Symptoms and Signs

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· Signs

o Adnexal mass

o Adnexal tenderness

o Uterine tenderness

§ Fixed retroversion

§ Lateral cervical displacement

o Cul-de-sac

§ Tenderness

§ Nodularity

§ Mass

o Uterosacral ligament

§ Tenderness

§ Nodularity

o Vaginal lesions

o Cervical lesions

· Symptoms

o Reproductive tract

§ Infertility

§ Dysmenorrhea

§ Dyspareunia

§ Noncyclic pelvic pain

o Gastrointestinal

§ Diarrhea and/or constipation

§ Tenesmus

§ Abdominal cramps

§ Cyclic rectal bleeding

o Urinary bleeding

o Low-back pain

The common signs and symptoms of endometriosis are pelvic pain, dysmenorrhea, dyspareunia, abnormal uterine bleeding, and infertility. The type and severity of symptoms are dependent on the extent of disease, the location, and the organs involved. Even limited amounts of disease may cause significant symptomatology.

Endometriosis is present in approximately one third of patients with chronic pelvic pain. The pain may be described as crampy, dull, or sharp and usually increases around menses. The discomfort may be unilateral or bilateral, and many patients complain of rectal pressure or low backache. Acute abdominal pain may result from hemorrhage secondary to a ruptured endometrioma.

Dysmenorrhea is a more frequent complaint than dyspareunia. There is some correlation between the extent of disease and the severity of pain. The morphologic appearance of an endometriotic implant appears to be unrelated to pain symptomatology. Dyspareunia is more common in women with invasive endometriotic nodules in the cul-de-sac, uterosacral ligaments, rectovaginal septum, and vagina.

Abnormal uterine bleeding occurs in up to one third of women with endometriosis with symptoms of oligomenorrhea, polymenorrhea, and midcycle or premenstrual spotting. The abnormal bleeding likely results from conditions associated with endometriosis: oligoanovulatory, luteinized unruptured follicles, luteal phase defects, and other pathology such as uterine fibroids.

Endometriosis involving the gastrointestinal or urinary tracts and extrapelvic sites causes symptoms characteristic of the location of disease. Bladder involvement is associated with frequency and urgency. Invasion of the mucosa results in hematuria. Ureteral and rare cases of renal endometriosis occasionally cause flank pain or gross hematuria. Symptoms suggestive of gastrointestinal involvement include, in decreasing order of frequency, diarrhea, rectal bleeding, constipation, and dyschezia.

All symptoms usually are exacerbated catamenially.

There are numerous case reports of extrapelvic endometriosis. Pulmonary endometriosis causes catamenial hemoptysis and dyspnea. Cutaneous lesions are associated with catamenial bleeding, tenderness, and swelling.

It is estimated that 25% to 50% of infertile women have endometriosis, and 30% to 50% of women with endometriosis are infertile. Although the association of endometriosis and infertility is well recognized, the pathophysiologic mechanisms are poorly understood. Endometriomas and endometriosis with adhesions distort pelvic anatomy and impair tubal ovum pickup, which is an acceptable explanation for infertility. In less severe cases, there are several theories to explain the observed subfecundity.

Research to explain the subfertility has focused on peritoneal fluid leukocytes and their cytokine products. Studies have suggested that constituents in the peritoneal fluid inhibit sperm function, fertilization, embryonic development, and implantation. The clinical significance of these findings has not been established.

The clinical manifestations are pelvic pain, pelvic mass, alterations of menses, and infertility. Some women with severe endometriosis may be asymptomatic, while others with minimal disease may have incapacitating pain. Dyspareunia and midline pelvic pain pre- or perimenstrually, particularly beginning after several years of pain-free menses, may occur. Such dysmenorrhea is an important diagnostic clue. Lesions on the large bowel or bladder may cause pain with defecation, abdominal bloating, rectal bleeding with menses, or suprapubic pain during urination. Endometriotic implants on the ovary or adnexal structures can form an endometrioma (a cystic mass of endometriosis localized to an ovary) or adnexal adhesions, giving rise to a pelvic mass. Occasionally, rupture or leakage from an endometrioma may be associated with acute abdominal pain.

Complications:
1- Infertility
2- Intestinal obstruction
3- Ureteric obstruction.
4- Secondary infection of the endometriotic lesions
5- Rupture of endometrioma.

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