Ana Sierra, MD - Endometriosis Like Pain without Endometriosis: The Venous Diagnosis Surgeons Miss

Sarah, first of all, I would like to thank Dr. Seking. I hope I pronounce his last name correctly. For this opportunity to show off a little bit of what we're doing about neuropelviology in Mexico City. For a disclosure, I would like to say that we have concept of all of our patients for sharing their medical imaging and their surgeries. A few years ago, I came up with this quote by Professor Mark Posobver. Pain is not a pathology. Pain is information that travels through the nerves. If we stop looking at pain as the enemy and we start treating it or finding the cause of it, instead of numbing it, we may will begin to start helping our patients. So first of all, if we've seen further is because we are standing on the shoulders of giants, and we have a lot of professors before us that have done a lot of things in the brain or in the field of neuropelviology that have help us so, so much.

So I'm going to show you three cases of patients that were diagnosed with endometriosis beforehand, and neither of them have endometriosis. This is the first patient. We have to think that there is another disease that causes that the patient has cyclical pain, that have dyspareunia, that have dysuria, and they do have dyskesia, and it's not endometriosis. Think about this the next time you're with this type of patient. So this patient is a three-year-old female that started with pain at age 16 and with oral contraceptive treatments since that day. She has cyclic dysmenoria, dysuria, hematuria, and she has a constant pain in her left iliac fossa, a pain level between eight and 10. It began being cyclical, and then it moved forward to being constant. She complained pain there, iliac phosa, but also when we began talking about her pain, it really was in her left lower crescent.

It will be like in her renal fossa. So what do we think about her? The initial evaluation showed that she had left lower prevalent trenderness, a pelvic floor hypertonicity, and no palpable masses. There were no expert ultrasound done prior, no vascular evaluation, no neopelviological assessment. But the persistent symptoms despite the hormonal therapy is the thing that made us change a little bit the thing that we were thinking about. This is another patient, the second case. It's a two-year history of chronic left-sided pelvic pain. Her left ilial fossa also and pelvic pressure that worsens after a prolonged standing or ending of the day. The left leg was really heavy and the feeling of swelling, and there was pelvic fullness, occasional visible bulbal varicosities. This is her walking in our office. So you can see how her left leg feels heavy for her.

And this will be the last case. This is another patient, our third case. And she had had this both type of symptoms because she also had cyclic pain, but with an S2 variation. You can know that it's S2 because she had ciclic pain on the sciatic nerve, but also in her bulba. So what do we think with S2 and why those S2 can give us both sciatic and pudendal nerve symptoms? Because S2 is the root for both nerves from sciatic and also for pudendal nerve. So if we can find a patient that has both sciatic and pudendal symptoms, the origin of the cause of the compression may be in S2, knowing one of each peripheral nerve. So what do we do with the clinical exploration of a patient with a chronic pelvic pain? First of all, I'm sorry, I didn't translate this slide. We have to remember that the location of the pain does not indicate where does the pain begin.

It just indicates in which nerves the pain signal is traveling through the brain. So we have to remember that there are two types of nerves that we can find or we can map when we are assessing a patient's pain. We have dermatomes, but we can also have myotomes. And we can also, not only the dermatomes, but we have to know where do those nerves give sensitivity to, and also which are the functions on the motor nerves. I'm going to fast forward a little bit because I don't have so much time. So let's go with ... Okay. So the iliopsoas muscle to evaluate L1, L2 and L3, we're going to ask the patient to flex her leg and you're not going to try to impede or do not preserve that movement. For the quadratus fumoralis, it's L2, L3 and L4. You're going to graph the patient's leg.

You're going to prevent it from lowering that leg.

Then for obturator's nerve, evaluating L2, L3 and L4, you have to prevent her from moving towards the body, the feet. So we're going to look like this, the abduction and the abduction. So for the superior gluteal nerve, which will be L4, L5, and S1, you're going to ask the patient to move inward the groin and flex the leg. To evaluate the muscles on the backside of the leg will be sciatic semimembranous and semitendinos. It will be LS, L5, S1, and S2. So how do you move your gluteal when you go to the gym? You move your leg backwards. And almost lastly.

Okay. And then you prevent this movement. And lastly, the gastrocnemius nerve, it is S2 and S1, and you can ask the patient to walk in tippy toeing or just to move her leg. The second thing that we as gynecological surgeons have to learn again is to do vaginal examinations and to really know where these pelvic floor muscles are. Because if you only remember how to do vaginal examinations and we only do what we were used to do when we do OB- GYN and we only think about the cervix ... Oh, maybe I won't move so much because the microphone fades. Okay. We need to learn from physical therapist. I learned all of this because we ... Well, I have really good teachers as pelvic therapy, pelvic floor therapists, and they show me where these muscles were and how do I can evaluate myofacial syndromes. So you can find the coccygeal, the iliocoxial, the pubocoxial, and the elevator's NI.

When we try to assess the obturator internals muscle, yes, I do evaluate males. That's why there were testicles in here, and here you have to do an NL exam. So we have the otherators anal, internal operator, the ischiocoxial, the puborectal, and the iliocoxial. Iliocoxial and ischiocoxial are really together, but you can see how the iliocoxial are a little bit more anterior to the ischeocoxial, that it's more near to the coccyx. And the patterns of the pain. You can see the little white dot where you can have the trigger point and all of the way that this pain irradiates to the patient. So you can assess really know really well how does the muscle work.

And for the congestive venous syndrome, we have a pelvic venous reflux point. This is the place where abnormal venous blood escapes from the pelvic venous system into superficial veins due to venous reflux or venous hypertension. In simple terms, it's like the door where blood leaves the pelvis in the wrong direction. So we're going to have to assess our patients. For the gonadal excess venous leaks, we can have the round ligament vein in the inguinal point. And I'm going to show you more pictures of patients that have problems in here. Like here, this is our patients that have inginal point and here on other patients that have reflux in the general point. And now for the internal iliac axis dependent leak, we have the internal pudendal point.

This patient have this inside. So you can may think about that this can be painful and you can assess them without doing anything just by looking at her internal pedantal point. How about the obturator's point? It's a little bit forward or upward into the inside part of her leg. And all of these patient have problems in the legs because of the high blood pressure or high venous pressure in the pelvis. This is internal iliac dependent pelvis venous leaks. It will be the inferior gluteal point and also the superior gluteal point. And we can see how these problems of venous problems or varicose veins in the feet or in the legs began at the gluteal point.

So these are all of them. And we can see how it's more common to have all of this. Have you ever seen a patient with this and think about pelvic congestion syndrome? And we have to think about two type of spatters in these cases. One is the congestive pattern and the other one is the derivative pattern. And the other one would be mixed. This is important for the diagnosis, but also this is important when you do the ultrasound that you can do in your office. It's not the same to have a congestive syndrome and which the valves of the veins are failing and the other one is the derivative syndromes like Mayturners and Nutcracker, in which the vein is compressed between something and they are looking for another way. So the congestive will be like a traffic jam because the blood is stuck in the pelvis.

And the derivative, it's like having a detour because there's something that is obstructing the flow and the mixed, well, you have both platters. So this would be an easy way to say it, and this is the hard way to say it. So the same congesting derivative and mixed. So it's basically the same. And here is how you assess it by transvaginal ultrasound patterns. You can see how congestive is different than derivative because not only you're going to check the diameter of the uterine artery, you're going to ask your patient to do a vasalva maneuver and they're going to see if they have bilateral fall or they do not have. If they have a bilateral gonadal reflux, we're talking about a congestive syndrome because the valves are failing. If they do not have this reflux with vasalva, we're thinking about another type, the derivative syndromes. So if you have a patient that have really enlarged veins on the left side, and if she pushes, the flow doesn't go upward and backward or with the doppler doesn't go red and blue, you're thinking about Mayturner or a notebracker.

So that's the way that you can differentiate and you can derivate or refer this patient to a vascular surgeon.

Okay. So how do we do the gonadal vein reflux, the US criteria? The direct findings would be the transvaginal Doppler, but you can also have the indirect findings by having the lower link venous doppler in the points that we were talking about earlier. So we have the uterovenium plexus dilation more than seven millimeters as low venous flow addressed with reflux. Remember the reflux during Vasalva and the higher resting venous velocity. That will be harder to look for. So if you're doing just basic ultrasound, this is either way. And also with the epcodoplar, this is the difference between congestive and compressive, okay? Remember, if it's congestive, it has reflux. If not, it can be compressive. Okay. So what the pathophysiology, we have reflux syndromes and compressive syndromes. Both of them cause pelvic venous hypertension that causes pelvic congestion and the appearance of pelvic viruses, but also it can happen with pelvic floor incompetence and leaking to lower limbs and it have pairs of bulbar and atypical viruses.

I'm sorry, I do not have too much time, so I want to move forward with this. The pelvic congenitone syndrome, as we were saying, is the same symptoms as endometriosis. So you have to think about this with your differential diagnosis. So this is the imaging for first case. It was a nutcracker syndrome. You can see how the right gonadal vein is really tiny in here, and then you can see the left gonadal vein is really, really thick, and this will be the degrees. So we have here at 3D reconstructions from a contrast enhanced CT and geography. So in the first image, we can see how the opacification on the renal veins with reflux into the left ovarian vein that is marked with a narrow. And then the reflux does not go and reach the ipsilateral parauterine plexus, so that will be a grade one. Then we see a case in which the left parauterine plexus is involved, so it's grade two, and then we observe reflux that crosses the midline through the uterus.

It involves the right parauterine plexus and the right ovarian vein, and it will correspond to grade three. So this is the MRI of this patient. We can see how everything is really enlarged on the left side. And this is the renal vein being compressed by the mesenterial arterial artery and her aorta. So this is the protocol that we do in hemodynamic studies. I do not do this. This has been done by my vascular surgeon, which is my partner or my business partner. The study sequence will be a selective cannulation of the, first, the left renal vein, then to rule out Notcracker syndrome, then the left gonadal vein. So left gonable vein cannulation, then right gonadal vein cannulation, then right iliac vein cannulation, and rule out iliac vein compression, then right internal iliac or hypogastric vein cannulation, left iliac vein cannulation, and to end the left internal iliac or hypogastric vein cannulation.

So this will be our second case.This was a May turner. The patient that have a really enlarged or the feeling that her left leg was really heavy. So you can see how in my turner the left iliac vein gets compressed by the right iliac artery. And here is the abnormal reflux or the abnormal flow. You see how they're using new blood vessels that are abnormal. So you go to the uration of the flow from the left to the right in here, and the passing of the cannula on the right path in here.

Then they open this net so that the flux can be again established, and this is the correct flow. So you can see that they are not longer using collaterals.This was our third case, and this involves a laparoscopic approach. This was a compression of S2, and this was the case that I was telling of the patient that have both sciatic and puzandal symptoms. So there was a vascular compression in between S2 and S3, and we can see how those vascular trajectories were compressing these nerves. So we did a vascular decompression using laparoscopy, and we know that the nerve is no longer compressed because we do use intraoperative neuromonitoring. So how do we know it? Because S2 will be the right sphincter or the right sphincter. You can see how when we began the surgery is the right or the baseline, the red one. So we can see the baseline that it's really almost flat.

And then here you begin the surgery and see how the signal, it increases a little bit more and then increases a little bit more. So this is how we know that we're making the nerve to function better. We publish everything here. This is the way that we do it in surgery. So you can see our neurophysiologist looking out for our nerves. This is the vulvo cavernous reflex, so we can see how the gas moves a little bit. Okay. To remember intraoperative neuromonitoring, we can see how the activity of the nerve of the electrical activity of the nerve works. You can do evocated potentials, both motors and sensory. I wouldn't advise you to trust in the sensory because the patients have anesthesia, and also because sensory potentials go from little nerves up to one big nerve. So to do evocated potential, you would need so much more.

If you do a motor potential, you go from the brain towards the peritea. So it's easier to monitor those or more trusted. So we don't trust neither in sensible motor ... Evocated potentials in sensory, we don't not trust them, and we also do not trust in autonomic nerves monitorization because autonomic nerves are not with myelin. So the signal takes more time in order for us to do harm and for the neurophysiologist to realize that there's some harm being done. So that's why you cannot monitor these type of nerves. Okay. So this is the way that we create or replace all of the electrodes. I don't have really much time, so I have to go through this just to face that the corkscrew electrodes are distributed according to the international like 10, 13 electroncephalogram system. The cranial motors are like C3 and C4, and the sensitive will be FCC and C3 in cervical.

I'm going to have to go through this video a little bit quicker. So the final branches of the pedantal nerve, we monitor both all of three of them, the dorsalis of the clitoris, the transversal of the perineum and the external anal sphincter.

We do do the train of four in the abdoctocolysis muscle. And why I was telling you about the EEG so they can do educated potential motors ... No, located moderate potentials. Okay. So this is our patient after the S2 release without pain walking, so this was really nice for us. And when the same phrase, that same quote that got me here, pain is not a pathology, pain is information that travels through the nerves. I want to invite everybody here. If you are interested in your pelviology, we're having the neuroperviology Congress this year in Morelia from the 13th to the 15th in August. Thank you.