Urogynaecology
Factors Associated with Severity of Irritable Bowel Syndrome Symptoms in Patients with Endometriosis

https://doi.org/10.1016/j.jogc.2017.06.025Get rights and content

Abstract

Objective

This study sought to examine factors associated with severity of irritable bowel syndrome (IBS) by using the Birmingham IBS symptom scale in patients presenting with endometriosis to a tertiary referral centre.

Methods

A prospective research cohort of patients presenting to a tertiary referral centre for endometriosis was evaluated for the presence and severity of IBS between December 2013 and April 2015. Patients with endometriosis had a diagnosis of IBS by using the Rome III criteria and were evaluated for severity of IBS symptoms by using the Birmingham IBS symptom scale. Multifactorial variables, including stage of endometriosis at the time of previous surgery, clinical examination findings, mood disorder questionnaire scores, and lifestyle factors, were evaluated using the t test and Spearman rank correlation test.

Results

A total of 194 of 373 (52%) women with confirmed endometriosis had a diagnosis of IBS. Factors associated with severity of IBS symptoms in patients with endometriosis included lower-stage endometriosis (P = 0.004), presence of mood disorders (P < 0.001), tenderness on physical examination (P ≤ 0.001), a history of sexual assault (P ≤ 0.02), and presence of sleep disturbance (P ≤ 0.01). Evaluation of the subscales of the Birmingham IBS symptom scale revealed a strong association between the previously identified factors and the pain subscale.

Conclusion

Using the Birmingham IBS symptom scale, our study revealed more severe IBS symptoms in patients with lower-stage endometriosis and identified other variables highly associated with severity of IBS. Continued research is required to characterize further the clinical importance of IBS symptoms in patients with endometriosis-associated pelvic pain.

Résumé

Objectif

Cette étude avait pour but d'étudier, au moyen du questionnaire Birmingham IBS symptom scale, les facteurs associés à la gravité du syndrome du côlon irritable (SCI) chez des patientes atteintes d'endométriose se présentant dans un centre régional de soins tertiaires.

Méthodologie

Une cohorte de patientes atteintes d'endométriose s'étant présentées dans un centre régional de soins tertiaires entre décembre 2013 et avril 2015 a été étudiée de façon prospective; on a déterminé si elles étaient atteintes d'un SCI et sa gravité, le cas échéant. Les patientes atteintes d'endométriose ayant reçu un diagnostic de SCI selon les critères de Rome III ont répondu au questionnaire Birmingham IBS symptom scale visant à évaluer la gravité de leurs symptômes de SCI. Les variables multifactorielles – stade de l'endométriose au moment de la dernière chirurgie, constatations à l'examen clinique, résultats des questionnaires sur les troubles de l'humeur et facteurs relatifs au mode de vie – ont été analysées au moyen du test t et du test de corrélation de rang de Spearman.

Résultats

Sur les 373 femmes de la cohorte, 194 (52 %) ont reçu un diagnostic de SCI. Les facteurs associés à des symptômes de SCI plus graves chez les patientes atteintes d'endométriose comprenaient l'endométriose de stade peu avancé (P = 0,004), la présence de troubles de l'humeur (P < 0,001), la présence de douleur à la pression au cours de l'examen physique (P ≤ 0,001), des antécédents d'agression sexuelle (P ≤ 0,02) et la présence de troubles du sommeil (P ≤ 0,01). L'évaluation des résultats de chaque catégorie du questionnaire Birmingham IBS symptom scale a révélé une forte association entre ces facteurs et la douleur.

Conclusion

À l'aide du questionnaire Birmingham IBS symptom scale, notre étude a montré que les patientes atteintes d'endométriose de stade peu avancé présentaient des symptômes de SCI plus graves que celles dont le stade était plus avancé. Elle a également permis de mettre en évidence d'autres facteurs fortement associés à la gravité du SCI. Cependant, d'autres études seront nécessaires pour mieux définir l'importance clinique des symptômes du SCI chez les patientes souffrant de douleur pelvienne associée à l'endométriose.

Introduction

Endometriosis is a gynaecological condition defined by the presence and proliferation of endometrial glands and stromal tissue outside the uterus, leading to an estrogen-mediated chronic inflammatory process.1, 2 The chronic condition affects between 5% to 10% of women of reproductive age but can present in 33% of women with chronic pelvic pain and 50% of women with infertility.1, 3, 4, 5, 6 At the time of laparoscopy, endometriosis is staged as minimal, mild, moderate, or severe according to the classification system described by the American Society for Reproductive Medicine.1, 7

Recently in the gynaecological literature, there has been an increased understanding of the relationship of endometriosis, chronic pelvic pain, and central sensitization.8 A multidisciplinary approach has been advocated in the management of endometriosis and chronic pelvic pain because of the association with other pain syndromes and mood disorders including irritable bowel syndrome (IBS), painful bladder syndrome, provoked vulvodynia, pelvic floor hypertonus or myofascial pain, pain catastrophizing, anxiety, and depression.8, 9, 10 Endometriosis has also been noted to be associated with increased visceral and pressure hypersensitivity.11, 12 This finding may provide some insight into the association with IBS.

IBS is a functional bowel disorder affecting approximately 11% of the population.13 According to the Rome III diagnostic criteria, the disorder is characterized by recurrent abdominal pain or discomfort that improves with defecation, and the onset is associated with a change in frequency of stool and/or a change in form of stool.14 Severity of gastrointestinal symptoms has been measured using various questionnaires including the visual analogue scales for IBS, the IBS symptom severity scale, and the Birmingham IBS symptom scale.15 The Birmingham IBS scale has been validated in several studies.15, 16, 17 The self-administered questionnaire consists of 11 questions that are further subcategorized into three symptom-specific scales assessing constipation, diarrhea, and pain.16, 17 To date, an in-depth exploration of the factors associated with severity of IBS symptoms in the context of endometriosis has not been completed.

Our current study aimed to provide an exploratory analysis of the factors associated with severity of IBS symptoms in patients presenting to a tertiary referral centre with endometriosis by using the validated Birmingham IBS symptom scale. The goal was to supply a clinical picture of patients with the dual diagnosis of endometriosis and IBS. In particular, we aimed to examine the associations among IBS severity, stage of endometriosis, psychological factors, and clinical examination findings.

Section snippets

Study Population

The study population was analyzed using cross-sectional baseline data of an ongoing prospective research cohort study conducted at the BC Women's Centre for Pelvic Pain and Endometriosis in Vancouver. Patients were recruited and enrolled between December 2013 and April 2015 after undergoing a full history and examination at the tertiary referral centre. Data collected prospectively from patients' online questionnaires, physical examinations, and physicians' evaluations was entered into an

Results

Of a total of 373 women with confirmed endometriosis, 194 women were diagnosed with IBS. The average age of participants was 35.0 ± 7.3, with an average BMI of 25.5 ± 5.8 kg/m2. Most patients were White, at 72.2% (140 of 194), and of nulligravid status, at 52.6% (102 of 194). Of patients with surgically diagnosed endometriosis, the stage could be determined from previous operative reports in 90.2% (175 of 194). Minimal-mild endometriosis was seen in 48.6% (85 of 175), and moderate-severe

Discussion

Our study aimed to explore the factors associated with severity of IBS symptoms in patients with a diagnosis of endometriosis. Assessing severity of IBS is important as it predicts quality of life, health care resource utilization, and work productivity.23 Severity of IBS is especially essential when it is diagnosed in the context of endometriosis, as both conditions are known to negatively impact quality of life.24, 25 The Birmingham IBS severity scale is a self-administered questionnaire that

Conclusion

By using the validated Birmingham IBS symptom scale, the present study revealed that patients presenting to our tertiary referral centre with endometriosis and IBS experienced more severe IBS symptoms than did the general population. A multifactorial analysis revealed that more severe IBS symptoms were associated with multiple other comorbidities, including greater pain, greater psychological symptoms, and more tenderness on physical examination. We also observed an inverse relationship between

References (36)

  • D. Hoffman

    Central and peripheral pain generators in women with chronic pelvic pain: patient centered assessment and treatment

    Curr Rheumatol Rev

    (2015)
  • P. Stratton et al.

    Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications

    Hum Reprod Update

    (2011)
  • S. As-Sanie et al.

    Increased pressure pain sensitivity in women with chronic pelvic pain

    Obstet Gynecol

    (2013)
  • B. Issa et al.

    Visceral hypersensitivity in endometriosis: a new target for treatment?

    Gut

    (2012)
  • R.M. Lovell et al.

    Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis

    Clin Gastroenterol Hepatol

    (2012)
  • Rome Foundation

    Guidelines: Rome III diagnostic criteria for functional gastrointestinal disorders

    J Gastrointestin Liver Dis

    (2006)
  • Z. Mujagic et al.

    Systematic review: instruments to assess abdominal pain in irritable bowel syndrome

    Aliment Pharmacol Ther

    (2015)
  • F. Jasper et al.

    Latent structure of irritable bowel syndrome symptom severity

    World J Gastroenterol

    (2015)
  • Cited by (0)

    Competing interests: None declared.

    View full text