Diagram to Map the Locations of Endometriosis

International Journal of Gynecology and Obstetrics 118 (2012) 42–46

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International Journal of Gynecology and Obstetrics

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CLINICAL ARTICLE Diagram to map the locations of endometriosis

Ricardo Bassil Lasmar ⁎, Bernardo Portugal Lasmar, Claudia Pillar

Department of Gynecology of Fluminense Federal University, Niteroi, Rio de Janeiro, Brazil article info abstract

Article history: Objective: To develop and test a visual map that corresponds practically and objectively to the anatomical areas Received 4 November 2011 affected by endometriosis. Method: The study comprised 150 questionnaires concerning 10 clinical cases of en- Received in revised form 9 February 2012 dometriosis presented as a visual diagram that were distributed at 3 different scientific events, among 3 groups Accepted 20 March 2012 of 50 gynecologists. Data were analyzed to evaluate the diagram's ability to graphically represent the endometriosis sites. Results: After presentation at the first event, the rate of correct answers on the site of endometriosis Keywords: was 84.7%; at the second event, after modifications implemented after feedback from the first event, the rate Classification of correct answers was 97.4%; and at the third event, when all suggestions and modifications had been made, Diagram Endometriosis the rate was 99.7%. Conclusion: The diagram proposed to map the location of endometriosis lesions appears Mapping to be an adequate and effective instrument to represent the site of the disease, with correlation at almost 100%. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction One of the major challenges of making a diagnosis in women with suspected endometriosis is to assess the extent of the disease and Endometriosis affects about 10% of women of reproductive age. Its its functional consequences for the pelvic or extra-pelvic organs. prevalence ranges from 30%–50% in women diagnosed as infertile Moreover, it is difficult to create a common language among specialists [1–4]. The disease is defined by the presence of endometrial glands that allows standardized diagnosis and treatment [9]. The endometri- and stroma in ectopic sites [1,2,5]. Endometriosis is associated with osis classification system produced by the American Fertility Society, re- variable clinical outcomes and presents an insidious and progressive vised in 1985, has been helpful in documenting the disease, but it has evolution, interfering with the quality of life and daily activities of serious limitations in clinical use for predicting prognosis and treatment those affected [1,6–8]. of pain and infertility [10–12]. Many researchers have suggested classi- The etiology and pathogenesis of endometriosis remain uncertain, fications of endometriosis, but there is still no validated system that including genetic, hormonal, and inflammatory aspects [2,8]. The meets clinical needs and pregnancy rates [10–14]. Sampson theory, from 1927, which proposed retrograde menstruation Choice of therapy depends on the symptoms of pelvic pain and in- as the trigger for endometriosis, is the most widely accepted theory [2]. fertility, the patient's goals, and the functional impairment assessed Owing to gene expression involved in cell apoptosis, endometrial by clinical history, physical examination, and imaging [2]. Hormone cells can survive in the peritoneal cavity. When activated macrophages therapy and surgery are treatment options [2]. Laparoscopy is consid- are present, neoangiogenesis begins, leading to implantation and ered the gold standard for diagnosis and offers a broader and more invasion of ectopic tissue, which is sustained and grows under estrogen detailed view of the pelvic organs, reduced risk of infection and stimulation [2]. abdominal wall complications, shorter hospitalization with faster From an anatomical and clinical viewpoint, endometriosis has return to daily activities, and a higher likelihood of conservative 3 forms: peritoneal or superficial, ovarian, and deep infiltrative. surgery [2,6,15]. The decision on indication for surgery must take late Multiple forms can be present in one patient. The peritoneal form diagnosis into account, and the first surgical approach must be the typically presents as pigmented or white, typical and atypical lesions best possible to achieve the benefits and to reduce the risks of functional throughout the surface of the peritoneum. Ovarian forms are charac- impairment [16]. Moreover, some studies have shown that recurrence terized by the presence of chocolate cysts. The deep forms include rates for endometriosis are 20% at 2 years, and 40%–50% at 5 years. For lesions with larger-than-5-mm infiltrates that can involve pelvic and this reason, experts avoid incomplete resections and carefully evaluate abdominal organs [5]. the possibility of multifocality and multicentricity of lesions [6,15]. Since clinical data are essential for therapeutic management, mainly in complex surgeries, the topographic locations of lesions should be accurately and objectively recorded [17]. Information is crucial ⁎ Corresponding author at: Department of Gynecology of Fluminense Federal to determine the appropriate treatment, coordinating the actions University, Rua Marques do Paraná 303, Niteroi, Brazil. Tel.: +55 21 99875354; fax: +55 21 25372321. of multidisciplinary clinical teams, and planning and obtaining the re- E-mail address: [email protected] (R.B. Lasmar). quired management and financial resources for every patient. To

0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2012.02.010 R.B. Lasmar et al. / International Journal of Gynecology and Obstetrics 118 (2012) 42–46 43 be useful, clinical records must be clear and precise, organized and gynecology meetings held from March to June, 2011, in Rio de Janeiro, standardized, and easily understood by team members [18].Avisual Brazil. At each meeting, the questionnaires were handed out to 50 diagram representing the sites affected by endometriosis may serve as different gynecologists, who voluntarily accepted to participate in a guide at the time of surgery and later during clinical follow up [17]. the study. All returned questionnaires were considered, including Several studies have described the most frequent locations of le- those that contained no answers or were incomplete. The study was sions and the trend toward multifocality, which must be taken into not submitted to the ethics committee because it was not involved account when deciding upon management [17]. The aim of the present in the direct care of patients. study was to develop a visual map corresponding to the anatomical The questionnaire requested open answers to questions concerning areas affected by endometriosis in a practical and objective manner, 10 different cases of endometriosis that had been provided by 10 to be included in patients’ clinical records and used in follow up. specialists with extensive experience in treating the condition. Each clinical case was interactively presented to the participants using an 2. Materials and methods endometriosis-mapping diagram. Before presenting the cases, an exam- ple of how the diagram worked was given, and the meaning of each The present study is a descriptive study of a case series. A total abbreviation and the diagram's purpose were explained for 5 minutes. of 150 questionnaires concerning 10 clinical cases of endometriosis As the clinical cases were presented, the participants were asked presented as visual diagrams were distributed during 3 scientiﬁc to record the areas affected by endometriosis. Each participant had

BL A( c m )

ROU VUS RO U LEFT RIGHT VAG

UTE PAR PAR CER OVA ( cm) OVA ( cm) SEP VAG

USC RTC USC

SAN Central SAN L RECTUM( cm) URE URE Around M S M D APE CEC H Distant SIG( cm)

LEGEND POSTERIOR Central

CER = cervix UTE = uterus

Around

VAG = vagina RTC = retrocervical SEP = rectovaginal septum PAR = paracolpos/parametrium VUS = vesicouterine septum OVA = ovary USC = uterosacral ligament ROU =round ligament

Distant

BLA = bladder URE = ureter RET = rectum SAN = sacral nerves SIG =sigmoidcolon CEC = cecum APE = appendix

Rectum penetration

S = superficial M = medium or muscular D = deep or mucosa

Rectum height

L = low M = medium H = high

Side

Right Left Anterior Posterior

Fig. 1. Diagram to map the anatomical areas affected by endometriosis. 44 R.B. Lasmar et al. / International Journal of Gynecology and Obstetrics 118 (2012) 42–46

2 minutes to look at the diagram representing the case and to write Table 2 a down where the endometriosis was located. During the presentation, Characteristics of the 150 participating gynecologists. some gynecologists raised questions and these were answered Participants Group 1 Group 2 Group 3 P value promptly and then noted down, thus generating data for future revi- (n=50) (n=50) (n=50) sions of the diagram to improve its understanding and interpretation. Age, y a 39.6±12.6 39.6±12.0 40.6±10.0 0.318 At completion, all data were tabulated for individual participants and Laparoscopic experience b 48 (96) 47 (94) 48 (96) 0.874 for the groups evaluated at different times. At the end of the third Endometriosis experience b 32 (64) 36 (72) 44 (88) 0.328 meeting, a total of 150 gynecologists, divided into 3 groups of 50, a Values are given as mean±SD and number (percentage). had completed the questionnaire. Each physician could list 38 endometriosis sites over the 10 clinical cases, totaling up to 1900 answers 3. Results per group of 50 gynecologists. These data were analyzed to evaluate the diagram's ability to graphically and precisely represent the endo- Out of 150 questionnaires returned, only 5 had blank answers metriosis sites. The answers were considered correct or incorrect. and these were interpreted as incorrect. The age of the participants fi fi The rst group of 50 physicians showed some dif culty in under- ranged between 26 and 65 years. In the first group of 50 physicians, fi standing the diagram (Fig. 1), which led to its modi cation by the 16 (32%) were aged under 30 years, and 14 (28%) were over 50 years. addition of one further letter to the abbreviations representing the In the second group, 15 (30%) were aged under 30 years, 14 (28%) — sites affected by endometriosis to indicate laterality. The central, were between 41 and 50 years, and 11 (22%) were over 50 years. In peripheral, and distal involved areas of the uterus are represented the third group, 12 (24%) were under 30 years and 15 (30%) were by distinct patterns of colors. The sites represented in the diagram over 50 years. Of the 150 respondents, 84 (56%) were male. are the cervix and uterine body, uterosacral ligament, paracolpos, In both the first and second groups, 33 (66%) participants had less ovaries, round ligaments, vagina, rectovaginal septum, retrocervical than 5 years of experience with laparoscopy, while 3 (6%) had more nodule, vesicouterine pouch, ureters, rectum, sigmoid colon, bladder, than 21 years of experience. In the third group, 23 (46%) physicians appendix, sacral nerve, and cecum. had less than 5 years of experience with laparoscopy, while 5 (10%) Among the 10 clinical cases, 6 cases showed 4 affected sites each; had more than 21 years of experience. 3 cases showed 3 affected sites each; and 1 case showed 6 affected The majority of gynecologists in all 3 groups responded that they sites. Involvement of the retrocervical area was described in 6 out of had performed surgery for endometriosis: 64% (n=32) in group 1; 10 clinical cases and of the paracolpos area in 5 cases; the other 72% (n=36) in group 2; and 88% (n=44) in group 3. areas were involved less often (Table 1). The third group of physicians comprised a more homogeneous The frequency of hits and errors was established in all 3 groups population, exhibiting lower coefficients of variation compared separately for each item and across all items, and the results of with the other 2 groups for age range and years of experience with the 3 groups were compared. For the total frequency of hits in the laparoscopy. However, there were no significant differences in these different groups, the proportion test for K(3) samples was applied, features among the 3 groups (Table 2). assuming as the null hypothesis that the population proportions are The average number of correct answers in each of the groups is equal, and as the alternative hypothesis that proportions among the shown in Table 3. Proportion tests were calculated using these data, 3 populations are not equal. As expected, the frequency was different and the χ2 value was 12.1. The critical χ2 value for α=0.01 and 2 de- fi in the last group tested. The con dence level was established at 1%, grees of freedom was 9.2. Since the calculated χ2 value was higher fi χ2 i.e. a signi cance of 0.01 with 2 degrees of freedom. The value was than the critical value, the null hypothesis was rejected, i.e., the results χ2 calculated and compared with critical values to determine whether analyzed differed among the groups. It was observed that group 3 had the null hypothesis was supported. Participant data on sex, age, and more correct answers than the other groups. experience with laparoscopy and other surgeries were collected. When evaluating the sites of endometriosis separately, correct Based on these data, proportions, means, medians, standard deviations, answers for retrocervical lesions were given by 86% of participants fi coef cients of variation, and asymmetry indices were calculated. in group 1, 86% in group 2, and 100% in group 3. For sigmoid sites, P value hypothesis testing was applied. correct answers were given by 80%, 100% and 97% of participants in groups 1, 2, and 3, respectively. For sites in the left ovary, the correct answers varied between 88.6% and 100%. In group 1, 13.3% of partici- Table 1 pants gave incomplete information about laterality in otherwise Sites of endometriosis in each of the 10 clinical cases. correct answers for ovarian sites. Site Cases

12345678910 Table 3 Correct answers for site of endometriosis by group. Posterior vagina XX Uterus XX Site Group 1 Group 2 Group 3 Retrocervical XXXXXX No. (%) No. (%) No. (%) Right uterosacral ligament X Left uterosacral ligament XX Vagina 79 (79) 100 (100) 100 (100) Right paracolpus XX Uterus 85 (85) 92 (92) 100 (100) Left paracolpos XXXRetrocervical 258 (86) 295 (86) 300 (100) Right round ligaments Uterosacral ligament 132 (88) 146 (97) 150 (100) Left round ligaments XX Paracolpos 214 (86) 250 (100) 250 (100) Right ovary X Round ligaments 81 (81) 92 (92) 100 (100) Left ovary XX Ovary 174 (87) 197 (99) 200 (100) Right ureter X Ureter 83 (83) 96 (96) 100 (100) Left Ureter XXSigmoid colon 120 (80) 150 (100) 146 (97) Sigmoid colon XX Rectum 220 (88) 243 (97) 250 (100) Rectum XXXXX Cecum 42 (84) 47 (94) 50 (100) Cecum XXAppendix 44 (88) 50 (100) 50 (100) Appendix X Vesicouterine pouch 39 (78) 45 (90) 48 (96) Vesicouterine pouch X Bladder 38 (76) 49 (98) 50 (100) Bladder X Total 1609 (84.7) 1852 (97.4) 1894 (99.7) R.B. Lasmar et al. / International Journal of Gynecology and Obstetrics 118 (2012) 42–46 45

Separate correct rates for mid- and high rectum sites varied between 88% and 100% in all 3 groups, but in up to 63% of correct answers, the size of lesions in centimeters was not included. This may have resulted from too brief a presentation of the clinical cases, or it might indicate that participants did not consider the size of lesions to be an important piece of information. On the other hand, after including laterality, identification of sites improved; for exam- ple, the correct answers for lesions in the left ovary increased from 88.6% in group 1 to 100% in group 2. Correct answers for the vesicouterine pouch site increased from 78% Site in group 1 to 90% in group 2. Some other terms, such as vesicouterine septum and anterior bladder, were used by physicians in reference to Fig. 2. Correct answers for site of endometriosis by group. the vesicouterine pouch, which might indicate a flaw in the uniformity of terminology; nevertheless, after modifications to the abbreviations, correct answers increased to 96% in group 3 (Fig. 2). The mapped area with the least correct answers in group 1 was the bladder (76%), followed by the vesicouterine pouch (78%); in 4. Discussion groups 2 and 3, these rates varied between 90% and 100%. Clinical cases 8 and 10 included lesions in the mid- and high rectum and A graphic mapping system of areas affected by endometriosis can their size was given in centimeters; the hit rates varied between be used as the basis for therapeutic decision making and follow up of 88% and 100% in these sites in the 3 groups. However, participants patients. The present study proposed a mapping diagram for everyday did not describe the size of these lesions in centimeters in 42% to clinical practice, both at the initial approach before surgery and at 63.4% of otherwise correct answers. When lesions were located in follow up. The primary aim of the study was to verify whether this the uterus, group 1 participants answered correctly in 85% of cases, kind of presentation is reproducible and easily understood. group 2 in 92%, and group 3 in 100%. Lesions located in the paracolpos The interactive method employed allowed us to detect some area were associated with hit rates varying between 86% and 100%. difficulties in the understanding of cases, which led to minor modifi- Ureteral lesions were identified by 83% to 100% of participants in cations in the abbreviations and inclusion of laterality indicators to the 3 groups. improve the final version of the diagram.

Diagram to Map Endometriosis Diagram to Map Endometriose Diagram to Map Endometriose

B L A (c m ) B L A (c m )

Case VUP VUP LEFT ROU ROU RIGHT LEFT ROU ROU RIGHT VAG VAG

UTE UTE PAR PAR PAR PAR CER OVA ( cm) CER OVA ( cm) • 2 cm left ovarian endometriosis OVA ( 2cm) OVA ( 2cm) SEP SEP VAG VAG

USC USC USC USC • Left uterosacral ligament RTC RTC

SNE SNE SNE SNE

L RET ( cm) URE L RET ( cm) URE • Right uterosacral ligament URE URE M M S M D S M D APP CEC0 H APP CEC0 H

SIG ( cm) SIG ( cm)

Lasmar Lasmar Lasmar

Diagram to Map Endometriosis Diagram to Map Endometriose Diagram to Map Endometriose Case B L A (2 c m ) BLA(2 c m ) VUP VUP LEFT ROU RIGHT ROU LEFT ROU ROU RIGHT VAG • 3 cm right ovarian endometriosis VAG UTE UTE PAR PAR PAR PAR CER OVA ( 3 cm) CER OVA ( 3 cm) • Right uterosacral ligament OVA ( cm) OVA ( cm) SEP SEP VAG VAG USC • Retrocervical endometriosis USC RTC USC RTC USC

• Right round ligament endometriosis SNE SNE SNE SNE

L RET ( 2 cm) URE L RET ( 2 cm) URE • 2 cm bladder endometriosis URE URE M S M D M S M D APP CEC0 • 2 cm deep endometriosis in high rectum H H APP CEC0 SIG ( cm) SIG ( cm)

Lasmar Lasmar Lasmar

Fig. 3. Diagrams representing two of the cases presented. 46 R.B. Lasmar et al. / International Journal of Gynecology and Obstetrics 118 (2012) 42–46

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