Prof. Prof. DK Prof. Dr. med. Marc Possover, MD, PhD
For many years, endometriosis has been considered a disease of the pelvic organs.
Women suffering from pelvic pain were usually diagnosed within this framework, and treatment was focused on the uterus, ovaries, or surrounding tissues.
However, clinical experience over the past two decades has revealed a different reality.
In a large series of patients with endometriosis affecting the sciatic nerve, it became clear that pelvic pain is not always caused by a single disease. Instead, it may originate from different conditions affecting the pelvic nerves themselves — conditions that require a completely different way of thinking, diagnosing, and treating pain.
One of the most important discoveries is the clear difference between two forms of nerve-related endometriosis.
Endometriosis of the sacral plexus is usually an extension of deep infiltrating endometriosis. It begins in the pelvic organs — often in the rectovaginal septum or the parametria — and progressively spreads along anatomical structures until it reaches the nerves.
In contrast, endometriosis of the sciatic nerve is a completely different disease.
It can develop independently, without any visible endometriosis in the pelvis, and without any connection to the uterus or surrounding organs.
In these cases, the disease originates directly within the nerve itself.
Understanding this difference is essential — because these are not variations of the same condition, but fundamentally different diseases.
One of the most surprising findings is that classical theories of endometriosis cannot explain this form of the disease.
How can tissue similar to the uterine lining develop inside a nerve — far away from the uterus, with no anatomical connection?
Based on long-term surgical experience and detailed analysis of hundreds of patients, a new hypothesis has been proposed:
endometriosis of the sciatic nerve may originate from special precursor cells located within the nerve itself, which, under certain conditions such as repeated micro-injury or inflammation, begin to transform and grow.
This concept represents a true paradigm shift in the understanding of endometriosis.
Another important difference concerns the behavior of the disease.
While many forms of deep infiltrating endometriosis tend to progress slowly, endometriosis of the sciatic nerve can evolve much more rapidly.
In the early stages, patients often experience cyclical sciatic pain, especially during menstruation.
Within a relatively short period — sometimes only one to three years — this pain may become constant.
As the disease progresses, it can begin to damage the nerve itself, leading to neurological symptoms such as weakness, difficulty walking, or even foot drop.
This means that, unlike many other forms of endometriosis, this condition is not only painful but can become destructive, with the risk of irreversible nerve damage if not treated in time.
Sciatic pain in women is still frequently attributed to spinal or orthopedic problems.
As a result, many patients undergo long and frustrating diagnostic journeys, often without answers.
However, in a significant number of cases, the origin of the pain is not the spine — but the pelvic nerves.
Recognizing this possibility is essential to avoid years of misdiagnosis and ineffective treatments.
The insights presented here are based on one of the largest clinical experiences worldwide, including more than 450 operated cases of sciatic nerve endometriosis and a detailed analysis of 267 patients with isolated disease.
This work represents a milestone in the understanding and treatment of endometriosis of the sciatic nerve, reflecting more than 20 years of clinical and surgical experience.
In recognition of its scientific and clinical impact, this research was awarded the ESGE Prize for the Best Scientific Paper, highlighting its importance for the international medical community.
These discoveries have led to the development of Neuropelveology, a medical discipline dedicated to the diagnosis and treatment of pelvic nerve disorders.
By combining advanced laparoscopic techniques with a deep understanding of nerve function, it becomes possible to identify the true origin of pain and to treat it at its source.
Endometriosis is not always the same disease.
In particular, endometriosis of the sciatic nerve is a distinct, aggressive, and often underestimated condition that requires early recognition and highly specialized expertise.
Understanding the nerve is the key to understanding the pain —
and to offering patients the right treatment.
— Prof. Marc Possover
Founder of Neuropelveology
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