Bowel Endometriosis Syndrome: a new scoring system for pelvic organ dysfunction and quality of life.

STUDY QUESTION: Is it possible to develop a validated score that can identify women with Bowel Endometriosis Syndrome (BENS) and be used to monitor the effect of medical and surgical treatment? SUMMARY ANSWER: The BENS score can be used to identify women with BENS and to monitor the effect of medical and surgical treatment of women suffering from bowel endometriosis. WHAT IS KNOWN ALREADY: Endometriosis is a heterogeneous disease with extensive variation in anatomical and clinical presentation, and symptoms do not always correspond to the disease burden. Current endometriosis scoring systems are mainly based on anatomical and surgical findings. STUDY DESIGN, SIZE, DURATION: The score was developed and validated from a cohort of 525 women with medically or surgically treated bowel endometriosis from Aarhus and Copenhagen University Hospitals, Denmark. PARTICIPANTS/MATERIALS, SETTING AND METHODS: Patients filled in questionnaires on pelvic pain, quality of life (QoL) and urinary, sexual and bowel function. Items were selected for the final score using clinical and statistical criteria. The chosen variables were included in a multivariate analysis. Individual score values were designated items to form the BENS score, which was divided into 'no BENS', 'minor BENS' and 'major BENS.' Internal and external validations were performed. MAIN RESULTS AND THE ROLE OF CHANCE: The six most important items were 'pelvic pain', 'use of analgesics', 'dyschezia', 'straining to urinate', 'fecal urgency' and 'satisfaction with sexual life'. The range of the BENS score (0-28) was divided into 0-8 (no BENS), 9-16 (minor BENS) and 17-28 (major BENS). External validation showed a significant association between BENS score and QoL (P = 0.0001). LIMITATIONS, REASONS FOR CAUTION: The BENS scoring system is limited by the fact that it was developed from a single endometriosis unit in Denmark, making it susceptible to social, cultural and demographic bias. WIDER IMPLICATIONS OF THE FINDINGS: It is the first endometriosis classification system to be based directly on the symptomatology of the patient. Validation in other languages will promote comparison of treatments and results across borders. STUDY FUNDING/COMPETING INTEREST(S): No external funding was either sought or obtained for this study. A.F. is an investigator for Bayer, outside this work.

Pelvic organ function before and after laparoscopic bowel resection for rectosigmoid endometriosis: a prospective, observational study.

OBJECTIVE: To assess urinary, sexual, and bowel function before and after laparoscopic bowel resection for rectosigmoid endometriosis. DESIGN: Prospectively collected data regarding the function of the pelvic organs. SETTING: Tertiary endometriosis referral unit, Aarhus University Hospital. SAMPLE: A cohort of 128 patients who underwent laparoscopic bowel resection for endometriosis. METHODS: The International Consultation on Incontinence Questionnaire (ICIQ), Sexual Function-Vaginal Changes Questionnaire (SVQ), and the Low Anterior Resection Syndrome (LARS) questionnaire were answered before and after surgery. Non-invasive urodynamic testing was performed. MAIN OUTCOME MEASURES: Pre- and postoperative function of the pelvic organs was compared, and risk factors for improved/impaired function were identified. RESULTS: A total of 96.1% of the women completed the 1-year follow-up. A significant decrease (P = 0.002) in bladder filling problems (F-score) was observed 1 year after surgery, primarily caused by a significant decrease in bladder pain (P = 0.0001). No change for urodynamic parameters was observed. A significant increase in overall sexual satisfaction (P = 0.0001) and decrease in worries about sexual life (P = 0.001) was seen 1 year after surgery. Frequency of defecation was significantly increased 1 year after surgery (P = 0.0001), but the overall bowel function measured by LARS score was unchanged. Patients with anastomotic leakage had a significantly higher risk (odds ratio, OR 5.40; P = 0.002) of increased incontinence problems (I-score) 1 year after surgery. CONCLUSION: A significant and clinically relevant improvement in urinary and sexual function 1 year after laparoscopic bowel resection for endometriosis was found. Except for anastomotic leakage, this could be observed independent of any patient- or treatment-related factor. Apprehension about impairment of urinary and sexual function should not be a contraindication for bowel resection in endometriosis patients. TWEETABLE ABSTRACT: Rectal resection for endometriosis does not impair urinary and sexual function 1 year after surgery.

Strength of colonic anastomoses and skin incisional wounds in old rats - influence by diabetes and growth hormone.

The influence of advanced age on the mechanical strength of colonic anastomoses and skin incisional wounds in diabetic rats was investigated after 0 (suture binding capacity) and after 7 days of healing. Furthermore, the effects of growth hormone (GH) injections to old diabetic rats were investigated. Diabetes in old rats did not influence the strength of colonic anastomoses after 0 and 7 days. However, in these diabetic animals, the strength of skin incisional wounds was reduced by 27% after 7 days of healing (P< 0.01). GH injections administered to old diabetic rats doubled the mortality compared with that of saline-injected old diabetic rats (P< 0.01). GH injections did not influence the strength formation of either colonic anastomoses or skin incisional wounds in old normal rats. In conclusion, the healing of colonic anastomoses in diabetic rats was not compromised by old age, while the strength of skin wounds was decreased.

Influence of biosynthetic human growth hormone on the biomechanical strength development in skin incisional wounds of diabetic rats.

The influence of biosynthetic human growth hormone (b-hGH) on the mechanical strength development of skin incisional wounds in diabetic rats has been investigated after 4, 7 and 21 days of healing. Diabetes caused decreased mechanical strength of the wounds. After 21 days of healing, the diabetic animals treated with b-hGH from 7 days before wound infliction had an increased maximum load (14%) compared with the untreated diabetic animals. After 4 and 7 days of healing, no differences in the biomechanical strength of diabetic wounds with and without b-hGH treatment were found. The diabetic animals receiving b-hGH showed a significant increase in body weight compared with the untreated diabetic animals. In the diabetic animals, the blood glucose concentration was increased by treatment with b-hGH. In conclusion, treatment with b-hGH from 7 days before operation can counteract the reduced mechanical strength of skin wounds in diabetic rats on day 21.

The influence of aminoguanidine on borohydride reducible collagen cross-links and wound strength.

The mechanical strength of skin wounds as well as the deposition of hydroxyproline and KB3H4 reducible hydroxylysinonorleucine (HLNL) and dihydroxylysinonorleucine (DHLNL) cross-links in subcutaneously implanted cellulose sponges have been investigated in rats treated with aminoguanidine (AG) or beta-aminopropionitrile (BAPN). Treatment with AG (25 mg/kg BW/day) did not influence the mechanical strength of the wounds, the deposition of hydroxyproline or the pattern of reducible collagen cross-links, whereas AG (125 mg/kg BW/day) reduced the maximum load by 17%, but did not influence the deposition of hydroxyproline or reducible cross-linking pattern. Treatment with BAPN (333 mg/kg BW/day) reduced the strength of the wounds by 59%, the HLNL by 50% and the DHLNL 57%, whereas the deposition of hydroxyproline did not seem to be influenced by BAPN treatment. In conclusion, AG at moderate dosage does not seem to influence the formation of lysyl oxidase dependent reducible cross-links of collagen.

Collagen deposition and mechanical strength of colon anastomoses and skin incisional wounds of rats.

The mechanical strength development of healing wounds depends on the formation of collagen fibrils bridging the wound cleft. A considerable deposition, degradation, and remodeling of these fibrils takes place influencing the mechanical strength of the healing wounds. A method for studies of wound collagen metabolism in vivo is delineated, enabling determination of collagen deposition per hour in rat colon anastomoses and skin incisional wounds. Labeled proline was incorporated into wound collagen with a flooding dose of unlabeled proline, reducing errors introduced by proline recycling and proline de novo synthesis. The mechanical strength was determined by a materials testing machine. In both colon anastomoses and skin wounds a substantial increase in collagen deposition was observed at Day 2, reached a maximum at Day 6, and was still relatively high at Day 12 during the remodeling of collagen fibers in the wound cleft. The collagen deposition in colon anastomoses at Day 6, however, was 10-fold higher compared with that of the skin incisional wounds. The time course of the collagen deposition was much alike in colon anastomoses and skin incisional wounds reaching a maximum at Day 6. The mechanical strength of these two rather different types of wounds was increased correspondingly and to the same level during the 1st week of healing. The measurements of collagen deposition, collagen content, and biomechanical strength indicated a substantial turnover of newly synthesized and deposited collagen during the early phases of wound healing. On the basis of this, it seems obvious that even small disturbances to the balance between collagen synthesis, deposition, collagen cross-linking, and collagen degradation/remodeling may result in defective wound healing.

Effect of experimental diabetes and growth hormone administration on the strength of colonic anastomoses in rats.

The influence of growth hormone (GH; 2 mg/kg/day) administration on the mechanical breaking strength of colonic anastomoses in diabetic rats has been investigated on the day of operation (suture binding capacity) and after 4 and 7 days of healing. In diabetic rats, the suture binding capacity was decreased by 26% in both ultimate load and relative failure energy. After 4 days of healing, no difference was observed between control and diabetic animals. After 7 days, relative failure energy in the diabetic animals was reduced by 33%. GH administration to diabetic animals did not alter strength during the first week of healing. We found an increased circumference (33%) and defatted dry weight (22%) of the colon in diabetic rats. In conclusion, diabetes impairs the suture-binding capacity of the colon in rats, while there is only little influence on healing in the following week. GH administration could not influence the strength of colonic anastomoses in diabetic animals.