Pain in the upper anterior-lateral part of the thigh in women affected by endometriosis: study of sensitive neuropathy

Laparoscopic nerve lysis for deep endometriosis improves quality of life and chronic pain levels: A pilot study

OBJECTIVES

To assess the benefit of surgical management of patients with endometriosis infiltrating pelvic nerves in terms of pain, analgesic consumption, and quality of life (QOL).

METHODS

We conducted a retrospective cohort study In an Endometriosis referral center at a tertiary care university affiliated medical center. Patients diagnosed with endometriosis that underwent laparoscopic neurolysis for chronic pain were included. Patients rated their pain before and after surgery and differentiated between chronic pain and acute crises. Patients were requested to maintain a record of analgesic consumption and to evaluate their quality-of-life (QOL).

RESULTS

Of the 21 patients in our study 15 (71.5 %) had obturator nerve involvement, 2 (9.5 %) had pudendal nerve involvement and 4 (19 %) had other pelvic nerve involvement. Median postoperative follow - up was of 8 months. All but 2 patients (9.6 %) had significant chronic pain improvement with a mean decrease of VAS of 3.05 (±2.5). Analgesic habits changed postoperatively with a significant decrease of 66 % of patients' daily consumption of any analgesics. Surgery improved QOL in 12 cases (57.1 %) and two patients (9.6 %) completely recovered with a high QOL.

CONCLUSION

Neurolysis and excision of endometriosis of pelvic nerves could results in significant improvement of quality of life.

A Novel Classification of Endometriosis Based on Clusters of Comorbidities

Endometriosis is a heterogeneous, complex, and still challenging disease, due to its epidemiological, etiological and pathogenic, diagnostic, therapeutic, and prognosis characteristics. The classification of endometriosis is contentious, and existing therapies show significant variability in their effectiveness. This study aims to capture and describe clusters of women with endometriosis based on their comorbidity. With data extracted from electronic records of primary care, this study performs a hierarchical clustering with the Ward method of women with endometriosis with a subsequent analysis of the distribution of comorbidities. Data were available for 4055 women with endometriosis, and six clusters of women were identified: cluster 1 (less comorbidity), cluster 2 (anxiety and musculoskeletal disorders), cluster 3 (type 1 allergy or immediate hypersensitivity); cluster 4 (multiple morbidities); cluster 5 (anemia and infertility); and cluster 6 (headache and migraine). Clustering aggregates similar units into similar clusters, partitioning dissimilar objects into other clusters at a progressively finer granularity-in this case, groups of women with similarities in their comorbidities. Clusters may provide a deeper insight into the multidimensionality of endometriosis and may represent diverse "endometriosis trajectories" which may be associated with specific molecular and biochemical mechanisms. Comorbidity-based clusters may be important to the scientific study of endometriosis, contributing to the clarification of its clinical complexity and variability. An awareness of those comorbidities may help elucidate the etiopathogenesis and facilitate the accurate earlier diagnosis and initiation of treatments targeted toward particular subgroups.

Gastroenterologist Primer: Endometriosis for Gastroenterologists

BACKGROUND AND AIM

A comprehensive understanding of endometriosis and its common gastrointestinal presentations are critical for gastroenterologists to ensure appropriate and timely screening and diagnosis. Endometriosis is a common inflammatory disease that frequently presents with gastrointestinal symptoms overlapping with irritable bowel syndrome (IBS) and other gastrointestinal disorders. Many endometriosis patients first present to a gastroenterologist or generalist, which may prolong the time to diagnosis and appropriate care.

METHOD AND RESULTS

This review describes the current literature on endometriosis presentation, overlap with gastrointestinal conditions, and standard diagnostic and treatment options for gastroenterologists to consider. For appropriate and swift treatment, gastroenterologists must consider an endometriosis diagnosis in females of menstruating age presenting with pain, bloating, altered stools, and non-gastrointestinal symptoms and refer patients for further evaluation.

Patient-Reported Outcome Measures in Endometriosis

Patient Reported Outcome Measures (PROM) evoke measurements that allow capturing patients’ perspectives on their condition. In endometriosis care, physicians’ understanding of the effect of the disease and the treatment on patients is often poor. The use of PROMs in endometriosis clinical practice can facilitate patient-provider communication and the implementation of patient-centered care, improve patients’ quality of life, as well as provide a tool for patients’ self-management of the disease. Today, PROMs are extensively used in research and clinical trials, however they are barely used in clinical practice. The development of digital tools facilitating capturing PROMs can contribute to their use by physicians in routine endometriosis care. However, all PROMs are not adapted to be used in routine care in the context of endometriosis. The objective of this study was to present a catalogue of available PROMs for routine endometriosis care and evaluate them according to selected criteria. To do so, we explored the different PROMs currently in the literature. Consequently, 48 PROM were identified as tools used to evaluate various dimensions of the impact of endometriosis on patients. The selected PROMs were evaluated for their potential to be used as a standard in clinical practice in endometriosis. The selected catalogue of PROMs is the starting point for the integration of digital tools to capture PROMs and the development of patient-centered dashboards to be used by patients and clinicians in endometriosis care and self-management to improve care processes, patient satisfaction, quality of life, and outcomes.

Peripheral, Central, and Cross Sensitization in Endometriosis-Associated Pain and Comorbid Pain Syndromes

Endometriosis-associated pain and the mechanisms responsible for its initiation and persistence are complex and difficult to treat. Endometriosis-associated pain is experienced as dysmenorrhea, cyclical pain related to organ function including dysuria, dyschezia and dyspareunia, and persistent pelvic pain. Pain symptomatology correlates poorly with the extent of macroscopic disease. In addition to the local effects of disease, endometriosis-associated pain develops as a product of peripheral sensitization, central sensitization and cross sensitization. Endometriosis-associated pain is further contributed to by comorbid pain conditions, such as bladder pain syndrome, irritable bowel syndrome, abdomino-pelvic myalgia and vulvodynia. This article will review endometriosis-associated pain, its mechanisms, and its comorbid pain syndromes with a view to aiding the clinician in navigating the literature and terminology of pain and pain syndromes. Limitations of our current understanding of endometriosis-associated pain will be acknowledged. Where possible, commonalities in pain mechanisms between endometriosis-associated pain and comorbid pain syndromes will be highlighted.

Learning endometriosis phenotypes from patient-generated data

Endometriosis is a systemic and chronic condition in women of childbearing age, yet a highly enigmatic disease with unresolved questions: there are no known biomarkers, nor established clinical stages. We here investigate the use of patient-generated health data and data-driven phenotyping to characterize endometriosis patient subtypes, based on their reported signs and symptoms. We aim at unsupervised learning of endometriosis phenotypes using self-tracking data from personal smartphones. We leverage data from an observational research study of over 4000 women with endometriosis that track their condition over more than 2 years. We extend a classical mixed-membership model to accommodate the idiosyncrasies of the data at hand, i.e., the multimodality and uncertainty of the self-tracked variables. The proposed method, by jointly modeling a wide range of observations (i.e., participant symptoms, quality of life, treatments), identifies clinically relevant endometriosis subtypes. Experiments show that our method is robust to different hyperparameter choices and the biases of self-tracking data (e.g., the wide variations in tracking frequency among participants). With this work, we show the promise of unsupervised learning of endometriosis subtypes from self-tracked data, as learned phenotypes align well with what is already known about the disease, but also suggest new clinically actionable findings. More generally, we argue that a continued research effort on unsupervised phenotyping methods with patient-generated health data via new mobile and digital technologies will have significant impact on the study of enigmatic diseases in particular, and health in general.

[Extragenital endometriosis: Parietal, thoracic, diaphragmatic and nervous lesions. CNGOF-HAS Endometriosis Guidelines]

According to some studies, extragenital endometriosis represents 5% of the localisations. Its prevalence seems to be underestimated. The extra pelvic localisation can make the diagnosis more difficult. Nevertheless, the recurrent and catamenial symptomatology can evoke this pathology. Surgery seems to be the unique efficient treatment for parietal lesions. Pain linked to nervous lesions (peripheric and sacral roots) seems to be underestimated and difficult to diagnose because of various localisations. Neurolysis seems to have encouraging results. Diaphragmatic lesions are often discovered either incidentally during laparoscopy, or by pulmonary symptomatology as recurrent catamenial pneumothorax or cyclic thoracic pain. Surgical treatment seems as well to be efficient.

A model for radiating leg pain of endometriosis

Endometriosis is a prevalent female health disorder that often leads to back pain and radiating leg pain. Patients with such pain often seek care from multiple health care professionals, including manual therapists. We hypothesized that endometrioma can induce nerve inflammation thus the radiating leg pain that often accompanies endometriosis. To model sciatic endometriosis in female Wistar rats, a section of uterine horn was autotransplanted to the sciatic nerve. Uterus sections with the endometrium removed and autotransplanted to the sciatic nerve served as controls. After 1, 3, and 15 months the nerves were harvested and processed for immune cell presence and for neural elements. Control nerves were harvested after 4 months. All autotransplants survived, resulting in a fusion of the uterus sections to the nerves. Macroscopically, turgid cysts apposed to the nerves characterized the complexes. Microscopically, the complexes contained recruited macrophages, indicating persistent inflammation, and were innervated by small diameter axons. Only 1 of 8 control rats developed a small cyst, presumably due to residual endometrium. The persistent immune response and innervation suggest the nerve-uterus complexes as sources of inflammation and persistent neural discharge, and thus pain. This model could shed light upon the radiating leg pain that often accompanies endometriosis. Manual therapists should be aware of the possibility of endometriosis causing symptoms and examination findings that mimic musculoskeletal etiologies.

Laparoscopic approach to intrapelvic nerve entrapments

It is long known that a large portion of the lumbosacral plexus is located intra-abdominally, in the retroperitoneal space. However, most of literature descriptions of lesions on this plexus refer to its extra-abdominal parts whereas its intra-abdominal portions are often neglected. The objective of this review article is to describe the laparoscopic anatomy of intrapelvic nerve bundles, as well as the findings and advances already achieved by Neuropelveology practitioners.

Prevalence and severity of cyclic leg pain in women with endometriosis and in controls - effect of laparoscopic surgery

OBJECTIVE

In addition to dysmenorrhea, dyspareunia, and subfertility, pain in the lower extremities has been described to be a further complaint in women affected by endometriosis, and lysis of nerve entrapment was thought to be associated with amelioration of leg pain. Therefore, we aimed to compare the prevalence of cyclic leg pain and pain intensity between women with endometriosis and without endometriosis, and to evaluate the effect of laparoscopic surgery.

STUDY DESIGN

Forty-four women with endometriosis and 58 controls were included in a prospective, controlled clinical trial at a University hospital/tertiary referral center. Participants were asked to complete questionnaires the day before and six to nine weeks after laparoscopy. The prevalence and intensity of leg pain and improvement after laparoscopic surgery, quantified according to a visual analog scale (VAS) score, were evaluated. We also recorded involvement of dermatomes, the presence and intensity of dysmenorrhea, and correlations between age, stage of endometriosis (rAFS-score), and preoperative VAS scores.

RESULTS

Before surgery, more women were affected by leg pain in the endometriosis group, compared to the control group (45.5% and 25.9%, respectively). Preoperative VAS scores for leg pain, however, were not significantly different between the two groups. A moderate correlation in the preoperative VAS scores between leg pain and dysmenorrhea was observed. After laparoscopy, we found a significant improvement in leg pain intensity in both groups. The mean difference in the VAS score for pain reduction between the study group and the control group was 0.74 (95% CI: -0.61-2.08), which was not statistically significant.

CONCLUSIONS

The prevalence of leg pain is increased in endometriosis, while leg pain intensity is not, compared to women without endometriosis. Laparoscopic surgery-even without preparation and decompression of nerve tissue-is associated with an improvement in pain intensity in women with endometriosis, as well as in the group without endometriosis.

A survey of Italian physicians' opinion about stem cells research: what doctors prefer and what the law requires

To evaluate the Italian physicians' knowledge/information level about the therapeutic potential of stem cells, the research choice between embryonic and cordonal stem cells, and the preference between autologous and heterologous storage of cordonal stem cells, we performed a national survey. The questionnaire--distributed to 3361 physicians--involved physicians of different religious orientations and of different medical specialities. Most of the physicians involved (67%) were Catholics, and the majority were gynaecologists and paediatricians (43%) who are mainly in charge to inform future mothers about the possibility of cordonal stem cells conservation. The majority of the physicians interviewed do not have specific knowledge about stem cells (59%), most of them having only generic information (92%). The largest part of physicians prefer to use umbilical cord blood cells rather than embryonic stem cells. Nevertheless, a large percentage of physicians were in favour of embryo research, especially when embryos are supernumerary (44% versus 34%). Eighty-seven % of the physicians interviewed proved to have a general knowledge about stem cells and believe in their therapeutic potential. They prefer research on cordonal stem cells rather than on embryo stem cells. Although they are in favour of heterologous stem cells donation, they still prefer cryopreservation for personal use.

Unilateral peripheral neuropathic pain: The role of neurodiagnostic skin biopsy

According to the current definition of neuropathic pain (“pain arising as a direct consequence of a lesion or disease affecting the somatosensory system”), the demonstration of a lesion or disease involving the somatosensory system is mandatory for the diagnosis of definite neuropathic pain. Although several methods are currently available for this aim, none is suitable for every type of disease (or lesion). Neurodiagnostic skin biopsy (NSB) is a relatively new technique for the diagnosis of peripheral nerve lesions. It is an objective method, completely independent from the patient’s complaining, based on immunohistochemical staining techniques that allow measurement of the density of the epidermal nerve fibers, currently considered the free nerve endings of small diameter (A-delta and C) afferent fibers. NSB has the important property of being used to investigate the skin, allowing obtaining a diagnosis of small fiber axonal neuropathy of peripheral nerves supplying every body part covered by skin. This feature appears to be very important, particularly in cases of unilateral nerve lesions, because it allows going beyond the possibilities of neurophysiological tests which are available only for a limited number of peripheral nerves. All these characteristics make NSB a precious instrument for the diagnosis of peripheral unilateral neuropathic pain.