Recent Advances in Diagnosis of Endometriosis
by Endoscopic Examination

Martin J. Clyman, M.D
Associate Clinical Professor of Obstetrics and Gynecology. Mt. Sinai School of Medicine. New York

Endometriosis, Aspects and Proceedings of a Symposium
Saint John's Hospital and Health Center, Santa Monica, California
Editor: J.J. Marik

Some thirty years ago, Dr. Albert Decker devised the knee-chest position for looking into the cul-de-sac by culdoscopy, with a 90° optical instrument under local anesthesia. The technique of culdoscopy is a very simple one, in that the patient is placed in knee-chest posture, with the thighs perpendicular to the table and a shoulder brace placed against the shoulder, with adequate preanesthetic medication and local anesthesia (1% Xylocaine,"~). Examination is preceded by puncture of the posterior fornix; this procedure does not require an operating room or having an anesthesiologist available. In over 40,000 cases reported in the literature, there have been no reported deaths due to culdoscopy, but there have been some cases of minor cul-de-sac infections, caused primarily by inexperience.

Laparoscopy was first introduced by Dr. Raoul Palmer in France in 1946, but with the advent of fiberoptics some ten years ago in Europe, laparoscopy came into its own with the laparoscope. Fiberoptics revolutionized the entire endoscopic visual field, as improved optical systems made possible the visualization of the abdominal pelvic viscera through laparoscopy.

Unfortunately, relatively few younger physicians today are at all conversant with culdoscopy, in spite of the fact that this procedure can document endometriosis with endometriomas of the ovaries adherent to the lateral pelvic walls, which may be missed entirely on laparoscopy.

Culdoscopic views of the ovaries and fallopian tubes of early endometriosis show that it begins as black blebs on the surface of the ovaries and tubes. In the early phase, these can be wiped clean using a peanut sponge; or they can be cauterized and thus destroyed.

Most individuals with early endometriosis are completely asymptomatic, with infertility as their main problem. In over 300 cases of endometriosis we have diagnosed by endoscopy, 50% had no symptoms whatsoever, including those with endometriomas of the ovaries, even if manually palpable on bimanual examination. This indicates that many patients with endometriosis do not suffer from the "classical" symptoms of thickened uterosacral ligaments, pelvic pain or dysmenorrhea.

Endometriosis, in cases of infertility, affects the fallopian tubes, although one does not see it often. On histologic examination, however, one can find endometriosis of the fallopian tubes either by light or electron microscopy. Often, in these cases, there is an increased amount of collagen on the wall of the tube, thereby altering its physiology due to scar-tissue formation, interspersed between the myometrial cells of the fallopian tube. The normal fallopian tube-as brought out into the vaginal vault by operative culdoscopy-is a transparent, translucent membrane. If it is stretched too hard, the ostium can rupture, causing bleeding. However, when perifimbrial adhesions are present, they lyse very readily without any bleeding. Cases of endometriosis causing such pathology can be completely missed by hysterosalpingogram or other tests for tubal patency.

Endoscopy is frequently required in order to confirm the presence or absence of endometriosis with infertility. When dye is infused through the uterine cavity, for example, results of a hysterosalpingogram may appear perfectly normal because the dye passes through, since the pressure used during a hysterosalpingogram is two to three times greater than that employed in doing a Rubin test.

In patients with pelvic endometriosis involving the ovaries and tubes, the tube wall often shows marked thickening and fibrosis. Biopsy of this type of lesion will show marked increase in collagen on electron microscopy, or with special staining techniques.

It must be borne in mind that everything that appears as black spots in the pelvis is not always endometriosis. On the ovaries, at times, there may be hemosiderin-filled, small dilated vesicles, not endometriomas.
Endometrianas of the ovaries adherent to the posterior aspect of the broad ligament or lateral pelvic walls can readily be seen on culdoscopy, yet are frequently missed by laparoscopy, unless the second probe moves behind the ovary and reveals it to be adherent in this area. In any case, using laparoscopy, one cannot definitely see the blackened area, whereas on culdoscopy the blackened endometrioma is readily visible and can be aspirated to prove the chocolate-cyst contents. If it is adherent to the ureter or the lateral pelvic wall of the pelvic vessels, abdominal surgery is required.

One patient presented with attacks similar to ureteral colic. A retrograde pyelogram found narrowing of the ureter which on culdoscopy was found to be due to endometriosis. Surgery freed the adhesions and the patient was cured of these attacks. Large endometriomas can of course be aspirated both by culdoscopy and operative laparoscopy, but are best removed by abdominal surgery.

The procedures of operative culdoscopy from below have been done by the author for the past fifteen years with good results, and Dr. Melvin Cohen has recently published the results of his use of operative laparoscopy. Using the Stortz Laparoscope, with a bipolar cautery tip for cauterization of the local areas, there is very little chance of any sparking onto the small bowel. This is a single-puncture technique, requiring more skill in the use of this instrument than does the double-puncture method. There are of course advantages and disadvantages to both procedures in the diagnosis and treatment of nonextensive endometriosis.

The new anti gonadotropic steroid, danazol, has been successfully employed in the treatment of endometriosis. Comparative biopsies before and after danazol revealed positive evidence of endometriomas, which resolved into cherry-red blebs; these could then be readily destroyed by cautery without concern about the contents of the dark chocolate-cyst material. The use of estrogen-progestogen combinations produces pseudopregnancy, causing a recession of from one to two years, but does not cure the disease, which is seen to recur in five-year follow-up studies. Danazol, (Danocrine', Winthrop Laboratories) is an excellent substitute for patients who cannot tolerate estrogen-progestogen combinations; it causes minimal, if any, side effects, and none at all which are ascribed to oral contraceptives.

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