel endometriosis, bladder endometriosis, sacral roots endometriosis interventions – you can in most cases figure out the location of the lesions after clinical and ultrasound examination of the patient. 

  • Transvaginal ultrasound is a first-line imaging method, within the reach of every gynecologist, to explain and correlate the symptoms of the disease with the location of endometriosis lesions.

In the management of deep infiltrative endometriosis, transvaginal ultrasound provides the primary data in the evaluation of the uterus and adnexa to assess ovarian endometriomas and their association with other endometriotic lesions that exceed the pelvic area and intrude other organs. In conjunction with clinical examination, ultrasound about area tenderness, ovarian mobility and Douglas assessment, an accurate identification of deep infiltrating endometriosis/DIE nodules and obliteration of the Douglas can provide accuracy and predictability in planning a surgical procedure, which in cases of DIE should be multidisciplinary.

The role of transvaginal ultrasound in the hands of a gynecologist specialized in endometriosis surgery is to give a diagnosis of certainty and to make a lesional map to guide the surgeon in a complex multidisciplinary surgery.

  • When is MRI with endometriosis protocol recommended?

Most of the time the MRI with endometriosis protocol comes as a confirmation of what the clinician has found sonographically and also brings the patient a reconfirmation of what she has been told.

Endometriosis protocol MRI performs imaging evaluation of all pelvic compartments that may be affected by endometriosis, often confirming lesions identified sonographically. The investigation provides additional information on the degree of infiltration of the endometriotic nodule in the wall of the digestive tract, the degree of stenosis produced and can provide data on the extent of the lesions – completing for the surgeon in the operative planning.

  • A correct diagnosis by an experienced gynaecologist, specialised in endometriosis surgery, ensures an optimal therapeutic course.

Because it is a complex pathology, with multiple determinants, it happens that the lesions may not have a typical appearance, may be white, fibrous, reddish, dark spots, may be overlooked on gynaecological examination, if the gynaecologist does not have experience in this pathology. Treatment for superficial endometriosis is different from that for deep infiltrating endometriosis/DIE (for example: bowel endometriosis, bladder endometriosis, sacral roots endometriosis.). This explains why operations are incompletely performed, due to non-recognition of lesions and incomplete approach in excisional surgery of endometriosis lesions.

  • Another difficulty that occurs in endometriosis surgery is incomplete excision of deep endometriosis lesions.

The aim of surgery is to correctly and completely excise endometriosis lesions, in balance with the conservative decision of fertility potential, when the patient wishes to become a mother. Complex deep infiltrating endometriosis/DIE surgeries – bowel endometriosis, bladder endometriosis, sacral roots endometriosis interventionsare performed in a multidisciplinary team, coordinated by a gynaecologist specialized in endometriosis excision surgery. The team is composed of doctors from different specialties: colorectal surgeons, urologists, thoracic surgeon, etc., in order to provide a 360-degree surgery, so that the radical objective, excision of all endometriosis lesions, can be achieved from the first surgery.

Endometriosis is a pathology in which expertise in complex cases is essential for a correct diagnosis, and the surgeon’s experience, as well as years of practice in a specialized surgery, can make the difference both in terms of certainty diagnosis and therapeutic management, in a specialized and multidisciplinary surgery.