Pelvic nerve endometriosis: Diagnostic and treatment insights.

Pelvic nerve endometriosis presents unique diagnostic and management challenges.

Key Points

Importance:

• Pelvic nerve endometriosis remains an underdiagnosed condition, often overlooked both in imaging studies and clinical evaluations.
• In patients with deep infiltrating endometriosis, the possibility of pelvic nerve involvement should always be considered. 

Highlights:

• Detailed imaging findings from radiologists play a crucial role in guiding surgeons toward optimal approaches for nerve involvement.
• Early recognition and treatment of neural endometriosis are essential to prevent irreversible nerve damage and chronic pain syndromes.

What's done here:

• This French review provides a comprehensive overview of pelvic nerve endometriosis, focusing on its clinical presentations, imaging features, and treatment approaches.
• It highlights the use of pelvic neurography MRI (3D T2-weighted sequences) to detect nerve involvement and guide surgical planning.
• The article links specific nerve pathways to characteristic symptoms and underscores the importance of early recognition for effective, nerve-sparing management.

Key Outlines:

• Endometriosis can infiltrate or compress pelvic nerves, leading to distortion or entrapment of nerve fibers and amplifying chronic myofascial pain.
• MRI with a dedicated "pelvic neurography protocol" (3D T2-weighted sequence) is key for identifying hypointense nodules and fibrotic thickening along nerve pathways.
• Inferior hypogastric plexus involvement may cause vegetative symptoms, including bladder and rectal dysfunctions.
• Sacral plexus and sciatic nerve involvement often result in gluteal or pudendal pain, sciatica, and pelvic organ dysfunction, with pain radiating down the leg during menstruation.
• Pudendal nerve involvement manifests as perineal pain or burning, worsening with sitting. Management may include antidepressants and neuromodulators.
• Obturator nerve endometriosis, though rare, presents with medial thigh pain and weakness in thigh adduction.

From the Editor-in-Chief – EndoNews

"This article is a timely reminder of the often-overlooked neural dimension of deep infiltrating endometriosis. As the authors underscore, nerve involvement is not merely an anatomical curiosity—it is a critical factor in chronic pain syndromes that can profoundly impact quality of life.

By highlighting the role of dedicated MRI protocols and structured radiology reporting, this review provides a roadmap for multidisciplinary teams tackling one of the most complex aspects of endometriosis care. Early recognition of pelvic nerve endometriosis allows for interventions that are not only nerve-sparing but life-restoring.

The message is clear: advancing diagnostic precision is key to breaking the cycle of misdiagnosis and delayed treatment that so many patients endure"

Lay Summary

The exact mechanisms behind pelvic pain in endometriosis remain complex. Current understanding suggests that endometriotic lesions interact with sensory, sympathetic, and parasympathetic nerve fibers, driving inflammation, angiogenesis, and even direct invasion of peripheral nerves. This explains why deep infiltrating endometriosis is strongly linked to severe neuropathic pain.

In a recent review published in Insights into Imaging, the team lead by Dr.Pascal Rousset from Lyon Sud University Hospital, France, detailed how MRI can detect endometriotic lesions involving pelvic nerves. The authors highlight eight key regions—such as the inferior hypogastric plexus, hypogastric nerve, sacral plexus, pudendal nerve, and sciatic nerve—where nerve involvement leads to distinct clinical symptoms.

Radiologists play a crucial role in mapping these affected nerves, providing surgeons with essential information for nerve-sparing or nerve-targeted treatment. While medical therapy remains the first step for managing pudendal nerve involvement, resistant cases may require decompression surgery.

The authors emphasize that early diagnosis with MRI is vital to prevent irreversible nerve damage, and add that "a comprehensive and structured radiology report is essential for surgical planning, as nerve involvement often requires precise interventions to alleviate symptoms and restore quality of life".

Research Source: https://pubmed.ncbi.nlm.nih.gov/40537672/