Severe Dyspareunia is Related with "Cul-de-sac" and "Uterosacral Ligament" Endometriosis

Multiple anatomic sites may be associated with severe dyspareunia in both women with and without endometriosis

Key Points

Highlights: 

• Anatomic sites involved in deep dyspareunia and their categorizations based on the severity and clinical factors associated with each zone was investigated.

Key Results: 

• The presence of tenderness was significantly associated with the severity of pain in each anatomic site. The number of miscarriages was higher in women with a tender cervix and uterus compared with women with a non-tender cervix and uterus. Tenderness of the cul-de-sac or uterosacral ligament was more frequent in women with endometriosis than without endometriosis.
• The severity of deep dyspareunia was associated with sensitivity of the bladder, pelvic floor, cervix, uterus, and uterosacral ligaments but not with adnexa.
• The severity of deep dyspareunia was associated with tenderness of the bladder, pelvic floor, cervix, uterus, and uterosacral ligaments but not with adnexa.

What’s done here?

• This study sought to find the areas that are involved in deep dyspareunia and to categorize these locations based on the severity and clinical factors associated with each zone.
• 548 women with either currently diagnosed endometriosis, confirmed the absence of endometriosis or the presence of suspected endometriosis were included in the study.
• For each patient, the bladder, pelvic floor, cervix, uterus, cul-de-sac, and adnexa (paracervical regions) were examined and assessed via a single digit palpitation during a standardized endovaginal ultrasound-assisted pelvic examination.
• The patients subsequently asked to score pain from 0 to 10, to report if tenderness was present, and about their comorbidities with past medical history via a comprehensive patient interview.

Limitations: 

• This study lied upon a subjective pain rating scale of 0 to 10, so consistency across each patient may or may not have been met.
• Cut offs for the evaluation of other risk factors including diet and mental health were not stated and could have been more comprehensive.

Lay Summary

Endometriosis and especially deep infiltrating endometriosis has been associated with an increased risk of severe dyspareunia. Studies reporting the anatomical sites associated with deep dyspareunia and the severity of pain, and the risk factors of these anatomic sites are incongruent; thus need to be confirmed.

In this study, published in the scientific journal "Sexual Medicine", 548 women with either currently diagnosed endometriosis, no confirmed presence of endometriosis, or suspected endometriosis were included. For each patient, the bladder, pelvic floor, cervix, uterus, cul-de-sac, and adnexa (paracervical regions) were examined and assessed via a single digit palpitation during a standardized endovaginal ultrasound-assisted pelvic examination. Patients were then subsequently asked to score pain from 0 to 10 and asked to report if tenderness was present. Additionally, to assess if other risk factors contributed to the tenderness seen in structures outside of the organs and tissues affected by endometriosis, patients were asked about their comorbidities and past medical history via a comprehensive patient interview.

19% of participants had tender bladder, 28% had a tender pelvic floor, 31% had a tender cervix and uterus, 38% had tender adnexa, and 57% had a tender cul-de-sac or uterosacral ligaments. 47% of patients had at least two tender anatomic sites while 24% had no tenderness at any location. Not surprisingly, the presence of tenderness was significantly associated with the severity of pain in each anatomic site. The number of miscarriages was higher in women with a tender cervix and uterus compared with women with a non-tender cervix and uterus. Tenderness of the cul-de-sac or uterosacral ligament was more frequent in women with endometriosis than without endometriosis.

These sites have been seen in the past to be present in women with and without endometriosis for various reasons. Thus, it is imperative to see your gynecologist regarding sudden-onset symptoms associated with dyspareunia. "Clinicians should be aware that there could be multiple anatomic factors for deep dyspareunia in women with and without endometriosis" concluded  Vancouver, BC, Canada based researchers. 

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/28778678