Quality of life and sexual function 1 year after laparoscopic rectosigmoid resection for endometriosis

Measurement properties of sexual function assessment questionnaires in women with endometriosis: A systematic review following COSMIN guidelines

INTRODUCTION

Sexual function of patients with endometriosis should be assessed by patient-reported outcome measures (PROMs) that present high reliability and validity. The objective was to study the PROMs used to assess sexual function for patients with endometriosis to improve their selection for research and clinical practice.

MATERIAL AND METHODS

We performed a systematic literature review from January 2000 to September 2023. All studies including women with confirmed endometriosis and assessing sexual quality of life or sexual function or sexual distress were retrieved. Different properties of PROMs used for sexual dysfunction were assessed according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) recommendations. Properties evaluated were: structural validity, internal consistency, cross-cultural validity, reliability, measurement error, criterion validity, construct validity, and responsiveness. This literature review was registered on Prospero as 2018 CRD42018102278.

RESULTS

Seventy-four articles with evaluation of sexual function were included. Of the 25 PROMs assessing sexual function, the Female Sexual Function Index (FSFI) was the most frequently used (34/74 [45.9%] items), followed by the Female Sexual Distress Scale (9/74 [12.2%] items) and the Sexual Activity Questionnaire (SAQ) (8/74 [10.8%] items). The most commonly used measurement properties were "hypothesis testing" and "responsiveness". The PROMs with a high level of evidence for these two measurement properties were the FSFI, the SAQ, the Short Sexual Functioning Scale, the Sexual Satisfaction Scale for Women, Sexual Quality of Life-Female, the Brief Profile of Female Sexual Function, and the Sexual Health Outcomes in Women Questionnaire. The FSFI questionnaire appeared to be more relevant for evaluating medical treatment, and the SAQ for evaluating surgical treatment. Only one instrument was specific to endometriosis (the Subjective Impact of Dyspareunia Inventory [SIDI]).

CONCLUSIONS

In this systematic literature review of sexual function assessment questionnaires in endometriosis, the FSFI and the SAQ questionnaires emerged as having the best measurement properties according to the COSMIN criteria. The FSFI questionnaire appears to be suited for evaluating medical treatment, and the SAQ for surgical treatment. The SIDI is the only specific questionnaire, but its responsiveness remains to be defined.

Early Quality of Life Assessment After Segmental Colorectal Resection for Deep Infiltrating Endometriosis

STUDY OBJECTIVE

Endometriosis is a benign condition afflicting women of reproductive age that significantly impacts their quality of life (QoL). Given its debilitating symptoms and prevalence, it is essential to define its proper management. In this study, we have assessed patient-reported outcomes among women having undergone segmental colorectal resection for deep infiltrating endometriosis. Any correlation between preoperative nutritional status and overall postoperative complications has also been analyzed.

STUDY DESIGN

Prospective observational study.

SETTING

Public medical center.

PATIENTS

One hundred forty consecutive patients that had undergone segmental colorectal resection for DIE between November 2020 and October 2021 at IRCCS Sacro Cuore Don Calabria Hospital of Negrar of Valpolicella (Verona, Italy).

INTERVENTIONS

Patient-reported outcomes were measured using data collected from the MD Anderson Symptom Inventory for gastrointestinal surgery patients and Euro-QoL Group EQ-5D-5L (EQ-5Q-5L) questionnaires, which were administered preoperatively (T0), at discharge (T1) and at 4 to 6 weeks after surgery (T2). Nutritional status was examined through the Mini Nutritional Assessment Short form and Prognostic Nutritional Index.

MEASUREMENTS AND MAIN RESULTS

A significant improvement in the EQ-5Q-5L and MDASI-GI scores was noted between T0 and T2 (p <. 001 and p <. 001, respectively.) No statistically significant differences were found in scores at T2 between patients who had experienced postoperative complications and those who had not. No statistically significant association was observed between the presence of malnutrition and overall postoperative complications and their severity.

CONCLUSION

This study confirms, through patient-reported outcomes, the pivotal role of surgery in improving the QoL at 4 to 6 weeks of women affected by endometriosis who have previously been unresponsive to medical therapy.

Laparoscopic natural orifice specimen extraction colectomy versus conventional laparoscopic colorectal resection in patients with rectal endometriosis: a randomized, controlled trial

BACKGROUND

The conventional laparoscopic approach for the surgical management of deep endometriosis (DE) infiltrating the rectum appears to ensure improved digestive functional outcomes. The natural orifice specimen extraction (NOSE) technique for the treatment of colorectal DE can significantly accelerate postoperative recovery; however, data on gastrointestinal function following conventional laparoscopic segmental bowel resection (CLR) compared with NOSE colectomy (NC) for DE are sparse.

MATERIALS AND METHODS

Between 30 September 2019 and 31 December 2020, a randomized, open-label, two-arm, parallel-group controlled trial with women aged 18-45 years was conducted at University Hospital.Ninety-nine patients were randomized to CLR or NC, with DE infiltrating at least the muscular layer, at least 50% of the circumference of the bowel, up to 15 cm from the anal verge, exhibiting pain and bowel symptoms and/or infertility. The primary endpoint was bowel function, represented by low anterior resection syndrome (LARS). Secondary parameters included the Endometriosis Health Profile 30 (EHP30), Gastrointestinal Quality of Life Index (GIQLI), Visual Analog Scale (VAS) scores preoperatively and at set times (1 and 6 months, 1 year) following surgery.

RESULTS

No significant differences were observed in the postoperative LARS scores, VAS, EHP30, and GIQLI between the NC and CLR groups. LARS scores did not reveal significant differences 12 months postoperatively compared to the preoperative values in both groups (CLR group P =0.93 versus NC group, P =0.87). GIQLI scores were significantly improved 12 months after the operation compared with baseline values in the CLR group ( P =0.002) and NC group ( P =0.001). Pain symptoms and quality of life scores significantly improved 12 months postoperatively in both groups.

CONCLUSIONS

NC is a feasible surgical approach for treating patients with rectal DE. Our study did not show a statistically significant difference between CLR and NC techniques in mid-term digestive and pain outcomes.

Sexual Function of Patients with Deep Endometriosis after Surgical Treatment: A Systematic Review

OBJECTIVE

 To review the current state of knowledge on the impact of the surgical treatment on the sexual function and dyspareunia of deep endometriosis patients.

DATA SOURCE

 A systematic review was conducted in accordance with the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We conducted systematic searches in the PubMed, EMBASE, LILACS, and Web of Science databases from inception until December 2022. The eligibility criteria were studies including: preoperative and postoperative comparative analyses; patients with a diagnosis of deep endometriosis; and questionnaires to measure sexual quality of life.

STUDY SELECTION

 Two reviewers screened and reviewed 1,100 full-text articles to analyze sexual function after the surgical treatment for deep endometriosis. The risk of bias was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Collaboration's tool for randomized controlled trials. The present study was registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration CRD42021289742).

DATA COLLECTION

 General variables about the studies, the surgical technique, complementary treatments, and questionnaires were inserted in an Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, United States) spreadsheet.

SYNTHESIS OF DATA

 We included 20 studies in which the videolaparoscopy technique was used for the excision of deep infiltrating endometriosis. A meta-analysis could not be performed due to the substantial heterogeneity among the studies. Classes III and IV of the revised American Fertility Society classification were predominant and multiple surgical techniques for the treatment of endometriosis were performed. Standardized and validated questionnaires were applied to evaluate sexual function.

CONCLUSION

 Laparoscopic surgery is a complex procedure that involves multiple organs, and it has been proved to be effective in improving sexual function and dyspareunia in women with deep infiltrating endometriosis.

Endometriosis Resection Using Nerve Sparing Versus Non-nerve Sparing Surgical Techniques

Introduction

Endometriosis is the condition in which there are ectopic endometrial tissues outside the uterine cavity. The use of nerve sparing technique has been well established in the field of oncology, leading to better quality of life following radical oncologic procedures without compromising on the long-term survival. The objective of this study is to compare the quality of life in terms of sexual function and urinary function in women undergoing nerve sparing surgeries for endometriosis and those undergoing non-nerve sparing surgeries.

Material and Methods

Data of 51 patients operated for endometriosis at Galaxy Care Laparoscopic Institute, Pune, India between 1st January 2020 till 31st December 2020 were collected and analysed. We included patients in age group between 38 and 44 years in monogamous relationship, with moderate to severe endometriosis (Revised American Society of Reproductive Medicine r-ASRM score of 16 and above 5), being operated for hysterectomy along with ureterolysis and/or bowel resection (including shaving of rectal endometriosis, discoid resection, segmental resection), and excision of large ovarian endometriomas (> 3 cm size) with cul-de-sac obliteration.

Results

The patients were evaluated for the following factors: age, parity, nature of surgery done, immediate intraoperative complications (bowel injury, bladder injury, ureteric injury), operative time in minutes, average blood loss, length of hospital stay, days to removal of foley's catheter and postoperative urinary and sexual function which were assessed on follow up visit and a 1-year follow up interview. We found that the urinary and sexual function in the group undergoing nerve sparing surgeries was significantly better than the patients undergoing non-nerve sparing surgeries.

Conclusion

Laparoscopic nerve sparing approach for clearance of endometriosis has allowed better quality of life post surgery. Proper understanding and demonstration of pelvic neuroanatomy has made this approach feasible and achievable in carefully selected patients.

Effect of sex education on sexual function and sexual quality of life in women with endometriosis: A quasi-experimental study

OBJECTIVE

To evaluate the effect of a sex education program on sexual function and sexual quality of life in women with endometriosis.

METHODS

In a quasi-experimental study, women with endometriosis who had undergone laparoscopic surgery were assigned to an intervention group (n = 36) or a control group (n = 36). The intervention group received a sex education program consisting of two sessions a week (90 min each) for two consecutive weeks; the control group received none. Both groups were followed for 12 weeks. Sexual function and sexual quality of life were assessed on the Female Sexual Function Index (FSFI) and the Sexual Quality of life-Female (SQOL-F) questionnaire before the intervention, as well as 8 and 12 weeks after the intervention. Outcomes were analyzed using Student t test, the χ² test, Fisher exact test, and repeated measures analysis of variance.

RESULTS

The mean age of the study participants was 36.9 ± 5.7 years. The two groups did not differ significantly in terms of demographics and pre-intervention clinical characteristics. At the end of the study, sex education reduced female sexual dysfunction by 58.1% in the intervention group. The mean FSFI score increased significantly in the intervention group from pre-intervention to 8 and 12 weeks post-intervention compared with the scores in the control group (P < 0.001).

CONCLUSIONS

Sex education appears to be a promising intervention for reducing sexual dysfunction and improving sexual function and sexual quality of life in women with endometriosis. Future studies should encompass longer periods of follow up to obtain further data on the efficacy of sex education in this setting.

Sexual Function of Women With Deep Endometriosis Before and After Surgery: A Prospective Study

BACKGROUND

Deep endometriosis (DE) may significantly affect women's quality of life. Limited data exists on the effect of surgery on the several domains of sexual function.

AIM

To prospectively compare various domains of sexual function before and after laparoscopic surgery for DE.

METHODS

A prospective observational cohort study in a tertiary university-affiliated referral center. Patients with suspected DE who were planned to undergo laparoscopic surgery completed the Female Sexual Function Index questionnaire before surgery. The same questionnaire was completed by the participants 6 weeks, 6 months, and 12 months after surgery. Rate of sexual dysfunction over time was compared using multilevel logistic regression. Summary scores were then compared at each time point to the corresponding score before surgery using multilevel linear regression. Multivariable analysis was performed of potential confounders.

OUTCOMES

Change in desire, arousal, orgasm, lubrication, satisfaction and pain summary scores as well as in the full-scale score between before and after surgery.

RESULTS

We followed 149 patients with surgically confirmed DE. Sexual dysfunction rate as per the full-scale score was 75.5% before surgery and remained over 60% to 12 months after. The full-scale sexual function score improved at 6 (change in score = 2.8 ± 9.5, P = .004) and 12 months (change in score = 2.1 ± 9.9, P = .03). None of the summary scores improved at 6 weeks. Desire score (P < .001), arousal score (P = .02), and pain score (P = .01) improved at 6 months. Desire score (P = .03) and pain score (P = .01) also improved at 12 months, as compared to before surgery. On multivariable multilevel analysis, scores before surgery significantly contributed to the scores after surgery (P < .001).

CLINICAL TRANSLATION

While sexual function improved after surgery, dysfunction rate remained substantial. Proper preoperative counseling should address sexual function measures and clinical and research attention should be given to seek ways to further reduce sexual dysfunction.

STRENGTHS AND LIMITATIONS

The main strengths of our study are the prospective design, the relatively long follow-up and the use of a detailed validated questionnaire allowing assessment of a large variety of clinically relevant sexual function domains and scores as well as a full-scale score. Among our limitations are the lower response rate at 12 months and the limited generalizability as this is a single center study.

CONCLUSION

Sexual function is a major and often under reported domain of quality of life. Further research is needed to identify the specific populations who may improve, not change or experience deterioration in their sexual functioning after surgery. Dior UP, Reddington C, Cheng C, et al. Sexual Function of Women With Deep Endometriosis Before and After Surgery: A Prospective Study. J Sex Med 2022;19:280-289.

Long-term Follow-up of Sexual Quality of Life after Laparoscopic Surgery in Patients with Deep Infiltrating Endometriosis

STUDY OBJECTIVE

We performed a long-term follow-up to quantify the impairment of sexual quality of life (SQL) and health-related QL (HRQL) in sexually active women after laparoscopic excision of deep infiltrating endometriosis (DIE).

DESIGN

Prospective case-control study.

SETTING

Hospital Clinic of Barcelona.

PATIENTS

A total of 193 patients (after dropout and exclusions) were divided into 2 groups: one hundred twenty-nine premenopausal women with DIE (DIE group) and 64 healthy women who underwent tubal ligation (C group).

INTERVENTIONS

All patients underwent laparoscopic surgery: laparoscopic endometriosis surgery in the DIE group and laparoscopic tubal ligation in the C group. All women were followed for at least 36 months, and they completed the Medical Outcomes Study 36-item short form questionnaire to assess their HRQL and 3 self-administered questionnaires that evaluate different aspects of SQL: the generic Sexual Quality of Life-Female questionnaire, the Female Sexual Distress Scale to evaluate "sexually related distress," and the Brief Profile of Female Sexual Function to screen hypoactive sexual desire disorder. The patients with DIE as well as the controls completed the 4 questionnaires before surgery, and the patients with DIE also completed the questionnaires at 6 and 36 months after surgery.

MEASUREMENTS AND MAIN RESULTS

A comparison of the patients and controls before surgery showed a statistically significant impairment in SQL and HRQL among the patients with DIE. A statistically significant improvement in SQL and HRQL was observed in the DIE group 6 months after surgery, with scores being similar to those of the C group. An evaluation 36 months after surgery showed that SQL and HRQL were better than presurgical SQL and HRQL in the DIE group, with a slight reduction compared with the 6-month evaluation.

CONCLUSION

SQL and HRQL improved in patients with DIE undergoing complete laparoscopic endometriosis resection and were comparable to those of healthy women at 6 months after surgery, showing a slight reduction at 36 months of follow-up.

Comparison of preoperative and postoperative sexual function in patients with deeply infiltrating endometriosis with and without bowel resection

OBJECTIVE

To analyze preoperative and postoperative sexual function following surgery for deeply infiltrating endometriosis (DIE) with and without bowel involvement.

STUDY DESIGN

Patients with DIE who underwent surgery between 2001 and 2011 with segmental bowel resection (WB) or without segmental bowel resection (WOB) were surveyed using the German version of the Massachusetts General Hospital Sexual Functioning Questionnaire (KFSP). Responses were given on a six-point scale for the items sexual interest, sexual arousal, orgasm, lubrication, and general sexual satisfaction. As there are no cut-off values for the existence of sexual function disorders, a control group with no history of endometriosis was evaluated. Differences between the preoperative and postoperative results, as well as between WB, WOB, and a control group, were compared using the Wilcoxon test, Mann-Whitney U test, and Fisher's exact test.

RESULTS

Eighty-nine patients without bowel resection (mean age 34.3 years; mean follow-up 63.2 months), 87 patients with bowel resection (mean age 37.7 years; mean follow-up 69.6 months), and 100 control patients aged 21-58 years (mean age 35.0 years) were evaluated. Preoperatively, both treatment groups had significantly poorer scores in all categories in comparison with the control group. The WOB group improved significantly in all categories postoperatively, with no further significant differences from the control group. No significant postoperative improvement was observed in the WB group, and the group had significantly poorer scores in comparison with the control group. The number of previous operations is associated with significantly poorer postoperative KFSP results. Sterility and age > 40 years are associated with significantly less improvement in the KFSP, although with lower initial values.

CONCLUSIONS

Patients with DIE with or without bowel involvement have significantly impaired sexual function preoperatively. Complete resection of endometriosis in the WOB group was able to improve sexual function, as the women had sexual scores similar to those in the healthy control group postoperatively. Possible explanations for the lack of postoperative improvement of sexual function after segmental bowel resection include the type of surgery carried out, or injury to the affected nerves resulting from the endometriosis.

Systematic review of quality of life measures in patients with endometriosis

OBJECTIVES

Endometriosis and quality of life has been the subject of much research, however, there is little consensus on how best to evaluate quality of life in endometriosis, resulting in many and diverse scales being used. In our study, we aim to identify quality of life scales used in endometriosis, to review their strengths and weaknesses and to establish what would define an ideal scale in the evaluation of endometriosis-related quality of life.

MATERIALS AND METHODS

A search of the MEDLINE and EMBASE databases was carried out for publications in English and French for the period from 1980 to February 2017, using the words 'endometriosis' and 'quality of life'. Publications were selected if they reported on quality of life in patients with endometriosis and specified use of a quality of life scale. A quantitative and a qualitative analysis of each scale was performed in order to establish the strengths and weaknesses for each scale (systematic registration number: PROSPERO 2014: CRD42014014210).

RESULTS

A total of 1538 articles publications were initially identified. After exclusion of duplicates and application of inclusion criteria, 201 studies were selected for analysis. The SF-36, a generic HRQoL measure, was found to be the most frequently used scale, followed by the EHP-30, a measure specific to endometriosis. Both perform well, when compared with other scales, with scale weaknesses offset by strengths. EHP-5 and EQ-5D also showed to be of good quality. All four were the only scales to report on MCID studied in endometriosis patients.

CONCLUSION

For clinical practice, routine evaluation of HRQOL in women with endometriosis is essential both for health-care providers and patients. Both SF-36 and EHP-30 perform better overall with regard to their strengths and weaknesses when compared to other scales.

LATE IMPACT OF THE LAPAROSCOPIC TREATMENT OF DEEP INFILTRATING ENDOMETRIOSIS WITH SEGMENTAL COLORECTAL RESECTION

BACKGROUND

Deep infiltrating colorectal endometriosis may severely affect the quality of life and fertility of patients. Although segmental resection is a therapeutic option that provides positive outcomes in the management of symptoms, its functional effects are still unproven.

AIM

Assess the late impact of the laparoscopic approach in treating deep infiltrating endometriosis with segmental colorectal resection.

METHODS

Prospective case series of 46 patients submitted to laparoscopic treatment of deep infiltrating endometriosis with segmental colorectal resection between 2013 and 2016. Fertility, gynecological and bowel symptoms were assessed at the preoperative period and at three and 12 months (or more) after the procedure.

RESULTS

Preoperative interview assessed the prevalence of infertility (45.6%), gynecological (87%) and intestinal (80.4%) symptoms. At the third month after the procedure a significant reduction in the prevalence of gynecological symptoms (p<0,001), tenesmus (p=0,001) and dysquesia (p=0,002) was observed. After a period of 12 months or more following the procedure a significant reduction in the prevalence persisted for dysmenorrhea (p=0,001), deep dyspareunia (p=0,041), chronic pelvic pain (p=0,011) and dysquesia (p=0,001), as compared to the preoperative period. Total pregnancy rate was 57.1% and spontaneous pregnancy 47.6%.

CONCLUSION

The treatment of deep infiltrating endometriosis using segmental colorectal resection has provided early and late relief of gynecological and bowel symptoms. The outcomes also indicate a positive impact on the fertility of infertile patients.

Surgery for Endometriosis Improves Major Domains of Quality of Life: A Systematic Review and Meta-Analysis

Because surgery for endometriosis can involve severe complications, it is important to determine if the patient's quality of life (QOL) is indeed improved after surgery. A systematic review and meta-analysis, when appropriate, was conducted and included 38 studies that assessed the QOL using validated questionnaires administered before and after surgery. Results were grouped according to the type of endometriosis reported: all types endometriosis, deep infiltrative endometriosis (DIE), and bowel endometriosis. Quantitative analysis was performed on 17 homogeneous studies. Pooled response mean differences between the 36-Item and 12-Item Short Form Survey (SF-36 and SF-12) showed significant improvement in Mental Component Score (MCS) after surgery for all types of endometriosis (.21; 95% confidence interval [CI], .04-.38); significant improvement after surgical treatment for DIE in Vitality (.67; 95% CI, .41-.94), Social Functioning (.59; 95% CI, .18-.99), Role Emotional .49; 95% CI, .02-.97), Mental Health (.39; 95% CI, .03-.74), Physical Functioning (.93; 95% CI, .49-1.38), Bodily Pain (1.23; 95% CI, .47-1.99), General Health (.57; 95% CI, .02-1.12), MCS (.55; 95% CI, .10-1.00), and Physical Component Score (PCS; .73; 95% CI, .27-1.18); and significant improvement after surgery for bowel endometriosis for all 8 domains (Vitality [1.00; 95% CI, .56-1.43], Social Functioning [.97; 95% CI, .57-1.37], Role Emotional [1.17; 95% CI, .7-1.63], Mental Health [.94; 95% CI, .5-1.38], Physical Functioning [.74; 95% CI, .3-1.18], Role Physical [1.25; 95% CI, .75-1.76], Bodily Pain [1.39; 95% CI, .79-1.98], General Health [.84; 95% CI, 1.46-1.22]), MCS (.93; 95% CI, .47-1.40), PCS (.82; 95% CI, .40-1.23), and total score (1.15; 95% CI, .48-1.83). Only 1 study assessed patients with minimal disease and showed significant improvement in PCS (p = .002) and MCS (p <.001). This systematic review reveals that surgery for endometriosis resulted in overall improvement in most health domains of health-related QOL, with the greatest improvement found in the Bodily Pain domain.

Outcomes after rectosigmoid resection for endometriosis: a systematic literature review

PURPOSE

"Endometriosis" is defined such as the presence of endometrial glands and stroma outside the uterine cavity. This ectopic condition may develop as deeply infiltrating endometriosis (DIE) when a solid mass is located deeper than 5 mm underneath the peritoneum including the intestinal wall. The ideal surgical treatment is still under search, and treatment may range from simple shaving to rectal resection. The aim of the present systematic review is to report and analyze the postoperative outcomes after rectosigmoid resection for endometriosis.

METHODS

We performed a systematic review according to Meta-analysis of Observational Studies in Epidemiology guidelines. The search was carried out in the PubMed database, using the keywords: "rectal resection" AND "endometriosis" and "rectosigmoid resection" AND "endometriosis." The search revealed 380 papers of which 78 were fully analyzed.

RESULTS

Thirty-eight articles published between 1998 and 2017 were included. Three thousand seventy-nine patients (mean age 34.28 ± 2.46) were included. Laparoscopic approach was the most employed (90.3%) followed by the open one (7.9%) and the robotic one (1.7%). Overall operative time was 238.47 ± 66.82. Conversion rate was 2.7%. In more than 80% of cases, associated procedures were performed. Intraoperative complications were observed in 1% of cases. The overall postoperative complications rate was 18.5% (571 patients), and the most frequent complication was recto-vaginal fistula (74 patients, 2.4%). Postoperative mortality rate was 0.03% and mean hospital stay was 8.88 ± 3.71 days.

CONCLUSIONS

Despite the large and extremely various number of associated procedures, rectosigmoid resection is a feasible and safe technique to treat endometriosis.

Bowel endometriosis: a diagnostic and therapeutic challenge

Bowel endometriosis is the most common extragenital manifestation of endometriosis. Clinical suspicion is of utmost importance for achieving its diagnosis. Management of this condition is, however, always challenging to the gynaecologist. We report a case of bowel endometriosis in which the patient presented with dyschezia and haematochezia prior to her menses for the past 2 years. A 44-year-old para two woman presented with worsening dysmenorrhea and dyspareunia. She also experienced dyschezia and haematochezia prior to her menses for the past 2 years. An examination revealed a fixed retroverted uterus. A computed tomography scan showed focal bowel thickening. She underwent a colonoscopy examination and biopsy that revealed stromal endometriosis. She was subsequently treated with dienogest and became asymptomatic. Diagnosis and management of this debilitating illness was revisited and discussed.

What Is Known and Unknown About the Association Between Endometriosis and Sexual Functioning: A Systematic Review of the Literature

It is well known that endometriosis is associated with an increase in the risk of deep dyspareunia, with potential negative effects on global female sexual functioning and couple relationship. The aims of this study were to review the literature on the impact of endometriosis on female sexual functioning and to suggest new avenues for future research and treatment strategies. An electronic database research was performed to identify all the studies on the relation between endometriosis and sexual functioning published in the period 2000 to 2016. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After the screening process, a total of 9 studies investigating the relation between endometriosis and female sexual functioning were considered. Overall, these studies indicated that around two thirds of women with endometriosis have some form of sexual dysfunction not limited to deep dyspareunia. These findings suggest that the global sexual impact of endometriosis requires further investigation, focusing not only on pain during intercourse but also on psychological and relational dimensions, including partner's sexual functioning. Because sexual functioning is a complex, multidimensional phenomenon, the ideal treatment for endometriosis-related sexual dysfunctions should be conducted by a multidisciplinary team composed of gynecologists, sexologists, and psychologists/psychotherapists.

Sexual function in endometriosis patients and their partners: effect of the disease and consequences of treatment

BACKGROUND

Sexual function is an important aspect of health and quality of life and is influenced by both medical conditions and health-care interventions, especially when gynecologic disorders are involved. Coital pain is among the main factors that affect sexual functioning, and this symptom is reported by almost half of women suffering from endometriosis. However, sexuality is a complex phenomenon driven by social, psychological and biological/hormonal factors and the presence of endometriosis might further affect domains of sexual function and the quality of a sexual relationship.

OBJECTIVE AND RATIONALE

The objective of this report is to review the current state of knowledge on the impact that endometriosis and its treatments have on the sexual function of women and their sexual partners.

SEARCH METHODS

A systematic literature search was performed to identify studies evaluating sexual function in endometriosis patients, and a narrative analysis of results is presented. The review discusses relevant quantitative and qualitative studies analyzing the effect of endometriosis and its hormonal and surgical treatments on measures of sexual function and quality of sexual relationship.

OUTCOMES

Endometriosis negatively affects different domains of sexual function, and the presence of dyspareunia is not the only determinant of sexual health in these women. Chronic pelvic pain, advanced stages of disease and the presence of physical and mental comorbidities affect sexual function, as well as personality traits and women's expectations. Although a number of studies have evaluated the effect of surgery and hormonal treatment on deep dyspareunia, overall sexual function and quality of the relationship with the partner are often under-investigated.

WIDER IMPLICATIONS

Multiple clinical and personal determinants affect sexual function in women with endometriosis, with potentially negative consequences on the sexual function of partners and quality of the relationship. Additional prospective and longitudinal investigations are warranted using specific instruments to analyze biopsychosocial variables of sexual pain in endometriosis patients and the effects that actual treatments have on measures of quality of sexual function and relationship.

Impact of Bowel Endometriosis Surgery on Bowel and Bladder Function, Pain Symptoms and Quality of Life

Purpose

To evaluate the impact of bowel endometriosis surgery on obstructive defecation syndrome symptoms, bladder dysfunction, pain symptoms and quality of life (QOL).

Methods

This was a retrospective cohort study of patients who underwent surgery for endometriosis where bowel was involved between 2005 and 2013. Patients were grouped according to extent of bowel endometriosis treatment: Group 1 - no treatment of bowel endometriosis, Group 2 - “shaving” of endometriosis, Group 3 - wedge resection, or Group 4 - segmental bowel resection. Data were collected via chart review and a mail-out survey consisting of six validated questionnaires designed to evaluate the study aims.

Results

Of 337 eligible patients, completed survey responses were returned by 99. There were 22 patients in Group 1, 61 in Group 2, 5 in Group 3 and 11 in Group 4. Patient demographic data were similar across the groups. There was no difference in disease severity between Groups 1-4, nor between respondents and non-respondents. Patients in Group 4 were more likely to have open surgery (p<0.001) and to have a stoma placed (p = 0.001). Patients in Group 3 were more likely to have dysmenorrhoea post-operatively (p = 0.02). Otherwise, bowel and bladder symptoms, pain, and health status were comparable between the groups, with a low incidence of bladder symptoms, generally low pain scores, and high QOL for all patients.

Conclusions

Deciding the extent of surgical aggressiveness based on symptom severity has resulted in similar long-term post-operative bowel and bladder symptoms, pain scores, quality of life and overall health across the groups.

Radical Surgery for Endometriosis: Analysis of Quality of Life and Surgical Procedure

OBJECTIVE

The main aim of this study is to determine the improvement in quality of life in patients who have undergone radical surgery because of severe endometriosis.

PATIENTS AND METHODS

This nonrandomized interventional study (quasi experimental) was carried out between January 2009 and September 2014. A total of 46 patients with diagnosis of severe endometriosis were included. Radical surgery, including hysterectomy, was performed. Acting as their own control group, the patients were asked to fill in a validated questionnaire of quality of life [Endometriosis Health Profile-5 (EHP-5)] and a visual analog scale of pain at the moment of the preoperative visit (one month prior to surgery) and six months after the surgery.

RESULTS

Radical surgery for endometriosis was performed in 46 patients at our center over the period of six years. Among the patients, 73.9% of them had undergone previous surgery for endometriosis. In 82.6% of cases, a complete laparoscopic resection was carried out. Gastrointestinal tract resection was performed in 21.7%, and urinary tract resection was necessary in 8.7%. The mean age of the patients was 38.6 years. The rate of complications was 30.4%. Six months after the surgery, all items of the EHP-5 questionnaire had a lower score, which means an improvement in all aspects of quality of life related to endometriosis. The difference obtained between the scores before and after the surgery was statistically significant. The mean visual analog scale score before the surgery was 8.5, whereas it decreased to 1.4 after the surgery (P < 0.001).

CONCLUSION

Performing a radical surgery is a difficult decision to make; however, it can provide optimal results in terms of improvement of quality of life and, therefore, should be considered when conservative therapy fails.

Sexual function in women undergoing surgery for deep infiltrating endometriosis: a comparison with healthy women

BACKGROUND

Endometriosis is a chronic and progressive condition of women of reproductive age. It is strongly associated with significant impairment of sexual function.

AIM

To objectively evaluate the impact of laparoscopic excision of endometriosis on sexual function in patients with deep infiltrating endometriosis (DIE) compared to healthy women.

SETTING AND DESIGN

Prospective study, including 250 patients with a diagnosis of DIE scheduled for laparoscopic surgery and 250 healthy women.

METHODS

A sexual activity questionnaire, SHOW-Q (Sexual Health Outcomes in Women Questionnaire), was used to collect data pertaining to women's satisfaction, orgasm, desire and pelvic problem interference with sexual function. Women with DIE underwent complete excision of endometriotic lesions. All participants were asked to complete the SHOW-Q questionnaire before and after surgery.

RESULTS

SHOW-Q scores in the endometriosis group before and 6 months after surgery were compared with the healthy group scores. A significant improvement was found between pre- and post-treatment in the scores of the satisfaction scale, desire scale and pelvic problem interference scale of SHOW-Q. The distribution of post-surgery SHOW-Q scores was comparable to healthy women's scores apart from the orgasm scale score, which was unchanged in the post-surgery group.

CONCLUSIONS

The surgical approach to treatment has a positive impact not only on organ impairment but also on sexual function in women affected by DIE.

Impact of Surgical Excision of Deep Infiltrating Bowel Endometriosis on Health-Related Quality of Life: Review of Current Literature

Background

The aim of this study was to systematically review the impact of surgical excision of deep infiltrating endometriosis involving the bowel, on health-related quality of life, based on the currently available literature.

Methods

A systematic review was completed of English-language publications in the last 10 years, which had assessed the impact of surgical excision on quality of life in patients with deep infiltrating endometriosis of the bowel using standardized, validated quality-of-life questionnaires.

Results

Fourteen studies were identified. Standardized questionnaires used to assess the therapeutic impact on quality of life were the SF-36, SF-12, EHP-30, EQ-5D and 15D. Overall, women with bowel endometriosis scored lower on quality-of-life measures than the general population. Regardless of which standardized, validated questionnaire was used, surgical treatment had a positive impact on health-related quality of life.

Conclusions

Endometriosis, in particular deep infiltrating endometriosis of the bowel, has a profound impact on the quality of life of women diagnosed with the condition. Though surgical excision has a positive short-term impact, studies are needed to assess the long-term impact on quality of life in this lifelong, chronic, recurring condition.

Bowel endometriosis: Colorectal surgeon’s perspective in a multidisciplinary surgical team

Endometriosis is a gynecological condition that presents as endometrial-like tissue outside the uterus and induces a chronic inflammatory reaction. Up to 15% of women in their reproductive period are affected by this condition. Deep endometriosis is defined as endometriosis located more than 5 mm beneath the peritoneal surface. This type of endometriosis is mostly found on the uterosacral ligaments, inside the rectovaginal septum or vagina, in the rectosigmoid area, ovarian fossa, pelvic peritoneum, ureters, and bladder, causing a distortion of the pelvic anatomy. The frequency of bowel endometriosis is unknown, but in cases of bowel infiltration, about 90% are localized on the sigmoid colon or the rectum. Colorectal involvement results in alterations of bowel habits such as constipation, diarrhea, tenesmus, dyschezia, and, rarely, rectal bleeding. Differential diagnosis must be made in case of irritable bowel syndrome, solitary rectal ulcer syndrome, and a rectal tumor. A precise diagnosis about the presence, location, and extent of endometriosis is necessary to plan surgical treatment. Multidisciplinary laparoscopic treatment has become the standard of care. Depending on the size of the lesion and site of involvement, full-thickness disc excision or bowel resection needs to be performed by an experienced colorectal surgeon. Long-term outcomes, following bowel resection for severe endometriosis, regarding pain and recurrence rate are good with a pregnancy rate of 50%.

Surgery Versus Pharmacological Treatment for Endometriosis

The two major consequences of endometriosis are pain and infertility. Despite numerous studies and proposed guidelines, some aspects of the treatment for these complications are still under debate or lack convincing evidence that favors one approach over the other. Future studies will hopefully present new evidence in regard to the optimal treatment for each indication and suggest innovative pharmacotherapy following improved understanding of the pathophysiology of endometriosis. Until then, individualization of the treatment according to the specific indication, taking into consideration the benefits versus the risks for the patient and the tolerability profile, remains the most appropriate approach.

Multidisciplinary laparoscopic treatment for bowel endometriosis

Endometriosis is a handicapping disease affecting young females in the reproductive period. It mainly occurs in the pelvis and affects the bowel in 3-37%. Endometriosis can cause menstrual and non-menstrual pelvic pain and infertility. Colorectal involvement results in alterations of bowel habit such as constipation, diarrhoea, tenesmus, and rarely rectal bleeding. A precise diagnosis about the presence, location and extent is necessary. Based on clinical examination, the diagnosis of bowel endometriosis can be made by transvaginal ultrasound, barium enema examination and magnetic resonance imaging. Multidisciplinary laparoscopic treatment has become the standard of care and depending on size of the lesion and site of involvement full-thickness disc excision or bowel resection is performed by an experienced colorectal surgeon. Anastomotic complications occur around 1%. Long-term outcome after bowel resection for severe endometriosis is good with a pregnancy rate of 50%.

Diagnosis, management, and long-term outcomes of rectovaginal endometriosis

Rectovaginal endometriosis is the most severe form of endometriosis. Clinically, it presents with a number of symptoms including chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia, and rectal bleeding. The gold standard for diagnosis is laparoscopy with histological confirmation; however, there are a number of options for presurgical diagnosis, including clinical examination, transvaginal/transrectal ultrasound, magnetic resonance imagining, colonoscopy, and computed tomography colonography. Treatment can be medical or surgical. Medical therapies include birth control pills, oral progestins, gonadotropin-releasing hormone agonists, danazol, and injectable progestins. Analgesics are often used as well. Surgery improves up to 70% of symptoms. Surgery is either ablative or excisional, and is conducted via transvaginal, laparoscopic, laparotomy, or combined approaches. Common surgical techniques involve shaving of the superficial rectal lesion, laparoscopic anterior discoid resection, and low anterior bowel resection and reanastomosis. Outcomes are generally favorable, but postoperative complications may include intra-abdominal bleeding, anastomotic leaks, rectovaginal fistulas, strictures, chronic constipation, and the need for reoperation. Recurrence of rectal endometriosis is a possibility as well. Other outcomes are improved pain-related symptoms and fertility. Long-term outcomes vary according to the management strategy used. This review will provide the most recent approaches and techniques for the diagnosis and treatment of rectovaginal endometriosis.

Dyspareunia and quality of sex life after surgical excision of endometriosis: a systematic review

Dyspareunia, a common symptom of endometriosis, severely affects quality of sex life in affected women. The objective of the present work was to review the effect of surgical resection of endometriosis on pain intensity and quality of sex life. MEDLINE and EMBASE databases were searched for papers investigating the outcome after surgical endometriosis resection on dyspareunia and quality of sex life measured via VAS/NAS respectively via standardised measuring instruments. Data did not permit a meaningful meta-analysis. Out of 64 papers, three studies fulfilled the predefined inclusion criteria involving 128 patients with endometriosis and dyspareunia preoperatively. All included studies showed a significant postoperative reduction (p<0.05) of dyspareunia after a follow-up period of 12 up to 60 months. Sex life also improved significantly (p<0.05), and predominantly evaluated parameters like quality of life and mental health. Intra- and postoperative complications were described in two out of three studies. Surgical excision of deep infiltrating endometriosis is feasible and improves dyspareunia and quality of sex life significantly.

Surgical Therapy of Endometriosis: Challenges and Controversies

Endometriosis is one of the most common disorders encountered in surgical gynaecology. The laparoscopic technique, the planning of the surgical intervention, the extent of information provided to patients and the interdisciplinary coordination make it a challenging intervention. Complete resection of all visible foci of disease offers the best control of symptoms. However, the possibility of achieving this goal is limited by the difficulty of detecting all foci and the risks associated with radical surgical strategies. Thus, the excision of ovarian endometrioma can result in a significant impairment of ovarian function, while damage to nerve structures during resection of the uterosacral ligaments, the parametrium, the rectovaginal septum or the vaginal cuff to treat deep infiltrating endometriosis can lead to serious functional impairments such as voiding disorders. A detailed risk-benefit analysis is therefore necessary, and patients must be treated using an individual approach.