Exploring the Role of Neuropathy in Re-Operative Endometriosis - Marc Possover, MD, PhD

Prof. Possover starts his presentation by summarizing the possible cause of pelvic neuropathy following endometriosis surgery. Pelvic neuropathy is the damage or dysfunction of the pelvic nerve. Prof. Possover explained that this could either be due to incomplete surgery, disease…

Key Points

Information about the presenter

This presentation is by Prof. Marc Possover, M.D., Ph.D., and is entitled “Exploring the Role of Neuropathy in Re-Operative Endometriosis”. Prof. Possover is the director of the Possover International Medical Center in Zurich, Switzerland, a professor of neuropelveology at the University of Aarhus in Denmark, an associate professor at the University of Cologne in Germany, and Honorary and Founding President of the International Society of Neuropelveology.

Highlights:

• Pelvic pain can persist following endometriosis surgery due to pelvic neuropathy and cause a number of symptoms. 

Importance: 

• It is of great importance to understand the cause of pelvic pain following endometriosis surgery to offer patients the right diagnosis and treatment.
• Listening to the patient and carefully reviewing her medical history is essential to understand the pain she is experiencing.

Remarks:

• Pelvic neuropathy following endometriosis surgery could be caused by incomplete surgery, disease recurrence, or nerve damage during surgery.
• To understand the cause of pelvic neuropathy after previous surgery, both the motor and sensory dysfunction of the pelvic nerves must be considered.
• The dysfunction of the efferent fibers of the pelvic nerve will cause difficulty walking, difficulty with sexuality, bladder, and bowel problems.
• In order to avoid bladder dysfunction, the so-called "nerve-sparing technique" must be adopted during endometriosis surgery. The laparoscopic neuro-navigation (LANN: nerve stimulation during the procedure to recognize sensitive fibers), can help.
• Patients may develop stenosis in the anastomosis following a bowel resection, so a colonoscopy should be performed before nerve damage is suspected.
• Pelvic pain following endometriosis surgery may also be caused by a lesion in the visceral pelvic nerve or in the pelvic somatic nerve:
  • In the case of the visceral pelvic nerve lesion: the patient will develop chronic pelvic pain syndrome, have an overactive sympathetic nervous system (dry lips, dilated pupils), either caused by incomplete surgery or compression of the nerve by scar tissue. The patient will develop bladder hypersensitivity and sometimes overactivity, colon irritability, and painful intercourse.
    • If the visceral pelvic nerve is destroyed during surgery, the patient will have a "lazy bladder", outlet constipation syndrome, and vaginal dryness accompanied by pain in the upper abdomen, gastric pain, cardiac dystonia, and pain in the shoulders, arms, and hands.
  • In the case of a lesion in the pelvic somatic nerve, the pain will be located in the pelvis and lower back going down to the legs, feet, and toes. It can be caused by incomplete surgery or surgical injury or nerve entrapment by secondary tissue such as scar tissue or blood vessels.
  • In case of surgical injury, the patient will report pain the day after the day of the surgery; as there is a lesion of the nerve, there will be numbness, and bladder, rectum, or leg weakness. 
  • Treatment focuses on laparoscopic neurolysis, re-anastomosis of the pelvic nerve, nerve reconstruction by using nerve by-pass or graft.
  • Pelvic pain following endometriosis surgery, if caused by nerve entrapment by scar tissue or secondary blood vessels, patients report pain to appear weeks or months after surgery, without numbness or weakness, and the patient experiences variable but constant pain.
  • In the case of blood vessel entrapment, the pain increases with blood pressure alterations.
  • Hormonal treatments combining estrogen and progesterone must be avoided in such cases due to the risk of thrombosis and pulmonary embolism. Instead, treatment should focus on decompression of the nerve through laparoscopic surgery.

Lay Summary

Prof. Possover starts his presentation by summarizing the possible cause of pelvic neuropathy following endometriosis surgery. Pelvic neuropathy is the damage or dysfunction of the pelvic nerve. Prof. Possover explained that this could either be due to incomplete surgery, disease recurrence, or actual damage to the pelvic nerves during endometriosis surgery. 

He then talks about the functions of the pelvic nerve including urinary function, rectal function, sexuality, and leg movement describing the role of both the efferent nerve fibers or those going from the brain to the rest of the body, and the afferent nerve fibers, or those carrying information from the pelvic to the brain. 

“When we try to understand pelvic neuropathy, especially after previous surgery, we have to combine and control both aspects, the sensory dysfunction, and the motor dysfunction,” Prof. Possover says.

He then talks about how motor dysfunction can be assessed. Approaches that can be used include vaginal sonography to check if the patient is able to empty their bladder, urodynamic testing (a procedure that looks at how well the bladder is storing and releasing urine), and checking the motor function of the legs, ankles, and toes. 

Prof. Possover also talks about the importance of listening to the patient and reading her body language to understand the pain she is experiencing, and carefully reviewing her medical history. He says that at least an hour-long consultation may be necessary.

Prof. Possover, then moves onto the different aspects of efferent nerve fibers dysfunction including difficulty walking, difficulty with sexuality, and bladder and bowel problems.   

Focusing on bladder dysfunction, Prof. Possover explains that patients may not be able to tell when she needs to void due to damage to the nerves controlling the bladder. Over time this could lead to an over dilated bladder and even though the patient can still void, she is not able to completely empty her bladder. This can have severe consequences such as infections and kidney damage. 

Prof. Possover explains that bowel dysfunction can cause chronic constipation. 

He finishes off by talking about the afferent functions of the pelvic nerve or pain. “You have two different kinds of pain,” he says. He adds that these two kinds of pain are completely different and that it is important to understand this in order to offer the right treatment to the patient. 

Research Source: https://www.endofound.org/medicalconference/presentations