UrogynaecologyFactors Associated with Severity of Irritable Bowel Syndrome Symptoms in Patients with Endometriosis
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.
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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
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Competing interests: None declared.