Endometriosis Foundation of America
Medical Conference – 2012
Simple Procedures to Reduce Unnecessary Surgeries
Maurice Chung RPh, MD
This disease sometimes makes it necessary to have an interdisciplinary approach to the treatments. I can tell you that there are no better people that I have met here at Lenox Hill Hospital than Dr. Ansari and Dr. Brodersan who are with us today. Our first speaker for this session is Dr. Maurice Chung. He is a well known advanced laparoendoscopic surgeon. He is president of the Midwest Regional Center for Endometriosis in Lima, Ohio. Dr Chung serves on the editorial board of the Journal of the Society of Laparoscopic Surgeons, as well as the Chinese Journal of Minimally Invasive Surgery, without further ado, Dr. Chung.
This is still morning, good morning New York! I am honored to be here by my good friend Tamer’s invitation. I see so many expert surgeons here. My presentation, basically, is just to add another twist to all these surgeons and to think about when patients have multiple surgeries and the symptoms have not improved. Of course we know that when you have endometriosis you need to do surgery and you need to do a good one. You need to clear the endometriosis and the best is the first time. What happens if the patient did not have very good surgeons and had multiple surgeries? Should we be doing surgery right away, should we trust our colleagues to a certain extent and give them some credit, and evaluate some other discipline of pelvic pain? Is it all endometriosis?
In my talk today I just want to share with you the experience that I have in the last 15 years dealing with these types of patients. It is a very new minimally invasive evaluation and treatment of pelvic pain to reduce unnecessary multiple laparoscopies. If you follow this new algorithm maybe you can save a few surgeries for some of the patients. As the president of Society of Laparoendoscopic Surgeons this year in Boston we are going to have a very good meeting with robotic surgeons and together we will talk about all the different types of approach and of course, treating endometriosis and hysterectomy. I welcome you all and invite you to be there in Boston in September.
Now we talk about chronic pelvic pain. It is a very significant and common disorder in women and over 40 percent of all laparoscopy and 18 percent of hysterectomy are all done for chronic pelvic pain. One of the major symptoms these patients have is dyspareunia; endometriosis, dyspareunia and dysmenorrhea. What do we usually do when a patient comes to see us presenting with pain, dysmenorrhea and dyspareunia? We usually check infection to make sure they do not have a pelvic infection. But sometimes they have had this pain for a while – we just give them antibiotics. Urinary tract infections – we do the culture, no infection, maybe it is a contamination – give them antibiotics. With bad dysmenorrhea sometimes on a young patient you give them birth control pills. NSAID, some would say in the 1990s you give a GnRH presuming endometriosis and treat that first. If it is endometriosis you need surgery. If it is painful intercourse we think about endometriosis – you need surgery. What about heavy bleeding? Pain is adenomyosis. We do not have the specimen and you do an adenomyomectomy or you do hysterectomy. Basically, laparoscopy has always been the first step. When you treat endometriosis we have all these expert surgeons here that do a very good surgery but not the rest of the country. Endometriosis is the most common diagnosis but the treatment has not been very successful, although it heavily depends on the skill of the surgeons too.
We have all these pictures, and endometriosis – this is fibrotic endometriosis and you excise it. You all know the results, stage one, two and three. This is an old study that talks about stage one patients at six months you have 38 percent reduction of the pain versus on stage three you have a lot more improvement. We all know that excision surgery carries much better pain-free for a long duration of time. Excisional surgery has always been the Gold standard. But what do you do if the surgery you have done, you excise endometriosis and the patient continues to have pain? What do you do next? Was it because it was an inexperienced surgeon, was excisional surgery done? Was it because endometriosis was not completely excised, or should we be doing medical therapy? And as Dr. Reich talked about, medical therapy has not been a good success with a 50 percent or higher recurrence rate. Why do we even care to use medical therapy? More laparoscopy? Do a presacral neurectomy for central pelvic pain dysmenorrhea? In my institution I am not allowed to videotape because of the medical legal issues. It would be nice to tape the surgery but I can only take pictures. You do presacral neurectomy, ligate it. All these meta-analysis only tells you that presacral neurectomy is only good for central dysmenorrhea and should be done by an expert surgeon. Again, the outcome has not been great. The endometriosis is gone, still hurts but do you do more surgery? Is it that the uterus has adenomyosis or do we need a hysterectomy? We know that if you do a hysterectomy for pelvic pain 40 percent of those patients continue to have pelvic pain. If you remove the uterus when the patient does not have pelvic pain five percent of the patients will develop new pelvic pain. So, should we be doing a hysterectomy?
Back in 2004 I looked at 111 women who had post-hysterectomy pelvic pain. Guess what? Seventy-nine percent of those patients have painful bladder syndrome. Or is it that after you have done the hysterectomy the patients still had their ovaries or is it ovarian remnants, or residual ovarian syndrome? Would a laparoscopic oophorectomy work? Or should we do a laparoscopic lysis of adhesions? More surgeries (showed slides).
In 2003 I presented this abstract. I just did not have time to write them all up. Seventy-nine patients with clinical diagnosis residual ovaries and remnant syndrome: close to 80 to 90 percent of those had a concomitant interstitial cystitis or you can call that painful bladder syndrome. It is pain. Do adhesions cause pain – yes or no?
This was another abstract I did in 2007. One hundred and five patients had previous abdominal surgery. Fifty percent of those patients, when I got back in there, had adhesions and of all of those 50 percent had pain. Of all those 50 percent of patients with pain 74 percent of those had painful bladder syndrome. So, is it the painful bladder that caused the pain or is it persistent endometriosis or recurrent endometriosis? How many surgeries do we have to do before it is enough? When we look at chronic pelvic pain we really have to look at all the disease conditions. We have interstitial cystitis, we have endometriosis and we have pudendal neuralgia, a very important one, IBS, UTI, infection, adhesions, hernia that can cause pain, and also pelvic tension myofascial syndrome, which is basically the muscle and nerve pain inside the vagina at the levator muscles hurt.
Do not just focus on endometriosis, especially for those patients who had multiple surgeries. It is the entire pelvis. The body is the source of chronic pelvic pain in over 30 percent of women. So when you look at this is the bowel component, the female reproductive system contributes only 20 percent of all the chronic pelvic pain. This is actually from an ACOG bulletin, 38 to 85 percent of patients who went to gynecologists for unresolved chronic pelvic pain may actually have painful bladder syndrome.
What is IC, painful bladder syndrome? Basically it is urinary urgency, frequency and pelvic pain, dyspareunia without any infections. It is as simple as that. These are the prevalence you can go 52, 67 per 100,000 to 1 in 4.5, so the number is pretty high. The age is around nine to one female to male at around 40 but I have seen very young women in their 20s have these problems and as young as in the teens. Where does IC begin? It starts early and progresses and it hurts a lot more with time. Basically when you have pain if you leave it alone, if you do not deal with it, it is going to get worse and worse and worse. Many of these patients have unnecessary hysterectomies, had seen about five doctors before the diagnosis was made. Sounds like endometriosis. There was a bladder insult causing epithelial damage, the leaking of potassium into the tissues, activated C-fibers and caused mass cell activation and histamine release causing more injuries. This becomes a vicious cycle that never stops.
Here are the layers that disappear and that is the IC when the solid tissue irritates the nerve. This is what I called the Evil Twins paper in 2002 - 2005. I basically looked at all pelvic pain patients and on study number one 90 percent of those patients had painful bladder syndrome and 80 percent of those had a biopsy that confirmed endometriosis. I thought it was very high so I repeated the study and the second time around I had similar results. When you get a patient with pelvic pain you find endometriosis. Chances are she also has painful bladder syndrome. It is very important to rule out other sources of pain even when endometriosis is confirmed as the diagnosis. The symptoms are basically the same IC, chronic pelvic pain they all have very similar symptoms.
In my office I look at the painful bladder syndrome first. I use this PUF score which is Dr. Parson in San Diego. This score has been validated over and over again and you ask these questions about what patients have urinary symptoms, painful intercourse and comprise of a score of 35 in total. Next is the examination. You have to do very good examinations in patients with chronic pelvic pain. You have to look at all the area where it hurts. Basically this is pain mapping. You have to examine the patient standing, sitting, supine and on the stirrups. Also, evaluate where the pain is, basically map out the area that hurts, and also check the spine for sacroiliac dysfunction. The patient with chronic pain, the muscle spasms with myofascial syndrome too. Checking for sensory; this is actually basically evaluation of pudendal neuralgia just to see whether the vulva is very sensitive. These are some of those things that I was not taught when I finished my training. It is very important to look at the sensory evaluation of the vulva. The bimanual examination is not necessary because it is going to hurt. Use one finger, check the bladder, check all the muscles, as Dr. Harry Reich said, do a rectovaginal examination to see where there is an endometriotic nodule in the cul-de-sac.
Testing…potassium sensitivity testing, which is what I use and you see that 80 percent of those patients with chronic pelvic pain, endometriosis, whatever, is positive for the potassium sensitivity testing. It is a very good test in predictions. The treatment is cystoscopy hydrodistention on medication and when you see this…glomerulations, mucosa ____ these are some of the findings on the cystoscopy with interstitial cystitis. The treatment is using pentosan polysulfate as a medication and it covers the layer and resolves the inflammations. It is a multimodal therapy; you add amitriptyline and an antihistamine for the treatment.
This is another paper that I worked on in 2005. I took all the chronic pelvic pain patients tested for painful bladder syndrome and treated them with intravesical therapy. Seventy percent of those patients had a 50 percent reduction in simply six to eight weeks. If that is the case I reduced by 70 percent those patients that needed surgery.
The next biggie is the pudendal nerve. We learned about it but we really do not know what it does. Basically, the three branches coming out from the iscshial spine are the clitoral branch, the labial branch and inferior hemorrhoidal branch. It innervates the entire pelvis. This is an abstract that I did just a couple of years ago since you all remember the Evil Twins when you find endometriosis, you find interstitial cystitis or painful bladder. On pudendal neuralgia patients with chronic pelvic pain 88.5 percent of those patients have pudendal neuralgia, 78.8 percent have both and 76 percent of those patients have a painful bladder.
So now, it is time to tie all these together. The pudendal nerve is S2, 3, and 4 innervations and comes down here, passes through the iscshial spine, the ____ canal and innervates the entire pelvis. It is a multiple nerve with multiple sensory and autonomic. The symptom depends on how the nerve is being impinged in the pelvis. These are the sacrospinous ligaments, the fat pad, when you sit it hurts more. So the patients with pelvic pain – w hen you interview them in your office the patient with multiple surgeries – watch how they sit. Sometimes they sit on one side because sometimes it hurts on sitting.
Pudendal neuralgia is peritoneal pain elevated by sitting, reduced by standing, not present when you lie down and the toilet seat is the best seat in the house. You get relief. These are all the areas for pudendal neuralgia it’s like an endometriosis patient.
What are some of the non-pain symptoms; sexual, decreased libido, reduced secretion, and dyspareunia. Patients with endometriosis have urgency, frequency, pudendal neuralgia – the same. Their bowel symptoms, obstructed defecation, they have problems moving their bowels – endometriosis on the bowel. Basically, pudendal neuralgia is very common. Also, this is a somatic component of the pudendal nerve, urinary retention, start stop incontinence – you can see that. On examination the most important thing is when you have one finger touching the iscshial spine; just touching you can send the patient off the roof. Basically, it is the sacrospinous ligament where the pudendal nerve travels under.
Diagnostic criteria of pudendal neuralgia – basically I use two. One is the examination; touching that sacrospinous ligament the patient usually has dyspareunia. When I give them a therapeutic or diagnostic block the pain goes away. The patient has pudendal neuralgia. A very simple thing that you can do for the patient to avoid some of these multiple surgeries, which are not necessary, this is another diagnostic criteria.
Sorry I am going so fast, but this lecture actually has three lectures in one.
Here we get perineal hyperprotection. Physical therapy is so important, injection is important and then pharmaceutical treatment and surgery is rarely needed. I will show you some of the study I have just done. Do not sit. You can sit on the toilet seat. Do not stretch, do not squat. Use the pad. What is the pad? Go to the MC Sport Store for kickball or something and just cut it out like your toilet seat. Sit on it to prevent that compression and you will get 15 percent improvement of the pain.
Pelvic physical therapy with physical therapy; basically you just do the myofascial release of the levator muscles. Drugs – tricyclic, Neurontin, Lyrica and Tegretol. Treatment injection – this is old fashioned gynecologic injection but actually what I do is go through this area. You can use the foroscopy to make your way to the iscshial spine. Or you can use a cat-scan to go in that area which is the pudendal nerve. I use both ways, the transvaginal and transperineal and because the patient is so…some of the iscshial spine is very difficult to find and during the examination in the office when patients have so much pain with the levator muscle spasm you cannot even get the finger near the iscshial spine. So the therapeutic or diagnostic block is always the test for me.
The classic pudendal nerve block to reduce the need of diagnostic laparoscopy; there are 46 patients in this study. Forty-three of them have a positive PSD testing and went through the treatment of intravesical therapy to treat their IC and they have some improvement but not to the point that they think that the pain is that much better. So I put them through injections. Out of the 43 patients 33 got relief of pain. Out of the 46 patients I put 13 patients through a diagnostic laparoscopy and then proceeded with the surgery. The pain dropped as a subjective improvement of 75 percent of the symptom and objectively it is a 33 percent reduction after three blocks which are separated one month apart.
We all see these patients, a 32-year-old woman, two pregnancies, pelvic pain, endometriosis, two laparoscopies, right salpingo oophorectomy, had a hysterectomy and removal of the left ovary. In the middle of the night I got a call and the patient was in ER. When the organ was gone the ER doctor usually calls the general surgeon. The general surgeon took the patient for laparoscopy and he called me and said there is some white stuff on the pelvic brim. I said to him, “That’s the ovary – take it out and I will see the patient in a few weeks”. I saw the patient in a few weeks, six weeks later, she had overactive bladder symptoms, the PUF score was 25, which is IC until proven otherwise. Interstitial cystitis index was 14 so I did the PSD testing and it was positive. When I checked the pudendal nerve the right side hurt more than the left. I put her through eight weeks of rescue rinses and her symptoms dropped from 25 down to 10, 14 down to three. Now, she still has some pain on the right side on examination so I just gave her a bilateral pudendal block. And guess what? Six weeks later her pain was dropped from 25 down to a four.
Does adhesion cause pain? Should hysterectomy be done? Excision and endometriosis – yes, it is very important, you have to excise all endometriosis in sight. Then we can top the rest.
Patients with endometriosis, especially for those with multiple laparoscopy surgeries should probably be evaluated for painful bladder syndrome pudendal neuralgia first. This algorithm could avoid many of those surgeries. However, I really think that when endometriosis is there you have to find the best surgeon to excise everything there is in the pelvis. Especially for those who already had multiple surgeries. Maybe we can just tweak the wheel a little bit and start from the other end instead of going ahead and doing surgery when the patient is at the height of the pain. When you have pain, you do surgery and you usually end up with more pain after the patient wakes up.
So now I give you a new concept. Maybe we just have to drop the old one and rethink and relearn. The eye does not see what the mind does not recognize. What the eye does not see and mind does not know does not exist. What you see may not be what it is. IC, you see, you do not see the IC, I see.
Thank you very much!
Endometriosis Foundation of America