Ambulatory Workup of Endometriosis Patients

[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.