Endometriosis, known among the public as the chocolate cyst, is the settling and growth of the endometrium tissue of the innermost layer of the uterus outside the uterus, inside healthy tissues and organs. Endometriosis is one of the conditions that are diagnosed late and with difficulty, because depending on the areas the disease involves it can cause different clinical situations and, accordingly, different signs.
The condition that occurs only on the surface of the organs is called superficial endometriosis, and the disease that has progressed more than 5 millimetres into the depth of the pelvic organs is called deep endometriosis. In these patients endometriomas (chocolate cysts) in the ovary and adenomyosis, the form of endometriosis in the uterus, are also frequently found. Inside these cysts there is a brown fluid, and because of their appearance they are called chocolate cysts.
The areas where deep endometriosis occurs can be listed as the bowel, the bladder, the ureters (the tube that carries the urine), the posterior wall of the vagina, the site of an old caesarean incision, the sacral and sciatic nerve, the diaphragm and the uterosacral ligaments (the ligaments that suspend the uterus; the nerve that carries the pain of the uterus also passes right next to them).
Deep endometriosis is the type of endometriosis that is the most difficult to diagnose and to treat. Deep endometriosis is seen less often than the endometrioma in the ovaries. In endometriosis cases the rate of deep endometriosis is around 10%.
Signs of Deep Endometriosis
One of the main factors that make diagnosis difficult in endometriosis is that there is no correlation between the level of pain and the stage of the condition. While patients with very few adhesions can have almost unbearable cramps and severe pain, patients with deep endometriosis can show very mild signs.
In general, however, deep endometriosis lesions usually cause a severe sensation of pain because of the large number of nerve networks. Among the most common signs of deep endometriosis are pelvic pain, painful menstrual cycles, painful sexual intercourse, painful defecation, swelling of the abdomen as if pregnant especially during menstruation, pencil-like stools and periods of diarrhoea resembling a bowel disease.
Depending on the organ involved, very different complaints are seen: foot drop and difficulty in walking in sciatic nerve endometriosis, right shoulder pain in diaphragmatic endometriosis, and in caesarean scar endometriosis a painful, hard swelling that can be felt at or right next to the caesarean site during menstruation. While some patients can have a single sign, in others more than one sign can occur.
Treatment Methods for Deep Endometriosis
The treatment of deep endometriosis generally varies according to where it is and how much it affects the organs. It can respond to drug treatment, and patients who respond well to the drug treatment given can continue to use these treatments under observation.
In advanced disease that does not respond to drug treatment, surgical treatment is used. In surgical treatment, closed surgery is accepted as the gold standard all over the world. In deep endometriosis the operation is more complex.
The endometriosis surgeon has to clear the lesions and the scar tissue without damaging the surrounding tissues. When an operation becomes necessary, it must certainly be performed by surgeons who have specialised in this field.
Deep endometriosis surgery must always be under the direction of a team. Depending on the tissue involved, a general surgeon, a urologist, a liver surgeon and a thoracic surgeon should accompany the endometriosis surgeon in the team.
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