syllabus - aagl.org · syllabus endo-609: endometriosis—the whole picture. professional education...

Be a Surgical “Multiplier” in MIGS Inspire Brilliance Through Teamwork

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Scientific Program ChairJubilee Brown, MD

Honorary ChairBarbara S. Levy, MD

PresidentMarie Fidela R. Paraiso, MD

SYLLABUSENDO-609:

Endometriosis—The Whole Picture

Professional Education Information

Target Audience This educational activity is developed to meet the needs of surgical gynecologists in practice and in training, as well as other healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Disclosure of Relevant Financial Relationships As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME. Anti-Harassment Statement AAGL encourages its members to interact with each other for the purposes of professional development and scholarly interchange so that all members may learn, network, and enjoy the company of colleagues in a professional atmosphere. Consequently, it is the policy of the AAGL to provide an environment free from all forms of discrimination, harassment, and retaliation to its members and guests at all regional educational meetings or courses, the annual global congress (i.e. annual meeting), and AAGL-hosted social events (AAGL sponsored activities). Every individual associated with the AAGL has a duty to maintain this environment free of harassment and intimidation. AAGL encourages reporting all perceived incidents of harassment, discrimination, or retaliation. Any individual covered by this policy who believes that he or she has been subjected to such an inappropriate incident has two (2) options for reporting:

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Table of Contents Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 Endometriosis—the Patient Perspective H.C. Guidone ................................................................................................................................................ 4 Neuropelveology and Endometriosis M. Possover .............................................................................................................................................. UNA Bowel Endometriosis—Surgical Treatment K.R. Sinervo ................................................................................................................................................... 8 Endometriosis of Sacral Nerve Roots and Sciatic Nerve M. Possover ............................................................................................................................................. UNA Endometriosis of the Bladder and Ureter—Surgical Approach J.I. Einarsson ............................................................................................................................................... 14 A Holistic Approach to Endometriosis. Evaluating Coexisting Conditions of Endometriosis I.K. Orbuch .................................................................................................................................................. 17 Unlocking Central Sensitization in Patients with Endometriosis A. Shrikhande .............................................................................................................................................. 24 The Role of the Pelvic Health Physiotherapist in Pelvic Floor Dysfunction and Endometriosis: How We Play a Vital Roll in the Integrative Team Approach of the Endometriosis Patient T.B. Nerreter .............................................................................................................................................. 28 Cultural and Linguistics Competency ......................................................................................................... 35

ENDO-609: Didactic: Endometriosis—The Whole Picture

Co-Chair: Jon I. Einarsson, Iris K. Orbuch

Faculty: Heather C. Guidone, Tamarah B. Nerreter, Marc Possover, Allyson Shrikhande, Ken R. Sinervo

Presented in cooperation with the AAGL Special Interest Group on Endometriosis/Reproductive Surgery.

Presented in affiliation with Society of Gynecologic Surgeons (SGS)

Course Description Endometriosis is commonly thought of as a surgical disease. Surgical excision is the cornerstone of treating women with endometriosis; however, taking a holistic approach to the patient can help treat other facets of a chronic condition. Expert physicians will provide an in-depth discussion on safe and appropriate surgical excision, including endometriosis affecting the bowel and urinary systems, as well as the pelvic and sacral nerves. The course will also cover neuropelveology as it relates to endometriosis patients. Practical tips for treating central sensitization will be provided as it is beneficial to many women with endometriosis. We will explore the co-existing conditions women with endometriosis often present with and learn how to identify and treat them. This course will have a practical focus, teaching tips and tricks for you to bring back to your operating room and how to incorporate them into your pre-operative assessment to ensure your chronic pain patient is holistically evaluated and treated.

Course Objectives At the conclusion of this activity, the participant will be able to: 1) Implement a multidisciplinary treatment plan for endometriosis patients including surgical excision as well as a holistic approach to the disease to evaluate for and treat coexisting conditions; 2) discuss how to apply surgical skills of excision of endometriosis on the bowel, ureter, and bladder to your own practice; 3) diagnose sacral nerve roots and sciatic nerve endometriosis, and construct a foundation of neuropelveology; and 4) recognize that close to 80% of women with endometriosis also have another reason, in addition to endometriosis, that may contribute to their pain.

Course Outline

12:30 Welcome, Introductions, and Course Overview J.I. Einarsson, I.K.

Orbuch

12:35 Endometriosis—the Patient Perspective H. C. Guidone

1:00 Neuropelveology and Endometriosis M. Possover

1:25 Bowel Endometriosis—Surgical Treatment K.R. Sinervo

1:50 Endometriosis of Sacral Nerve Roots and Sciatic Nerve M. Possover

2:15 Questions & Answers All Faculty

2:25 Break

2:40 Endometriosis of the Bladder and Ureter—Surgical Approach J.I. Einarsson

3:05 A Holistic Approach to Endometriosis. Evaluating Coexisting

Conditions of Endometriosis

I.K. Orbuch

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3:30 Unlocking Central Sensitization in Patients with Endometriosis A. Shrikhande

3:55 The Role of the Pelvic Health Physiotherapist in Pelvic Floor

Dysfunction and Endometriosis: How We Play a Vital Roll in the

Integrative Team Approach of the Endometriosis Patient

T.B. Nerreter

4:20 Questions & Answers All Faculty

4:30 Adjourn

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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Director, AAGL* Linda D. Bradley, Medical Director, AAGL* Erin T. Carey Consultant: MedIQ Mark W. Dassel Contracted Research: Myovant Sciences Erica Dun* Adi Katz* Linda Michels, Executive Director, AAGL* Erinn M. Myers Speakers Bureau: Laborie Medical Technologies, Teleflex Medical Other: Unrestricted educational grant to support NC FPMRS Fellow Cadaver Lab: Boston Scientific Corp. Inc. Amy Park* Grace Phan, Professional Education Specialist, AAGL* Harold Y. Wu* Linda C. Yang Other: Ownership Interest: KLAAS LLC Jon I. Einarsson* Iris K. Orbuch*

SCIENTIFIC PROGRAM COMMITTEE Linda D. Bradley, Medical Director, AAGL* Jubilee Brown* Nichole Mahnert* Shanti Indira Mohling* Fariba Mohtashami Consultant: Hologic Marie Fidela R. Paraiso* Shailesh P. Puntambekar* Matthew T. Siedhoff Consultant: Applied Medical, Caldera Medical, CooperSurgical, Olympus Amanda C. Yunker Consultant: Olympus Linda Michels, Executive Director, AAGL*

FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Jon I. Einarsson* Heather C. Guidone* Tamarah B. Nerreter* Iris K. Orbuch* Marc Possover* Allyson Shrikhande* Ken R. Sinervo*

Content Reviewer has nothing to disclose.

Asterisk (*) denotes no financial relationships to disclose.

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Endometriosis-The Patient Perspective

48th AAGL Global Congress on MIGSNovember 9-13, 2019 – Vancouver, BC Canada

Heather C. Guidone, BCPA, Program DirectorCenter For Endometriosis Care

Kenny R. Sinervo, MD, FRCSC, LLC

Copyright © Center for Endometriosis Care & Kenny R. Sinervo MD FRCSC LLC except where otherwise noted. No use or reproduction permitted without express permission.2

DISCLOSURES

● I have no financial relationships to disclose

Copyright © Center for Endometriosis Care & Kenny R. Sinervo MD FRCSC LLC except where otherwise noted. No use or reproduction permitted without express permission.

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OBJECTIVES

• Discuss the necessity of patient perspective in endometriosis

care/treatment;

• Review deficits in endometriosis research/treatment/support which

can negatively impact patient’s HRQOL;

• Articulate proactive strategies to increase engagement and improve

the endometriosis patient healthcare experience.


“Despite the existence of severe pain, often described as 'intense' or 'overwhelming',

women experienced delay in receiving a diagnosis of endometriosis, and their

symptoms were frequently trivialized or normalized. This, and the limited effectiveness

of treatments, affected relationships with partners and family, work, and sexual relations,

although individual experiences in each area were diverse...the experience of endometriosis

pervades all aspects of a woman's life. This experience is compounded by the side effects of

many treatments. Women with this disease need to be taken seriously, and not

have their pain trivialized or normalized.”

-Denny E. Women's Experience of Endometriosis. J Adv Nurs. 2004 Jun;46(6):641-8.


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Patient Perspective is the Foundation of Patient Engagement– “lived experience of disease and its impact on them and their caregivers,

including symptomatic, intellectual, psychosocial, spiritual and goal-oriented dimensions of the disease and its treatment” [McGoon et al. 2019]

– “value”=more than just financial

Patient Perspective is Vital– ‘evaluating patient experience along with...effectiveness and safety of care

is essential to providing a complete picture of healthcare quality’ [Agencyfor Healthcare Research & Quality 2017]

Patients are the Drivers of Change - not just Objects of Change

NECESSITY OF PATIENT PERSPECTIVE


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Paternalistic Pitfalls–Oliver Wendell Holmes, 1871: "Your patient has no more right to all the truth you know, than he has to all the medicine in your saddle bags...he should get only as much as is good for him" [Smith 2004]

• some still resist patient involvement; place emphasis on treating endometriosis vs. treating person with endometriosis

–few patients willing to accept antiquated authoritarian attitudes any longer!

Patients Seek Autonomy in Care –‘the right to hold views, make choices and act based on own values and beliefs’ [Beauchamp & Childress 2009]–want to be “understood as individual human being” [Lindberg et al. 2014]; be partners in own care

Why Wasn’t I heard? Believed? Told about Other – Better – Options?–and why has so little changed over the course of almost 30 years??


The Literature: too Far Removed from Actual Patient Experiences?– “...descriptors are flat and don’t convey the suffering women experience." [Curtis et al. 2004]

Bedside Manner = Less Pain? ‘Clinician-patient relationship may affect pain experienced during medical care’ [Reynolds-Losin et al. 2017]

Patient Experience & Expectations of Care are ‘Relational’ & ‘Functional’– Relational: doctors empowering patients by recognizing, respecting and including preferences;

politeness, honesty, level of respect demonstrated throughout doctor–patient interactions– Functional: effectiveness of communication across healthcare system, accessibility and continuity

of care [Sirdifield et al. 2016]

All Dimensions of Patient Satisfaction Matter– “women with endometriosis often have negative health care experiences; pain is normalized,

minimalized or trivialized by healthcare staff...” [Bach et al. 2016] – “...characterized by ignorance, exposure and disbelief.” [Grundström et al. 2018]


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Universally, Patients Want...– To be seen, heard, believed and valued as authorities on their own narratives– To have access to high level, gold standard care regardless of financial status– To have emphasis placed on relief - or at least reduction - of symptoms - not just procreative

potential– To make own choices through truly informed consent - not based on bias or agenda of

physician– To be treated as partners in care; patient-centered care/shared decision making starts with

listening to – and really hearing us

“Patient satisfaction with medical support is essential since it does not only strongly influence quality of life and the psychological strain associated with endometriosis, but is also related to an improving health status.”[Lukas et al. 2018]


WE ARE THE ONLY CREDIBLE NARRATORS OF OUR EXPERIENCES


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DEFICITS IN TREATMENT, RESEARCH & SUPPORT NEGATIVELY IMPACT HRQOL

The More Things Change, the More they Stay the Same– failed “standards” of care = poor outcomes– dismissal, normalization= poor outcomes– delay in treatment/poor treatments = poor outcomes

• “…[D]elay in diagnosis can be a high source of stress responsible for an important psychological impact in these patients, having a sense of misunderstanding and neglect of the medical profession” [Leroy et al. 2016]

Continued Barriers to Universal Quality Care for All = poor outcomes– lack of proper coding, insurance red tape, lack of coverage leads to financial toxicity

Fertility Valuation over Quality of Life/Pain Eradication: Why??


Poor Health Literacy– generational inability to discriminate between normal/abnormal; need to inform early, inform

correctly

Redundant Research– Heavy focus on repurposing existing therapies; ‘industry sponsored research brings pro-industry

results’– must end “innovation drought” [Guo & Groothuis 2018]– “None of the evaluated RCTs met all the methodological criteria, none had only a low risk of bias

and provided sufficient details on methods and randomization to allow for the reproduction and replication of the study” [Capraş et al. 2019]

No Incentive to Improve Quality of Treatment for Endometriosis– those dedicated to endometriosis care poorly represented at institutional levels– system largely rewards approach of untreated/poorly treated disease– financial ties, agendas, bureaucratic red tape must not continue to drive standard of care!


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PROACTIVE STRATEGIESTO IMPROVE EXPERIENCE

Personalized Medicine– evaluate / encourage narrative which details not just symptoms, but also functional

burden/psychosocial impact as well as objectives of treatment– encourage/be receptive to patient perspective; incorporate views into management– inform patients about ALL possible therapies - let them participate in decision-making process

and gain control over own management [Lukas et al. 2018]

[Patients] “are looking for highly personalized, simple and connectedexperiences that place them squarely in charge and make them feelempowered. They want to be heard, understood and accompanied byfriends, family and healthcare experts as they traverse their health journey,all while receiving the highest levels of quality care.“

-Geeta Wilson [Gingess 2019]


Accurate Education Matters!– perception that society at large, including many clinicians, lack awareness and accurate

knowledge about endometriosis is distressing factor for many [Kundu et al. 2015]– share what you know/challenge misinformation wherever it appears

Judicious & Timely Referrals - Collaborative Care Enhances Patient Experience– referrals to multidimensional teams: address physical, clinical, psychological, social and

educational needs; tertiary referral centers with interprofessional networks in place can offer access to optimal management

– long-term, patient-focused, multidisciplinary chronic care model [Agarwal & Foster 2019]• pain, psychology, gastroenterology, urology, expert surgeons, pelvic physical therapy,

integrative medicine e.g. acupuncture, nutrition, mind-body– connect with institutions, groups and other resources that can enhance and support engagement

efforts [Moen 2017]• but...caveat emptor!


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"The most important thingwhen planning a patient'streatment for endometriosisis to LISTEN TO THEM.“

-Ken Sinervo, MD MSc FRCSC ACGE


IN SUMMARY...

Patient Perspective is Cornerstone of Quality Care– being heard/believed would have accelerated access to quality care

When in Doubt, Refer Them Out– it is unethical to deny any treatment (unless strong medical indication to do so)– earlier referral to a subspecialist may have had life-changing impact on long-term outcomes

“Enduring & Existing” isn’t the Same as “Living”– the impact on our bodies of a lesion of just a few millimeters is seismic– 20 minute office visit is mere flash into lived experience

Consequences for Decisions Made About Us without Us– we need allies and advocates for change from the inside the broken system

Continue to Break Barriers & Move Forward to Achieve/Effect Real Change – valuing patient perspectives– disseminating correct education – sharing legacy of expertise through training – be both learner and teacher


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“[When patients] participate more actively in the process of medical care, we cancreate a new healthcare system with higher quality services, better outcomes, lowercosts, fewer medical mistakes, and happier, healthier patients. We must make this thenew gold standard of healthcare quality and the ultimate goal of all our improvementefforts:

Not better hospitals.

Not better physician practices.

Not more sophisticated electronic medical systems.

Happier, healthier patients.”-Dr Charles Safran [Ferguson 2007]


REFERENCESAgarwal SK, Foster WG. Rethinking endometriosis care: applying the chronic care model via a

multidisciplinary program for the care of women with endometriosis. International Journal of Women's Health. Volume 2019:11. Pages 405-410, 23 July 2019.

Agency for Healthcare Research & Quality, Rockville, MD. What Is Patient Experience? March 2017. Web: www.ahrq.gov/cahps/about-cahps/patient-experience/index.html. Accessed June 30, 2019.

Bach AM, Risoer MB, Forman A, Seibaek L. Practices and Attitudes Concerning Endometriosis Among Nurses Specializing in Gynecology. Glob Qual Nurs Res. 2016;3:2333393616651351. May 26, 2016.

Beauchamp TL, Childress JF (2009). Principles of Biomedical Ethics, 6th Edn. Oxford University Press, New York.

Capraş RD, Urda-Cîmpean AE, Bolboacă SD. Is Scientific Medical Literature Related to Endometriosis Treatment Evidence-Based? A Systematic Review on Methodological Quality of Randomized Clinical Trials. Medicina (Kaunas). 2019 Jul 15;55(7)

Curtis A, Erickson-Owens D. Women’s lived experience with endometriosis assists clinician sensitivity and awareness. Journal of Midwifery & Women's Health. Volume 49, No. 6, November/December 2004.

Denny E. Women's experience of endometriosis. J Adv Nurs. 2004 Jun;46(6):641-8.


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REFERENCESFerguson T and the ePatient Scholars Working Group. ePatients: How They can Help us Heal Health Care.

Society for Participatory Medicine; 2007. Web: e-patients.net/e-Patients_White_Paper.pdf. Accessed June 23, 2019.

Grundström H, Alehagen S, Kjølhede P, Berterö C. The double-edged experience of healthcare encounters among women with endometriosis: A qualitative study. J Clin Nurs. 2018 Jan;27(1-2):205-211.

Guo SW, Groothuis P. Is it time for a paradigm shift in drug research and development in endometriosis/adenomyosis? Hum Reprod Update. 2018 Sep 1;24(5):577-598.

Kundu S, Wildgrube J, Schippert C, Hillemanns P, Brandes I. Supporting and Inhibiting Factors When Coping with Endometriosis From the Patients' Perspective. Geburtshilfe Frauenheilkd. 2015;75(5):462–469.

Leroy A, Azaïs H, Garabedian C, Bregegere S, Rubod C, Collier F. Psychology and sexology are essential, from diagnosis to comprehensive care of endometriosis. Gynecol Obstet Fertil. 2016 May 20.

Lindberg C, Fagerström C, Sivberg B, Willman A. Concept analysis: patient autonomy in a caring context. J Adv Nurs. 2014 Oct;70(10):2208-21.

Losin EAR, Anderson SR, Wager TD. Feelings of Clinician-Patient Similarity and Trust Influence Pain: Evidence From Simulated Clinical Interactions. J Pain. 2017 Jul;18(7):787-799.


REFERENCESLukas I, Kohl-Schwartz A, Geraedts K, et al. Satisfaction with medical support in women with endometriosis.

PLoS One. 2018;13(11):e0208023.McGoon M, Ferrari P, Armstrong I, Denis M, Howard L, Lowe G, Mehta S, Murakami N, Wong B. European

Respiratory Journal. 2019 53: 1801919. Moen MH. Endometriosis, an everlasting challenge. Acta Obstet Gynecol Scand. 2017 Jun;96(6):783-786.Sirdifield C, Godoy Caballero A, Windle K, Jackson C, McKay S, Schäfer W, Niroshan Siriwardena A.

Comparing importance and performance from a patient perspective in English general practice: a cross-sectional survey. Family Practice. Volume 33, Issue 2, April 2016, Pages 179–185.

Smith R. Why transparency is fundamental to quality. BMJ Talks. 2004. Reprinted, web: www.pitt.edu/~super7/14011-15001/14511.ppt. Accessed July 15 2019.

Weiner J. How good patient satisfaction can reduce malpractice risk. June 4, 2018. Modern Medicine Network. Web: www.physicianspractice.com/malpractice/how-good-patient-satisfaction-can-reduce-malpractice-risk. Accessed June 5, 2019.

Wilson, Geeta in “Why Treating Patients As Consumers Can Improve The Healthcare Experience” by Dan Gingiss. Forbes Magazine. July 9, 2019. Web: www.forbes.com/sites/dangingiss/2019/07/09/why-treating-patients-as-consumers-can-improve-the-healthcare-experience/?ss=cmo-network#78c9b01c63a1. Accessed July 10, 2019.


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Bowel Endometriosis:Surgical Treatment

Ken Sinervo, M.D., M.Sc.Medical Director

The Center for Endometriosis CareAtlanta, GA

Disclosure

• I have no financial relationships to disclose.

© 2019 Ken Sinervo, MD

Objectives

Discuss the diagnosis of invasive bowel endometriosisApply the current management of invasive bowel endometriosisDiscuss outcomes and complications following treatment of bowel endometriosisDemonstrate different techniques for treating bowel endometriosis


Bowel Endo Path


DiagnosisHistory

History of IBS, dyschezia, alternating constipation and diarrhea, intestinal cramping, rarely rectal bleeding (dark red vs. BRB likely with hemorrhoids, fissures)

Examination

Fixed retroverted uterus, thickening of the USLs or RVS, puckering or mass on RVE

Investigations

TVUS, MRI, Colonoscopy?


MRI has been found to be accurate in diagnosing deeply invasive lesions in approximately 83% of the patients

MRI is highly specific, but sensitivity can be low when dealing with areas other than the bowel (86%) such as vagina, bladder and ureter

MRE has been shown to be more sensitive than MRI in recent studies, particularly in multifocal (multiple lesions in the same bowel segment) and multicentric lesions (multiple lesions in different bowel segments) - Timoh et al. 2018


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Bowel prep was 5mg sodium picosulfate night before and fleet enema within 1 hour of the TVUSHighly sensitive (83%) and specific (94%)


• The sliding sign is used to determine CDS obliteration.

• A negative sliding sign is indicative of an obliterated CDS as the bowel does not slide.

• When combined with the direct visualization of the bowel lesion, the sensitivity and specificity is much higher than when compared to individual markers alone.

• Areas of fibrosis will be seen as white lesions as they are more dense, corresponding to deeply infiltrative lesions and/or USL thickening.


Bowel Treatment Techniques

Essentially there are 4 different modalities to treat invasive bowel endo

SHAVING/EXCISION

NODULECTOMY

DISCOID RESECTION

SEGMENTAL RESECTION


Shaving


Discoid Resection


Determining Extent of Surgery


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Abrao et al. (2015)


Discoid Resection


Multiple Discoidectomies


Double Staple Resection


Combined Shaving and Discoid Resection


Discoid vs. Segmental Resection


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Nodulectomy


Optimizing Outcomes Based on Pre-op Imaging


U/S Based Algorithm (Abrao et al. 2019)


Characteristics of Lesions (Abrao et al. 2019)


Fast Track Care for Colorectal Endometriosis


Diverting Stoma


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Colorectal Stenosis


Prevention of Fistula


Assessing Bowel Integrity


Conclusions

Individualization of the extent of surgery based on size of lesion, depth of invasion, multifocalityMove towards combined shaving/discectomy or double stapler may reduce complications compared to segmental resectionPotential role for Fast Track Care with no bowel prep, early advancement of diet, no post-op AbxUse of preventive omental or mesenteric flaps if vaginal incision with resection; avoidance of ileostomyPossible use of ICG sigmoidoscopy to assess blood supply of the bowel


Bowel Dissection ReferencesChamié LP, Blasbalg R, Gonçalves MO, Carvalho FM, Abrão MS, de Oliveira IS. Accuracy of magnetic resonance imaging for diagnosis and preoperative assessment of deeply infiltrating endometriosis. Int J Gynaecol Obstet. 2009 Sep;106(3):198-201. doi: 10.1016/j.ijgo.2009.04.013.

Nyangoh Timoh K, Stewart Z, Benjoar M, Beldjord S, Ballester M, Bazot M, Thomassin-Naggara I, Darai E. Magnetic Resonance Enterographyto Assess Multifocal and Multicentric Bowel Endometriosis. Journal of Minimally Invasive Gynecology. 2018 May-Jun;25(4):697-705. doi: 10.1016/j.jmig.2017.10.037.

Goncalves MO, Podgaec S, Dias JA Jr, Gonzalez M, Abrao MS. Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis, defining surgical strategy. Hum Reprod. 2010 Mar;25(3):665-71. doi: 10.1093/humrep/dep433.

Reid S, Espada M, Lu C, Condous G. To determine the optimal ultrasonographic screening method for rectal/rectosigmoid deep endometriosis: Ultrasound “sliding sign,” transvaginal ultrasound direct visualization or both? Acta Obstet Gynecol Scand. 2018; 97: 1287– 1292. doi.org/10.1111/aogs.13425

Abrão MS, Podgaec S, Dias JA Jr, Averbach M, Silva LF, Marino de Carvalho F. Endometriosis Lesions That Compromise the Rectum Deeper Than the Inner Muscularis Layer Have More Than 40% of the Circumference of the Rectum Affected by the Disease. Journal of Minimally Invasive Gynecology. Volume 15, Issue 3, 2008, Pages 280-285. doi.org/10.1016/j.jmig.2008.01.006.

Abrao MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. Deep Endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update 2015; 15:1-11.


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ReferencesJayot A, Bendifallah S, Abo C, Arfi A, Owen C, Darai E. Feasibility, Complications, and Recurrence after Discoid Resection for Colorectal Endometriosis: A Series of 93 Cases. Journal of Minimally Invasive Gynecology. July 18, 2019. doi.org/10.1016/j.jmig.2019.07.011.

Millochau JC, Stochino-Loi E, Darwish B, Abo C, Coget J, Chati R, Tuech JJ, Roman H. Multiple Nodule Removal by Disc Excision and Segmental Resection in Multifocal Colorectal Endometriosis. Journal of Minimally Invasive Gynecology. Volume 25, Issue 1, 2018, Pages 139-146. doi.org/10.1016/j.jmig.2017.09.007.

Oliveira MD, Crispi CP, Oliveira FM, Junior PS, Raymundo TS, Pereira, TD. Double Circular Stapler Technique for Bowel Resection in Rectosigmoid Endometriosis. Journal of Minimally Invasive Gynecology. Volume 21, Issue 1, 2014, Pages 136-141. doi.org/10.1016/j.jmig.2013.07.022.

Roman H, Tuech JJ, Arambage K. Deep Rectal Shaving Followed by Transanal Disc Excision in Large Deep Endometriosis of the Lower Rectum. Journal of Minimally Invasive Gynecology, Volume 21, Issue 5, 2014, Pages 730-731.doi.org/10.1016/j.jmig.2014.03.003.

Jayot A, Nyangoh Timoh K, Bendifallah S, Ballester M, Darai E. Comparison of Laparoscopic Discoid Resection and Segmental Resection for Colorectal Endometriosis Using a Propensity Score Matching Analysis. Journal of Minimally Invasive Gynecology. Volume 25, Issue 3, 2018, Pages 440-446. doi.org/10.1016/j.jmig.2017.09.019.

Stuparich M, Lee TTM. Discoid Resection of Rectosigmoid Endometriotic Nodules. Journal of Minimally Invasive Gynecology. Volume 25, Issue 3, 2018, Page 388. doi.org/10.1016/j.jmig.2017.09.024.


ReferencesAbrao MS, Andres MP, Barbosa RN, Bassi MA, Kho RM. Optimizing perioperative outcomes with selective bowel resection following algorithm based on pre-operative imaging for bowel endometriosis. Journal of Minimally Invasive Gynecology. June 22, 2019. doi.org/10.1016/j.jmig.2019.06.010.

Scioscia M, Ceccaroni M, Gentile I, Rossini R, Clarizia R, Brunelli D, Ruffo G. Randomized Trial on Fast Track Care in Colorectal Surgery for Deep Infiltrating Endometriosis. Journal of Minimally Invasive Gynecology. 2017 Jul-Aug;24(5):815-821. doi: 10.1016/j.jmig.2017.04.004.

Bonin E, Bridoux V, Chati R, Kermiche S, Coget J, Tuech JJ, Roman H. Diverting stoma-related complications following colorectal endometriosis surgery: a 163-patient cohort. Eur J Obstet Gynecol Reprod Biol. 2019 Jan;232:46-53. doi: 10.1016/j.ejogrb.2018.11.008.

Bertocchi E, Barugola G, Benini M, Bocus P, Rossini R, Ceccaroni M, Ruffo G. Colorectal Anastomotic Stenosis: Lessons Learned after 1643 Colorectal Resections for Deep Infiltrating Endometriosis. Journal of Minimally Invasive Gynecology. 2019 Jan;26(1):100-104. doi: 10.1016/j.jmig.2018.03.033.

Hanacek J, Havluj L, Drahonovsky J, Urbankova I, Krepelka P, Feyereisl J. Interposition of the mesorectal flap as prevention of rectovaginal fistula in patients with endometriosis. Int Urogynecol J. 2019 Jul 1. doi: 10.1007/s00192-019-04030-8.

Seracchioli R, Raimondo D, Arena A, Zanello M, Mabrouk M. Clinical use of endovenous indocyanine green during rectosigmoid segmental resection for endometriosis. Fertil Steril. 2018 Jun;109(6):1135. doi: 10.1016/j.fertnstert.2018.02.122.


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Jon Ivar Einarsson MD PhD MPHDirector of Minimally Invasive Gynecologic SurgeryBrigham and Women’s HospitalProfessor of Obstetrics, Gynecology and Reproductive BiologyHarvard Medical School

I have no financial relationships todisclose

� Discuss the surgical approach for endometriosis of the bladder and ureter

� The bladder or ureter are only involved in 1% of women with endometriosis

� A ratio of 40:5:1 has been described for proportion of bladder to ureteral to renal involvement

� Specific symptoms are lacking� Often an incidental finding during surgery for pelvic

pain� Most significant outcome can be silent loss of renal

function due to progressive obstruction and hydronephrosis

� Loss of renal function occurs in up to 50% of cases

� Endometriosis of the ureter Intrinsic ‐ invades the ureter wall

Extrinsic ‐ endometriosis of surrounding structures causes ureteral compression

Incidence of extrinsic to intrinsic is approximately 4:1

� Symptoms Flank pain (25%)

Gross hematuria (15%)

Asymptomatic (50%)

� Suspect if large (>3 cm) rectovaginal lesion

� Also more common with uterosacral ligament nodules, severe pelvic disease and older age

� Renal ultrasound is a good first line test

� MRI is very helpful to map out the lesion to to evaluate the kidneys as well

� Surgical therapy is first line, medical management is generally not successful

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� Ureteral stenting should be the first step if resection is planned

� If stent cannot be placed initially, it can be placed after the nodule is removed

� Ureterolysis can be adequate if the disease is not infiltrating into the wall of the ureter

� 2 main surgical treatment options End to end anastomosis

Ureteroneocystostomy� End to end anastomosis is often feasible

� End‐to‐end anastomosis For lesions less than 3‐4cm Simpler Can be done by a gynecologist

� Ureteroneocystostomy For lesions larger than 3‐4 cm For lesions located in proximity to the bladder or involving the trigone May need a vesico‐psoas hitch and/or a Boari flap for a tension free

anastomosis Usually requires collaboration with urology

� Nephrectomy Can be considered if GFR is less than 10 ml/min Observation is also acceptable Indicated if there is suspected malignancy

� A recent review identified 151 published cases

75 laparoscopic

18 laparotomy

1 robot

57 unspecified

� Operating time was about 300 minutes� Recurrence of obstructive uropathy occurred in 11 cases (7.3%)

Goggins et al. Ureteroureteral anastomosis for endometriosis involving the ureter: Case series and literature review. J endometriosis and pain disorders. May 2019

� Symptoms include Frequency

Urgency

Dysuria

Bladder spasms

Hematuria� Diagnosis can be made by Pelvic ultrasound

Pelvic MRI

Page 15

� Segmental bladder resection is the treatment of choice

� Lesions at the bladder dome are more common and easily resected and repaired

� Keep catheter in for 7‐10 days post op� Can perform retrograde cystogram to confirm bladder integrity at that time

� If the lesion is near the trigonal area, stenting is recommended and concurrent cystocopicguidance is advisable during the resection

� Ureteral reimplantation may be necessary

� Urinary tract endometriosis is fairly rare� Surgical management is generally indicated� Bladder endometriosis is most common and generally most easily treated surgically

� Ureteral endometriosis is often extrinsic, but if intrinsic, then either end‐t0‐end anastomosis or reimplantation are required

� Renal function is compromised in up to 50% of patients and a nephrectomy is sometimes indicated

Page 16

A Holistic Approach to Endometriosis. Evaluating Co-existing Conditions of

Endometriosis

Iris Kerin Orbuch, M.D. Director, Advanced Gynecologic Laparoscopy Center, Los Angeles & New York City

Endometriosis SIG President, AAGL 2018-19Author, Beating Endo How to Reclaim Your Life from Endometriosis

Disclosure

I have no financial relationships to disclose

Objectives

● Implement a multidisciplinary treatment plan for endometriosis patients encompassing a holistic approach to the disease, evaluating for and treating co-existing conditions, and surgical excision.

● Recognize that close to 80% of women with endometriosis also have another pain generator, in addition to endometriosis, that contributes to their pain.

● Recognize that 70% of teens with dysmenorrhea have endometriosis.

● Recognize that endometriosis is not only a disease of lesions/implants, but an inflammatory process as well.

4

20’s 30’s 40’sTeenager

G.I.

Urologist

Another GIPediatrician

Gynecologist

Gynecologist

Rheumatologist

Physical Therapist

Psychiatrist

Ablation

Pain Doc

EXCISION

Teenager

30’s

R.E.I.

20’s

2019

Fetal Endometriosis

Page 17

7

Endometriosis is found in 70% of girls with dysmenorrhea.

8

10


Pediatrician

EXCISION

2019

11


G.I.

Urologist


Gynecologist

Gynecologist

Rheumatologist

Physical Therapist

Psychiatrist

Ablation

Pain Doc

EXCISION

Teenager

30’s

Endocrinologist

20’s

2019 How Do You Think About Endometriosis?

Page 18

How do you think about Endometriosis? FACT

● It is well accepted that there’s no correlation between extent of endometriosis seen at laparoscopy and amount of pain.

● Fauconnier A, Chapron C. Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications. Hum Reprod Update. 2005; 11;595- 606.

Rethinking about endometriosis

Co-existing conditions

Pelvic Floor Dysfunction

Interstitial Cystitis

Central Sensitization

SIBO

Anxiety/ Depression

Endometriosis

Prevalence of myofascial pain in patients with history or presence of endometriosis: 91%

Page 19

Prevalence of centralized pain syndrome in patients with endometriosis: 87%

Patients with endometriosis are more likely to have central sensitization (87%).

This figure illustrates how endometrial lesions can engage the nervous system to give rise to different types of pain associated with endometriosis and co-morbid conditions.

Stratton P , and Berkley K J Hum. Reprod. Update 2011;17:327-346

Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology 2010

86% of Endometriosis patients have I.C.

Prevalence of pelvic floor dysfunction and interstitial cystitis: 87%

I.C. is present in 40-60% of patients with IBS

Treating SIBO improved symptoms of I.C. as both share a pathophysiology of increased proinflammatory cytokines, and increased mast cells and visceral hypersensitivity.

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Patients with anxiety and depression are more likely to have central sensitization.

When taking a patients history with chronic pelvic pain, it is critical to ask questions not only regarding pain but also urologic, GI, musculoskeletal and reproductive systems

Howard F. Chronic Pelvic Pain. J Obstet and Gynecol. 2003;101(3):594-611.

Because of the 10 year diagnostic delay, Endometriosis and its inflammatory effects set off other conditions

ENDOMETRIOSIS

PELVIC FLOOR DYSFUNCTION

INTERSTITIAL CYSTITIS/ PBS

CENTRAL SENSITIZATION

SMALL INTESTINAL BACTERIAL OVERGROWTH (SIBO)

ANXIETY DEPRESSION

10 + YEAR DELAY IN DIAGNOSIS OF ENDOEMTRIOSIS

WHY TREATING ONE CONDITION DOES NOT WORK Co-existing conditions

Pelvic Floor Dysfunction

Interstitial Cystitis


SIBO

Anxiety/ Depression

Endometriosis

Page 21

31


G.I.

Urologist


Gynecologist

Gynecologist

Rheumatologist

Physical Therapist

Psychiatrist

Ablation

Pain Doc

EXCISION

Teenager

30’s

Endocrinologist

20’s

EARLY DIAGNOSIS OF ENDOMETRIOSIS

ENDOMETRIOSIS

33


Pediatrician

EXCISION

34

Take home points

● Strive for early diagnosis in teens

● Evaluation and treatment of all co-existing conditions

References

Hoffman D Curr Rheumatology Rev 2015 11(2) 146-66 Central and peripheral pain generators in women with chronic pelvic pain: patient centered assessment and treatment

Stratton P et al. Obstet Gyenecol 2015 March 125(3), 719-728 Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain

Peters KM, Carrico DJ, Kalinowski SE, et al. Prevalence of pelvic floor dysfunction in patients with interstitial cystitis. Urology 2007; 70:16-8

Page 22

Weinstock L, Klutke CG, Lin HC. Small Intestinal Bacterial Overgrowth in Patients with Interstitial Cystitis and Gastrointestinal Symptoms. Dig Dis Science (2008) 53: 1246-1251

Fauconnier A, Chapron C. Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications. Hum Reprod Update. 2005; 11;595- 606.

Chung M et al. Interstitial cystitis and endometriosis in patients with chronic pelvic pain: The "Evil Twins" syndrome. JSLS. 2005 Jan-Mar;9(1):25-9.

Saridogan E. Endometriosis in Teenagers. Women's Health. 2015 11(5), 705-709.

ACOG Committee Opinion. Dysmenorrhea and Endometriosis in the Adolescent. Vol132, No 6, December 2018 p. 249-58.

Dowlut-McElroy T, Strickland J. Endometriosis in Adolescents. Curr Opin Obstet Gynecol 2017; 29:306-9.

Morotti M, Vincent K, et al. Peripheral changes in endometriosis-associated pain. Human Reprod Update. 2014; 20(5): 717-736.

Page 23

Unlocking Central Sensitization in Patients with

EndometriosisAllyson Shrikhande MD

Medical DirectorPelvic Rehabilitation Medicine

Volunteer Faculty Lenox Hill Hospital

Disclosure

I have no financial relationships to disclose

Objectives

Describe the Physiatrist Approach to Endometriosis Explain Neurogenic Inflammation and it’s role in the sensitization process Delineate the Pathophysiology of Central Sensitization Describe Treatment Options for Central Sensitization

Physiatrists and Pelvic Pain??

Muscles Nerves Joints

Image Citations: https://abdominalkey.com/anatomy-of-the-lower-urinary-tract-and-male-genitalia/,http://www.sportsinjuryclinic.net/sport-injuries/low-back-pain/sacroiliac-joint-pain, http://www.medicalartlibrary.com/pelvic-floor-muscles/

SYMPTOMS WE SEE and TREAT

Image Citations: https://www.dreamstime.com/illustration/stomachache.html

Muscle Spasm

Decreased Circulation

Neuro-inflammatoryMediators Released

Peripheral Nerve

Irritation


Weakness

Compensation

Mechanical Changes

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Nerve Pain related to Peripheral and Central Sensitization

Pathophysiology of Central Sensitization

1) EXPERIENCING PAIN FOR A LONG PERIOD OF TIME

2) CHANGES HOW THE BRAIN PERCEIVES AND PROCESSES PAIN SIGNALS

3) AMPLIFICATION OF PAIN P AI NImage Citations: http://keywordsuggest.org/content/1100963-megaphone-icon.html, http://www.abc.net.au/radionational/programs/allinthemind/pain-on-the-brain/7232844, http://tape-llc.com/2017/03/serving-client-almost-30-years/

Morotti M, Vincent K, Brawn J, Zondervan KT, Becker CM. Peripheral changes in endometriosis-associated pain. Hum Reprod Update. 2014 Sep-Oct;20(5):717-36.

There are many overlapping pathways that lead to pain

12

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PeriAqueductal Gray and the Medial Motor Cortex

Patients with Primary Dysmenorrhea fMRI during Menstrual Phase

Increased Functional Connectivity PAG and Medial Motor Cortex

● Muscles such as the pelvic floor, abdominals and toes are represented in Medial Motor Cortex

Visceral Pain Syndromes Demonstrate Functional Connectivity Disturbances

● Women with Primary Dysmenorrhea● Women with Interstitial Cystitis/Painful

Bladder Syndrome● Women with Localized Provoked

Vulvodynia● Men with Chronic Prostatitis/Chronic

Pelvic Pain Syndrome

Alterations in Resting State Oscillations and Connectivity in Sensory and Motor Networks in Women with Interstitial Cystitis/Painful Bladder

Syndrome

Lisa A. Kilpatrick, Jason J. Kutch, Kirsten Tillisch, Bruce D. Naliboff, Jennifer S. Labus, Zhiguo Jiang, Melissa A. Farmer, A. Vania Apkarian, Sean Mackey,

Katherine T. Martucci, Daniel J. Clauw, Richard E. Harris, Georg Deutsch, Timothy J. Ness, Claire C. Yang, Kenneth Maravilla, Chris Mullins, Emeran A. Mayer

The Journal of UrologyVolume 192, Issue 3, Pages 947-955 (September 2014)

DOI: 10.1016/j.juro.2014.03.093

Copyright © 2014 American Urological Association Education and Research, Inc. Terms and Conditions

Figure 2

The Journal of Urology 2014 192, 947-955DOI: (10.1016/j.juro.2014.03.093) Copyright © 2014 American Urological Association Education and Research, Inc. Terms and Conditions

Page 26

Multimodal management for a multidimensional disease

Brawn et al. Human Repro Update 2014

Morotti M, Vincent K, Brawn J, Zondervan KT, Becker CM. Central changes associated with chronic pelvic pain and endometriosis. Hum Reprod Update. 2014 Sep-Oct;20(5):737-47.

Page 27

“The Role of the Pelvic Health Physiotherapist in Pelvic Floor Dysfunction

and Endometriosis: How we play a vital roll in the

integrative team approach of the endometriosis

patient”

DisclosureI have no financial relationships to disclose

Objectives• Explain to fellow clinicians on the importance of considering the pelvic

floor in their assessments of their patients with Endometriosis• The pelvic floor may be the victim with those who have Endo • We want you to realize that you have a role in screening for pelvic floor

dysfunction that your client didn’t even know could be addressed

• Explain to clinicians that there is no cookbook approach for PFD (ie:can’t give strengthening exercises to everyone)

• Discuss the relationship of the rest of the body to the pelvic floor-impact of endo with respect to this

• Recommend an alternative way of thinking about “the core”, integratingthe pelvic floor

• Explain the importance of pelvic health screening and treatment forEndometriosis patients (and others)

Tamarah Nerreter, MScPT, CAFCI, GCOMPT-FCAMPT Graduated from Curtin University, Australia with a Masters in Physiotherapy (MScPT) 2007

Graduated from Queens University, Canada with a Double Major in Psychology and Health Sciences 2002

UBC Post Graduate GCOMPT Advanced Ortho/Manual Therapy and Manipulation (FCAMPT)

Clinical Pilates Instructor – Balanced Body

Owner BoDynamics Physiotherapy (2007- present)

Extensive post graduate training in Orthopaedics/Manual Therapy (FCAMPT), Integrated Systems Model (ISM), Vestibular Rehabilitation, Pelvic Floor/Continence/Pelvic Pain Rehabilitation, Barral Visceral Training and Acupuncture Certification (CAFCI) 2008

Diane Lee and Associates 2012-2019 (Senior Women’s Health Physiotherapist) (Teaching assistant)

c Floor/Continence/Pelvic Pain Rehabilitation,ification (CAFCI) 2008

Women’s Health Physiotherapist) (Teaching

AcknowledgementsLarge network of Pelvic Health Physiotherapists in BC

Thank the tireless work of our predecessors who paved the way for the work we can do today

Current Observations in Practice:Self Referral

Majority of clients are self-referred

Assumption that symptoms are normal don’t disclose to care provider

Early overwhelm decreased self careNot seeking appointments for themselves unless it is REALLY BAD

Page 28

Current Observations in Practice: Confusion

“Why didn’t anybody ever tell me?”

“Why didn’t anybody ever ask?”

Words we hear:FearShameAloneVulnerableConfusedFailureBroken

How Can Pelvic Health Physiotherapy Help?

Research for endometriosis is lacking, but clinical experience and low grade evidence suggests it is beneficial.

Myofascial or nervous system mechanisms may be important for deep dyspareunia in women with Endo- even those with moderate to severe diseases (Orr NL et al., 2018)

LLevel 1/Grade A evidence for Pelvic HHealthPhysiotherapy as a first line treatment for stress,urge, mixed incontinence and prolapse.

Summary from the International Consultation on Incontinence 2013 (7)

Chronic Pelvic Pain SyndromeICS: ‘persistent pain lasting longer than 6 mos or recurrent episodes of abdominal or pelvic pain, hypersensitivity or discomfort often associated with elimination changes and sexual dysfunction often in the absence of organic etiology’

EAU: ‘chronic or persistent pain perceived in structures reltated to the pelvis…often associated with negative cognitive, behavioral, sexual and emotional consequences’

About 19% in reproductive age; 14% experience once in lifetime and 42% report restriction in daily activities

Multi organ systems contribute (lower urinary tract, female genital, gastrointiestinal, MSk, neurological, psychological, sexual dysfunction) and caring for women MUST be multidisciplinary

Leads to comorbitities with depression, anxiety, fatigue and use of pain meds

= HIGH TONE PELVIC FLOOR DYSFUNCTION

(Xibei J, Rana N, Crouss T, and Whitmore K., (2019) Gynecological Associated Disorders and Management International Journal of Urology. 26(1): 46-51.

Functions of the pelvic floor1. MSK support

2. Organ support

3. Continence

4. Sexual function

5. Circulation

• To perform these functions the muscles need to be able to:

1. Contract concentrically

2. Relax

3. Lengthen while holding tension (eccentrically contract)

A little about the pelvic floor…

Pelvic FloorThree Layers of Muscle

Direct continuity of Layer 1 to the adductors of the thigh

Page 29

Direct continuity of Layer 2 to the TrA fascia


\

Direct continuity of Layer 3 to the hips


\

The pelvic floor and LBP• Up to 95% of women with low back pain have

objective findings of pelvic floor dysfunction (Dufour et al, 2018)

PFD

LBP

The pelvic floor and LBP• Consider fascial connections (Myers)

• Direct connection from the PF to the ALL, QL, psoas, iliacus

The pelvic floor and SIJ dysfunction

• Overactive PF sacral counternutation loss of form closure motor control impairment

• Ineffective PF contraction loss of force closure motor control impairment

• Loss of form and force closure at the SIJ increased hamstring tension to increase tension on sacrotuberous ligament OR activation of muscles of the hip to increase force closure muscle strains/tears

Vleeming et al 1989Hungerford et al 2003D Lee

• In patients with chronic unilateral SIJ pain, ASLR results in bracing pattern through the abdominal and chest walls, increased IAP and depression of the pelvic floor (Beales 2009)

The pelvic floor and the hip• Asymmetric activation of the PFM (ischiococcygeus

& levator ani) displaces the coccyx, innominate and femoral head (Bendova et al 2007)

• Change in position of the innominate and/or the femoral head is going to affect the available movement of the hip joint• Often the pelvic floor is a contributing factor in hip

impingement syndromes and labral tears

Page 30

The pelvic floor and the

hip• Obturator internus• Direct connection

between the pelvic floor and the hip

The pelvic floor and groin injuries

• Ineffective PF contraction loss of form closure at pubic symphysis overactive adductors adductor strains, osteitis pubis

• Fascial connections from adductors to pelvic floor

• Obturator nerve passes through the pelvic floor muscles and supplies the adductors

• Ilioinguinal nerve, genitofemoral nerve pass through the pelvis and can cause groin, thigh, penile, scrotal, or vulvar pain/irritation • T12-L2 origin of these nerves – consider the TL

junction

The pelvic floor and neuromobility• Connection from the cerebral falx,

cerebellar tentorium to the spinal dura to the coccyx• the terminal end of the dura (the

filum terminale) attaches to the coccyx

• Consider how tension in the pelvic floor can create tension in the duralsystem through a pull on the coccyx

• Consider how tension in the duralsystem can cause overactivation of the pelvic floor

The pelvic floor and neck/upper

back pain• Fascial connections from the

pelvic floor up to the jaw

• Position of the diaphragm can affect the pull on the upper thorax and neck via these fascial connections• Eg: post partum, poor organ

support

• Consider posture• Overactive pelvic floor can

posteriorly rotate the pelvis can lead to postural changes up the chain

The Pelvic floor, Endo and their Visceral relationshipBladder

Frequent urination leading to Dx IC (pain, pressure, frequency, discomfort)Amplification of pain cycle- hieghtens nerves PF reacts hypertoneAbdominal muscle involvement viscero-somatic

GI tract The second (arguably first) brainAbdomino-pelvic cavity- secured between diaphragm and pelvicsOrgans adhere- muscle/fascia tensions (asymm.)Diarrhea, constipation, bloating, painful bowels, abdo painConstipation- pressure on pelvic floor (push, strain)Diarrhea – irritation to pelvic floor

But….

• Contrary to most people’s beliefs…PF strengthening exercises are NOT THE ONLY WAY to address the pelvic floor

Page 31

Why not? – because a lot of people do it incorrectly

• 25%-40% of women have decreased cortical awareness of PFM and will Valsalva when attempting to do a PFM contraction (Bump et al 1991)

• Alternately, they may contract but not lift the levator plate

• When PFM are over-active lift may be restricted (depends on PFM starting position) (Whittaker 2007)

• PFM able to contract but no fascial tension is generated

• Many present with asymmetry of resting activation, ability to contract/relax – left/right, front back

**MUCH MORE INVOLVED THAN JUST CONTRACTING THE PELVIC FLOOR!

Why not?• If the problem is caused by an overactive PF or

asymmetrical PF activation, strengthening exercises may make it worse!

• Can contribute to:• Improper bracing strategies• Pelvic pain syndromes• Vulvar pain syndromes• Pudendal neuralgia• Coccyx pain• Hip/SI/LB pain• Worsening symptoms of prolapse and incontinence• Sexual dysfunction• And more!

BEFORE PRESCRIBING ANY TREATMENT REGIME FOR THE PELVIC YOU MUST IDENTIFY IF THE PELVIC FLOOR IS

OVERACTIVE OR UNDERACTIVE and WHY

\

The pelvic floor is not a light switch

• Postural and respiratory functions of the pelvic floor muscles (Hodges et al 2007) • Preparatory increase in PFM activity with arm

movements

• Tonic activation of the PFM with a sustained task with modulation in response to perturbations

• Modulation of the PFM activation with breath

• Note that the pelvic floor activation varies according to the task• Volume dial vs light switch

The canister• The pelvic floor doesn’t work in isolation, nor does

the abdominal wall• Why do we train it as if it does?

• There is a synchronous movement of the pelvic floor, ab wall and diaphragm with breath and cough (Talasz et al, 2011)• *Canister activity*

Inhalation

Modified from Sapsford 2004

Page 32

Exhalation

Modified from Sapsford 2004

Functions of the canister• MSK support

• Organ support

• Pressure management• This is a dynamic activity; requires modulation of the

muscle activity

• A pattern that involves tonic holding of these postural muscles doesn’t allow for dynamic pressure management• Eg: running or skipping with the pelvic floor and TA “on”

The canister• It’s time to shift our thinking of “the core” to include the:

• Ab wall• Pelvic floor• Diaphragm

• Train them together, not in isolation!• If one area isn’t functioning properly, the entire canister won’t• Julie Wiebe Piston Science online course is a great resource for this

• BUT…don’t assume that just because part of the canister is working well that the entire canister is• Eg: you can’t infer that the pelvic floor is activating optimally just

because the TA is• This synergy of TrA and PF is commonly lost in subjects with UI (Bo

et al 2009)

Physiotherapy & CPPSIUGA/ICS 2016 combined report

Chronic pelvic pain syndrome (CPPS): persistent pain perceived in structures related to the pelvis, in the absence of proven infection or other obvious local pathology that may account for the pain. It is often associated with neg-ative cognitive, behavioral, sexual or emotional consequences, and with symptoms suggestive of lower urinary tract, sexual, bowel or gynecological dysfunction

* pelvic floor muscle training

*exercise training

*myofascial / TrP release

* manual therapy /joint moblization

*connective tissue manipulation

*scar tissue mobilization

*neural/visceral mobilization

*neuromuscular re education

Working TogetherHelp us Help Your Patients

Working Together – Our AsksScreen pelvic health function

Ask specific questions about symptomsTest specific function

“proper performance of Kegel exercises should be confirmed by digital vaginal exam or biofeedback” - Society of Obstetricians and Gynecologists of Canada 2006 guidelines (18)

Understand risk factors for pelvic floor dysfunction (such as endometriosis)

Write a requisition for PFPT for clients who have endometriosis and its associated issues (CPP, bowel/bladder issues and/or pain, myofascial dysfynction etc)

Page 33

Discussion and QuestionsHow can we help you?

References• Thom DH, Rortveit G. Prevalence of postpartum urinary incontinence: a systematic review.

Acta Obstet Gynecol Scand. 2010; 89(12): 1511-22

• Guise JM, Morris C, Osterweil P, Li H, Rosenberg D, Greenlick M. Incidence of fecal incontinence after childbirth. Obstet Gynecol. 2007; 109 (2 pt 1):281-8

• McDonald EA, Gartland D, Small R, Brown SJ. Frequency, severity and persistence of postnatal dyspareunia to 18 months post partum: A cohort study. Midwifery. 2016 Mar; 34: 15-20

• Hendrix S, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic Organ Prolapse in Women’s Health Initiative: Gravity and gravidity. Am J Obstet Gynecol. 2002; 186:1160-6

• Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG: An International Journal Of Obstetrics And Gynaecology. 2013;120(2):152-160.

• Mason D, Newman D, Palmer M. Changing UI Practice: This report challenges nurses to lead the way in managing incontinence. American Journal of Nursing. 2003. 103:2-3

• Nygaard IE, Thompson FL, Svengalis SL, Albright JP. Urinary incontinence in elite nulliparous athletes. ObstetGynecol. 1994;84(2):183-7.

• Thyssen HH, Clevin L, Olesen S, Lose G. Urinary incontinence in elite female athletes and dancers. Int Urogynecol J Pelvic Floor Dysfunct. 2002; 13(1): 15-7

References• Rajindrajith S, Devanarayana NM, Crispus Perera BJ, Benninga MA. Childhood constipation as

an emerging public health problem. World J Gastroenterol 2016; 14; 22(30)

• Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, Rittig S, Vande Walle J, von Gontard A, Wright A, Yang SS, Nevéus T. The standardization of terminology of lower urinary tract function in children and adolescents: update report from the Standardization Committee of the International Children's Continence Society. J Urol. 2014 Jun;191(6):1863-1865.

• Liberi V, Liberi KH. Pelvic Pain and Pelvic Floor Dysfunction in Male Athletes. International Journal of Athletic Therapy and Training. 2011; 16(1): 8-12

• Newman D, Guzzo T, Lee D, Jayadevappa R. An evidence-based strategy for the conservative management of the male patient with incontinence. Curr Opin Urol 2014, 24:553–559.

• Emanu. Erectile dysfunction after radical prostatectomy: prevalence, medical treatments, and psychosocial interventions. Curr Opin Support Palliat Care. 2016 Mar;10(1):102-7.

• Herschorn S, Bruschini H, Comiter C, Grise P, Hanus T, Kirschner-Hermanns R, Abrams P. Surgical treatment of stress incontinence in men. Neurourol Urodyn. 2010;29(1):179-90

• Neels H, Tjalma WA, Wyndaele JJ, De Wachter S, Wyndaele M, Vermandel A. Knowledge of the pelvic floor in menopausal and in peripartum women.J Phys Ther Sci. 2016 Nov;28(11):3020-3029.

References• Bo K, Morkved S, Frawley H, Sherburn M. Evidence for benefit of transversus abdominis training alone or in

combination with pelvic floor muscle training to treat female urinary incontinence: A systematic review. Neurourol Urodyn. 2009;28(5):368-73

• Vleeming A, Stoeckart R, Snijders CJ. The sacrotuberous ligament: a conceptual approach to its dynamic role in stabi- lizing the sacroiliac joint. Clin Biomech. 1989; 4, 201–203.

• Vleeming A, van Wingerden JP, Snijders CJ, et al. Load application to the sacrotuberous ligament: influences on sacroiliac joint mechanics. Clin Biomech. 1989; 4, 204–209.

• Hungerford, B., Gilleard, W. & Hodges, P., 2003. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine. 2003; 28(14), pp.1593–1600.

• Beales DJ, O’Sullivan PB, Briffa NK. Motor control patterns during an active straight leg raise in chronic pelvic girdle pain subjects. Spine. 2009; 34(9): 861-870

• Bendova P, Ruzicja P, Peterova V, Fricova M, Sprinrova I. MRI-based registration of pelvic alignment affected by altered pelvic floor muscle characteristics. Clin Biomech. 2007 Nov;22(9):980-7

• Bump R C, Hurt G W, Fantl J A et al. Assessment of Kegal pelvic muscle exercise performance after brief verbal instruction. American Journal of Obstetrics and Gynecology. 1991; 165:322

• Sherburn M, Murphy CA, Carroll S, Allen TJ, Galea MP. Investigation of transabdominal real-time ultrasound to visualise the muscles of the pelvic floor. Aust J Physiother. 2005;51(3):167-70.

References• Whittaker JL, Thompson JA, Teyhen DS, Hodges P. Rehabilitative ultrasound imaging of pelvic floor muscle

function. J Orthop Sports Phys Ther. 2007 Aug;37(8):487-98.

• Hodges PW, Sapsford R, Pengel LHM. Postural and respiratory functions of the pelvic floor muscles. Neurourology and Urodynamics. 2007; 26:362–371

• Smith MD, Coppieters MW, Hodges PW. Postural response of the pelvic floor and abdominal muscles in women with and without incontinence Neurourology and Urodynamics. 2007; 26:377–385

• Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A. Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing—a dynamic MRI investigation in healthy females. Int Urogynecol J. 2001; 22:61–68

• Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Manual Therapy. 2004; 9: 3–12

• Dufour S, Vandyken B, Forget MJ, Vandyken C. Association between lumbopelvic painand pelvic floor dysfunction in women: A cross sectional study. Musculoskelet Sci Pract.2018;34:47-53.

• Robert M, Ross S. SOGC Clinical Practice Guideline: Conservative management of urinary incontience. J Obstet Gynaecol Can. 2006;28(12):1113-8

Abdu-Rafea, B. et al. No. 164 – Consensus Guidelines for the Management of Chronic Pelvic Pain. Journal Obstet Gynaecol Care. (2018); Nov.

Orr, N. et al.Deep Dyspareunia in Edometriosis: Role of the Bladder and Pelvic Floor. Journal of Sexual Medicine. ( 2018). 15(8): 1158-1166

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Xia J. et al. Gynecological Associated Disorders and Management. The International Journal of Urology. (2019). 26(1): 46-51.

Bo K. et al. International Urogynecological Association (IUGA)/InternatinalContinence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of pelvic floor dysfunction. International Urogynecological Journal. (2017). 28: 191-231.

Page 34

CULTURAL AND LINGUISTIC COMPETENCY

Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is providedby the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

Page 35

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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