No more pelvic pain
Pain, debilitating pain, not for a day or two, but daily. The person who is affected is not just anyone, but the pivot around whom the home revolves. This chronic pelvic pain affects the wife and mother, making her literally disabled and leading to a complete disruption in the running of the home, while also having a major impact even on the intimacy between her and her husband.
For all the women affected by severe endometriosis who have been grinding their teeth in pain, suffering in silence and swallowing paracetamol in a desperate bid to gain some relief, there is good news. “When chronic pelvic pain is very severe, the prime suspect is severe endometriosis,” says Consultant Obstetrician and Gynaecologist Dr. Dhammike Silva, who is attached to the Colombo South Teaching Hospital at Kalubowila and is also a Senior Lecturer at the Medical Faculty of the Sri Jayewardenepura University.
The Kalubowila Hospital offers the “best option” of overcoming Grade 4 (severe) endometriosis, through laparoscopic or keyhole surgery.Getting into the intricacies of endometriosis, Dr. Silva explains that sometimes even severe endometriosis may be asymptomatic and some women may not even know they have it. But in others, it is the be all and end all of their lives, with pain so severe, it prevents them from going anywhere, attending to their daily routine and even harming their sexual life.
They have extremely painful periods (dysmenorrhoea), pain starting before or continuing after the periods, painful sex and pain in the lower abdomen and pelvic area. They may also be infertile, MediScene understands. The endometrium is the tissue-layer usually inside the womb (uterus) but for reasons unknown, it passes through the fallopian tubes and gets implanted in areas where it should not be. Then the endometrial tissue forms large patches or hard nodules in the places they get implanted in. Endometriotic tissue in the ovaries will cause cysts filled with blood which are called ‘chocolate cysts’. Leaking of blood to the surrounding tissues causes stickiness and could paste the bladder, bowel etc., onto the womb, it is learnt.
The theories on the causes of endometriosis include environmental pollution, according to Dr. Silva. Referring to the monthly menstrual cycle that a woman goes through, he explains that when a woman has her period, usually the thickened inside tissue-layer of the womb breaks and bleeds out through the vagina. In women who have endometriosis, the endometrial implants also follow the same pattern outside the womb.
“However, this bleeding has no way to exit. This blood, without an outlet, gets trapped inside the body and results in the woman having very severe pain in the pelvic area,” says Dr. Silva, adding that it could also have an impact on bowel movements and bladder function.
The statistics are an eye-opener:
Almost 30% to 40% of infertile women have endometriosis, as this condition leads to many structures inside the body sticking (adhering) together as well as altering the chemical environment inside the abdomen.
Among those having chronic pelvic pain, in 25% to 30%, it would be due to endometriosis.
Making MediScene take a peek inside a woman’s body, Dr. Silva says that all organs and structures are usually smooth and have glistening surfaces, sliding easily against each other. When affected by endometriosis, there comes a drastic change in the architecture, not only with adhesions but also the collection of blood in the ovaries forming ‘chocolate cysts’ which take their name from the dark brown colour of old blood which is similar to chocolate.
Comparing and contrasting laparoscopy (key-hole surgery) and laparotomy (opening up of the abdomen), Dr. Silva says that in the latter the visibility is poor. However, in the laparoscopic procedure, the magnification is 10-15 times more which helps in the easy identification of different tissues and vital structures. The gas which is pumped into the abdomen opens-up the tissue-planes making it possible to do very delicate dissection of tissues.
“Systematically going deeper from one level to another, laparoscopic surgery enables a skilful surgeon to minimize bleeding by sealing off by diathermy (burning with control) even the smallest bleeders while such precision surgery will minimize organs from sticking to each other after surgery,” he says, creating the image of a military-style operation in dealing with chocolate cysts, patches, deposits and nodules caused by endometriosis. This annihilation provides immense relief to the patient.
Laparotomy, meanwhile, can worsen the condition if a complete job is not done and all patches, deposits and nodules are not dealt with, especially implants in sites such as the Pouch of Douglas and the recto-vaginal septum, deep between the womb and rectum. If resections of the implants are not performed fully and properly, adhesions would recur, making a future laparoscopic procedure more difficult and complex as well as highly dangerous, MediScene understands.
Laparoscopy has minimal blood loss, fewer adhesions, quicker recovery, faster return to normalcy and a far better cosmetic result externally. While macroscopic endometriosis (patches, nodules, chocolate cysts etc) can be removed to a greater extent, there may, however, be microscopic deposits which could lead to some patients continuing to have pain even after the laparoscopic procedure, says Dr. Silva, adding that then the back-up plan is suppressing ovarian action for about one year with medications to prolong remission. If the patient has a fertility wish, then fertility enhancing treatment is given without ovarian suppression.
Being a complex gynaecological procedure of about four to five hours, it also comes with high-risks such as injury to bowel, bladder, ureters and large blood vessels. This is why such procedures should be handled by experts with very skilled hands, MediScene understands, for then the risk is about 4%, of which 70% would be detected intra-operatively (during the procedure) and attended to immediately. In the case of the balance unseen 30% of the 4% risk, which are mostly dangerous thermal injuries (caused by the diathermizing), the detection and treatment comes after the procedure. This is why the monitoring and after-care of the patient are of paramount importance, MediScene learns.
With a proven track record, slowly and surely, Kalubowila Hospital is turning into a centre of excellence in treating endometriosis through laparoscopy, with many referrals from across the country.