Physical Therapy After Excision Surgery

Why do You Get a Referral for Physical Therapy After Excision Surgery?

• Endometriosis is a chronic condition and it takes almost 10 years to diagnose the condition in most cases. 
• The women suffer from severe pain and disability before they are really diagnosed with endometriosis. Pain leads to muscle guarding and spasms which leads to further limitation in mobility and function.
• Muscle guarding can also affect fascial mobility. Fascia covers our body from head to toe, it covers the muscles and organs and connects muscle to muscle and muscle to organ. Any fascial restrictions can affect the mobility of the organ and body and also function.
• Decreased mobility can affect the circulation and lymphatic draining. Many women present with blood stasis and swelling of pelvic region- vulva, discoloration and sometimes itching.
• Some women with endometriosis can present with the descend of a small intestine between uterus and rectum and it pushes the wall of vagina, it is called “enterocele”.
• Surgery can lead to scar tissue and muscle guarding which can affect the normal biomechanical movement. 
• Many women have pain and pelvic floor dysfunction after surgery which can affect the function.

How does Fascial Mobility Affect the Pelvic Floor Function?

• Facia lines from Amygornall.com
• The abdominal fascial restrictions from guarding can affect the mobility of the fascia of the large and small intestine. Scar tissue after surgery can also affect the abdominal fascial mobility.

• This is image is taken from Grey’s Anatomy
• The restrictions of the fascia around cecum (ascending colon on right side) and sigmoid colon (descending colon on left side) can affect bowel movement- many women have constipation, diarrhea, pain after bowel movement, bloating, and food intolerance. Constipation is defined as 

1. Small palates, hard stools, straining
2. Not able to empty bowels completely
3. Less than 3 spontaneous bowel movements a week
4. The patient has to do manual maneuver to pass the stool
5. Straining with stools can lead to pelvic floor dysfunction and increase the risk of prolapse
6. Bristol stool scale helps to understand the consistency of stool and relation to constipation. As if you have bowel movement everyday does not mean you are not constipated. Bristol stool scale 1-2 is considered as constipation, 3-4 is considered as normal bowel movement as long as the person is not straining while doing bowel movement, 5-7 is considered as diarrhea

The restrictions of fascia around the bladder can cause

The image is taken from Grey’s Anatomy

1. Increase in urinary urgency and frequency
2. Bladder fascia shares the fascia with pelvic floor through urethra and it can cause stress/urge or both urinary incontinence.
3. Bladder fascia also shares the fascia with obturator foramen where obturator internus muscle attaches. Obturator internus muscle is one of the major rotator muscles of the hip. Restrictions of bladder fascia can affect the mobility/mechanics of the hip and also can cause pain. Many women with hip pain without any pathology might have a connection to the bladder fascia. They always have one of the bladder symptoms such as urgency/frequency/burning of urination or incontinence.

• Anatomically small intestine sits on the bladder. The small intestine moves up and allows the bladder to fill. If the fascial mobility of the small intestine is limited or if the small intestine has descended, the bladder does not get enough room to fill and that leads to increase in urgency and frequency.

• The image is taken from Sloan Kettering Institute – research 
• The diaphragm and pelvic floor work as a piston during the breathing. When we breathe in, the diaphragm moves down along with the pelvic floor and when we breathe out they both move up. Breathing mechanics is very important for pressure mechanics- that means it provides stability, keeps the organ continence, pelvic floor function, lymphatic draining, and reduces the strain on joints. The factors can affect the breathing mechanics

1. Abdominal fascial restrictions
2. Shallow breathing from pain
3. Decreased mobility of fascia of diaphragm/pelvic floor

• The image is taken from Grey’s Anatomy
• The restriction of fascia can affect the circulation and lymphatic drainage. Many women have pelvic congestion and also swelling of vulva and itching.

How can Physical Therapy help?

Goals of Physical Therapy are

• Reduction of pain
• Improve posture
• Improve mobility of muscle/fascia and organ to improve biomechanics and movement of the body
• Improve circulation and lymphatic drainage

The Physical Therapist have to perform detailed evaluation on fascial mobility, joint mechanics, muscle guarding pattern, posture, any swelling or signs of congestion, bowel and bladder function, sexual function, pelvic floor muscle function, lumbar spine/sacroiliac joint mobility and stability, breathing mechanics, load transfer, and central sensatization. I have found great success with fascia mobilization on abdomen/chest wall/diaphragm, and around the abdominal organ/pelvic floor muscles to reduce pain, improve mobility, circulation, breathing mechanics, bowel/bladder function and overall well being.

About the author

The author of this article, Neha Golwala, PT, DPT  is a vetted endometriosis physical therapist. With more than 10 years of experience, she works at Zuppa Physical Therapy P.C. in New York. Neha uses manual therapy techniques including myofascial release, joint mobs, and neurominetic energy. She is an expert in the development of posture awareness and connecting mind to body to recover from injuries and prevent injuries and improve performance.

3 years ago Endometriosis , Endometriosis Education

Pelvic Congestion Syndrome- another cause of chronic pelvic pain

When talking about endometriosis and chronic pelvic pain, it is important to remember that often endometriosis is not the only pelvic pain generator. Another possible contributor to chronic pelvic pain is pelvic congestion syndrome (PCS). “Pelvic congestion syndrome (PCS) accounts for up to 30% of patients presenting with chronic pelvic pain” (Reardon & Dillavou, 2021). There isn’t a significant amount of data about endometriosis and PCS, but one study found “the prevalence of ovarian varices in patients with endometriosis was 80%, whereas the control group was only 26.1%” (Pacheco & de Oliveira, 2016).

PCS is like having varicose veins in the pelvis. Blood pulls in the veins and can cause symptoms such as heaviness, pain with penetration, noncyclical pain, positional lower back pain, pelvic and upper thigh pain, prolonged postcoital discomfort, symptoms that worsen throughout the day and are exacerbated by activity or prolonged standing, and non-specific lower abdominal and pelvic pain (Durham & Machan, 2013; Mistry & le Roux, 2017). The cause of PCS is not clear, but it is associated with obstructions such as iliac vein compression (i.e., MTS) or left renal vein compression (i.e., Nutcracker syndrome) (Reardon & Dillavou, 2021).

For more information see: https://icarebetter.com/pelvic-congestion-syndrome/

References

Durham, J. D., & Machan, L. (2013, December). Pelvic congestion syndrome. In Seminars in interventional radiology (Vol. 30, No. 04, pp. 372-380). Thieme Medical Publishers. Retrieved from https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0033-1359731

LIANG, D. E., & Brown, B. (2021). Pelvic congestion syndrome: Are we missing the diagnosis?. The Medical Republic. Retrieved from https://www.sydneyfibroidclinic.com.au/app/uploads/2021/06/PCS-Medical-Republic.pdf

Mistry, P. P., & le Roux, D. A. (2017). Pelvic congestion syndrome (PCS). Practice Perspectives for Venous Disorders, 46. Retrieved from http://www.vascularsociety.co.za/wp-content/uploads/2019/02/VASSA-venous-guidelines-Practice-perspectives-for-venous-disorders-2017.pdf#page=46

Pacheco, K. G., & de Oliveira, M. R. F. (2016). The prevalence of ovarian varices in patients with endometriosis. Annals of Vascular Surgery, 34, 135-143. https://www.annalsofvascularsurgery.com/article/S0890-5096(16)30232-1/fulltext

Reardon, E. S., & Dillavou, E. D. (2021). Venous disease—What we still do not know. In Vascular Disease in Women (pp. 157-163). Academic Press. https://www.sciencedirect.com/science/article/pii/B9780128229590000031

3 years ago Endometriosis , Endometriosis Education

Fibroids

We have been looking at some of the related conditions that can cause overlapping symptoms with endometriosis. This is important because, if you only treat one condition and not the others, this can lead to continued symptoms and a great deal of discouragement. Another condition with overlapping symptoms with endometriosis is uterine fibroids (leiomyomas).

Fibroids are benign tumors of the smooth muscle cells of the uterus with symptoms that can range from being asymptomatic to having “abnormal uterine bleeding, specifically in terms of heavy and prolonged bleeding” as well as pain with penetration and non-cyclic pelvic pain (Zimmermann et al., 2012). They can also affect fertility and cause urinary dysfunction (Fortin, Flyckt, & Falcone, 2018).

There has not been much research on the correlation between endometriosis and fibroids. One study reports “an incidence of concomitant fibroids and endometriosis ranging between 12 and 20%, based on 2 previously published studies” (Nezhat et al., 2016). A small study that looked at patients with abnormal uterine bleeding found that “of the 208 patients with the presenting chief concern of symptomatic leiomyoma and who underwent surgical therapy, 181 had concomitant diagnoses of leiomyoma and endometriosis” (Nezhat et al., 2016). Another study looking at those with infertility found (by using ultrasound findings) the “diagnosis of fibroids was made in 3.1% of cases, adenomyosis was found in 21.2%, and the co-existence of both uterine disorders with endometriosis was reported in 14.6% of patients” (Capezzuoli et al., 2020). Nezhat et al. (2016) states that “because of the significant overlap of symptoms, it is often difficult to discern which pathology is responsible for the patient’s complaints” and recommends “a high level of suspicion for endometriosis before and during surgery in these women, with the goal of treating both pathologies in a single surgery.”

For more information see: https://icarebetter.com/fibroids/

References

Capezzuoli, T., Vannuccini, S., Fantappiè, G., Orlandi, G., Rizzello, F., Coccia, M. E., & Petraglia, F. (2020). Ultrasound findings in infertile women with endometriosis: evidence of concomitant uterine disorders. Gynecological Endocrinology, 36(9), 808-812. https://doi.org/10.1080/09513590.2020.1736027

Fortin, C., Flyckt, R., & Falcone, T. (2018). Alternatives to hysterectomy: the burden of fibroids and the quality of life. Best Practice & Research Clinical Obstetrics & Gynaecology, 46, 31-42. https://www.sciencedirect.com/science/article/abs/pii/S1521693417301487

Nezhat, C., Li, A., Abed, S., Balassiano, E., Soliemannjad, R., Nezhat, A., … & Nezhat, F. (2016). Strong association between endometriosis and symptomatic leiomyomas. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 20(3). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5019190/

Zimmermann, A., Bernuit, D., Gerlinger, C., Schaefers, M., & Geppert, K. (2012). Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women. BMC women’s health, 12(1), 1-11. https://link.springer.com/article/10.1186/1472-6874-12-6

3 years ago Endometriosis , Endometriosis Education

Endometrial Polyps

The last couple of weeks, we have seen that adenomyosis and interstitial cystitis are found frequently in those with endometriosis and can cause similar symptoms. Another finding noted in those with endometriosis is endometrial (uterine) polyps. One meta-analysis found a significantly higher risk of endometrial polyps (EP) in those with endometriosis (Zheng et al., 2015). These polyps are overgrowths of endometrial glands and stroma (Zheng et al., 2015). While they may not cause any symptoms, they can cause abnormal menstrual bleeding, bleeding between menstrual periods, vaginal bleeding after menopause, and might affect fertility.

Zheng et al. (2015) notes that, like in endometriosis, the expression of estrogen receptors and aromatase (an enzyme that converts androgens to estrogens) is altered in endometrial polyps and can increase the local concentration of estrogen. The authors suggest that “it is important to determine whether patients with endometriosis also have EP and then remove any coexisting EP via hysteroscopy, especially for infertile patients” (Zheng et al., 2015).

For more information on endometrial polyps, see: https://icarebetter.com/endometrial_uterine-polyps/

Reference

Zheng, Q. M., Mao, H. L., Zhao, Y. J., Zhao, J., Wei, X., & Liu, P. S. (2015). Risk of endometrial polyps in women with endometriosis: a meta-analysis. Reproductive biology and endocrinology, 13(1), 1-9. https://link.springer.com/article/10.1186/s12958-015-0092-2

3 years ago Endometriosis , Endometriosis Education

Interstitial cystitis- “evil twin” of endometriosis

Last week, we noted that adenomyosis can frequently coexist in people with endometriosis. Another one of those conditions that can frequently coexist with endometriosis, aptly named the “evil twin” to endometriosis, is interstitial cystitis (IC) (also called painful bladder syndrome). The walls of the bladder become inflamed or irritated, resulting in symptoms similar to a bladder infection, such as urinary urgency and/or frequency, painful urination, and pelvic pain (Al-Shaiji et al., 2021). However, in IC, there is no infection, and the symptoms can often be exacerbated during the time around menses (Al-Shaiji et al., 2021).

Endometriosis and IC can both be found in 80% of people with chronic pelvic pain (Al-Shaiji et al., 2021). Like endometriosis, it can take several years for a diagnosis of IC to be made (Al-Shaiji et al., 2021). It is important to consider this condition when looking at treatments for chronic pelvic pain. Al-Shaiji et al. (2021) reports that “up to 25%–40% of patients who undergo hysterectomy as a treatment of CPP will continue to have pain postoperatively.”  Al-Shaiji et al. (2021) also cites another study that discovered that “IC was found in 79% of the patients” who had persistent pelvic pain after a hysterectomy (who were subsequently treated for IC and had improvements in their symptoms). Al-Shaiji et al. (2021) concluded that it is important to look beyond endometriosis as the only cause of a person’s pelvic pain, especially if previous treatments have been ineffective.

For more information on IC, see: https://icarebetter.com/interstitial-cystitis_bladder-pain-syndrome-by-susan-pierce-richards/

Reference

Al-Shaiji, T. F., Alshammaa, D. H., Al-Mansouri, M. M., & Al-Terki, A. E. (2021). Association of endometriosis with interstitial cystitis in chronic pelvic pain syndrome: Short narrative on prevalence, diagnostic limitations, and clinical implications. Qatar Medical Journal, 2021(3), 50. https://doi.org/10.5339/qmj.2021.50

3 years ago Endometriosis , Endometriosis Education

Adenomyosis- sister to endometriosis

Endometriosis is often found along with other conditions that can cause similar symptoms (see Related Conditions). One of those conditions is called adenomyosis, where endometrial glands and stroma invade the muscular part of the uterine wall (Gracia et al., 2022). Vannuccini and Petraglia  (2019) report that “adenomyosis and endometriosis share a number of features, so that for many years adenomyosis has been called endometriosis interna,” but the authors go on to point out that “nevertheless, they are considered two different entities.” Adenomyosis is found in those with endometriosis anywhere from 20-80% of the time (Vannuccini & Petraglia, 2019)!

Both conditions share similar symptoms, such as painful periods and abnormal uterine bleeding. This is important to keep in mind when looking at treatment options as it has been seen that “after surgical treatment…pelvic pain and abnormal uterine bleeding (AUB) were significantly more likely to persist with the presence of adenomyosis” (Gracia et al., 2022). Vannuccini and Petraglia  (2019)  also found this- noting that “on ultrasound pre-operative assessment, 47.8% of patients undergoing surgery for [deep infiltrating endometriosis] were affected by adenomyosis, and in those affected by both conditions, the surgical treatment was not as effective in treating pain as it was in those with only endometriosis.” The ability to diagnose adenomyosis with magnetic resonance imaging and/or transvaginal ultrasound (versus only after a hysterectomy) has made it easier to plan prior to surgery and adjust expectations.  

When looking at treating chronic pelvic pain, it is important to note that endometriosis often coexists with several other conditions that can cause similar symptoms. These other conditions, if left untreated, can continue to cause symptoms, which can lead to a great deal of discouragement if you are not aware.

For more information on adenomyosis, see: https://icarebetter.com/adenomyosis/

References

Vannuccini, S., & Petraglia, F. (2019). Recent advances in understanding and managing adenomyosis. F1000Research, 8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6419978/

Loring, M., Chen, T. Y., & Isaacson, K. B. (2021). A Systematic review of adenomyosis: It is time to reassess what we thought we knew about the disease. Journal of minimally invasive gynecology, 28(3), 644-655. https://www.sciencedirect.com/science/article/pii/S1553465020311006

Gracia, M., de Guirior, C., Valdés-Bango, M., Rius, M., Ros, C., Matas, I., … & Carmona, F. (2022). Adenomyosis is an independent risk factor for complications in deep endometriosis laparoscopic surgery. Scientific Reports, 12(1), 1-8. https://www.nature.com/articles/s41598-022-11179-8

3 years ago Endometriosis , Endometriosis Education

Teens with endometriosis

Endometriosis in adolescents was recently reviewed by Liakopoulou et al. (2022), and they report that “adolescent endometriosis is a challenging diagnosis” and that “the disease can be easily overlooked”- thus the true incidence of endometriosis in teens is not really known. The diagnosis in teens is often delayed which “can lead to suffering for several years.” The authors state that “consequently, early diagnosis appears to be of upmost importance, especially as far as adolescents and young patients are concerned, as it can optimize life quality, relief symptomatology, and decrease the negative impact of the disease on future fertility.”

To achieve earlier diagnosis, the authors suggest that “further evaluation should be considered when prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) is reported by the patient, there are relatives diagnosed with endometriosis (in cases of frequent absenteeism from everyday activities during menstruation), and estroprogestin contraceptives have been prescribed before the age of 18 years for primary dysmenorrhea treatment.” They report that “ACOG recommends laparoscopy for diagnosing endometriosis in adolescents” and that “diagnostic laparoscopy is indicated if there is no relief after 3–6 months of medical management.” The authors do report that ultrasounds and MRI’s may be utilized, but that normal imaging doesn’t rule out endometriosis. The authors state that “the benefits of laparoscopy do not only include the confirmation of diagnosis, but also the opportunity of intraoperative treatment.” But the ability to identify endometriosis is important as “during laparoscopy, endometriosis may have a variable appearance.” In adolescents, they report that “white, yellow-brown, red-pink lesions, as well as clear shiny vesicular lesions, are more frequent” and are “associated with greater levels of pain.” The authors also advise that “if suspicious lesions are not identified during laparoscopy, random biopsies of the cul-de-sac should be obtained.” The authors also remind us that “most adolescents present with stage I–II disease; however, advanced stage III–IV disease, including ovarian endometriomas, is increasingly diagnosed in adolescents” and that “the stage and location of the lesions do not directly corelate with the severity or frequency of symptoms.”

The authors note that to help with symptom relief “continuous hormonal therapy can be used to suppress menstruation and is considered safe.” But they report that the use of “gonadotropin releasing hormone (GnRH) agonist or antagonist is not recommended in adolescents with chronic pelvic pain and suspected endometriosis, due to potential impact on bone density.” If GnRH agonists are used, they state that the use “cannot exceed short periods of time, as long-term use may lead to bone density loss and potentially affect negatively cardiovascular risk.” They also caution that “GnRH agonists, when administered before surgery, change the macroscopic image of endometriotic lesions, make their visualization harder, and, thus, preclude effective surgical treatment.” They also state that “depot medroxyprogesterone acetate (DMPA) use is limited, due its association with lower bone mineral density” as well.

Reference

Liakopoulou, M. K., Tsarna, E., Eleftheriades, A., Arapaki, A., Toutoudaki, K., & Christopoulos, P. (2022). Medical and Behavioral Aspects of Adolescent Endometriosis: A Review of the Literature. Children, 9(3), 384. https://www.mdpi.com/2227-9067/9/3/384/htm

3 years ago Endometriosis , Endometriosis Education

Endometriosis and early menopause

Is there an association between endometriosis and early menopause? Kulkarni et al. (2022) looked this question and found that there just might be. The authors state that early natural menopause (ENM) is the cessation of ovarian function before age 45 years. They report that endometriomas in particular (and some treatments for them) might affect ovarian reserves which could lead to earlier onset of menopause. The authors also note that the increase in inflammatory markers in the peritoneal fluid of those with endometriosis might affect follicular and ovarian function (thus leading to earlier menopause).

The authors report that “in this large, prospective cohort study, we observed that surgically confirmed endometriosis was associated with a significantly greater risk of ENM.” They noted the highest risk for ENM was among those who never used oral contraceptives (OC) or had never given birth (more ovulations throughout the lifetime that used up the number of oocytes at that were present at birth). The authors further comment that “although a meta-analysis found an association between OC use and later age at natural menopause, a recent discovery in the Nurses’ Health Study II population did not support a clear association between duration of OC use (decreasing lifetime number of ovulatory cycles) and risk for ENM.” In the study performed by Kulkarni et al (2022), they did find that “among participants who never used OCs, endometriosis was associated with a 2-fold greater risk for ENM.” The authors comment that “it is likely that OC use masks menopause, which is important to consider in this analysis particularly because women may use OCs to control endometriosis-associated symptoms.”

In the end, the researchers concluded that “endometriosis may be an important risk factor for ENM, and women with endometriosis, particularly those who are nulliparous and never-users of OCs, may be at a higher risk for a shortened reproductive duration.” Early menopause is important because it has an affect on osteoporosis, cardiovascular health, and other aspects of health.

Reference

Kulkarni, M. T., Shafrir, A., Farland, L. V., Terry, K. L., Whitcomb, B. W., Eliassen, A. H., … & Missmer, S. A. (2022). Association Between Laparoscopically Confirmed Endometriosis and Risk of Early Natural Menopause. JAMA Network Open, 5(1), e2144391-e2144391. https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2788287

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