Persistence of dysmenorrhea after surgical excision of pelvic endometriosis and colorectal resection may be caused by uterine adenomyosis

Introduction: This study aims to determine whether uterine adenomyosis may impair the improvement of pain symptoms afterlaparoscopic excision of pelvic endometriosis combined with colorectal resection. Materials and methods: Subjects of this prospective study (n 1⁄4 50) underwent excision of pelvic endometriosis and segmental colorectal resection because of pain and gastrointestinal symptoms in the period between June 2004 and June 2006. In all cases, symptoms were resistant to hormonal therapies and had persisted for at least one year. Exclusion criteria for the study were use of hormonal therapies at the time of surgery or in the 18 months after surgery. Before surgery, the patients underwent transvaginal ultrasonography and magnetic resonance imaging to investigate the presence of uterine adeno- myosis. Presence and severity of pain and gastrointestinal symptoms were eval- uated during the last preoperative consultation; follow-up was performed at 6, 12, and 18 months after surgery. Subjects of the study were asked to rate the intensity of dysmenorrhea, deep dyspareunia, and chronic pelvic pain by using a 10 cm visual analogue scale (VAS). Bowel function was evaluated by investigating the presence of gastrointestinal symptoms (i.e., diarrhea, con- stipation, dyschezia, painful bowel movements) and by using the GIQLI Ques- tionnaire (Gastrointestinal Quality of Life). Changes in the intensity of pain symptoms and GIQLI scores at follow-up were analyzed using the Wilcoxon signed rank test. Results: 33 women had no evidence of uterine adenomyosis, 17 women had uterine adenomyosis which was excised at surgery in 5 cases. 8 women had diffuse adenomyosis which enlarged the entire uterus and 9 patients had focal lesions. Excision of pelvic endometriosis and bowel resection were performed by laparoscopy; adenomyosis was excised by laparoscopy in 2 cases (diameter of the lesion, mean+SD, 4.2+0.8 cm) and by laparotomy in 3 cases (diameter of the lesion, mean+SD, 5.7+1.2 cm). Histology confirmed the presence endometriosis in all the resected bowel segments; the diagnosis of adenomyosis was confirmed in the 5 women who underwent uterine surgery. 8 women (16.0%) had intraoperative or postoperative complications. After 6-month follow-up, dysmenorrhea significantly improved in women without uterine adenomyosis (P , 0.001) and in those with adenomyosis that was excised at surgery (P,0.001); this improvement persisted at 18-month follow-up. Women with uterine adenomyosis not excised at surgery did not have improvement in the intensity of dysmenorrhea at follow-up (P 1⁄4 0.129); only 3 women included in this study group (25.0%) reported a decrease in the intensity of dysmenorrhea which persisted at 18-month follow-up. Intensity of deep dyspar- eunia and chronic pelvic pain significantly improved at follow-up in all the study groups. Most of gastrointestinal symptoms improved or disappeared at 6-month follow-up. Three women experienced de novo constipation after surgery; however, this symptom disappeared at 18-month follow-up. Before surgery, GIQLI scores were similar in the three study groups (P 1⁄4 0.068). GIQLI scores were significantly higher at 6-month follow-up (P , 0.001) and this improvement persisted at 18-month follow-up (P , 0.001). Conclusions: Excision of pelvic endometriosis combined with colorectal resection significantly improves pain and gastrointestinal symptoms; presence of uterine adenomyosis may determine persistence of dysmenorrhea.