子宫内膜异位症患者疼痛与盆腔病灶解剖分布的关系

目的研究子宫内膜异位症（内异症）患者疼痛症状与盆腔病灶解剖分布特点的关系。方法详细记录130例内异症患者痛经、慢性盆腔痛（CPP）、性交痛及排便痛的发生情况。以腹腔镜检查为诊断标准。评价疼痛症状包括痛经、CPP、性交痛及排便痛与盆腔内不同部位内异症病灶的关系。结果130例内异症患者中,痛经100例（76．9％）,无痛经30例（23．1％）。轻、中度和重度痛经者分别为27例（20．8％）、41例（31．5％）、32例（24．6％）,性交痛46例（35．4％）,CPP45例（34．6％）,排便痛67例（51．5％）。痛经者深部宫骶韧带结节、阴道直肠隔结节发生率分别为45．0％、16．0％,无痛经者深部宫骶韧带结节、阴道直肠隔结节发生率为13．3％、0,两者分别比较,差异均有统计学意义（P=0．00、P=0．01）;痛经者与无痛经者比较,子宫直肠窝封闭的比例增加（分别为41．0％、10．0％,P=0．00）,深部浸润型内异症（DIE）比例增加（分别为51．0％、16．7％,P=0．00）。痛经程度与宫骶韧带结节的数目（P=0．005,r=0．302）、宫骶韧带结节浸润深度（P=0．017,r=0．227）呈线性相关。痛经伴卵巢内异症囊肿患者中,发生中、重度盆腔粘连的比例增加（分别为29．1％、8．3％,P=0．029）。与无CPP的患者比较,CPP患者深部宫骶韧带结节（分别为51．1％、30．6％,P=0．018）以及DIE（分别为57．8％、35．3％,P=0．011）比例明显升高。与无排便痛的患者比较,排便痛患者深部宫骶韧带结节（分别为46．3％、28．6％,P=0．028）、阴道直肠隔结节（分别为19．4％、4．8％,P=0．01）、子宫直肠窝封闭（分别为44．8％、22．2％,P=0．005）以及DIE（分别为53．7％、31．7％,P=0．01）的比例升高。阴道直肠隔结节是性交痛的独立危险因素（OR=3．61）。结论痛经、CPP、性交痛以及排便痛与盆腔内异症病灶的部位和浸润深度有关,位于盆腔后部的深部浸润病灶以及子宫直肠窝封闭与疼痛症状关系密切。

Relationship between pain symptoms and clinico-pathological features of pelvic endometriosis

OBJECTIVE: To study the relationship between pain symptoms and the clinico-pathological features of pelvic endometriosis (EM). METHODS: One hundred thirty patients with laparoscopic diagnosis of EM were studied retrospectively and the relationship between pain symptoms including dysmenorrhea, chronic pelvic pain (CPP), dyspareunia and dyschezia and the anatomical features of pelvic endometriosis were evaluated. RESULTS: One hundred (76.9%) patients with pain symptoms and 30 (23.1%) without were included in this study. The number of patients with mild, moderate and severe dysmenorrhoea was 27 (20.8%), 41 (31.5%), and 32 (24.6%), respectively. Patients with dyspareunia, CPP and dyschezia were 46 (35.4%), 45 (34.6%) and 67 (51.5%), respectively. Compared with patients without dysmenorrhea, the proportion of deep utero-sacral nodules (45.0% vs 13.3%, P=0.00), recto-vaginal nodules (16.0% vs 0, P=0.01), complete obliteration of cul-de sac (41.0% vs 10.0%, P=0.00), and lesions of DIE (51.0% vs 16.7%, P=0.00) was significantly increased in patients with dysmenorrhea. The severity of dysmenorrhea was positively correlated with nodules in uterosacral ligaments (P=0.005, r=0.302), and invasive depth of uterosacral ligaments (P=0.016, OR=5.085). Among patients with endometrioma, significantly more moderate to severe adhesions were found in patients with dysmenorrhea, compared with those patients without dysmenorrhea (29.1% vs 8.3%, P=0.029). Patients with CPP had more nodules in the utero-sacral ligaments (51.1% vs 30.6%, P=0.018) and DIE lesions (57.8% vs 35.3%, P=0.011), compared with those without. More nodules in the utero-sacral ligaments (46.3% vs 28.6%, P=0.028), recto-vaginal nodules (19.4% vs 4.8%, P=0.01), complete obliteration of cul-de sac (44.8% vs 22.2%, P=0.005) and DIE lesions (53.7% vs 31.7%, P=0.01) were found in patients with dyschezia, compared with those without. Nodules in the recto-vaginal pouch were an independent risk factor of dyspareunia. CONCLUSION: Pain symptoms including dysmenorrhea, dyspareunia, chronic pelvic pain, and dyschezia are remarkably related to endometriotic nodules at the posterior part of the pelvis or those with deep invasions.