Location of lesions and where pain is felt

Endometriosis lesions in different locations may cause different symptoms. Often the symptoms are referred pain (pain in a different place than where the endometriosis lesion is located). There is also some information about central sensitization. 

Overview

• Foti, P. V., Farina, R., Palmucci, S., Vizzini, I. A. A., Libertini, N., Coronella, M., … & Milone, P. (2018). Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights into imaging, 9(2), 149-172. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5893487/?fbclid=IwAR1pNnmH35Jukt-7gBv3d7DSEkq8i_uz1BwRGuDqOy61QGoWYmwYvT9Jo9I 

  “Clinical manifestations depend on the anatomic locations of the disease.

• Bladder: dysuria, gross hematuria during menses, irritative voiding symptoms, urgency, frequent urination, urinary storage symptoms, tenesmus, burning sensation, suprapubic discomfort and pain, urinary incontinence [2, 3, 15].
• Ureters: dysmenorrhea, dyspareunia, urinary symptoms, hydronephrosis, flank pain, decline of renal function [2, 3].
• Round ligaments: painful, palpable inguinal mass (extra-pelvic portion of the ligaments); nonspecific pelvic pain (intra-pelvic portion) [11].
• Retrocervical region and uterosacral ligaments: severe and painful symptoms, dyspareunia [3].
• Vagina: dysmenorrhea, dyspareunia, postcoital spotting, prolonged menstruation not responding to medical therapy leading to anaemia [3, 16].
• Rectosigmoid colon: cyclic pain during defecation, dyschezia, cyclic hematochezia, bloating, constipation, bowel cramping, catamenial diarrhoea, pencil-like stools, bowel obstruction [2, 3, 12, 17].
• When unusual locations outside the pelvis occur, the pain may be site specific.
• Thoracic-diaphragmatic endometriosis: chest pain (diffuse or basithoracic) with right-sided predominance, scapular or cervical pain associated with menses, sometimes radiating to the arm, pneumothorax, dyspnea, hemoptysis [18–20].
• Sciatic nerve: cyclic sciatica, back pain, gluteal pain radiating to the dorsal thigh and lateral lower leg, positive Lasègue’s sign, sensory loss, reflex alterations, muscle weakness, paresis [2, 21–23].”
• Riazi, H., Tehranian, N., Ziaei, S., Mohammadi, E., Hajizadeh, E., & Montazeri, A. (2015). Clinical diagnosis of pelvic endometriosis: a scoping review. BMC women’s health, 15(1), 39. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450847/pdf/12905_2015_Article_196.pdf 

“Clinical diagnosis by signs obtained from physical examination: Clinical signs of the disease that identified by physical examination (pelvic examination by inspection and palpation) included a broad range of signs. External genitalia and the vaginal surface were usually unremarkable [15]. Findings of physical examination are listed as follows:

• External genitalia: Visible red, blue, or hemorrhagic nodules on the external genitalia [21].
• Vagina: Visible red, blue, or hemorrhagic nodules on the vagina, and tender masses, nodules, and fibrosis on palpation of the upper vagina [8,15-17,21].
• Cervix: Visible lesions on the cervix, tenderness on cervical movement, lateral cervical displacement, and cervical stenosis [15,16,19,21,37].
• Uterus: A fixed (decreased or absent mobility) and retroverted uterus, and uterine motion tenderness in pelvic examination [8,15-17,19,21,24].
• Adnexa: Tender or fixed adnexal masses resulting from endometriomas, adnexal enlargement, and pelvic masses [8,14,17,19,21].
• Posterior vaginal fornix: Tender nodules in the posterior vaginal fornix, bluish implants typical of endometriosis or red, hypertrophic lesions bleeding on contact [15,17].
• Pouch of Douglas: Fullness or mass or nodularity or pain in the pouch of Douglas, local tenderness or palpable tender nodules in cul de sac [8,14,16,19,30].
• Rectovaginal septum: Tender masses, nodules, and fibrosis of the rectovaginal septum [15,19-21,37].
• Uterosacral ligament: Thickening, pain or tenderness or nodularity in uterosacral ligament [8,14-16,19,21,24,30].”
• Demco, L. (2000). Review of pain associated with minimal endometriosis. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 4(1), 5. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015350/ 

“What is most interesting is that right-left orientation of the pelvis does not exist in some patients. That is to say, palpation of a lesion of endometriosis on the left side of the pelvis may produce pain that the patient perceives as being on the right side of the abdomen, and the opposite is also true.”   

Low back pain and Sciatic nerve pain (sciatica)

• Case Study of Sciatic Endometriosis:

Possover, M. (2017). Five-year follow-up after laparoscopic large nerve resection for deep infiltrating sciatic nerve endometriosis. Journal of minimally invasive gynecology, 24(5), 822-826. Retrieved from https://www.jmig.org/article/S1553-4650(17)30260-1/fulltext?fbclid=IwAR1OzlK62hXEY-TFBIx9flq10cgSjxLLyTOUAMqp0zyo3FBW3v2fgqE3dGA 

“In deep infiltrating intraneural endometriosis of the sciatic nerve, patients present with motor disorders before and after surgical resection. The average VAS score was reduced from 9.33 preoperatively to 1.25 at a 3-year follow-up. When full resection of endometriosis including nerve resection is completed, sciatic nerve function recover, but recovery of a normal gait may take at least 3 years and intensive physiotherapy.”

• Case study of Sciatica and Back pain due to endometriosis:

Uppal, J., Sobotka, S., & Jenkins III, A. L. (2017). Cyclic sciatica and back pain responds to treatment of underlying endometriosis: case illustration. World Neurosurgery, 97, 760-e1. Retrieved from https://doi.org/10.1016/j.wneu.2016.09.111 

“We report on a 39-year-old gymnast with cyclic sciatica and back pain, whose initial presentation initially led to a spinal fusion at L4/5 and L5/S1, but that procedure did not change her symptoms. Her diagnosis of endometriosis was not made until 2 years after her spinal fusion. Ultimately, once diagnosed with endometriosis of the retroperitoneal spinal and neural elements, her back and leg pain responded completely to hormonal therapy and then to a hysterectomy and a bilateral salpingo-oophorectomy. Because her true diagnosis of endometriosis was unknown and she had some degenerative changes in her spine, she underwent a spinal fusion that would probably not have been done if the diagnosis of endometriosis had been suggested.”

• Case Study Low Back Pain due to spinal endometriosis:

Dongxu, Z., Fei, Y., Xing, X., Bo-Yin, Z., & Qingsan, Z. (2014). Low back pain tied to spinal endometriosis. European Spine Journal, 23(2), 214-217. Retrieved from https://pubmed.ncbi.nlm.nih.gov/24531988/ 

“A 33-year-old woman presented with severe low back pain. She had the low back pain periodically for 3 years, and the pain was associated with menstruation. Radiographs showed a lesion in the posterior L3 body. After surgery, tissue biopsy indicated the presence of endometrial tissue in the lesion and thus confirmed endometriosis.”

• Surgical video of “Endometriosis of the Sciatic Nerve with large infiltration of the pelvic sidewall”

Links:

• “Endometriosis in and around the nerves – What can be done?”
• “Treatment of endometriosis of the sciatic nerve at the Zuerich International Endometriosis Center”
• “Sensitization in Chronic Pain: Pain itself can change how pain works, resulting in more pain with less provocation”