{"paper_id":"bd846511-d2b2-41a5-b3ba-4a2a731016a9","body_text":"REPRODUCTIVE HEALTH  •  March 2021 EMJ\nPhysiotherapy in Urinary Dysfunction Post-Surgery \nfor Endometriosis: Case Report\nAbstract\nEndometriosis is characterised by the presence of endometrial tissue outside the uterine cavity that \nresponds to oestrogen and stimulates local inflammatory processes, adhesions, pelvic pain, and \ninfertility. The treatment of endometriosis includes the use of medications and videolaparoscopy \nfor excision of adhesions or lesions. Some complications are associated with the videolaparoscopy, \nsuch as vascular, intestinal, urinary, neurological, and more rarely, vulvar oedema, which makes the \nrehabilitation difficult in the immediate postoperative period. In relation to the urinary dysfunction \nand to the vulvar oedema, physiotherapy has resources with demonstrated efficacy in the treatment \nof such complications after videolaparoscopy; they can rehabilitate the patient and improve their \nquality of life in a short time. In this study, the authors report the case of a patient treated by the \nPhysical Therapy Service of the Santa Casa de Misericórdia Hospital of São Paulo, São Paulo, Brazil, \nwith urinary retention and vulvar oedema after videolaparoscopy for endometriosis, which showed \nimprovement in vulvar oedema with the application of physiotherapy.\nAuthors: Natália Mainardi Simas,1 Domingos Mantelli Borges Filho,2-6 Erica M. \nC. Mantelli Borges,6,7 *Carla Maria de Abreu Pereira,1,6 Vera Lúcia dos \nSantos Alves1,8,9\n1. Santa Casa of São Paulo Medical Science College, São Paulo, Brazil\n2. Fetus Institute of Ultrasonography, São Paulo, Brazil\n3. USP Medical School, São Paulo, Brazil\n4. Scientific Technical Police of the State of São Paulo, São Paulo, Brazil\n5. Civil Police Academy of the State of São Paulo, São Paulo, Brazil \n6. Mantelli Clinic, São Paulo, Brazil \n7. Gynecology and Human Sexuality Sector of the Mantelli Clinic, São Paulo, Brazil \n8. Mogi das Cruzes University, São Paulo, Brazil \n9. Cardiopulmonary and Metabolic Physical Therapy Service of Santa Casa de São \nPaulo, São Paulo, Brazil \n*Correspondence to fisiocarlapereira@gmail.com\nDisclosure: The authors have declared no conflicts of interest.\nAcknowledgements: Images were obtained from the Pelvic Physiotherapy Outpatient Clinic of the \nIrmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil. The patient \nprovided written, informed consent for the use of their photographs and case details \nfor scientific study.\nReceived: 23.06.20\nAccepted: 30.09.20\nKeywords: Endometriosis, physical therapy, urinary retention, vulvar oedema.\nCitation: EMJ Repro Health. 2021;DOI/10.33590/emjreprohealth/19-00133.\n\nCreative Commons Attribution-Non Commercial 4.0 March 2021  •  REPRODUCTIVE HEALTH\nBACKGROUND\nEndometriosis is a chronic condition, \ncharacterised by the presence of endometrial \ntissue outside of the uterine cavity, such as \nthe pelvic cavity, the rectum, the ovary, and \nthe uterosacral ligament and in rare cases also \nin the diaphragm, pleura, and pericardium. \nEndometriosis responds to oestrogen hormone \nstimulation, which stimulates local inflammatory \nprocesses, accompanied by adhesions, fibrosis, \nneuronal infiltration, and anatomical distortion, \nwhich contribute to the presence of pelvic pain \nand infertility.1-3\nEndometriosis affects 6–10% of females of \nreproductive age and is seen in up to 60% of \nthose who present with pelvic pain complaint and \nin up to 50% of cases of infertility.3 The diagnosis \nis based on the clinical history of the patient, signs \nand symptoms, physical examination, medical \nimaging techniques (e.g., MRI), and proven by \nhistological examination of the materials collected \nduring the laparoscopy.4 Several theories attempt \nto explain the pathogenesis of the condition \nand can be divided into those that suggest that \nthe implants originate from endometrial tissue, \nsuch as the retrograde menstruation theory, \nand those that propose a nonuterine origin,  \nsuch as the theory of coelomic metaplasia.5,6\nAccording to the American Society for \nReproductive Medicine (ASRM), endometriosis \ncan be classified into four stages (mild to \nsevere), with different degrees of impairment \nand affected areas in each of them. 7 The \ntreatment for endometriosis includes oral \nprogestogen contraceptives, testosterone-\nderived agonists of gonadotropin releasing \nhormone, and nonsteroidal anti-inflammatory \ndrugs.8 Surgery plays an important role in the \ncontrol of endometriosis and aims to completely \nablate and/or excise the endometrial tissue \nand to correct anatomical changes caused by \nadhesions or lesions.9 Laparoscopy is considered \nto be the gold standard test for the diagnosis of \nthis pathology and resection of endometriosis \nthrough this technique is effective in pain \ncontrol.10 Vulvar oedema and urinary retention \nare some of the urinary complications related  \nto videolaparoscopy.9\nPostlaparoscopic vulvar oedema is a rare \ncomplication, but when presented it may affect \nthe patient's urination. Unfortunately, there are \nstill no guidelines for its management and the \nphysiopathology associated with the procedure \nis unknown.11 The studies of Guven et al. 11 and \nof Trout et al.12 reported cases of patients who \nunderwent laparoscopic surgery and presented \nwith vulvar oedema in the postoperative period. \nConsequently, urination was impaired and relief \ncatheterisation to decrease the oedema and \nrest were required. The authors observed that \nthe decreasing of oedema was associated with \nan improvement in diuresis. It is important to \nmention that vulvar oedema can also have other \ncauses, such as vulvar trauma as a result of \nuterine manipulation during hysterectomy and \nvoiding dysfunction in the postoperative period \nof females with deep endometriosis undergoing \nsurgery can be secondary to other causes \n(neurogenic dysfunctions of the pelvic floor).\nCASE REPORT\nDescribed here is the physiotherapeutic \nintervention in vulvar oedema and urinary \nretention presented in the postoperative \nperiod of videolaparoscopy for the treatment  \nof endometriosis.\nThe case report followed the sequence \nof identification, main complaint, history \nof the current disease, and evolution. The \nresearch instruments used in this case were \nanamnesis, evaluation of the pelvic floor with \nvisual inspection, and physiotherapeutic care  \n(seven sessions).\nA 45-year-old female of Caucasian background \nwas diagnosed with endometriosis, on the 3rd \npostoperative day of right oophoroplasty with \nhysterectomy and bilateral salpingectomy and \nright pararectal tumour excision. Following \nremoval of the bladder catheter, the patient \ndeveloped urinary retention and urinary \nincontinence as a result of overflow; the \ncatheter was inserted again and maintained. \nThe patient was evaluated in bed by the Pelvic \nPhysiotherapy Service of the Irmandade da \nSanta Casa de Misericórdia de São Paulo on the \nfifth postoperative day. In the inspection, vulvar \noedema and altered sensitivity of the external \nregion of the vulva were observed ( Figure 1A). \nSensitivity in the vulva region was assessed \nby the Semmes-Weinstein Monofilament \n(SWM) test. The patient was instructed by the \n\nREPRODUCTIVE HEALTH  •  March 2021 EMJ\nphysiotherapy team to apply cryotherapy (ice \npack) to the vulvar region for 20 minutes and \nperform stimulation in the inguinal lymph nodes \n(20 circles in the inguinal lymph node chain), \ntwice a day.\nThe patient was discharged on the 5th \npostoperative day and returned to the \nphysiotherapy outpatient clinic after 48 hours \nfor the first session of physical therapy, already \nshowing improvement of the oedema (Figure 1B).\nDuring the first postdischarge session, functional \nelectrical stimulation was performed in the supra \npubic region and in the labia majora (Figure 2), \nwith a pulse width of 500 microseconds, 50 \nHz frequency, 2-second ramp rise, 5-second \nmaintenance, 2-second ramp descent, with an \napplication time of 10 minutes.13,14 A device with \ntwo channels was used: adhesive electrodes \n(5 cm x 5 cm) were applied in the supra pubic \nregion and adhesive electrodes (3 cm x 5 \ncm) in the labia majora; the application was \nsimultaneous. The purpose of electrostimulation \nwas to activate muscle contraction to perform a \nmechanism of pumping the accumulated liquids \nin the application regions.13,14\nTranscutaneous electrical nerve stimulation \ncurrent was also applied in the presacral region \n(S2 to S4) for neuromodulation, with a pulse \nwidth of 250 microseconds and a frequency of \n8 Hz for 30 minutes, aiming to improve urinary \nretention. The patient was instructed to perform \nperineal exercises 3 times a day (the patient \nwas in the supine position, with abducted hips, \nbent knees, and feet on the bed). The exercise \nconsisted of contracting the pelvic floor for 5 \nseconds and relaxing it for 10 seconds, for 5 times. \nThe patient was also instructed to maintain the \napplication of cryotherapy to the vulvar region \nas well as the stimulation of the inguinal lymph \nnodes (20 circular movements). \nDuring the second physiotherapy session, \nperformed in the same week, the patient was \nno longer using a bladder catheter, the oedema \nhad decreased, and they reported a sensation of \nincomplete emptying of the bladder (Figure 3). \nThe conduct was maintained, and the patient \nwas instructed to perform scheduled urination \nevery 3 hours.\nAt the third session, the patient no longer \npresented with oedema, they reported a strong \nurinary stream, good urine flow, and postvoid \nresidual; the conduct was maintained until the \nsixth session.\nGENERAL CONSIDERATIONS\nOperative laparoscopy has undergone \ntechnological advances in the last decade. 11 \nAccording to several studies, vulvar oedema \nis a complication that rarely occurs in the \npostoperative period of laparoscopy, which may \nexplain the lack of studies on the subject. 11,12,15,16 \nThe first description of this complication, \nrelated to laparoscopic surgery, was made by \nTrout and Kemmann in 1996. 12 The researchers \nreported a case of three patients undergoing \nlaparoscopy for treatment of ovarian cyst, pelvic \nadhesions, and gamete intrafallopian transfer, \nwho presented with vulvar oedema in a 24-hour \npostoperative period, as well as discomfort and \ninability to urinate. The patients were hospitalised \nand received traditional  treatment with Foley \ncatheter for urine drainage, local application of \nice, and rest. Their condition improved between \n1 and 3 days, but one patient developed a urinary \ntract infection. The researchers also reported \nthat in their 3 years’ of experience, they only \nobserved three cases of vulvar oedema among \napproximately 900 laparoscopies, which confirms \nthe low rate of occurrence of this complication. \nThe studies of Pados et al. 15 and Guven et \nal.11 reported vulvar oedema in laparoscopic \ncystectomy. In the report by Pados et al., the \npatient presented with discomfort and vulvar \noedema 3 hours after the surgery. The treatment \nconsisted of a Foley catheter, introduced to \nprevent urinary retention due to the worsening of \ntheir condition; application of ice to the vulva; rest \nfor the patient; and bandaging of the oedema \nafter application of topical steroid cream. The \noedema improved after a few minutes and the \ncatheter and the bandage were removed after \n48 hours and the patient was discharged from \nhospital. In the report by Guven et al., the patient \nwas readmitted 27 hours after the procedure with \nvulvar oedema and inability to urinate. In parallel \nto the study by Pados et al., the treatment was \nperformed with application of ice to the vulva, \nFoley catheter, and rest, with improvement of the \noedema in 30 hours and hospital discharge after \n2 days, without complications. These results are \nsimilar to the case report presented here.\n\nCreative Commons Attribution-Non Commercial 4.0 March 2021  •  REPRODUCTIVE HEALTH\nFigure 1: Postoperative vulvar oedema.\nA) Vulvar oedema at the time of evaluation of physical therapy on the 5th postoperative day. B) Improvement of the \noedema and of urination after 48 hours of hospital discharge. \nSource: Pelvic Physiotherapy Outpatient Clinic of the ISCMSP (Irmandade da Santa Casa de Misericórdia  \nde São Paulo).\nA B\nFigure 2: Surface electrostimulation. \n\n\nREPRODUCTIVE HEALTH  •  March 2021 EMJ\nIt was possible to observe that the time of onset \nof vulvar oedema in the postoperative period and \nthe time elapsed for its improvement varied in all \nthe studies. A common complication was urinary \nretention, a consequence of vulvar oedema, \nwhich makes it impossible for the urine to be \nreleased as the oedema compresses the urethra. \nIts cause is complex and unpredictable, and its \nincidence rate associated with laparoscopy varies \nbetween 1.2% and 22.9%.16 The pathophysiology \nof vulvar oedema is still unknown. 11 One of \nthe hypotheses is the intraoperative or post-\nsurgery migration of an intra-abdominal fluid \nfrom a suprapubic puncture area to the vulvar \nsubcutaneous tissue.15,16 The persistence of the \ncanal of Nuck may also be one of the causes \nof fluid leakage from the peritoneal cavity to \nthe vulvar region. 11,15,17,18 The canal of Nuck is \na small wrapping of the parietal peritoneum, \nit is connected to the uterus by the round \nligament through the inner inguinal ring in the \ninguinal canal and it communicates with the \nlabia majora. It is a predelivery canal, which is \nclosed at birth or disappears in the first year of \nlife. When this communication remains open it \nmay be the cause of the inguinal hernia and of \nthe hydrocele of the canal of Nuck.18,19 Reed and \nRobinson18 related the use of 4% icodextrin in \nlaparoscopic gynaecological surgery to vulvar \noedema and urinary retention presented by \none patient. Icodextrin is used laparoscopically \nat the time of surgery to prevent the formation \nof adhesions that can lead to complications \nsuch as infertility, chronic pelvic pain, and small \nintestine obstruction. The authors reported the \ncase of a patient readmitted after laparoscopic \nsalpingectomy using 4% of icodextrin to prevent \nadhesions. The patient complained of inability \nto urinate and presented significant vulvar \noedema on physical examination. According \nto the authors, few complications are reported \nin the literature associated with the use of this \nsubstance, and the mechanism of vulvar oedema \nassociated with it is unknown. However, they \nconsidered the patient's persistence of the canal \nof Nuck as a possible cause of vulvar oedema, \nsince the substance is expected to remain in \nthe peritoneal cavity until it is absorbed by the \nlymphatic system.\nRegarding the management of vulvar oedema, it \nwas observed that cryotherapy was a common \ntherapeutic resource in the case reports discussed \nhere, possibly because it presents results in the \ncontrol and treatment of acute oedema with \nsolid physiological and well-established bases \nin the literature, in addition the fact that it is a \nresource of low cost and easy application.20,21 The \nintervention in the management of vulvar oedema \nthe authors applied was composed, in addition \nFigure 3: Decreased vulvar oedema during physiotherapy treatment.\nA) During the second session of physiotherapy, the patient did not require the use of a bladder catheter and showed \nimprovement of the oedema and urinary retention. B) During the seventh session, the patient had no complaints and \nno urinary retention; they were discharged from physiotherapy treatment.\nA B\n\nCreative Commons Attribution-Non Commercial 4.0 March 2021  •  REPRODUCTIVE HEALTH\nto cryotherapy, of electrostimulation, perineal \nexercises, and inguinal ganglion stimulation, which \ntogether presented excellent results. However, \ncitations about the application of these resources \nin the other reports presented here were not \nfound in author publications. The authors also did \nnot comment if physical therapy was performed \nat some point during the treatment of the \npatients. Pinto e Silva et al. 22 reported cases of \nfour patients with vulvar oedema due to different \naetiologies: one case of cervical cancer, one \ncase of bilateral adrenalectomy postoperative \nfor pheochromocytoma, and two cases of \npregnancy with pre-eclampsia. The physical \ntherapy treatment consisted of manual lymphatic \ndrainage in the vulva region; stimulating lymphatic \nflow towards the inguinal lymph nodes; multilayer \ncompression therapy, with overlapping bandages \nthroughout the genital area, arranged as an \nunderwear, aiming at lymphatic reabsorption \nand stimulation of lymphatic transport; and skin \ncare. The physiotherapists used their knowledge \nof applying compressive bandages to upper \nand lower limbs to adapt the technique to the \ngenital area. The researchers observed that this \nintervention had faster results in the resolution \nof vulvar oedema (mean: 3.5 days) compared \nwith other studies in which the oedema was not \ntreated, or other types of intervention were used.\nCONCLUSION\nThe physiotherapeutic performance presents \nuseful knowledge and resources to assist in \nthe treatment of vulvar oedema and urinary \nretention. These complications are rare, but they \nmay occur in the postoperative period for the \ntreatment of endometriosis. The importance of \nphysical therapy practise in these complications \nshould be emphasised. Although endometriosis \nhas no cure, it can be treated and controlled \nthrough periodic follow-up.\nReferences\n1. Acién P, Velasco I. Endometriosis: a \ndisease that remains enigmatic. ISRN \nObstet Gynecol. 2013;http:/ /dx.doi.\norg/10.1155/2013/242149.\n2. Maggiore ULR et al. A systematic \nreview on endometriosis during \npregnancy: diag-nosis, misdiagnosis, \ncomplications and outcomes. Hum \nReprod Update. 2016;22(1):70-103.\n3. Giudice LC. Clinical practice: \nendometriosis. N Engl J Med. \n2010;362(25):2389-98. \n4. Dunselman GAJ et al. ESHRE \nguideline: management of women \nwith endometrio-sis. Hum Reprod. \n2014;29(3):400-12. \n5. Burney RO, Giudice LC. \nPathogenesis and pathophysiology \nof endometriosis. Fertil Steril. \n2012;98(3):511-9. \n6. Marques AAM, Petta CA, “Fisioterapia \nna endometriose,” Tratado De \nFisioterapia Em Saúde Da Mulher \n(2011), São Paulo: Roca, pp.345-50. \n[In Portuguese].\n7. American Society for Reproductive \nMedicine (ASRM). Revised American \nSociety for Reproductive Medicine \nclassification of endometriosis: 1996. \nFertil Steril. 1997;67(5):817-21.\n8. Abrão MS, Gaec SP, “Tratamento \nda endometriose por laparoscopia \noperatória,” Pi-notti JA et al. (eds.), \nTratado de Ginecologia: Condutas e \nRotinas da Disciplina de Ginecologia \nda Faculdade de Medicina da \nUniversidade de São Paulo – USP \n(2005), Rio de Janeiro: Revinter, \npp.562-6. [In Portuguese]. \n9. Neme RM et al. “Complicações em \nlaparoscopia,” Pinotti JA et al. (eds.), \nTratado de Ginecologia: Condutas e \nRotinas da Disciplina de Ginecologia \nda Faculdade de Me-dicina da \nUniversidade de São Paulo – USP \n(2005), Rio de Janeiro: Revinter, \npp.562-6. [In Portuguese]. \n10. Kondo W et al. Tratamento cirúrgico \nda endometriose baseado em \nevidências/ evi-dence-based surgical \ntreatment of endometriosis. Femina. \n2011;39(3):143-8. \n11. Guven S et al. Vulvar edema as a \nrare complication of laparoscopy. \nJ Am Assoc Gy-necol Laparosc. \n2004;11(3):429-32. \n12. Trout SW, Kemmann E. Vulvar edema \nas a complication of laparoscopic \nsurgery. J Am Assoc Gynecol \nLaparosc. 1996;4(1):81-3. \n13. Hwang UJ et al. Pelvic floor muscle \nparameters affect sexual function \nafter 8 weeks of transcutaneous \nelectrical stimulation in women with \nstress urinary incontinence. Sex Med. \n2019;7(4):505-13.\n14. Vallinga MS et al. Transcutaneous \nelectrical nerve stimulation as an \nadditional treatment for women \nsuffering from therapy-resistant \nprovoked vestibulodynia: a feasibility \nstudy. J Sex Med. 2015;12(1):228-37.\n15. Pados G et al. Unilateral vulvar edema \nafter operative laparoscopy: a case \nreport and literature review. Fertil \nSteril. 2005;83(2):471-3.\n16. Nesbitt-Hawes EM et al. Urinary \nretention following laparoscopic \ngynaecological surgery with or \nwithout 4% icodextrin anti-adhesion \nsolution. Aust N Z J Obstet and \nGynaecol. 2013;53:305-9. \n17. Bhairavi S et al. Postparacentesis \nvulvar edema in ovarian hyper \nstimulation syn-drome. Int J Reprod \nContracept Obstet Gynecol. \n2016;5(11):4064-6. \n18. Reed B, Robinson R. Postoperative \nurinary retention with gross vulvar \nedema after use of 4% icodextrin. Mil \nMed. 2015;180(7):e858-60. \n19. Amani MR. Hernie inguinale chez la \nfille. 2018. Available at: http:/ /www.\nchirurgie-pediatrique.net/pathologie-\nde-paroi-/hernie-inguinale-chez-la-\nfille/. Last ac-cessed: 01 February \n2021. [In French].\n20. Kwang SK et al. Hydrocele of the \ncanal of nuck in a female adult. Arch \nPlast Surg. 2016;43(5):476-78. \n21. Guirro R et al. [The physiological \neffects of cryotherapy: a review]. \nRev. Fisiot. 1999;6(2):164-70. [In \nPortuguese].\n22. Pinto e Silva MPP et al. Manual \nlymphatic drainage and multilayer \ncompression therapy for vulvar \nedema: a case series. Physiother \nTheory Pract. 2015;31(7):527-31.","source_license":"CC0","license_restricted":false}