Pelvic adhesions refer to strong bands of tissue sticking organs together in an unnatural way. They are a common source of pain in many women.
There are four broad categories of adhesion formation:
- Post-surgical: where there has been continued leakage of blood from the surgical margins
- Residual pathology: where the excision of particular endometriosis has been incomplete, leaving tissue to continue to grow, bleed and eventually form further deep fibrous bands
- Infective adhesions: where there has been a rupture of an organ (a burst appendix is a good example) or a transmitted infection (PID, chlamydia/gonorrhoea); treatment with appropriate antibiotics is the first-line measure in dealing with any STD
- Radiation adhesions: rare in general gynaecology, and seen in patients who may have undergone pelvic lymph node radiotherapy (eg cervical cancer); these patients generally remain under the care of an oncology team rather than a general gynaecologist.
What causes pelvic adhesions?
Adhesions seen in the pelvis can be caused by the following:
- an ongoing inflammatory disease process (endometriosis is the classic example). Patients with incompletely excised endometriosis may have short term relief of chronic pelvic pain, then a return of familiar symptoms. Patients with a longer history of feeling well, then years later having a return of that pain are most likely to have recurrent endometriosis, especially if that diagnosis was previously confirmed at laparoscopy.
- infection (chlamydia, gonorrhoea most commonly), Tuberculosis
- Iatrogenic Organ injury – most commonly damaged bowel during a surgical procedure
- Iatrogenic Haemorrhage – bleeding at the time of surgery creating a mass of fibrous adhesions
What are the symptoms of pelvic adhesions?
Adhesions from Pelvic inflammatory disease are associated with localised pain, fever, and even a malodorous vaginal discharge.
Treatment for this problem is usually IV antibiotics, possibly surgical drainage of a collection. Partner tracing and treatment is vital in this uncommon circumstance. Tuberculosis (TB) is a rare condition in Australia, but should be suspected especially in immigrant patients where TB is common (Indian subcontinent, Southeast Asia).
Iatrogenic (meaning caused by the surgeon) adhesions present very early after a surgical procedure. Almost all of these situations would require revision surgery, especially if bowel injury is suspected. Patients with a post-surgical bleed would need as a minimum, follow-up scans to assess resolution of bleeding. Some would require further surgery, or even blood transfusion.
What does pelvic adhesion pain feel like?
Adhesions mean that organs or tissues are stuck together, and no longer freely move. There is usually discomfort or pain. Adhesions caused by (recurrent) endometriosis tend to have similar pain patterns (back pain, sex pain, etc). The treatment may be surgical, depending on severity etc
How do you treat and prevent pelvic adhesions?
The most effective treatment and prevention for adhesions in the first instance is excellent and meticulous surgical technique. In patients with very advanced endometriosis, the challenge is to excuse all of the inflammatory scar tissue as safely as possible; in certain circumstances, it may not be safe to proceed at this surgery, and it is better in this situation to discuss options for management in the post-op period, rather than create an inadvertent injury!
Attention to detail and ensuring that there is the least blood loss will definitely minimise the risk of local adhesion formation. The use of a drain to catch any additional irrigation fluid or blood is also a well-proven technique to prevent adhesions.
The most effective additional technique to prevent adhesions, especially in the gynaecological patient with endometriosis is to perform oophoropexy, which temporarily suspends the ovaries away from the pelvic sidewall, to which they might otherwise adhere to in the post-op period.
In 22 years as a specialist surgeon, Dr Gordon has found this to be the most successful technique to ensure normal ovarian mobility and function post-surgery.
These techniques are hallmarks of surgery under the care of Dr Gordon and are routinely employed in any advanced laparoscopic procedure.
