Abstract
To assess individual changes of deep dyspareunia (DDyspareunia) six months after laparoscopic nerve-sparing complete excision of endometriosis, with or without robotic assistance. This preplanned interdisciplinary observational study with a retrospective analysis of intervention enrolled 126 consecutive women who underwent surgery between January 2018 and September 2019 at a private specialized center. Demographics, medical history and surgery details were recorded systematically. DDyspareunia (primary outcome), dysmenorrhea and acyclic pelvic pain were assessed on self-reported 11-point numeric rating scales both preoperatively and at six-month follow-up. Cases with poor prognosis in relation to dyspareunia were described individually in greater detail. Preoperative DDyspareunia showed weak correlation with dysmenorrhea (rho = .240; P = .014) and pelvic pain (rho = .260; P = .004). Although DDyspareunia improved significantly (P < .001) by 3 points or more in 75.8% (95%CI: 64.7-86.2) and disappeared totally in 59.7% of cases (95%CI:47.8-71.6), individual analysis identified different patterns of response. The probability of a preoperative moderate/severe DDyspareunia worsening more than 2 points was 4.8% (95%CI: 0.0-10.7) and the probability of a woman with no DDyspareunia developing "de novo" moderate or severe DDyspareunia was 7.7% (95%CI: 1.8-15.8) and 5.8% (95%CI: 0.0-13.0), respectively. In a qualitative analysis, several conditions were hypothesized to impact the post-operative DDyspareunia response; these included adenomyosis, mental health disorders, lack of hormone therapy after surgery, colporrhaphy, nodule excision in ENZIAN B compartment (uterosacral ligament/parametrium), the rectovaginal septum or the retrocervical region. Endometriosis surgery provides significant improvement in DDyspareunia. However, patients should be alerted about the possibility of unsatisfactory results.
Highlights
Endometriosis is an endemic condition that is associated with pain and different dysfunctions [1, 2]
Surgical eradication is the treatment of choice to improve health-related quality of life in cases in which medical management has been ineffective for pain relief [3, 4] or in selected cases of endometriosis-related infertility [5]
The latest guidelines on the practical aspects of surgery for the treatment of deep infiltrating endometriosis were elaborated by a clinical expert consensus panel [8] and efforts to identify and preserve autonomic pelvic nerves whenever possible are recommended [9]
Summary
Endometriosis is an endemic condition that is associated with pain and different dysfunctions [1, 2]. The latest guidelines on the practical aspects of surgery for the treatment of deep infiltrating endometriosis were elaborated by a clinical expert consensus panel [8] and efforts to identify and preserve autonomic pelvic nerves whenever possible are recommended [9]. The two pain symptoms most frequently associated with endometriosis are dysmenorrhea and deep dyspareunia, which may occur independently [10]. Dysmenorrhea and chronic pelvic pain are the clinical manifestations most commonly associated with diminished health-related quality of life [1], deep dyspareunia is a cardinal symptom of endometriosis [11]. Adolescent and young adult women with endometriosis experienced dyspareunia twice as often than those without endometriosis; painful intercourse has a negative impact on their physical and mental wellbeing [12]. There are several promising avenues for exploration of the pathophysiology and treatment of deep dyspareunia [14]
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