As we enter a turning point in healthcare, more physicians are finally beginning to recognize endometriosis for the significant, public health crisis it is. Better still, teens and women with the disease are advocating strongly for themselves – and each other. Armed with authoritative knowledge about endometriosis, they are rightfully acting as partners in their own healthcare and taking a role in their disease management.
Sadly, we still have a long way to go, however. There are many who continue to maintain that endometriosis “is cured by pregnancy/hysterectomy/drug therapy/menopause” and who believe the disease only occurs in and on reproductive organs, and even then only in older women. Of course; we know none of these old wives’ tales are true.
Indeed, while endometriosis typically develops on the pelvic structures including rectovaginal septum, bladder, bowels, intestines, ovaries and fallopian tubes, it has also been found in uncommon/distant regions including nervous system, rectus abdominis muscle (“abs”), lungs (where it can induce Catamenial Pneumothorax), and even rarely, the brain. The ovaries are among the most common of locations, with the gastrointestinal tract, urinary tract and soft tissues following1 - but even disease as far remote as the gastrocnemius has been documented in the literature.2
Image Linked from Wikipedia Commons
Symptoms of endometriosis, in general, do vary considerably, and may mimic those of other conditions like pelvic inflammatory disease or pelvic infection (but remember, endometriosis itself is NEVER an infection!), ovarian torsion, adenomyosis, fibroids or even ovarian cancer. Classic signs include severe dysmenorrhea (painful periods are NOT the same as endometriosis!), deep dyspareunia (pain associated with sex), infertility/pregnancy loss, chronic pelvic pain, Middleschmertz (painful ovulation) and cyclical or perimenstrual symptoms, and the disease may present as bowel obstruction, melena (bloody stool), hematuria (bloody urine), dysuria (painful urination), dyspnea when the diaphragm or lungs are affected (shortness of breath), and swelling in soft tissues. Degree of disease present (“stage” of endometriosis; 1-4 based on severity) has no correlation with severity of pain or symptomatic impairment.
Few laboratory tests are valuable in the diagnostic spectrum, as markers like CA-125 (cancer antigen), CCR1/mRNA and MCP1 (certain transcription factors modulated in endometriosis) all have very low specificity and sensitivity thus far. Imaging tests (MRI, ultrasound, CT scan) may be more specific and helpful (particularly in the surgical planning stage), but it is very difficult if not impossible to confirm or exclude a diagnosis of endometriosis based on symptoms and tests alone. Certainly, though some prefer ‘medical diagnosis’ through use of hormonal treatments, this is far from accurate as well. True confirmation can only be obtained through surgical biopsy. Therefore, suspected extrapelvic disease should never be dismissed out of hand.
Extrapelvic endometriosis certainly does exist, with just a few references to such noted above; indeed, these diagnoses are becoming even more prevalent. This increased recognition may be in part due to the practitioner’s own improved understanding of the disease, and/or to the patient’s active role in her own care: speaking up and making herself heard about new or different symptoms she is experiencing and insisting on proper, authoritative treatment. To that end, one consideration for some patients who may present with specific symptoms is sciatic endometriosis.
ADAM has a rendering of sciatic pain in their graphic linked here:
Image Linked from ADAM
Sciatic endometriosis is not abundantly common – but it should always be included in the diagnostic approach to pain and symptoms affecting the sciatic nerve distribution.
Mayo Clinic depicts the region in their rendering linked here:
Image linked from Mayo Clinic
The first case of biopsy-confirmed sciatic endometriosis was described by Denton & Sherill in 1955.3 Since then, many additional cases have appeared in the literature. Symptoms that may lead to suspicion of sciatic disease may be predominantly left-sided, though infiltration of the pelvic wall and somatic nerves causing severe neuropathic symptoms due to endometriosis infiltrating the right sciatic nerve has also been well-documented.4
Pain may begin just before menstruation and last several days after end of flow and be accompanied by motor deficits, low back discomfort radiating to the leg, foot drop, gait disorder due to sciatic musculature weakness, cramping and/or numbness radiating down the leg, often when – but not limited to – walking, especially long distances, and tenderness of the sciatic notch. There may also be positive Lasègue’s Sign (an indication of lumbar root or sciatic nerve irritation in which “dorsiflexion of the ankle of an individual lying supine with the hip flexed causes pain or muscle spasm in the posterior thigh” [Kosteljanetz et al.]). There is almost always a history of pelvic endometriosis.
Left untreated, sciatic endometriosis may presumably cause nerve damage through cyclical inflammation and advance “aggressively” to the epineurium and perineurium.5 Unchecked, symptoms will likely lose their cyclical nature with time, due to scarring, resulting in progressively shorter pain-free intervals until constant pain prevails.6
Physical examination may reveal various neurological deficits involving the sciatic nerve rootlets. There may be localized tenderness over the sciatic notch, but this is not a classical finding [Ellias et al.]. Pelvic examination may also even be normal. The disease can be seen on imaging tests in some cases,7 though ultimately a visual (surgical) diagnosis is indicated. Early diagnosis and treatment is indeed critical in order to minimize the damage caused by the recurrent cycles of bleeding and fibrosis, characteristics of endometriosis.8 While sacral radiculopathies (pudendal, gluteal pain), vascular entrapment or sciatic neuralgia may be at the root of symptoms for some women, in patients with sciatica of unknown genesis and/or suspicion of pathology such as endometriosis, laparoscopic exploration of the sacral plexus and/or sciatic nerve is advisable.9
Sciatic endometriosis is generally treated the same way as pelvic disease: preferably gold-standard surgical eradication (excision). When not possible, a course of medical therapy may suppress symptoms until such time as the patient can receive proper surgical intervention with a skilled, minimally invasive pelvic surgeon who has vast experience in highly complex cases of endometriosis.
It is very important to understand that not every patient with symptoms relating to the lumbosacral plexus or proximal sciatic nerve bundle will actually have sciatic endometriosis, as there can be several differential diagnoses. However – endometriosis can be a real (albeit less common) cause of nerve injury and symptomology.10 This extrapelvic manifestation of the disease must be considered in the differential diagnosis of women and girls with symptomatic presentation, particularly if a history of endometriosis or chronic pelvic pain is present.
If you or someone you love suffers (or thinks they may be suffering) from endometriosis, we’d be honored to lend our expertise and free opinion. Please visit us here to learn more about the CEC’s services.