Key message
Involvement of certain anatomical compartments and the total number of affected compartments as described by the revised ENZIAN score
Endometriosis is a common disease affecting an estimated 1.5% of women of childbearing age (Ballard et al., 2008). Although it is sometimes asymptomatic, it represents a frequent cause of various symptoms such as dysmenorrhoea, dyspareunia, dyschezia, dysuria and chronic pelvic pain, as well as infertility. Possible disease localizations comprise superficial peritoneal lesions or lesions involving the ovaries with the formation of so-called endometriomas, also known as ‘chocolate cysts’. Deep infiltrating endometriosis (DIE), representing a severe form of the disease, may involve the urinary bladder, ureters, uterosacral ligaments (USL), pouch of Douglas (POD) with partial or complete obliteration, rectovaginal septum (RVS) or bowel (Chapron and Dubuisson, 2001, Fedele et al., 1997, Keckstein and Wiesinger, 2005, Koninckx et al., 1991). Infiltration of surrounding anatomical structures by ectopic endometriotic tissue may result in impairment of organ function and pain (Bergqvist, 1993).
To date, different classification systems have been developed in order to easily and uniformly describe the localization and severity of the lesions and to allow for better international comparisons of studies involving women with endometriosis. The revised American Society for Reproductive Medicine (rASRM) score is currently the most widely used classification system rASRM (1997). However, DIE involving retroperitoneal structures is not fully taken into account in this score and the extent of endometriosis shows only a poor correlation with pain (Vercellini et al., 1996) as well as with sterility (Guzick et al., 1997). The endometriosis fertility index was created and validated specifically to predict pregnancy rates after surgery for endometriosis, in addition to and partly based on the rASRM score, and also taking into account other parameters such as patient history factors and the least function score at the conclusion of surgery, i.e. the sum of the lowest function score on each side taking into account the tubes, fimbriae and ovaries (Adamson and Pasta, 2010).
To additionally describe DIE involving retroperitoneal structures more accurately, the ENZIAN classification was developed in addition to the rASRM score (Keckstein et al., 2003, Tuttlies et al., 2005), being revised in 2010 and 2011 (Haas et al., 2013b; Keckstein, 2017). So far, there are only very limited data on the association between the anatomical extent of DIE as described by the revised ENZIAN score and symptoms such as dymenorrhoea, dyspareunia, dysuria or dyschezia. One report with limited patient numbers found that the affected localizations described by the revised ENZIAN score were partially correlated with clinical symptoms; for example, the presence of uterine adenomyosis (ENZIAN compartment FA) was associated with dysmenorrhoea and dyspareunia, whereas involvement of ENZIAN compartment C (rectum, sigmoid colon) was associated with bowel symptoms (Haas et al., 2013a).
The aim of the present study was to further investigate a possible correlation between disease extent and localization, as defined by the revised ENZIAN score, and specific pain symptoms such as dysmenorrhoea, dyspareunia, dysuria and dyschezia in a larger number of women undergoing radical surgical treatment and intraoperative staging using both scoring systems for DIE.
This study is a retrospective analysis of a prospectively generated database including all consecutive women who had undergone surgical treatment for DIE of the bowel between January 2014 and August 2018 at the Department of Gynecology of the St. John of God Hospital, Vienna. In addition, all consecutive women who underwent surgical treatment for DIE of the urinary tract between September 2015 and August 2018 at the Department of Gynecology of the St. John of God Hospital, Vienna, were
Between January 2014 and August 2018, 273 women underwent surgical treatment for DIE at the Department of Gynecology, Hospital St. John of God, Vienna. Twenty-eight patients were excluded because of age, a history of hysterectomy, inflammatory disease or malignancy-related conditions. Therefore, data from 245 patients were analysed. Table 1 outlines the demographic characteristics of these patients as well as the frequencies of four different pre-operative symptoms (dysmenorrhoea, dyspareunia,
In the present study, associations were found between the localization of DIE lesions described by ENZIAN compartments and the presence of certain pain symptoms in women undergoing radical surgery for the disease, as were correlations between the size of such lesions in specific ENZIAN compartments and symptom severity. In accordance with previous research on this topic (Haas et al., 2013a), involvement of the rectum, as reflected by ENZIAN compartment C, was associated with the presence of
Taken together, the present work shows associations and mostly small to moderate correlations of specific pain symptoms and their severity with the localization and extent of DIE as well as with the total number of affected ENZIAN compartments in a large number of women with DIE undergoing radical surgery with intraoperative staging of the disease using the revised ENZIAN score. The present exploratory findings suggest that the revised ENZIAN score might be useful in addition to the rASRM score
Eliana Montanari, MD, PhD, works at the Department of Obstetrics and Gynecology, Medical University of Vienna, with research activity on endometriosis at the Department of Gynecology of the Hospital St. John of God, Vienna, Austria. Her main research interest is endometriosis, with a particular focus on laparoscopy and sonography. Key message Involvement of certain anatomical compartments and the total number of affected compartments as described by the revised ENZIAN score
In a recent retrospective series of 266 women, cycle-related dyschezia was independently associated with rectal involvement [25]. In a recent study that evaluated the association between preoperative symptoms and revised ENZIAN classification, dyschezia was significantly correlated with rectal involvement corresponding to the ENZIAN compartment C [26]. Women with endometriosis sparing the bowel could also report gastrointestinal symptoms, as deep endometriosis nodules may be responsible for bowel adhesions, impacting bowel function.
No such data, however, exists for less severe localizations. Endometriosis is a polymorphic disease that can affect many different organs, resulting in a broad variety of symptoms [15,16]. This complexity in part accounts for the prevarication and disagreements surrounding its management [17].
The rate of concordance between preoperative TVUS findings and intraoperatively assessed lesion sizes according to the Enzian classification varied depending on anatomical localizations; DIE can be preoperatively detected by TVUS in #Enzian compartments A, B, C and FB with an overall sensitivity of 84%, 91%, 92% and 88%, respectively, and a specificity of 85%, 73%, 95% and 99%, respectively [20]. Both the location and the extent of endometriosis, as described by the ISGE-recommended #Enzian score (revised Enzian classification), are correlated with the presence and severity of preoperative symptoms [62]. Furthermore, the Enzian and two other endometriosis classification/scoring systems, revised American Society for Reproductive Medicine (rASRM) classification and Endometriosis Fertility Index (EFI), merge into the first recently developed digital visual classification system – the EQUSUM [63].
Eliana Montanari, MD, PhD, works at the Department of Obstetrics and Gynecology, Medical University of Vienna, with research activity on endometriosis at the Department of Gynecology of the Hospital St. John of God, Vienna, Austria. Her main research interest is endometriosis, with a particular focus on laparoscopy and sonography. Key message Involvement of certain anatomical compartments and the total number of affected compartments as described by the revised ENZIAN score correlate with the presence and severity of different presurgical pain symptoms. These explorative findings suggest that it may be important to evaluate the extent of deep infiltrating endometriosis using the revised ENZIAN score in addition to the revised ASRM score.