definition permanent or intermittent pain or a feeling of
discomfort localized to the pelvis or lower abdomen, which is not
tied to menstruation or sexual intercourse for more than 6 months
synonym pelvic pain syndrome (PPS), pelvic pain, pelipathia,
chronic pelvic pain (CPP), pelvialgie
Slide 3
Difficult rating due to unclear and inconsistent terminology
According to Gallop Institute prevalence of 14.7%
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In U.S. CPP indication in 25 to 35% for laparoscopy In U.S. CPP
indication in 10 to 15% for hysterectomy Patients with CPP are 4 to
5 times more often operated than women without difficulty
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Dependence on age 18 to 30 years 44 to 49%, from 31 to 40 years
22 to 28%, 41-45 years 37% Max. 27 to 29 years (Jamieson et al.,
Obstet. Gynec.1996) Dependence between education, education and
socio-economic situation has not been demonstrated (Mathias et al.
Obstet.Gynec.1996) The average length of difficulties - 2.5
years
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First described in 1860 (Rokitansky) The presence of functional
endometrial glands and stroma outside their usual localization
Histopathological definition requires a hemorrhage and fibrous
reaction around
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glands inflitrate fibrosis
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The character of progressive malignant disease metastatic
Character - Invasive, monoclonal,multiorgan deterioration Invasive
disease associated with a small but defined risk of malignant
progression (Garry, Gyn.Endoscop., 2001,10,79-82)
Slide 9
Is Endometriosis primarily a disease or physiological process
that under certain conditions progresses with typical symptoms? -
patients regression, - progression, - stationary
Slide 10
Random occurrence in 4.1 - 22% of women with tubal
sterilization (Evers 1996) Prevalence in the population and 50%
(Olive, 1993) Prevalence of 25% (4.5 - 82%) women diagnosed with
pelvic pain Prevalence of 20% (2,1-78%) infertile women The
youngest patient with endometriosis 10.5 years, the oldest 78
years
Slide 11
A. Dissemination of endometrial cells - transport respectively.
implantation lymphatic dissemination - vascular dissemination -
iatrogenic - angiogenic B. metaplastic - celomic metaplasia - Mller
embryonic cell debris - induction
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genetic immunological toxic hormonal
Slide 13
Pain in the lower abdomen (deep deposits) - dysmenorhoe
(60-80%) - dyspareunia (25-50%) - chronic pelvic pain (30-50%)
Sterility - (12-40%) (surface deposits) Tumour - (10%) abnormal
bleeding Extragenitln symptoms - the incidence of bowel loops,
lung, bladder
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History Pain and its characteristics Gynecological examination,
examination in mirrors Imaging techniques
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Laboratory examination - no known specific marker of
endometriosis (TNF- , Ca-125) Imaging techniques transvaginal
sonography endorectal sonography NMR CT colonoscopy IVU
Slide 16
Laparoscopy - the "golden standard" Better visualization than
with laparotomy (infertility - timing in LUT. Stage) Histological
examination excidid leasions Character - peritoneal,
retroperitoneal bearings - adhesions - nodular deposits -
endometrioms Problem of endoscopy - identification of lesions
photodynamic diagnosis. Specificity 94%, sensitivity 60%
Slide 17
A different mechanism of three forms Explanation of the
mechanism of peritoneal endometriosis = Transplantation Ovarian
endometriosis = celomic metaplasia of invaginated ovarian surface
Rectovaginal endometriosis and adenomyosis= reminds metaplasia is
the result of the rest of the Mllerian ducts uterine
adenomyosis
Slide 18
PMD 2006 Peritoneln endometriza - podobnost mezi eutopickm
proliferanm endometriem a ervenou peritoneln lz (asn stadium)
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Pokroil stadium - ern loiska, dsledek stenho odluovn v
zvislosti na cyklu
Slide 21
Fibrotizace - redukce vaskularizace tvorba blch plak, jizev i
srst
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probably metaplasia invaginovanho coelomovho epithelial ovarian
cortex (Hughesdon, Donnez) invaginated cortex around primordial
follicles, frequent occurrence of cysts corpuslutel - Superficial
hemorrhagic lesions - hemorrhagic cysts - deep infiltrating
endometriosis ovarian Hyperplasia of smooth muscle in the deeper
layers of the ovarian cortex High degree of resistance to hormone
therapy
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probably result from metaplasia Mllerian ducts in rectovaginal
septum increased production of smooth muscle in the area and the
creation of nodes in rectovaginal septum - endometrial glands,
scanty stroma, smooth muscle similarities adenomyosis low E and P
receptors resistance to hormonal therapy leasions at 5-6 mm depth
is morphologically distinct from superficial endometriosis - more
frequent active form E
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Is it possible to surgically remove all leasionss? Does it make
sense prophylactic therapy in young women? Necessary to take the
patient wishes to become pregnant, the quality of her life, family
environment... 1.Conservative 2. Surgery 3. Combination
Excision of peritoneal deposits, adheziolysis Resection or
extirpation of endometriomas Salpingo-oophorectomy, ovariectomy
Removal of tubal endometriosis Rectovaginal septum resection
Infiltrative bowel resection and ureteral endometriosis
resection
Slide 39
Necessary is complete surgical removal of endometrial deposits
beyond the lesion and histological verification of diagnosis this
tend to: pain relief restore fertility prevent progression and
recurrence Significant effect dependence on the person of the
surgeon!
