Hanáček Jiří
Ústav pro péči o matku a dítě
definition
 permanent or intermittent pain or a feeling of
discomfort
 localized to the pelvis or lower abdomen,
which is not tied to menstruation or sexual
intercourse for more than 6 months
synonym
 pelvic pain syndrome (PPS), pelvic pain,
pelipathia,
 chronic pelvic pain (CPP), pelvialgie
 Difficult
rating due to unclear and
inconsistent terminology
 According
of 14.7%
to Gallop Institute prevalence
 In
U.S. CPP indication in 25 to 35% for
laparoscopy
 In U.S. CPP indication in 10 to 15% for
hysterectomy
 Patients with CPP are 4 to 5 times more
often operated than women without
difficulty
 Dependence
on age 18 to 30 years 44 to 49% ,
from 31 to 40 years 22 to 28% , 41-45 years 37%
 Max. 27 to 29 years (Jamieson et al., Obstet.
Gynec.1996)
 Dependence between education, education
and socio-economic situation has not been
demonstrated (Mathias et al.
Obstet.Gynec.1996)
 The average length of difficulties - 2.5 years
 First
described in 1860 (Rokitansky)
 The presence of functional endometrial
glands and stroma outside their usual
localization
 Histopathological definition requires a
hemorrhage and fibrous reaction around
glands
inflitrate
fibrosis
 The
character of progressive malignant
disease metastatic
 Character - Invasive,
monoclonal,multiorgan deterioration
 Invasive disease associated with a small
but defined risk of malignant progression

(Garry, Gyn.Endoscop., 2001,10,79-82)
 Is
Endometriosis primarily a disease or
physiological process that under certain
conditions progresses with typical
symptoms?
 ¼ - patients regression, ½ - progression,
¼ - stationary
 Random
occurrence in 4.1 - 22% of women with
tubal sterilization (Evers 1996)
 Prevalence in the population and 50% (Olive,
1993)
 Prevalence of 25% (4.5 - 82%) women
diagnosed with pelvic pain
 Prevalence of 20% (2,1-78%) infertile women
 The youngest patient with endometriosis 10.5
years, the oldest 78 years
 A. Dissemination
of endometrial cells
- transport respectively. implantation
– lymphatic dissemination
- vascular dissemination –
- iatrogenic
- angiogenic
 B. metaplastic
-
celomic metaplasia
 - Müller embryonic cell debris
 - induction




genetic
immunological
toxic
hormonal
 Pain
in the lower abdomen (deep
deposits) - dysmenorhoe (60-80%) dyspareunia (25-50%) - chronic pelvic
pain (30-50%)

Sterility - (12-40%) (surface deposits)

Tumour - (10%)

abnormal bleeding

Extragenitální symptoms - the
incidence of bowel loops, lung, bladder
 History
 Pain
and its characteristics
 Gynecological
examination, examination
in mirrors
•
Imaging techniques
 Laboratory
examination - no known specific
marker of endometriosis (TNF-α, Ca-125)
 Imaging techniques transvaginal sonography
 endorectal sonography
 NMR
 CT
 colonoscopy
 IVU
 Laparoscopy
- the "golden standard"
 Better visualization than with laparotomy
(infertility - timing in LUT. Stage)
 Histological examination excidid leasions
 Character - peritoneal, retroperitoneal
bearings - adhesions - nodular deposits endometrioms
 Problem of endoscopy - identification of
lesions photodynamic diagnosis.
 Specificity 94%, sensitivity 60%
A
different mechanism of three forms
 Explanation of the mechanism of peritoneal
endometriosis = Transplantation
 Ovarian endometriosis = celomic metaplasia of
invaginated ovarian surface
 Rectovaginal endometriosis and adenomyosis=
reminds metaplasia is the result of the rest of
the Müllerian ducts
 uterine adenomyosis
Peritoneální endometrióza - podobnost mezi eutopickým proliferačním
endometriem a červenou peritoneální lézí (časné stadium)
ÚPMD 2006
Pokročilé stadium - černá ložiska, důsledek částečného
odlučování v závislosti na cyklu
Fibrotizace - redukce vaskularizace – tvorba bílých plaků, jizev či srůstů
 probably
metaplasia invaginovaného
coelomového epithelial ovarian cortex
(Hughesdon, Donnez)
 invaginated cortex around primordial follicles,
frequent occurrence of cysts corpuslutel
 - Superficial hemorrhagic lesions hemorrhagic cysts - deep infiltrating
endometriosis ovarian
 Hyperplasia of smooth muscle in the deeper
layers of the ovarian cortex
 High degree of resistance to hormone therapy
probably result from metaplasia Müllerian ducts in
rectovaginal septum
 increased production of smooth muscle in the area and
the creation of nodes in rectovaginal septum endometrial glands, scanty stroma, smooth muscle
similarities adenomyosis
 low E and P receptors
 resistance to hormonal therapy
 leasions at 5-6 mm depth is morphologically distinct
from superficial endometriosis - more frequent active
form E

 Is
it possible to surgically remove all leasionss?
 Does it make sense prophylactic therapy in
young women?
 Necessary to take the patient wishes to become
pregnant, the quality of her life, family
environment ...
 1.Conservative
 2. Surgery
 3. Combination
 symptomatic
treatment
 hormonal modulation
 hormonal suppression
 Antiprogestins
 aromatase inhibitors
 growth factors
 immunological treatment
 Excision
of peritoneal deposits,
adheziolysis
 Resection or extirpation of
endometriomas
 Salpingo-oophorectomy, ovariectomy
 Removal of tubal endometriosis
 Rectovaginal septum resection
 Infiltrative bowel resection and ureteral
endometriosis resection
 Necessary
is complete surgical removal
of endometrial deposits beyond the
lesion and histological verification of
diagnosis this tend to:
 pain relief
 restore fertility
 prevent progression and recurrence
 Significant effect dependence on the
person of the surgeon!
MUDr Hanáček Jiří