Clinical Presentation
Patients with symptoms suggestive of
endometriosis should be promptly evaluated to minimize diagnostic delay and
enable timely management.
The main clinical features of
endometriosis include severe dysmenorrhea, chronic pelvic pain (found in 70-82%
of patients), dyspareunia (suggests deep posterior infiltration), and infertility
(21% prevalence rate). Other symptoms may include dyschezia, dysuria, pain on ovulation, non-cyclical
pelvic pain, cyclical bowel or bladder symptoms with or without abnormal
bleeding or pain, dyschezia, dysuria, chronic fatigue, abdominal or lower back
discomfort, sciatic nerve pain, and
depression.
In
adolescents, endometriosis is a primary cause of secondary dysmenorrhea,
typically presenting as chronic pelvic pain and painful menses. Although
it is vital to consider the patient’s complaints affecting physical, mental,
and social well-being, it should be noted that patients with endometriosis may
be completely asymptomatic (with a 2-22% prevalence rate).
Endometriosis_Initial AssesmentHistory
History should include the patient’s age, in utero exposure to environmental toxins like Diethylstilbestrol which increases the incidence of endometriosis, family history of endometriosis, particularly first-degree relative (7 times higher risk than with no family history), and inquiry on the patient’s menstrual cycle, history of infertility, and presence of endometriosis symptom.
Physical Examination
Physical examination is ideally done during early menses when endometrial
implants are likely to be largest and deep infiltrating, hence more easily
detectable.
It
is important to perform inspection of vaginal mucosa to look for posterior
vaginal fornix lesions, abdominal inspection and palpation taking note of tone
and pelvic tenderness, bimanual examination to assess pelvic tenderness,
nodularity and uterine mobility, position, and size. If the posterior
compartment is abnormal on bimanual examination, consider a rectovaginal
examination. Diagnosis is more definite if deeply infiltrative nodules
are found on the uterosacral ligaments or in the pouch of Douglas, and/or
lesions are directly seen in the vagina or cervix.
A cotton swab can be inserted into the vagina to document patency and
exclude complete or partially obstructive anomalies such as a transverse
vaginal septum, imperforate or microperforate hymen, or an obstructed hemivagina.
For patients who are not sexually active, a rectal-abdominal examination
may be better tolerated than a vaginal-abdominal examination. Note that there may be no abnormal
findings on physical examination and that severity of symptoms may not reflect
the degree of endometriosis.
Other frequent findings during a physical examination include pain
with uterine movement or pelvic tenderness, tender and enlarged adnexal masses,
fixation of adnexa or uterus in a retroverted position, uterosacral ligament
tenderness, and rectovaginal septum induration.