True Prevalence of Diaphragmatic Endometriosis and Its Association with Severe Endometriosis: A Call for Awareness and Investigation

Abstract

To identify characteristics indicating preoperatively the presence of diaphragmatic endometriosis (DE). Comparison of characteristics of patients with DE with characteristics of patients with abdominal endometriosis without diaphragmatic involvement, in a prospective cohort study. Tertiary referral center; endometriosis center. 1372 patients with histologically proven endometriosis. Surgery performed laparoscopically under general anesthesia. All patients with suspected endometriosis underwent a complete bilateral inspection of the diaphragm. Demographic and clinical pathologic characteristics were evaluated using basic descriptive statistics (comparison of the groups using the chi-square test and the Mann-Whitney t-test). A logistic regression analysis was performed to evaluate the relationship (hazard ratio) between symptoms and the presence of DE. DE was diagnosed in 4.7% of the patients (65/1372). There was no significant difference between the two groups (patients with abdominal endometriosis with or without DE) with regard to typical endometriosis pain (dysmenorrhea, dyschezia, dysuria, and/or dyspareunia). However, in the DE group, diaphragmatic pain was present significantly more often pre-operatively (27.7% vs 1.8% p<.001). Four DE patients (6.1 %) were asymptomatic (with infertility the indication for surgery). In the DE group, 78.4 % had advanced stages of endometriosis (rAFS III° or IV°); the left lower pelvis was affected in more patients (73.8%). In cases of ovarian endometriosis, patients with DE showed a significantly higher prevalence of left ovaries involvement (left 63% vs right 35.7%, p<.001). Patients with DE had a significantly higher rate of infertility (49.2% vs 28.7%, p<.05). Patients with shoulder pain, infertility, and/or endometriosis in the left pelvis have a significant higher risk of DE and therefore need specific preoperative counseling and if indicated surgical treatment.