BY Dr. Marjorie Mamsaang, DO

First things first: it’s important to understand what endometriosis is before discussing how to prepare for surgery.

Endometriosis is when inflammatory tissue similar to the lining of the uterus grows outside of the uterus. It can grow anywhere in the body, however, most commonly around the abdominal and pelvic area, surrounding the bowels, bladder, and the pelvic floor.  The tissue releases inflammatory compounds that can cause pain. 

Symptoms of Endometriosis

The most well-known symptom of endometriosis is dysmenorrhea, also known as painful periods.  Women with endometriosis may also have abdominal pain and distention or bloating, pain during and/or after sexual intercourse, painful urination or bowel movements, bleeding between periods, urinary urgency and frequency, and severe fatigue or low energy.  In addition to these symptoms, patients may also have digestive issues, such as constipation, diarrhea, or a cyclical pattern of both.  At times this pain is so debilitating that women may miss work, school or cannot participate in daily activities.  However, the severity and symptoms vary from patient to patient.  

Treatment for Endometriosis: The Muscles and Nerves of the Pelvic Floor

The definitive treatment for endometriosis is surgery, usually laparoscopically, by an experienced endometriosis excision specialist.  However, there are some things you can do prior to surgery that can help promote an optimal recovery post-operatively.  But first you will want to understand how endometriosis impacts the nerves and muscles of your pelvic floor.

Endometriosis affects the muscles and nerves of the body, particularly those of the pelvic floor.  Endometriosis tissue releases inflammatory markers, which can cause pain. 

Pain can cause the muscles of the pelvic floor, back, abdomen and hips to become hypertonic.  In other words, the muscles respond to pain by becoming spastic. 

  • Pain that is chronic can lead to muscles that stay “stuck” in the shortened, contracted and weakened position. 
  • Spastic muscles can lead to low back pain, abdominal guarding and gluteal or external hip pain. 
  • Spastic pelvic floor muscles may affect the bowel, bladder and sexual function. 
  • This may lead to pain with sex-pain with deep penetration, pain superficially, or pain with positions. 
  • Other symptoms are urinary urgency, frequency, sensation of retention, severe constipation or painful bowel movements. 

Additionally, spastic muscles may compress nearby nerves, which then causes nerve irritation and inflammation. Endometriosis is inflammatory, progressive and can invade the space in and around nerves, which in turn, causes the nerves to become inflamed. 

  • Inflamed nerves do not function properly or can elicit pain, such as electrical sensations, numbness, tingling, and radiating pain to the legs. 
  • Inflamed pelvic floor nerves can cause sensitivity and pain in the vulva, perineum, anus, and may cause difficulty achieving sexual orgasm. 

Initially, the pain may only be present during menstruation, however, over time the pain can become constant.

Chronic pain can lead to compensatory patterns of the muscles, which can lead to functional misalignments, asymmetry and poor body mechanics.  Osteopaths call this somatic dysfunction. 

Treating these neuromusculoskeletal conditions prior to endometriosis excision surgery may help the patient to have an optimal recovery post-operatively!

Preparing for Endometriosis Excision Surgery: A Multimodal Approach

A multimodal approach is preferred as a combination of means of treatment works best in treating chronic pain.  This comprehensive treatment plan may include pelvic nerve and muscle treatments, also called ultrasound guided pelvic peripheral nerve blocks and trigger point injections, medications, lifestyle changes and physical therapy.  

  • The goal of injections is to treat the underlying myofascial pain syndrome and neurogenic inflammation or nerve pain.  Trigger point injections to the pelvic floor muscles, along with other spastic muscles, can break the cycle of spasticity.  This allows the muscle to return to the lengthened, relaxed position, which decreases pain and allows for strengthening.  In turn, this allows the body to break out of compensatory patterns, encouraging symmetry and proper mechanics and posture. 
  • Peripheral nerve blocks or hydrodissection can reverse the neural ischemia due to compression of nerves, create space, increase blood flow and decrease the neurogenic inflammation.  Additionally, injecting with Lidocaine desensitizes the nerve repetitively and decreases mast cell release of histamine, which is an inflammatory compound. 

Unlike temporary band-aids that give short-term relief, trigger point injections and peripheral nerve blocks provide a restorative approach to create an optimal environment for the nerves and muscles to “heal.”

Medications, such as muscle relaxers and nerve pain medications may also provide relief.   Muscle relaxers in suppository form are preferred over oral muscle relaxers as suppositories provide more localized relief and have less systemic side effects.  In addition to suppositories, oral medications help with central sensitization.

Central sensitization is when the central nervous system is upregulated due to membrane excitability in chronic pain syndromes.  In other words, central sensitization causes an altered pain processing that leads to magnification of pain.  Oral central nervous system neuromodulating medications, even for a short term of 3 months, help to down-regulate the central nervous system.  Meditation and movement meditation, like yoga, can also calm the central nervous system.  

Another crucial component of this multimodal treatment is pelvic floor physical therapy.  A licensed pelvic therapist with additional training in the pelvic floor should evaluate you.  The pelvic therapist will perform manual work to relieve spastic muscles, provide nerve desensitization techniques, and teach exercises to help relax spastic muscles as well as strengthen weak muscles.  Pelvic floor physical therapy often includes internal work, vaginally or rectally.  

Lastly, lifestyle modifications may aid in the relief of symptoms.  Hippocrates said, “Let food be thy medicine, and let medicine be thy food.”  Since endometriosis is an inflammatory condition, an anti-inflammatory diet will help minimize inflammation in the body, and thereby, reduce overall pain.  Avoiding inflammatory foods may also help resolve diarrhea.  Additionally, eating fiber in the form of whole foods and adequate hydration aids in constipation. 

the national experts in endometriosis

Since 2017, Pelvic Rehabilitation Medicine has provided a modern, functional wellness solution to a health crisis that affects 15% of women. Persistent pelvic pain is often overlooked, untreated, and misguided. At PRM, our mission is to decrease the time patients are suffering from pelvic pain symptoms and conditions like endometriosis by offering a multimodal approach. We believe in ‘everything at once’- we provide a functional, restorative approach to persistent pelvic pain that has proven to help decrease pain and restore function.