Hypogastric and Sacral Root Nerve Entrapment By Deep Infiltrating Endometriosis

Study Objective Raise awareness of rare presentations of Deep Infiltrating Endometriosis (DIE) and its treatment. Sacral root (S2-S3-S4) and inferior hypogastric nerve compromise is a usual component of parametrial (cardinal and uterosacral) DIE but entrapment is rarely observed. Design Discussion and case presentation along with histopathologic analysis of surgical findings. Setting Private tertiary care clinic in Chile Patients or Participants 32-year-old patient with progressive dysmenorrea, dyspareunia and dysquezia. Pelvic gel-contrasted ultrasound and MRI are consistent with DIE with a 2 cm right uterosacral/parametrial nodule and a 5 cm rectal nodule without mucosal involvement. She only had mild initial response with fast relapse of symptoms after a 2-month course of 2mg/day oral Dienogest. Interventions Radical excision of deep infiltrating endometriosis nodule that entrapped both right inferior hypogastric nerve and sacral roots. Measurements and Main Results After surgery the patient reported pelvic pain had completely disspeared. Postoperative urinary retention that required Foley´s catheterization for 30 hours. Also complained of total loss of rectal or vesical sensation. Progressively recovered and by POD 7 she reported having an almost normal bladder/micturition sensation. One month after surgery she has no autonomic pelvic visceral complaints. Histopathological analysis of the nodule showed endometriosis and intense fibrosis infiltrating the uterine smooth muscle fibers. It also included the deep uterine vein, with two nerves, the hypogastric nerve and a sacral root. Conclusion It is recommended to identify and preserve autonomic pelvic nerves whenever possible because it improves postoperative vegetative pelvic organ and specially voiding functions.