BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada.
Women's Health Research Institute, Vancouver, BC, Canada.
J Sex Med. 2018 Aug;15(8):1158-1166. doi: 10.1016/j.jsxm.2018.06.007.
The etiology of endometriosis-associated deep dyspareunia may include direct endometriosis-specific factors (eg, stage or invasiveness of disease) and/or indirect contributors such as bladder/pelvic floor dysfunction (eg, related to myofascial mechanisms or nervous system sensitization).
This study aimed to determine whether bladder/pelvic floor tenderness and painful bladder syndrome were associated with severity of deep dyspareunia in women with endometriosis, regardless of Stage (I/II vs III/IV) or other endometriosis-specific factors.
Observational study from a prospective patient registry (January 2014 to December 2016) at a tertiary centre for endometriosis. Included were women aged 18 to 49 years who had surgical removal and histopathologic confirmation of endometriosis at the centre. Cases with Stage I/II vs Stage III/IV endometriosis were analyzed separately. Bivariate associations with the primary outcome (severity of deep dyspareunia) were tested for bladder/pelvic floor tenderness, painful bladder syndrome, as well as endometriosis-specific factors identified at the time of laparoscopic surgery (eg, deep infiltrating endometriosis) and demographic factors (eg, age). Multivariable ordinal logistic regression was carried out to adjust for factors associated with the primary outcome.
Primary outcome was severity of deep dyspareunia on an 11-point numeric rating scale, categorized as none/mild (0-3), moderate (4-6), and severe (7-10), from a preoperative self-reported questionnaire.
Overall, 411 women had surgically confirmed endometriosis: 263 had Stage I/II and 148 had Stage III/IV endometriosis. Among women with Stage I/II endometriosis, severity of deep dyspareunia was associated with both bladder/pelvic floor tenderness and painful bladder syndrome (AOR = 1.94, 95% CI: 1.11-3.38, P = .019 and AOR = 1.99, 95% CI: 1.15-3.44, P = .013, respectively), independent of endometriosis-specific factors or other factors associated with deep dyspareunia severity. Similar associations were found in women with Stage III/IV endometriosis (bladder/pelvic floor tenderness AOR =2.51, 95% CI: 1.25-5.02, P = .01, painful bladder syndrome: AOR = 1.90, 95% CI: 1.01-3.57, P = .048).
Myofascial or nervous system mechanisms may be important for deep dyspareunia in women with endometriosis, even in those with moderate-to-severe disease (Stage III/IV).
STRENGTHS & LIMITATIONS: Strengths include the prospective registry, and histological confirmation of endometriosis and staging by experienced endometriosis surgeons. Limitations include assessment of only one pelvic floor muscle (levator ani).
In women with Stage I/II or Stage III/IV endometriosis, severity of deep dyspareunia was strongly associated with bladder/pelvic floor tenderness and painful bladder syndrome, independent of endometriosis-specific factors, which suggests the role of myofascial or sensitization pain mechanisms in some women with deep dyspareunia. Orr NL, Noga H, Williams C, et al. Deep Dyspareunia in Endometriosis: Role of the Bladder and Pelvic Floor. J Sex Med 2018;15:1158-1166.
子宫内膜异位症相关深部性交痛的病因可能包括子宫内膜异位症特异性因素（例如疾病的阶段或侵袭性）和/或间接因素，如膀胱/盆底功能障碍（例如与肌筋膜机制或神经系统敏化有关）。
本研究旨在确定无论疾病阶段（I/II 期与 III/IV 期）或其他子宫内膜异位症特异性因素如何，膀胱/盆底触痛和膀胱疼痛综合征是否与子宫内膜异位症女性深部性交痛的严重程度相关。
这是一项在子宫内膜异位症的三级中心进行的前瞻性患者登记研究（2014 年 1 月至 2016 年 12 月）。纳入的患者年龄为 18 至 49 岁，在中心接受了手术切除和组织病理学确认患有子宫内膜异位症。分别分析了 I/II 期与 III/IV 期子宫内膜异位症的病例。对膀胱/盆底触痛、膀胱疼痛综合征以及腹腔镜手术时确定的子宫内膜异位症特异性因素（例如深部浸润性子宫内膜异位症）和人口统计学因素（例如年龄）与主要结局（深部性交痛的严重程度）进行了双变量关联测试。采用多变量有序逻辑回归对与主要结局相关的因素进行调整。
主要结局为术前自我报告问卷评估的深部性交痛的严重程度，分为无/轻度（0-3）、中度（4-6）和重度（7-10）。
共有 411 名女性经手术证实患有子宫内膜异位症：263 名患有 I/II 期子宫内膜异位症，148 名患有 III/IV 期子宫内膜异位症。在患有 I/II 期子宫内膜异位症的女性中，深部性交痛的严重程度与膀胱/盆底触痛和膀胱疼痛综合征相关（优势比[OR]分别为 1.94，95%置信区间[CI]：1.11-3.38，P =.019 和 1.99，95%CI：1.15-3.44，P =.013），独立于子宫内膜异位症特异性因素或其他与深部性交痛严重程度相关的因素。在患有 III/IV 期子宫内膜异位症的女性中也发现了类似的关联（膀胱/盆底触痛 OR = 2.51，95%CI：1.25-5.02，P =.01，膀胱疼痛综合征：OR = 1.90，95%CI：1.01-3.57，P =.048）。
肌筋膜或神经系统机制可能对子宫内膜异位症女性的深部性交痛很重要，即使是疾病程度中度至重度（III/IV 期）的女性。
优势包括前瞻性登记和由经验丰富的子宫内膜异位症外科医生进行的组织学确认和分期。局限性包括仅评估了一块盆底肌肉（提肛肌）。
在患有 I/II 期或 III/IV 期子宫内膜异位症的女性中，深部性交痛的严重程度与膀胱/盆底触痛和膀胱疼痛综合征密切相关，与子宫内膜异位症特异性因素无关，这表明在一些深部性交痛女性中，肌筋膜或敏化疼痛机制起作用。Orr NL，Noga H，Williams C，等。子宫内膜异位症相关深部性交痛：膀胱和盆底的作用。J 性医学 2018；15：1158-1166。
