If women suffer from cyclical sciatica with onset of numbness in the buttocks or legs, or experience movement restrictions in the foot - either on its own or in conjunction with numbness - a deep infiltrating endometriosis of the sciatic nerve should be considered as a possible cause of the problem. Patients describe the symptoms as excruciatingly painful and searing -pain radiating in to the pelvis, the back, the legs and the foot. Often it is no longer possible to lead a normal everyday life. In this case, laparoscopic exploration of the sciatic nerve by a neuropelveologist must be carried out without delay.
Endometriosis of the sciatic nerve is a new chapter in the teaching and treatment of endometriosis. However, this particular clinical form of pelvic neuropathy is still too little known. The presence of this disease can be established or ruled out with a few specific questions. Such a survey should form part of the systematic diagnosis of every endometriosis patient and can be carried out by any physician who has acquired the basic knowledge of Neuropelveology.
The future will certainly show that endometriosis of the sciatic nerve is indeed rare, but occurs more frequently than previously thought. Not least because the majority of affected patients tend to consult neurologists, back specialists (neurosurgeons, orthopaedists) or pain therapists primarily because of the non-gynaecological nature of the pain. The spread of the perception of this disease must therefore not only be communicated to gynaecologists, but also to colleagues specializing in the above-mentioned mentioned fields.
As a doctor, you know that endometriosis is one of the most common gynaecological diseases affecting millions of women and girls worldwide. It is also well known that this disease not only causes bleeding disorders and abdominal pain, but can also affect and partially destroy pelvic organs such as the ovaries, urinary organs or the intestines. This latter form of endometriosis, also known as "deep infiltrating endometriosis" (TIE), is fortunately rather rare, but must be taken seriously because of the possible severe consequences.
Little is known about endometriosis of the pelvic nerves1. The pelvic nerves determine all motor functions of the pelvic organs, the pelvic floor and the legs, such as urination, bowel movement, continence, orgasm, standing, walking, balance and many more. They are also responsible for transmitting all "emotional information" to the brain, including pain information. Accordingly, the complaints that can be triggered by endometriosis of the pelvic nerves are extremely complex. In addition to gynaecological symptoms, the following symptoms may also occur:
Urological symptoms: bladder complaints, bladder emptying disorders, etc.
Orthopaedic symptoms: gait disorders, movement restrictions, etc.
Neurological symptoms: sciatic pain, Pudendal genital pain, numbness, sensory disorders, etc.
Gastroenterological symptoms: bowel emptying disorders etc.
One of these pelvic nerves is the sciatic nerve, the largest nerve in the human body. It originates in the small pelvis from the fusion of the sacral roots, which in turn emerges directly from the spinal cord. The sacral roots are located in the posterior compartment of the pelvis in the coccyx region, close to the rectum and ureter, while the sciatic nerve runs more in the middle of the pelvis deep along the pelvic bone before leaving the pelvis to supply the gluteal muscles and legs. From the sacral roots all nerves for the intestines, the bladder, the sphincters and the genital organs develop. Thus endometriosis of the sacral roots and endometriosis of the sciatic nerve represent two different forms of the disease, with their own symptoms and treatment.
Neuropelveology deals with the diagnosis and treatment of pelvic nerves and plexus 2. It covers in-depth knowledge of neurology, urology, gastroenterology and gynaecology necessary for a reliable diagnosis of endometriosis of the sciatic nerve. Neuropelveology uses knowledge from various disciplines for the diagnosis, which takes into account the complexity of the disease. The focus is on the teaching of pelvic topographic and functional neuroanatomy.
The diagnosis of endometriosis of the sciatic nerve is primarily based on an exact neuropelveological anamnesis in the form of a precise and detailed questioning of the patient as well as on a neuropelveological examination in the form of a digital (trigger point, Hoffmann-Tinel sign) and sonographic examination by vaginal or rectal route - an unusual procedure for neurologists and neurosurgeons. The disease, however, can only be confirmed by laparoscopy with targeted imaging and inspection of the sciatic nerve.
Endometriosis of the sciatic nerve leads to typical sciatica with severe, almost unbearable burning or electrical pain in the deep back region, in the buttocks, at the back of the thighs as far down as the calves and feet, especially at the outer edge of the foot. This pain can occur either in only some of these regions or in the entire posterior leg ("sciatic nerve pain"). A distinct difference to similar pain experienced in herniated discs: in endometriosis of the sciatic nerve, the front sides of the thighs remain pain-free.
Similar to abdominal pain, the pain - at least at the onset of the disease - may appear exclusively during the menstrual cycle. Since endometriosis of the sciatic nerve is extremely destructive and the nerve is systematically attacked, sooner or later the pain will remain at a permanently elevated level and sooner or later will most likely intensify during the period.
The increasing destruction of the nerve gradually leads to numbness in the legs, most often at the sole of the foot or the outer edge of the foot or the rear side of the legs. This is accompanied by a loss of strength or a restriction of movement of the ankle joint - both dorsal and plantar flexion of the ankle joint are restricted. Climbing stairs becomes increasingly difficult for patients and becomes impossible over time. Clinically, the Achilles reflex is reduced or, in extreme cases, no longer reproducible.
The surgical treatment of this disease represents the greatest challenge in endometriosis surgery due to the deep position of the pelvic nerves, in a perilous position behind numerous pelvic blood vessels.
The attempt to treat an endometriosis of the sciatic nerve hormonally or simply with painkillers and a wait and see approach is negligent. The progression of such a deeply infiltrating endometriosis is unstoppable and results in increasing and irreversible nerve damage. Endometriosis of the sciatic nerve cannot be equated with intestinal or bladder endometriosis: every millimetre of the nerve must be preserved, as even the smallest impairment will lead to neurological deficits.
The only effective treatment for endometriosis of the sciatic nerve is laparoscopic surgery in the hands of an expert. Every surgeon who performs such an operation must be sure of his abilities and knowledge of the anatomy of the pelvic nerves and vessels, because these operations are associated with high risks. In an incomplete operation, changes in anatomical conditions, adhesions and scar tissue make any further intervention more complicated. This endometriosis also cannot be operated through the buttocks, because the disease develops in the pelvis and grows along the nerve outside the pelvis to the buttocks and not vice versa.
Prof. Possover specializes in the neuropelveological treatment of deep infiltrating endometriosis of the sciatic nerve. In a series of more than 259 laparoscopic operations of deep infiltrating endometriosis of the sciatic nerve, Prof. Possover has shown that laparoscopic surgery leads to significant pain reduction4. If the continuity of the sciatic nerve is maintained, the nerve will recover and the natural function of the legs will be restored.
Live recordings of an operation of the endometriosis of the sciatic nerve:
After the operation, patients still suffer for some time from neuropathic pain and motor disorders, the degree of which may even increase. However, after about three to five years, the functions of the sciatic nerve recover to such an extent that - in combination with muscular compensation - normal walking is possible again. Despite the complete resection of the endometriosis and the maintenance of a certain continuity of the sciatic nerve, two further factors are indispensable: postoperative physiotherapy and medical treatment with neuroleptic drugs, which must be started immediately after the procedure in order to control postoperative neuropathic pain and prevent the development of phantom pain.
This form of endometriosis is less aggressive and usually grows around the nerves without destroying them. Therefore, numbness and motor impairment are rare. Endometriosis of the sacral roots is usually caused by lateral extension of the disease from a TIE of the vagina (septum rectovaginale), rectum or ureter. Due to this peculiarity, the lowest three of a total of five sacral roots are more likely to be affected. These nerves supply the ano-genital region as well as the posterior and inner leg region. They are responsible for the bladder and intestinal function as well as the turgidity of the clitoris.
The pain is also perceived by the affected patients as extremely severe and burning. It can occur in the vulva area (vulvodynia), in the perineum and perianum (pudendal pain) as well as on the inside of the buttocks up to the inner/rear side of the legs. Endometriosis of the sacral roots also increases pain during the period. The bladder and intestines are irritated - with symptoms similar to bladder inflammation or an "irritable bowel". The nerves usually remain undamaged, which is why patients rarely have problems emptying their bladders and bowels.
Every patient with a deeply infiltrating endometriosis (TIE) of the vagina, intestine or ureter must be asked about such nerve pain! Also in this form of the disease, the treatment consists in the surgical removal of the endometriosis, whereby the nerves are only freed from the tissue infestation and thus preserved.
The new discipline of Neuropelveology is attracting increasing interest from physicians worldwide. The International Society Of Neuropelveology was founded in 2014 and offers certified training in Neuropelveology to dedicated physicians. The neuropelveological approach offers new diagnostic and therapeutic options for the treatment of chronic unexplained pelvic pain or dysfunction, which can conceal endometriosis of the sciatic nerve or sacral roots.
As a dedicated physician, you would like to familiarize yourself with the specialist discipline of Neuropleveology in order to offer your patients, who may be suffering from endometriosis of the sciatic nerve or sacral roots, the chance of an etiological and thus curative treatment? You can find more information here:
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