Abstract

Pain is a prominent symptom of endometriosis with prevalence ranging from 30 to 90% amongst women undergoing laparoscopy for evaluation of chronic pelvic pain. Pain symptoms most commonly associated with endometriosis are dysmenorrhoea, dyspareunia and non-menstrual pelvic pain. These symptoms may exist in variable combination from person to person and may fluctuate in severity and from time to time.

As endometriotic lesions similar to those found in women presenting with pain have also been detected in asymptomatic women, the relationship and the mechanisms by which endometriosis causes pain are still not fully understood.

Evidence from randomised controlled trials demonstrates that laparoscopic surgery is effective in treating overall pain associated with endometriosis. In general, the aims of laparoscopic surgery of endometriosis are to remove (excise) or destroy (ablate) all visible endometriotic lesions, to divide adhesions, to restore normal anatomy and to repair damage to reproductive organs. Surgery can be used as first-line therapy or after failed medical therapy.

The available techniques for surgical treatment of endometriosis include sharp dissection, electro-surgery, Argon Neutral Plasma Energy, laser or harmonic energy. While limited evidence does not allow conclusion to be made regarding which surgical technique is most effective, it is generally recommended that deep endometriotic lesions should be excised, particularly when dealing with pain recurrence in women having undergone previous endometrial ablation.

While effective, pain recurrence is not uncommon following laparoscopic destruction of endometriosis, with reported incidence ranging from 30 to 60% of patients. The addition of laparoscopic uterosacral nerve ablation has not been shown to improve pain relief. Presacral neurectomy, on the other hand, has been shown to benefit some women with chronic, intractable pelvic pain, the benefits may be outweighed by the potential harmful side-effects.

Conclusions

High-quality evidence exists demonstrating statistically significant benefit of laparoscopic surgery in the treatment of endometriosis-related pain. Pain recurrence, sadly, is not uncommon after surgical treatment. Much research is required to expand our knowledge of mechanisms of pain in endometriosis, thus increasing our understanding of the benefits and limitations of surgical treatment of this enigmatic condition.