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BackTable / OBGYN / Article
Endometriosis Workup: Exam Techniques For Early, Advanced & Diaphragmatic Endometriosis
Dana Schmitz • Aug 29, 2023 • 38 hits
A comprehensive clinical examination for suspected endometriosis necessitates an expansive perspective on the patient's presentation and history. However, particularly telling is the rectovaginal exam—a diagnostic tool that, while underutilized, provides invaluable insights, especially concerning the cul-de-sac and uterosacral ligament. Nodules often signal late-stage disease, with localized tenderness also being a strong endometriosis indicator. Advanced endometriosis management demands an exacting approach, especially when endometrial tissue deeply infiltrates other organs, underscoring the importance of in-depth pre-operative imaging. Collaborative efforts with seasoned specialists amplify the likelihood of optimal outcomes. Moreover, diaphragmatic endometriosis, though rare, presents its own set of challenges, especially when close to pivotal structures like the vena cava. As a result, staged procedures often become the method of choice to guarantee a thorough and accurate diagnosis.
The BackTable OBGYN Brief
• While performing a rectovaginal exam, focus on palpating different regions in the pelvis to reproduce or identify the patient's pain. The uterosacral ligament and the cul-de-sac are crucial areas to assess.
• Feeling for granular nodularities or large nodules can give insights about the stage of endometriosis.
• Abdominal wall endometriosis might require resection of a segment of the rectus muscles or fascia, potentially requiring the placement of a mesh.
• Discoid resections can be handled by gynecologists comfortable with the procedure; however, large or multifocal nodules might require collaboration with general surgeons for segmental resection. Strong relationships with general surgeons and urologists can facilitate smoother operations, with some pre-dissections handled by gynecologists to expedite the primary procedure.
• Diaphragmatic endometriosis can present with cyclic chest or shoulder pain, and imaging might not always be conclusive.
• Endometriosis near the diaphragm's central tendon poses significant risks due to its proximity to crucial structures. Staged procedures are recommended for thorough evaluation of diaphragmatic endometriosis.
Table of Contents
(1) Exam Techniques for Suspected Endometriosis
(2) The Role of Collaboration in Advanced Endometriosis Management
(3) Diaphragmatic Endometriosis: From Symptoms to Surgical Strategy
Exam Techniques for Suspected Endometriosis
During a clinical exam for suspected endometriosis, a holistic view of the patient’s behavior and presentation is essential. This is followed by a detailed rectovaginal exam, a technique that not all practitioners employ but offers insightful diagnostic information for endometriosis, especially concerning the cul-de-sac and uterosacral ligament. Dr. Lee explains specific techniques and landmarks in a rectovaginal exam for suspected endometriosis, and which findings are of most concern. Nodules in patients are indicative of late-stage disease, and the mere presence of localized tenderness in the said areas can often be a strong sign of endometriosis.
[Dr. Mark Hoffman]
Okay, so you've got a patient. You're suspicious that they have endometriosis based on history, touched on it a little bit. What are the exam findings that make you think a patient is more likely to have endometriosis, less likely to have endometriosis?
[Dr. Ted Lee]
I do, obviously, see the patients. Obviously, see how their general behavior is and everything before I even start the exams. I usually tell the patient exactly what I'm going to do and the reason, the purpose behind my exams.
[Dr. Mark Hoffman]
So important.
[Dr. Ted Lee]
Yes, I tell the patients that, "I'm going to palpate different regions in your pelvis. I want you to tell me whether I reproduce your pain or produce a different kind of pain altogether. The better I can reproduce your pain, the more likely I can help you. I also tell them about, I perform a rectovaginal exam on all my patients with pelvic pain, essentially. It's not something that everybody does. For them, it's the first time for them to have rectovaginal exams. I tell them exactly the reason behind that I do the rectovaginal exam. I tell them that the most common site of endometriosis is going to be the cul-de-sac or uterosacral ligament, and it's a lot easier for me to access that area with the finger in the rectum.
[Dr. Mark Hoffman]
Are you feeling for big nodules or are you feeling for nodularity? Is it pretty subtle sometimes, the findings on the--
[Dr. Ted Lee]
Most of patient don't have nodules. Most patient with endometriosis are not going to have nodules. Nodule is a sign of late disease. It's, obviously, when you feel nodules you know that deep infiltrating endometriosis. Majority of the patients just going to have localized tenderness in the area. Usually, most people don't know how to do rectovaginal exam. Obviously, this is a podcast. People have to use their imagination to see how I do the exam. I have one finger, my index finger in the vagina, my middle finger in the rectum.
I have my middle rectal finger palpate anteriorly, and then I feel the cervix. Cervix is a very reliable landmark you can feel on the recto exam because it's firm. We all know that uterosacral ligament is there behind the cervix, so on either side of the cervix would be the uterosacral ligament. If you sweep it laterally and posteriorly, that would be your uterosacral ligament. Whatever is in between, it's the cul-de-sac. If you touch that part of the pelvis and you reproduce the pain, the reaction that I describe as a visceral reaction to the exam, I feel pretty confident that those patients very, very likely would have endometriosis.
That visceral reaction is something that it's, you cannot fake that part of the exam. Obviously, with pelvic pain, there's always a lot of drug-seeking patients who want to get medication from you. With this exam, it's very specific. If everything hurts, typically, I don't feel confident the surgery is going to help them. This is something beyond surgery if everything hurts. They may have vaginismus.
[Dr. Mark Hoffman]
You're looking for more localized pain at the uterosacral ligaments, at posterior lower uterine segment is a place I feel like we feel it all the time.
[Dr. Ted Lee]
Yes, most of the posterior cul-de-sac uterosacral. I can also feel tethering. If there's scar tissues, then I feel some tethering. If they have very small, what I say, granular nodularities, like little rice grains in the area, I can feel that sometimes as well. Obviously, the big nodules I can feel. Those are what I do; rectovaginal exam. Before I even get to that part, I usually tap in the anterior vaginal wall. That would be the first thing I do unless I know the patient have interstitial cystitis. They're very strongly suspicious, patient might have interstitial cystitis.
I do one digit or two-finger exam on the anterior vaginal wall. You just start on that first unless I strongly suspect that patient might have IC because if you have a patient with IC, you touch that part first, then the exam is done basically. Those patient, I don't start anteriorly, but in general, for most of the patients, I start anterior vaginal wall, palpate that area, I then palpate levator, coccygeus muscles, just for focal tenderness. Patient might develop myofascial pain. I used to do lot of injections in the muscles, but a lot of times, in my experience is that the muscle spasms and pain tend to be reactionary to the disease. If you treat a disease that you would treat a patient, a lot of injections that you may get some temporary relief, but the pain will come back.
[Dr. Mark Hoffman]
The analogy I use for that, I did the same thing, if you hold a gallon of water for a week, I can take the gallon of water away, but your muscle is still going to be hurting for a while. Occasionally, we can address the initial insult. At times, though, the muscle pain that was associated with may continue, and there may be opportunities for improvement with PT. I agree, starting with the insult, the initial nitis of pain that led to that musculoskeletal pain, you address that first, and then see what's left over. I think that's a common thing.
[Dr. Ted Lee]
Yes.
[Dr. Mark Hoffman]
Are you starting your exam with the back and the belly, or are you going straight to the pelvic exam first?
[Dr. Ted Lee]
Obviously, I just inspect the abdominal wall initially. Especially in patients with C-sections, I'll palpate the anterior vaginal wall. Most patients with endometriosis, unless they have abdominal wall endometriosis, typically abdominal proportion exam are quite non-tender. I suspect something is not quite right when patient, you barely put your hands on their abdomen, they are having so much pain. Those patients, sometimes you're not sure if it's endometriosis-related or something else. After anterior vaginal wall, levator ani muscles, and then I touch posterior fornix.
In patient with endometriosis, if you lift the cervix, stretch cervical motion tenderness, you can stretch the uterosacral ligaments. They're going to have pain with that as well. Then I do the rectovaginal exam at the last part because that's the most difficult part of the exam that you don't want to do that first because you may not be able to do any of the exam after that.
[Dr. Mark Hoffman]
Right, the exam enders, or you've found something that's extremely painful.
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The Role of Collaboration in Advanced Endometriosis Management
Dr. Ted Lee emphasizes the meticulous approach required when handling cases of advanced endometriosis, particularly in patients where endometrial tissue infiltrates deep tissues or other organs. It is essential for clinicians to have a clear understanding of the disease's extent and depth. For example, abdominal wall endometriosis might necessitate a more invasive approach, possibly even the placement of a mesh. This speaks to the critical role of thorough pre-operative imaging and assessment. Notably, collaboration is paramount; having a network of experienced specialists ensures the best outcomes for patients.
[Dr. Ted Lee]
If I suspect abdominal wall endometriosis, I want to see the front layers of the abdominal wall, this endometriosis involving because some of those patient might require resection of a segment of the rectus muscles and might have a piece of fascia removed that may require you to place a mesh. I have placed a mesh myself for a lot of those patients. I've been doing it for so many years. Those kind of things you need to know. Then frequently, a lot of times, because if you don't know the depth of the invasions and you think that the endometriosis is just subcutaneous and you begin digging and digging and you hit a fascia, most people just back out and just say, "Stop right there. I don't want to do anymore." Then you end up with patients who still have endometriosis on the rectus muscle. It's important to know that information ahead of time. Just like you want to know if patient have bowel endometriosis or bladder endometriosis. Usually, even in patients that I think that I can just do a discoid resections without doing the whole segmental resections, they will see my general surgeons regardless, ahead of time.
[Dr. Mark Hoffman]
Yes, I do the same. I think those of us that are out there doing this without senior partners like you, as we develop these practice plans, it's always so reassuring to me. I was watching a video of one of our other colleagues when I was first out and we were operating on a bladder nodule, and I thought, "Man, I'm just so far from being in that level." Then I hear the person say, "Oh, and now is my urology colleague is going to take over." It's like, "Okay, good. I'm not the only person who's using other people in the OR to help these patients get what they need."
I think, especially in academic centers when you've got a colorectal surgeon next door and then urology on the other side, if you're doing that stuff as a gynecologist, you have to be pretty careful about whether you're going to be doing those surgeries when you've got the experts next door. I've got a colorectal surgeon who I work very closely with,on our advanced endo cases. If I suspect bowel endometriosis for the reasons you're talking about, I always have them go see them first. They oftentimes get a colonoscopy if there's concern about transmural disease.
In that way, they're able to be counseled about what bowel surgery is going to look like. It's nice to hear that you also are referring to general surgery colleagues as well. I think it helps when they know the surgeons who are going to be involved on their team at that time.
[Dr. Ted Lee]
Right, yes. I do my discoid resection myself and that's because I work very well with my general surgeons. Typically if the patient's disease is a minimal to discoid resection, I do it myself. Then if the nodules is very large or it's multifocal, then they will come in to do segmental resection. Fortunately for me, I operate three days a week. Mondays, I operate with one general surgeon, and Thursday, I operate with different general surgeons. They all have cases going on at the same time, and so they don't come in to do the surgery unless I tell them that, "You need to come in to do the segmental resection." The discoid resection, I just take care of myself. That's what I do. For bladder endometriosis, I do it myself, and then for uterine endometriosis, I usually do it myself with them watching me doing it for the most part.
[Dr. Mark Hoffman]
What was the last part? For the?
[Dr. Ted Lee]
Ureteral reimplantations. Ureteral reconstructive surgery.
[Dr. Mark Hoffman]
Yes, because you're doing it on a straight stick, a lot of the urologists are robot only.
[Dr. Ted Lee]
Yes, I'm their Da Vinci basically.
[Dr. Mark Hoffman]
I was closing a cuff one time because the urologist came in to look at something. I was like, "Oh, let me just close it real quick so they can get in and do their part." I hear the urology attending turn to his fellow and go, [whispers] "He's making it look really easy. Yes, very easy," because they're not doing a ton of straight stick stuff in urology. Again, I think it's not necessarily should or shouldn't you be doing things yourself. Also, if there's a bladder issue, I'll have the urologist come in but I'll close it myself. I think the key is understanding what your comfort level is.
Getting to a point that you got to where you are now, I'm guessing, took working with these other surgeons for years and years to get to where they know that you can handle these things on your own. You're not doing this fresh out.
[Dr. Ted Lee]
Right. I think it's, no, I just feel very fortunate that I have all these people to rely on when things gets beyond what I can offer them. Also, too, is my general surgeons really trusts me. If they are stuck in their own case and want me to get started with their dissection for their segmental resections, I do all the dissections for them. I lift the rectum, open the retro rectal space, tunnel between the [unintelligible] and the ureter, get out all that space. That's enough for them, so when they come in, they can just do a segmental resection with the staplers.
[Dr. Mark Hoffman]
How important it is for your patients and for those of us to do this, to develop those relationships. That's something that I don't know that I thought about ahead of time, but over the years, I've got colleagues that I consider friends who I've operated with countless times, and who, like you said, there's times when they pop in, and they go, "Looks like you got it", and we do those parts or whatever. Over time, it's, surgery is a team sport. As we get further and further along, there's more and more people that are responsible for my training and my growth and those things. It's such an important part of this job is to have good colleagues.
[Dr. Ted Lee]
Right. On the flip side of the coin, for the endometriosis surgery, the gynecologist should be the captain-
[Dr. Mark Hoffman]
For sure.
[Dr. Ted Lee]
-in terms of what needs to be removed because the general surgeon doesn't know what needs to be removed.
[Dr. Mark Hoffman]
Important point.
[Dr. Ted Lee]
It's important for you to be able to-- For example, if you just have the general surgeon coming in to do the bowel endometriosis and you leave all the endometriosis on the rectovaginal septum, recto-cervical region, which is in the same patient with bowel endometriosis, they have lot of endometriosis behind the cervix, causing the uterus to rip onto itself. The uterus can rip onto a bowel and it stuck to the cervix. When you unravel that between the uterus and the cervix, is all this disease that needs to be removed. The general surgeons are not going to do that.
You are the one who is going to recognize that and take care of those endometrioses. You are responsible for separating the bowel from the posterior vagina, and you say, "Okay, here is a huge nodule," or, "This is a multifocal nodule," or, "This is a patient with a stricture. You need to come in do the segmental resections." You're the one who should decide that this should be a segmental or discoid. That's my take on that.
Diaphragmatic Endometriosis: From Symptoms to Surgical Strategy
An uncommon yet complex manifestation, diaphragmatic endometriosis involvement often presents with cyclic chest or shoulder pain. The positioning of the patient, particularly a left lateral decubitus position, is crucial to displace the liver and gain clear visibility of the posterior diaphragm. The diagnostic challenge lies in imaging, which may not always offer clarity on the severity and location of the disease. Moreover, when dealing with endometriosis near the central tendon of the diaphragm, extra caution is required due to the proximity to vital structures like the vena cava, aorta, and phrenic nerve. Staged procedures are suggested as best practice to ensure a thorough and accurate diagnosis.
[Dr. Mark Hoffman]
We'll have to have you back on the show to talk through the surgical side of things too. It's so tempting for me to just keep going with this thread. I want to make sure for the purposes of this show that we make sure we touch on all the ambulatory stuff too. The other thing I was thinking about in the ambulatory workup is the non-pelvic endometriosis. I think we see occasional videos in our societies about diaphragmatic stripping and those things. What's your threshold for referring to or getting CT surgery involved for these particular cases? How often are you finding diaphragmatic disease?
[Dr. Ted Lee]
The people who I worked with, the two general surgeon I worked with, they also are surgical gynecologists.
[Dr. Mark Hoffman]
Wow. They're comfortable in that space.
[Dr. Ted Lee]
Yes. Both of them are surgical gynecologists and the bariatric surgery, they do two fellowships, both of them. For diaphragmatic endometriosis, I work with them and then they'll help me position the patients. Then frequently, a lot of diaphragmatic endometriosis, the best position would be left lateral decubitus position because you use gravity to get to retreat the liver all the way and give you a good exposure to the posterior diaphragm.
[Dr. Mark Hoffman]
Are you repositioning them interop?
[Dr. Ted Lee]
No, usually, I don't like to do them in the same settings.
[Dr. Mark Hoffman]
Oh, so separate. surgery?
[Dr. Ted Lee]
Yes, because a lot of times you don't really know how bad the diaphragmatic endometriosis, and the imaging is not always that great for diaphragmatic endometriosis. I tell the patients that usually it's just better to do a staged procedure if you have diaphragmatic endometriosis just to know exactly where the disease is and everything because not all diaphragmatic endometriosis is the same because if you have diaphragmatic endometriosis near the central tendon, that's much more dangerous because that's where all-
[Dr. Mark Hoffman]
It all sounds dangerous to me.
[Dr. Ted Lee]
No, it's because, near the central tendon, that's where all the vena cava, the aorta, the portal vein, and all the phrenic nerve is in the central portion of the diaphragm.
[Dr. Mark Hoffman]
What's the clinical findings where you're suspecting that? What gets you to the point in the clinic, in the office to where you suspect endometriosis in those spaces?
[Dr. Ted Lee]
Yes, the cyclic chest pain or shoulder pain, they will tell you that and there's not many things that can cause that. The problem is that when I tell a patient I'll put additional pore under the rib for me to reach that area, do a bit of visual, I put my scope, my camera underneath the rib to look around the liver.
[Dr. Mark Hoffman]
I see.
[Dr. Ted Lee]
If you keep your umbilical trochar as your primary visual port for diaphragmatic endometriosis, you'll miss a lot.
[Dr. Mark Hoffman]
You'll see it, you'll diagnose it, and then you'll wake him up and talk to him about it, and then come back another day to manage if you do find it.
[Dr. Ted Lee]
Exactly, yes. Actually, a lot of patients don't have it.
[Dr. Mark Hoffman]
Right, but you won't know if you don't look.
[Dr. Ted Lee]
Exactly, yes. If you just say, "Okay, I look at it from my umbilical port," you may miss it.
[Dr. Mark Hoffman]
Interesting.
[Dr. Ted Lee]
If you really want to know, you have to put a subcostal port there.
[Dr. Mark Hoffman]
I do a lot of palmar splint entry as well.
[Dr. Ted Lee]
On the right side, if you do that on the right side and use the angle scope to look around the liver, then you'll find it.
[Dr. Mark Hoffman]
Excellent.
[Dr. Ted Lee]
Most of posterior diaphragmatic endometriosis, you're not going to find it with umbilical port, so that's important.
Podcast Contributors
Dr. Ted Lee
Dr. Ted Lee is a clinical professor and director of minimally invasive gynecologic surgery at Magee Womens Hospital of UPMC in Pittsburgh, Pennsylvania.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2023, August 17). Ep. 30 – Ambulatory Workup of Endometriosis Patients [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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