Neuropelveology, why is it important for a surgeon specialized in endometriosis to know this field?

Neuropelveology refers to the study of the innervation of the pelvis, of the effects of pelvic nerve damage on the human body, including both somatic and vegetative nerves.

Pelvic surgery involves knowledge of the innervation of the pelvis, and neuropelveology brings additional knowledge to the pelvic surgeon for certain sensitive conditions such as endometriosis, tumour pathology, conditions that irritate or compress the pelvic nerves.

The sympathetic and parasympathetic nervous systems, two mechanisms that act antagonistically but simultaneously, consists the vegetative nervous system in the pelvis.

The sympathetic nervous system is responsible for the so-called fight or flight reaction, i.e. the fight or flight reaction in the event of great danger, called the sympatho-adrenal response.
The sympathetic vegetative nervous system, which originates in the solar plexus, is the most delicate by keeping our bowels and bladders full and essentially preventing us from urinating and defecating.

The parasympathetic system originates from the splanchnic nerves, the nerves that come from the last sacral roots. They are few in number, 3-4 on the left, 3-4 on the right and when they are damaged by a certain pathology or during surgery, it is very difficult to restore their function. These nerves, antagonists of the sympathetic nerves, help the bladder evacuate by contracting its muscles, relax the urethral sphincter and the bowel.

The somatic nervous system is sensory and motor and it is coordinated by the central nervous system: brain and spine. The somatic system provides sensory sensation, perception of pain, touch stimuli, sensation of cold, heat, etc.

The motor nerves are those that come from the central nervous system, from the spine to the periphery – the muscles – and dictate the body’s reaction (e.g.: if you get stung, you withdraw your hand or leg).

Why is it necessary for endometriosis specialists to know neuropelveology?

Diseases like endometriosis affect the nerves, particularly the parasympathetic system, and often, especially if the condition is chronic, even if you want to excise and maintain those nerve threads, you cannot always do that since the disease itself affects the nerve threads.

How can we relate the symptoms expressed by the patient to the pelvic innervation damage?

The first sign that leads the patient to the doctor is pelvic pain, which can occur through irritation of the nerves in that territory by some cause or through damage to the nerves in that territory.

Visceral pain is caused by irritation of small nerve threads in the pelvic organs or their supporting tissues. Visceral pain is vague, difficult to localize, sometimes localized in the entire lower abdomen and radiating to the lumbar region. It is frequently accompanied by one or two of the following vegetative symptoms – nausea, fatigue, irritability, or even syncope through irritation of the solar plexus. Symptoms of SNS (sympathetic nervous system) activation may occur – pupil dilation, tachycardia, pallor, sweating, anxiety.

Somatic pain is caused by irritation of larger nerve pathways – obturator nerve, sciatic nerve.

Somatic pain can be located very precisely by the patient, and it is perceived as a burn, electric shock and sting. It is not accompanied by vegetative phenomena, and very important, which also differentiates it from visceral pain, it radiates caudally on the specific dermatoma of the affected area. The causes that lead to somatic pain also lead to pelvic motor dysfunction, both in the pelvic organs and locomotor dysfunction.

The pain described by the patient can lead you to the source and mechanism of the pain, to complete a complex clinical picture and choose the optimal therapeutic management.

When experiencing pain, the vegetative system that innervates the pelvic organs does not transmit pain signals to the legs, particularly not to the dorsal side of the legs.

 It goes to the upper floor and it is accompanied by all kinds of vegetative reactions such as digestive disorders, nausea, mydriasis, etc. It rather radiates to the inside of the leg, but never to the back of the leg.

Somatic pain goes downwards – because somatic nerves come from the spinal roots, usually somatic innervation is on the dermatomes. If there is an injury to the T12 vertebra, the somatic response is on the nerves that come corresponding to the T12 vertebra.

The vertebrae L1-L4 correspond to the lumbar plexus, which provides the nerves that supply the lower abdomen and legs, and from there, the pain travels to the lower half of the body.

L5 radiates to the front side. S1-S2 is on the back of the leg. S3-S4 is in the perineum.

The physician who integrates the symptoms of a patient must know the theoretical knowledge, each nerve that irritates as a territory, because from the symptoms expressed by the patient, the physician extracts a lot of information. The symptomatology expressed leads to the diagnosis and implicitly to the therapeutic conduct.

The information is useful throughout the therapeutic course, anamnesis, diagnosis, pre-surgical, during and post-surgery. What dysfunctions may remain after surgery is important.

I have encountered cases in my experience that can be easily overlooked or referred to other specialists than endometriosis specialists.

The patient who says, “During my period I have pains in the back of my leg!” can easily be referred to a neurologist, if you don’t count overlooking an endometriosis affecting the sciatic nerve. There are plenty of such cases, which if you have a thorough knowledge of neuropelveology you can approach, diagnose, and treat correctly and responsibly, to improve the patients’ quality of life.

Knowing neuropelveology – an asset in pelvic surgery

A thorough knowledge of neuropelveology is very important. When we talk about damage to large nerves, which also have a sensory and motor function, such as the sciatic nerve or the obturator nerve, their damage by the endometriosis lesion must be very well weighed in terms of the excision decision.

If the nerve is fully removed or severed, the patient may be invalidated and experience major disabilities, including paralysis.

Radical surgery performed in an attempt to remove the entire lesion may have negative effects on the patient’s quality of life. While the patient’s pain can be managed, she may end up needing a urinary catheter because she will be unable to urinate normally or may have (faecal or urine) incontinence, which can cause a major disabling potential.

There is a fine line between being radical and preserving pelvic innervation, between “when, how and how much” you operate in certain pathologies.

It is very important that the doctor be specialized in neuropelveology, because she/he must know how to take action in the pelvis. It is very easy to cut and stop the bleeding (there are so many instruments in the room that help us to stop potential bleeding, but what is important is what you leave behind after surgery and especially the results of the medical act, which are expressed in terms of recovery and quality of life of patients after surgery.

The Endomedicare Academy team, coordinated by Elvira Bratila, MD PhD has extensive expertise in complex surgical cases of deeply infiltrative endometriosis, in which the application of neuropelveology and its principles is very important.

These complex cases are frequently referred to us, because these patients should only be treated in dedicated centres, by surgeons specialising in endometriosis who have the knowledge, skill and experience in a relatively recently studied global science such as neuropelveology. Our objective is to preserve pelvic innervation, in a field of great finesse, where sometimes there is the paradox that “the better is the enemy of the good”.

In surgery, what you excise is important, but what you leave behind is more crucial.