ME84.2 Low back pain
ME84.3 Sciatica
ME81 Musculoskeletal chest pain
ME86.D Symptom or complaint of the shoulder
ME86.C Symptom or complaint of the neck
Overall
GA34.40 Premenstrual tension syndrome
(Menstrual migraine)
GA34.41 Premenstrual dysphoric disorder
MG22 Fatigue
MB20.2 Clouding of consciousness
3A00 Iron deficiency anaemia
5A41 Hypoglycaemia without diabetes
5C64.41 Hypomagnesaemia
Exam
Pelvic
Physical examination can identify endometriosis with high accuracy.Use defined criteria for a positive bimanual pelvic examination (ie, palpable nodularity, stiffened and/or thickened pelvic anatomy, especially the uterosacral ligaments, vagina, rectovaginal space, Recto-uterine pouch, adnexa, rectosigmoid, or posterior wall of the urinary bladder), Anterior vaginal wall tenderness has low sensitivity for detecting endometriosis in women with chronic pelvic pain, but demonstrates prognostic value for endometriosis among women with unexplained infertility.
A caveat to bimanual examination is that it may not be feasible for non−sexually active adolescents/young adults and may not identify early-stage, superficial disease.
Abdomen
Bowel
Clinically, patients may be asymptomatic or may present with a variety of nonspecific symptoms that are frequently associated with other diseases, such as constipation or diarrhea, a palpable mass, melena, rectal bleeding, tenesmus, abdominal distention, or meteorism due to the accumulation of gas in the bowel. Gastrointestinal endometriosis can manifest as acute abdomen with perforation, intussusception, and obstruction.
Wall
The abdominal wall is one of the most frequent extrapelvic locations of endometriosis. Endometriotic implants are usually embedded in the subcutaneous fatty layer and the muscles of the abdominal wall near or at the site of surgical scars. Abdominal endometriosis is often misdiagnosed and is commonly confused with abscess, lipoma, hematoma, sebaceous cyst, stitch granuloma, and desmoid tumors, which results in diagnostic delay. The condition is frequently associated with a gynecologic procedure such as cesarean delivery, episiotomy, amniocentesis, laparoscopy, tubal ligation, or hysterectomy, but it can be found in nongynecologic surgical scars such as those from appendectomy or umbilical hernioplasty. Patients can also feel a papable mass in the area.
Thoracic
Diaphragm
Lung Collapse
Diagnosis of TES is difficult and remains a clinical challenge unless TES is strongly suspected by the typical clinical history. Repeated pneumothorax or hemoptysis during menstruation followed by a symptomless intervening period is diagnostic for thoracic endometriosis. At physical examination, diminished or absent breath sounds on the affected side are heard.
Nerve
Comprehensive neurologic and radiologic evaluation is mandatory to rule out lumbar disk disease, spondylotic nerve root compression, primary neural tumor, and metastasis. Early diagnosis of endometriosis infiltrating the nerve is important to prevent irreversible damage to the nerve and corresponding muscle. Results of electrophysiologic studies can help in positive diagnosis of peripheral nerve damage and can help localize the disease to the nerve trunk or nerve root involved, but they do not indicate the mechanism of the damage.
Imaging XY9R
1. Ultrasound
Superficial
DIE
Pelvic
Urinary
Bowel
Diaphragm
Abdominal Wall
Thoracic
Diaphagm paralysis
Lung Collapse
Heart palpitations
VATs planning and follow up
Nerve
Sciatic nerve
MRI / CT
Pelvic
MF3Y Other specified symptoms, signs or clinical findings involving the female genital system (OTHER)
• Endometrioma - thick walled ovarian or paraovarian cyst containing blood of varying age
• Superficial endometriosis implant – implant with < 5 mm of peritoneal invasion
• Deep infiltrating endometriosis – implant with > 5 mm of peritoneal invasion
• Active glandular DIE - morphology in which hemorrhagic glandular and cystic tissue predominates
• Chronic stromal fibrotic DIE - morphology in which fibrosis and smooth muscle hypertrophy predominates
• Tethering/obliteration - fibrotic scarring across a peritoneal or retroperitoneal space, bringing adjacent organs into fixed contact with one another
• Vaginal Fornix - most superior reflection of the vaginal wall/recess of the vaginal lumen, formed by the protrusion of the cervix into the vaginal vault
• Hematosalpinx - a Fallopian tube filled with hemorrhagic products, implies the presence of endometriosis implants within the tube
MG01 Clinical findings on diagnostic imaging of urinary organs
• Extrinsic ureteral involvement - DIE that abuts the ureter causing tethering and a resultant angulated course, but no invasion
• Intrinsic ureteral involvement - DIE that invades the wall of the ureter resulting in luminal narrowing and obstruction/hydroureteronephrosis
• Uterine version – anteversion or retroversion
• Uterine flexion – : anteflexed or retroflexed
• Torus uterinus - junction of the uterine corpus and the cervix along the posterior serosa/origin of the uterosacral ligaments
Abdomen
ME22 Clinical findings on diagnostic imaging of digestive tract
Enteric endometriosis characteristically manifests as a mural nodule that affects the serosa, muscularis propria, and submucosa. The mucosa is usually intact. Noninvasive diagnosis of bowel endometriosis can be achieved with use of CT or MR imaging, and obtaining good distention is a key factor, particularly in the small bowel. CT enteroclysis may allow good visualization of the terminal ileum, but this technique requires retrograde opacification and ionizing radiation and is of limited value for other pelvic sites. MR enterography, which uses anterograde opacification, is a radiation-free imaging modality that is widely used to investigate small-bowel and ileocecal diseases. Endometriosis is a multifocal disease with multiple sites affected. MR imaging allows concomitant evaluation of the bowel, urinary tract, and pelvic nerves, along with other commonly involved sites such as the retrocervical space, vagina, and ovaries . The typical MR imaging finding is a nodule with low signal intensity on T2-weighted images and postcontrast enhancement.
Thoracic
MD41 Clinical findings on diagnostic imaging of lung
Diagnostic imaging includes chest radiography, thin-section CT, and MR imaging. Chest radiography and thin-section CT may reveal pneumothorax, pleural effusions, nodules, opacities and nodular infiltrates, thin-walled cavities, segmental atelectasis, and bullous formation. MR imaging is an excellent imaging modality with high accuracy for identification of diaphragmatic and pericardial implants, and it is superior to thin-section CT. Typically, MR imaging patterns include lesions that vary from punctate spots to large nodules, or confluent plaques with low signal intensity on T2-weighted images and high signal intensity on T1-weighted gradient-echo images due to the hemorrhagic content.
MB71 Clinical findings on diagnostic imaging of central nervous system
MR imaging is the best imaging modality to investigate neural involvement. MR imaging findings can vary from solid spiculated nodules or complex cystic masses to cystic lesions with thick walls. Cystic components often exhibit high signal intensity on T1-weighted images and low signal intensity on T2-weighted images. Adjacent muscles and bones usually demonstrate a diffuse increase in signal intensity on T2-weighted images and diffuse contrast enhancement due to the inflammatory process and edema
MD41 Xray
Catamenial pneumothorax
GE: Critcal Care AI
Chest Fluoroscopy / SNIFF Test
Required for Diaphragm Evaluation of Paralysis and for Surgical Resection
Biomarkers
Microbiome
Organ System: Surgery
GA10.0 Endometriosis of
the Reproductive System
Endometriosis is associated with severe, life-impacting pain during periods, sexual intercourse, bowel movements and/or urination, chronic pelvic pain, abdominal bloating, nausea, fatigue, and sometimes depression, anxiety, and infertility. Common locations of endometrial implants include the ovaries, fallopian tubes, ligaments that support the uterus. Confirmation is by laparoscopy and histological identification of ectopic fragments.
Urinary Endometriosis lesions can be in or around the urethra, bladder, ureters, or kidney. Ureteral endometriosis can lead to urinary tract obstruction, with subsequent hydroureter, hydronephrosis, and potential kidney loss. Urinary involvement may present with frequency, incontinence, dyspareunia, pain and urgency.
Bowel endometriosis symptoms include dyschezia, constipation, diarrhea,
abdominal bloating, painful bowel movements, passage of mucus in
the stools and cyclical rectal bleeding
Bowel lesions can be present anywhere along the lower gastrointestinal tract, but have a predilection for the distal colon (sigmoid and rectum). Bowel lesions can be superficial or deep; or can invade the bowel wall being associated with fibrosis and adhesions.
Gastrointestinal endometriosis can manifest as acute abdomen with perforation, intussusception, and obstruction.
APPROVED: Thoracic endometriosis lesions can affect the diaphragm, pleura, lung and bronchi. There may be a greater affinity for the right hemi thorax, and the parenchyma is more commonly affected in the lower lobes. Macroscopically, the endometriotic implants appear as brown–yellow and sometimes red nodules surrounded by neovascularization. Symptoms include: dyspnea, shortness of breath, rapid heartbeat, coughing up blood and a variety of pain patterns to include scapula, chest, ipsilateral neck and shoulder, upper abdominal and epigastric. Thoracic endometriosis may present with catamenial pneumothorax (recurrent pneumothorax occurring within 72 hours of menstruation), haemoptysis in case of bronchial location, haemothorax, pericardial effusions. A diagnosis of thoracic endometriosis is simple when both endometrial stroma and gland are present. In cases of endometriosis with stroma only, a further classification of “aggregated pattern”, in which immunohistochemistry is ER-, PR- and CD10-positive might be necessary for diagnosis.
XA57M6 Lung
XA2JL0 Diaphragm
GA10.4 Endometriosis of the Circulatory System
Pericardial Endometriosis can have mediastinal involvements such as catamenial pericardial effusion, pericardial nodules, hemopericardium accompanied by sudden and excruciating chest pain due to parietal pericardial irritation.
XA6H07 Heart
XA2XU0 Pericardium
GA10.5 Endometriosis of the Nervous System
Nerve involvement may manifest with neurological symptoms, including pain, muscle weakness, bowel and bladder incontinence, and paraplegia. The neural involvement may be isolated or caused by a direct extension of a deep infiltrating endometriosis of the pelvic structure. Magnetic resonance imaging (MRI) is a reliable imaging modality for detecting neural involvement of endometriosis. Both the disease and radical removal of endometriosis may lead to the destruction of the nerve fibres with corresponding symptoms, which can be very debilitating for the patient. Endometriosis close to the sympathetic and parasympathetic nerve fibres (hypogastric plexus and splanchnic nerves) can lead to a dysfunction of pelvic organs (e.g. dysfunction of the bladder as well as disturbance of vaginal lubrication and intestinal dysfunction). Involvement of somatic nerves, such as the sacral plexus and the sciatic nerve, leads to corresponding neurological symptoms or deficits. Neural entrapment is a possible occurrence and has been described in different pelvic nerves, such as the sciatic, obturator, femoral, and pudendal nerves and the inferior hypogastric and lumbosacral plexus.
Lymphatic endometriosis. The presence of endometrial tissues in the lymphatics and lymph nodes (both with and without endometriosis) suggests lymphatic routes of dissemination of endometrial tissue. Lymphangiogenic growth factor and receptor expression and the density of lymphatic vessels are altered in the eutopic endometrium of women with endometriosis. Lymphatic vessels in the peritoneum are numerous, continuous, and found mainly around arterioles and in the subperitoneal tissues. The peritoneum can be considered as one lymph space with multiple and parallel draining patterns into celiac, periportal, superior mesenteric, intrathoracic, and intra-abdominal lymph nodes.
Immune system
XA4NC8 Lymphoid organs
XA33X2 Lymph nodes
XA0GJ0 Mononuclear phagocyte system
Spread of IELCs to PSLN is common in ovarian and/or peritoneal endometriosis. Metastatic lesions in PSLN are present in 11% of women. Further studies to evaluate the prognostic and predictive value of endometriotic spread to PSLN are warranted.
immunohistochemical panel with antibodies against ER, PR and p53 useful in diagnosing atypical endometriosis has been described.
Intraoperative findings include red lesions and endometriotic implants frequently associated with multiple diaphragmatic holes, fenestrations, perforations, and pores of different sizes, usually located at the central tendon.
A multidisciplinary approach involving the radiographers, gynecologists, pulmonologists, and thoracic surgeons is required.
Pelvic imaging examinations, including transvaginal US after bowel preparation and pelvic MR imaging, should be performed to investigate pelvic disease because of the high prevalence of concomitant thoracic and severe abdominal endometriosis.
Pneumothorax or haemothorax requires immediate treatment
GA10.5 Other
Ectopic endometrium has been found in the umbilicus, skin, spleen, breasts, brain, eye, and lymph nodes. Exceptional cases have also been described in males.
XS3V No endometriosis
XS5N Filmy endometriosis
XS55 Dense endometriosis
GA15.3 Adhesions of cervix
GC01.Y Bladder adhesions
DB1Y Adhesion of appendix
DB30.2 Adhesions of large intestine with obstruction
DC51.1 Peritoneal adhesions - Diaphragm
BB2Y Pericardial adhesions
CB40.Y Adhesion of lung
GA10.B Endometriosis in cutaneous scar
Associated with
PK80.30
Gastrointestinal, abdominal, or abdominal wall procedure associated with injury or harm, open approach
PK80.32
Gastrointestinal, abdominal, or abdominal wall procedure associated with injury or harm, endoscopic approach
PK80.70
Caesarean section or other obstetric procedure associated with injury or harm, open approach
PL11.0
Cut, puncture or tear, as mode of injury or harm
GA10.C Salpingitis isthmica nodosa
A condition of the fallopian tube caused by infection or inflammation. This condition is characterised by bilateral, nodular thickening of the isthmic and proximal ampullary tunica muscularis. This condition may also present with infertility or ectopic pregnancy. Confirmation is by imaging.
2F76 Neoplasms of uncertain behaviour of female genital organs
Stromal endometriosis uncertain behaviour of unspecified site ⇒
2F96 Endometrial stromal sarcoma, low grade
Stromal endometriosis
JA05.0 Endometriosis following pregnancy or abortion
Stage
Lesion
stage 0 – CYST: indicates that the endometriosis is where it started and hasn't spread
stage I – SUPERFICIAL: endometriosis is small and hasn't spread anywhere else
stage II – DIE: endometriosis has grown, but hasn't spread
stage III – EXTRAPELVIC: endometriosis has spread to the surrounding tissues
stage IV – NEOPLASMS or CAUSED BY: endometriosis has spread from where it started to at least one other body organ; also known as "secondary" or "metastatic" endometriosis
Adhesion
XS3V No endometriosis
XS5N Filmy endometriosis
XS55 Dense endometriosis
Severity
XS0J A Remission / Free of disease
XS05 B Local Disease
Reproductive
XS9S C Regional disease
Abdominal
XS4Z D Distant disease
Thoracic
Stages Detail
Lesion
Endometrioma
thick walled ovarian or paraovarian cyst containing blood of varying age
Superficial
peritoneal lesions of varying color
Deep
nodules with a depth of penetration exceeding 5 mm
Extrapelvic lesions
Neoplasms
Adhesions
Caused by
Appearance
Once cellular attachment and invasion of endometrial cells are established, the subsequent growth or maintenance of endometriotic lesions is maintained by the promotion of mitogenesis and angiogenesis with the continuation of the menstrual cycle. An orchestrated action of estrogen and other inflammatory or proinflammatory mediators contributes to the growth promoting effect of endometriosis.
These sequential events indicate that, once exfoliated, the endometrium enters into the pelvic cavity, becomes attached to the mesothelial layer, and then a process of angiogenesis, heme metabolism, and fibrosis ensue to maintain the natural course of endometriosis
Translucent
Nonopaque lesions containing either watery, serous, or mucinous secretion and there is no collection of blood in the stroma by histology
Red
Overproliferation of microvessels in the growing endometriotic lesions causes oozing of blood in the stroma and appears as blood-filled opaque red lesions by laparoscope.
Black-Blue
With the progression of time, there is deoxygenation from hemoglobin to methemoglobin or hemosiderin leading to color changes of these opaque red lesions to black or related lesions. At this stage, collection of blood in the stroma disappears.
White -yellow
White lesions are due to the collection of bilirubin or biliverdin and accumulation of fibrous tissue. In this stage, the gland gradually becomes smaller and stroma sometimes disappears due to a deposition of fibrous tissue. Finally, old lesions disappear and there is a new focus of endometriosis due to continuation of menstrual reflux.
Fibrosis
Fibrosis, also known as fibrotic scarring, is a pathological wound healing in which connective tissue replaces normal parenchymal tissue to the extent that it goes unchecked, leading to considerable tissue remodelling and the formation of permanent scar tissue.
FB51.4 Retroperitoneal fibrosis
GA14.Y Vaginal fibrosis
GA15.Y Fibrosis of cervix
GA16.Y Fibrosis of uterus
GA17.Y Fibrosis of oviduct
GC01.Y Bladder fibrosis
MF54.0 Kidney fibrosis
Pathology
Histopathology
Immunohistochemical staining for estrogen receptor ER and progesterone receptor PR is observed in both endometrial epithelial and stromal components
PAX8 can highlight the endometrial glandular cells
CD10 and WT-1 can highlight endometrial stromal cells
Cytopathology
In the pleural fluid specimens, recognition of endometrial epithelial cells, which generally occur in tissue fragments or singly, and of hemosiderin-laden histiocytic cells, which probably represent endometrial stromal elements, is considered essential to establishing such a diagnosis on a morphologic basis alone.
Condition defined by the presence of at least 2 of the following 3 criteria: oligo/anovulation; clinical or biochemical signs of hyperandrogenism; presence of polycystic ovaries as identified by ultrasound.
GC70 Postoperative adhesions of vagina
GC71 Prolapse of vaginal vault after hysterectomy
GC72 Postprocedural urethral stricture
GC73 Postprocedural pelvic peritoneal adhesions
GC74 Malfunction or complication of external stoma of urinary tract
GC75 Malfunction of the afferent segment of a continent urinary pouch
GC76 Malfunction of the efferent segment of a continent urinary pouch
GC77 Postprocedural nonmenstrual uterine bleeding
GC78 Postprocedural acute female pelvic inflammatory disease
GC7B Postinterventional ischemia or infarction of kidney
Injury or harm arising from surgical or medical care, not elsewhere classified
Acquired Abnormalities
GA16 Acquired abnormalities
of uterus, except cervix
GA16.0 Endometrial glandular hyperplasia
A condition of the uterus, caused by chronic, excess oestrogen stimulation due to obesity, anovulation, or oestrogen therapy. This condition is characterised by excessive proliferation of the endometrial gland cells and a greater gland-to-stroma ratio of endometrial cells. This condition may also present with abnormal uterine bleeding, particularly among postmenopausal women and premenopausal women of increasing age. Confirmation is by sampling endometrial tissue through biopsy or dilation and curettage.
GA16.1 Malposition of uterus
A condition of the uterus, caused by weakened pelvic ligaments, enlargement of the uterus, scarred pelvic tissue from pregnancy, tumour, menopause, endometriosis, inflammation, or salpingitis. This condition is characterised by a deviation in the position of the uterus from normal.
GA16.2 Intrauterine synechiae
Intrauterine adhesions caused by pelvic inflammatory disease, uterine surgery, or complications related to spontaneous, incomplete or induced abortion. May be asymptomatic or associated with amenorrhea or light menstrual bleeding and subfertility.
GA17 Acquired abnormalities
of fallopian tube
GA17.3 Haematosalpinx
A condition of the Fallopian tube, caused by tubal pregnancy, endometriosis, tubal carcinoma, or cryptomenorrhoea. This condition is characterised by bleeding and the presence of blood clots inside the Fallopian tubes, and pelvic pain or uterine bleeding. Confirmation is by imaging.
GA18 Acquired abnormalities of ovary
GA18.0 Follicular cyst
of ovary
A condition of the ovary, caused by a follicular growth or involution due to failure of ovulation. This condition is characterised by the non-neoplastic formation of closed sac-like structures filled with fluid on or in the ovary and lined by layers of granulosa cells. This condition is commonly asymptomatic, but may also present with pelvic pain, irregular menstrual bleeding, dyspareunia, nausea, vomiting, or urgency to urinate. Confirmation is by imaging.
26 Supplementary Chapter Traditional Medicine Conditions - Module I
Endometriosis causes a chronic inflammatory reaction that may result in lesions, adhesions, and fibrosis within the pelvis and other parts of the body. Endometriosis is a benign gynecological disease characterized by the presence of endometriotic glands and stroma outside the uterine cavity.
Endometriotic lesions can differ in their biochemistry, hormonal response, immunology, inflammatory response when compared to endometrium. Endometriotic lesions time-dependently change their color appearance resulting from certain biochemical change within lesions
The distribution of these lesions are most often found within the pelvic peritoneum but can include the pelvic viscera, rectovaginal septum, pleura, kidneys, bladder, abdominal wall, cesarean section scar and rarely, the brain. Diagnosis is reliably established with surgical visualization with histological verification, although ovarian endometrioma and deep nodular forms of disease can be detected through ultrasonography and MRI.
Complications of endometriosis include internal scarring, adhesions, pelvic cysts, chocolate cysts of ovaries, ruptured cysts, and bowel and ureter obstruction resulting from pelvic adhesions. Thoracic complications are lung collapse and diaphragm paralysis.
Early suspicion of endometriosis is a key factor for early diagnosis, as endometriosis can often present symptoms that mimic other conditions and contribute to a diagnostic delay.
Has manifestation: CHRONIC PAIN
MG30.4 Chronic secondary visceral pain
MG30.40 Chronic visceral pain from mechanical factors
MG30.41 Chronic visceral pain from vascular mechanisms
MG30.42 Chronic visceral pain from persistent inflammation
MG30.4Y Other specified chronic secondary visceral pain
MG30.4Z Chronic secondary visceral pain, unspecified
OVERALL:
Change Endometriosis to an inflammatory disorder of the female genital tract.
The immune system behaves abnormally in tissues affected by endometriosis. While some important functions of the immune system are suppressed, other parts appear to be overactive, including the production of antibodies against ovarian and uterine cells. Specific white blood cells and inflammatory compounds (e.g., cytokines, prostaglandins) are concentrated in endometriosis lesions, triggering inflammation. The pathogenesis of Endometriosis has numerous cellular processes within the lesion and interaction of the immune system which results in a chronic inflammatory state induced by self-perpetuated mechanisms within the endometrial lesions.These mechanisms impact the ability of the immune system to successfully advance cellular death and remove debri for homeostasis. As a result, the environment is continuously exposed to cyclical fluctuations that maintain inflammation. The lesions themselves are identified by the immune system as inappropriate. As lesions advance through stages from gland and stroma, producing enzymes and estrogen, the immune system is compromised in its ability to regulate cell growth. The rate of apoptysis is reduced, which favors sustained growth of these lesions. Continued growth most often leads to transformation into smooth muscle, atypia and terminal fibrosis. The result of inflammation throughout lesion life precipitates adhesion formation. These changes further impact function, mobility of tissues, organs and system wide changes.
Examination during menses
improves detection.
Considering the importance of endometriosis and its relatively high prevalence among women as well as the wide range of endometriosis symptoms (including asymptomatic to severe life-threatening pain).
Accurate diagnosis of disease spread using non-invasive methods can be effective in the treatment and follow-up of patients.
Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated, and if so, for planning complete surgical excision.
Surgical expertise for the treatment of severe endometriosis, where comprehensive knowledge of radical and oncological surgical techniques and anatomy is required to manage unexpected findings such as diaphragmatic, pleural or even pericardial endometriosis.
Adenomyyosis is a condition of the uterus characterised by endometrial tissue growth in the myometrium, hypertrophy of the myometrium, and heavy or prolonged menstrual bleeding, dysmenorrhoea, dyspareunia, bleeding between menstruation, infertility, or is asymptomatic. Confirmation is by histopathology or ultrasound.
GA11 Adenomyosis
Deep infiltrating endometriosis and lymph node endometriosis appear to represent the same entity. A immunohistochemical panel with antibodies against ER, PR and p53 useful in diagnosing atypical endometriosis has been described.
Histologic confirmation of ectopic endometrial tissue is not always feasible, nor is histologic examination always performed; histologic confirmation is obtained in only one-third of cases.
In peritoneal fluid, levels of growth factors known to promote lymphangiogenesis, including VEGF-A, FGF-2, IGF-1, and IGF-2, are increased with endometriosis.
• Active glandular DIE - morphology in which hemorrhagic glandular and cystic tissue predominates
• Chronic stromal fibrotic DIE - morphology in which fibrosis and smooth muscle hypertrophy predominates
• Tethering/obliteration - fibrotic scarring across a peritoneal or retroperitoneal space, bringing adjacent organs into fixed contact with one another
The Spaces:
Prevesical space – extraperitoneal space located anterior to the bladder, bounded by the transversalis fascia (anterior), the umbilicovesical fascia (posterior), the inferior border of the pubic symphysis (inferior), and the umbilicus (superior)
Vesicouterine space – intraperitoneal recess between the bladder (anterior) and the uterus (posterior)
Vesicocervical/vesicovaginal space – extraperitoneal space between the bladder (anterior), the cervix or vagina (posterior), and the vesicouterine ligaments (lateral)
Rectouterine space – intraperitoneal recess located between the uterus (anterior) and the upper 1/3 of the rectum (posterior)
Rectocervical space – intraperitoneal recess located between the cervix (anterior) and the middle 1/3 of the rectum (posterior)
Rectovaginal space – extraperitoneal space located between the vagina (anterior) and the lower 1/3 of the rectum (posterior), includes the posterior vaginal fornix and the rectovaginal septum
New Chronic Pain Classification:
Level 3 of Codes
The Ligaments:
Broad ligaments – extends from the lateral uterus to the lateral pelvic sidewall, contains the ovary and fallopian tube, ovarian ligament, round ligament, suspensory ligament of the ovary, and the ovarian and uterine arteries
Cardinal ligaments – extends from the lateral cervix and vagina to the pelvic sidewall, comprised of the parametrium (superiorly/above the ureter) and the paracervix (inferiorly/below the ureter)
Round ligaments – originate at the superolateral aspect of the uterus just below the fallopian tubes, travel laterally through the broad ligaments, anteriorly into the inguinal canal, and inferiorly into in the labia majora
Canal of Nuck – distal portion of the round ligaments in the inguinal canal and labia majora
Uterine ligaments – umbrella term including the round ligaments, broad ligaments, and cardinal ligaments
Uterosacral ligaments – originates at the torus uterinus, lateral cervix, and upper vagina anteriorly, runs between the visceral and parietal layers of the mesorectal fascia along either side of the mid-rectum, and inserts onto the coccygeus, sacrospinous ligament, ischial spine, and presacral fascia between S2-S4 posteriorly
*Heart transplant: Endometriosis must be considered even in large displacing tumors and despite the absence of typical cyclical symptoms or laboratory markers.