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Highlights from the 2018 Society of Gynecologic Surgeons Scientific Meeting Part 2

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Highlights from the 2018 Society of Gynecologic Surgeons Scientific Meeting Part 2 SPECIAL SECTION HIGHLIGHTS FROM THE 2018 SOCIETY OF GYNECOLOGIC SURGEONS SCIENTIFIC MEETING PART 2 Rosanne M. Kho, MD Alicia Scribner, MD, MPH Head, Section of Benign Gynecology Director, Ob/Gyn Simulation Curriculum Women’s Health Institute Madigan Army Medical Center Department of Obstetrics and Gynecology Tacoma, Washington Cleveland Clinic Clinical Instructor Cleveland, Ohio Department of Obstetrics and Gynecology University of Washington, Seattle Mauricio S. Abrão, MD Associate Professor and Christine Vaccaro, DO Director, Endometriosis Division Medical Director, Andersen Simulation Center Department of Obstetrics and Gynecology Madigan Army Medical Center São Paulo University Medical School Tacoma, Washington São Paulo, Brazil Clinical Assistant Professor Department of Obstetrics and Gynecology University of Washington, Seattle Uniformed Services University of Health Sciences Bethesda, Maryland PHOTO: SCIENCE SOURCE IMAGES / ANATOMICAL TRAVELOGUE PHOTO: SCIENCE SOURCE IMAGES / ANATOMICAL mdedge.com/obgmanagement May 2018 | OBG Management SS1 Deep infiltrating endometriosis: Evaluation and management Deep endometriosis is successfully diagnosed with clinical signs and symptoms and specific MRI or TVUS protocols, and treatment options are available to relieve pain and optimize outcomes Rosanne M. Kho, MD, and Mauricio S. Abrão, MD ndometriosis affects up to 10% of women of reproductive age or, conservatively, about Take-home points E 6.5 million women in the United States.1,2 There are 3 types of endometriosis—superficial, • Specific MRI or TVUS protocols are highly ovarian, and deep—and in the past each of these accurate in making a nonsurgical diagnosis of was assumed to have a distinct pathogenesis.3 deep infiltrating endometriosis (DIE). • The combination of compelling clinical signs Deep infiltrating endometriosis (DIE) is the pres- and symptoms and absence of imaging findings ence of one or more endometriotic nodules deeper for DIE can be used to make a presumptive than 5 mm. In a study at a large tertiary-care center, nonsurgical diagnosis of endometriosis. 40% of patients with endometriosis had deep dis- • Empiric medical therapy may provide pain relief. ease.4 DIE is associated with more severe pain and • Conservative treatment, including observation infertility.5 In patients with endometriosis, diagno- alone, may be considered in asymptomatic sis is commonly made 7 to 9 years after the initial patients with DIE and in those with minimal pain. • Before surgery, it is imperative to know lesion pelvic pain presentation.6 For these reasons, well- size, depth, circumferential bowel involvement, directed history taking and proper evaluation and and location (or distance from the anal verge treatment should be pursued to relieve pain and in cases of rectosigmoid lesion) to optimize optimize outcomes. surgical outcomes. CASE Young woman with intensifying pelvic pain Mary is a 26-year-old social worker who presents to addition, it is of paramount importance to under- her ObGyn with symptoms of worsening pain during stand the differential diagnoses that can present as as well as outside her periods. What additional infor- pelvic pain (TABLE, page SS4). mation would you want to obtain from Mary, given her chief symptom of pain? CASE Continued: Mary’s history Mary reports that she always has had painful periods and that she was started on oral contraceptive pills for Investigate the type of pain pain control and regulation of her periods soon after It is important to ask the patient about her men- the onset of menses, when she was 12 years old. In strual and sexual history, her thoughts regarding college, she was prescribed oral contraceptive pills near- and long-term fertility, and the type and se- for contraception. Recently engaged, she is interested verity of her pain symptoms. The 5 pain symptoms in becoming pregnant in 3 years. specific to pelvic pain are dysmenorrhea, dyspareu- A year ago, Mary discontinued the pills because nia, dysuria, dyschezia, and noncyclic pelvic pain. of their adverse effects. Now she has severe pain dur- A visual analog scale (VAS) for pain as well as pel- ing (VAS score, 8/10) and outside (VAS score, 7) her vic pain questionnaires can be used to guide evalu- monthly periods. Because of this pain, she has taken ation options and monitor treatment outcomes. In time off from work twice within the past 6 months. She has pain during intercourse (VAS score, 7) and some Dr. Kho and Dr. Abrão report that they are consultants to AbbVie. pain with bowel movements during her menses (VAS CONTINUED ON PAGE SS4 SS2 OBG Management | May 2018 mdedge.com/obgmanagement -US GYN 82 2.0 01/2018/A Perfection in Resection – NEW 15 Fr. – clinical outpatient setting and office resectoscope, extending the set together with 22 Fr., and 26 Fr. KARL STORZ SE & Co. KG, Dr.-Karl-Storz-Straße 34, 78532 Tuttlingen/Germany KARL STORZ Endoscopy-America, Inc. 2151 East Grand Avenue El Segundo, CA 90245-5017/USA www.karlstorz.com SPECIAL SECTION Deep infiltrating endometriosis: Evaluation and management CONTINUED FROM PAGE SS2 TABLE Differential diagnosis for pelvic pain Organ system Differential diagnosis Musculoskeletal • Abdominal wall pain • Pelvic floor tension myalgia • Myofascial pain • Osteitis pubis • Fibromyalgia • Levator ani syndrome • Coccydynia • Abdominal wall hernia Urologic • Interstitial cystitis • Nephrolithiasis Gastrointestinal • Inflammatory bowel disease • Chronic constipation • Irritable bowel disease • Chronic pseudo-obstruction • Chronic constipation Psychologic • Sexual abuse history • Depression • Opiate dependency • Somatization Gynecologic (excluding • Fibroid uterus • Adenomyosis endometriosis) • Ovarian remnant syndrome • Pelvic adhesion • Pelvic inflammatory disease score, 4). Pelvic examination reveals a normal-sized pelvic pain should undergo diagnostic laparos- uterus and adnexa as well as a tender nodule in the copy with tissue biopsies. rectovaginal septum. The combination of compelling clinical signs, What diagnostic tests and imaging would you symptoms, and imaging findings (such as absence obtain? of findings for ovarian and deep endometriosis) can be used to make a presumptive nonsurgical (that is, clinical) diagnosis of endometriosis. Ma- Imaging’s role in diagnosis jor societies recommend empiric medical therapy At many advanced centers for endometriosis, (for example, combination oral contraceptives) for DIE is successfully diagnosed with specific mag- the pain associated with superficial endometrio- netic resonance imaging (MRI) or transvaginal sis.10,11 When there is no response to treatment, or ultrasound (TVUS) protocols. In a recent review, when a patient declines or has contraindications MRI’s pooled sensitivity and specificity for rec- to medical therapy, diagnostic laparoscopy with tosigmoid endometriosis were 92% and 96%, re- excision of endometriosis should be considered. spectively.7 Choice of imaging for DIE depends on the skills and experience of the clinicians at each CASE Continued: Diagnosis center. At a large referral center in São Paulo, Bra- Mary undergoes TVUS with bowel preparation, which zil, TVUS with bowel preparation had better sen- reveals a normal uterus and adnexa and the presence sitivity and specificity for deep retrocervical and of 2 lesions, a 2×1.5-cm retrocervical lesion and a rectosigmoid disease compared with MRI and 1.8×2-cm rectosigmoid lesion 9 cm above the anal digital pelvic examination.8 In addition, at a cen- verge. The rectosigmoid lesion involves the exter- ter in the United States, we found that proficiency nal muscularis and compromises 30% of the bowel in performing TVUS for DIE was achieved after 70 circumference. to 75 cases, and the exam took an average of only How would you manage the bowel DIE? 20 minutes.9 Despite recent advances in imaging, most gynecologic societies still hold that endometrio- Management options: sis is to be definitively diagnosed with histologic Factor in the variables confirmation from tissue biopsies during surgery. DIE can involve the ureters and bladder, the ret- Although surgery remains the diagnostic gold rocervical and rectovaginal spaces, the appendix, standard, it does not mean that all patients with and the bowel. Lesions can be single or multifocal. SS4 OBG Management | May 2018 mdedge.com/obgmanagement Although our institutions’ imaging with MRI and ovarian reserve in patients with DIE and infertility, TVUS is highly accurate, we additionally recom- we counsel them regarding assisted reproductive mend the use of colonoscopy (with directed biop- technology options before surgery. sies if appropriate) to evaluate patients who present with rectal bleeding, large endometriotic rectal nod- CASE Resolved ules, or have a family history of bowel cancer. After thorough discussion, Mary opts to try a different While many studies have found that surgical combination oral contraceptive pill formulation. The resection of DIE improves pain and quality of life, pills improve her pain symptoms significantly (VAS surgery can have significant complications.12 Ob- score, 4), and she decides to forgo surgery. She will be servation is adequate for asymptomatic patients followed up closely on an outpatient basis with serial with DIE. Medical treatment may be offered to TVUS imaging. patients with mild pain (there is no evidence of a reduction in lesion size with medical therapy). In cases of surgical treatment, we encourage the in- Individualize management based volvement of a multidisciplinary surgical team to
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