Adhesions are bands of scar tissue that form between internal body surfaces that are usually separate. They develop as the body’s natural response to tissue disturbance caused by surgery, infection, injury, or radiation.
The most commonly affected organs in or near the pelvic region are the fallopian tubes, uterus, ovaries, and bladder. Adhesions can vary in appearance, ranging from thin sheets resembling plastic wrap to thick fibrous bands. Many adhesions are painless and go unnoticed, but in certain cases, they may cause complications and lead to a condition known as adhesion-related disorder (ARD).
How Do They Form?
During surgical procedures or as a result of infection, the protective lining inside the abdomen and pelvis, the peritoneum, can be damaged. This damage triggers inflammation at the site, leading to the accumulation of pus cells and fluid. Over time, they combine and solidify, forming a scar similar to what you might see on the surface of a typical wound.
The exact process by which these scars, known as adhesions, develop is not fully understood. But it is believed that increased inflammation caused by inflammatory cells and fluid in the affected area plays a role. The inflammatory cells cause the area to thicken, eventually transforming into scar tissue and dense bands, which are referred to as adhesions.
Pelvic Adhesions, Pain, and Blockages
Adhesions are commonly formed as a consequence of prior surgical procedures. However, they can also develop after pelvic infection, particularly in cases of advanced endometriosis. Adhesions are essentially bands of scar tissue that can cause pain when they become dense or impede the natural movement of organs within the body, such as the bowels.
Adhesions, when they contribute to pain, are usually found alongside other conditions like irritable bowel syndrome, which can also cause pain. These adhesions may worsen the symptoms of IBS or cause pain during sexual intercourse.
In rare instances, adhesions may even cause a blockage in the bowels, resulting in a condition known as intestinal obstruction.
What is an Adhesion-Related Disorder?
Adhesion-related disorder (ARD) is a collection of symptoms caused by the presence of adhesions. A common symptom experienced by people with ARD is persistent abdominal pain.
As previously mentioned, adhesions form shortly after surgery, but the symptoms can persist for months or even years. The pain may be localised to a specific area of the abdomen, but it can also be widespread, vague, and cramp-like, making it difficult to pinpoint. This makes diagnosing ARD challenging.
The symptoms of ARD include:
- Chronic pain
- Bowel obstruction, leading to difficulty passing gas
- Problems with the urinary bladder
- Pain and difficulty during bowel movements
- Pain while moving, such as walking, sitting, or assuming certain positions
- Emotional disorders like depression, feelings of hopelessness, or thoughts of suicide
- other intestinal issues, such as constipation, obstruction, or a combination of constipation and diarrhoea due to partial blockage
It may be accompanied by gynaecological problems, further contributing to anxiety and issues related to self-esteem.
The symptoms can sometimes be mistaken for signs of other conditions. Some possible misdiagnoses include chronic fatigue syndrome, endometriosis, irritable bowel syndrome, fibromyalgia, and depression and anxiety.
In Diagnosing Pelvic Adhesions
However, diagnosing pelvic adhesions can be challenging. In most cases, a doctor cannot feel them during a regular pelvic examination, and imaging tests like ultrasound, MRI scans, and CT scans are not very effective in detecting them.
One of the most reliable methods used for identifying pelvic adhesions are a comprehensive medical history and a thorough pelvic examination conducted by a knowledgeable gynaecologist who is experienced in evaluating pain-related issues and other symptoms. These are the key tools that gynaecologists rely on to recognise the presence of adhesions and guide appropriate management and treatment strategies.
If adhesions are suspected to be a significant factor, a laparoscopy can be performed to visualise and potentially remove the adhesions during the same procedure. However, there are a few important points to consider.
What to Consider
It is crucial to have the procedure conducted by laparoscopic surgeons who have received specialised training and possess experience in this specific type of surgery. In most cases, opting for a large open incision (laparotomy) to treat adhesions is not advisable, as they tend to recur more frequently after open surgery.
Secondly, you must understand that the presence of adhesions does not automatically mean they are the sole cause of pain. Evaluating whether surgical treatment of adhesions would be beneficial or not often requires the clinical expertise of physicians who have received training in pain assessment. The most effective outcomes are achieved when surgery for adhesions is combined with a comprehensive approach that addresses all aspects of the person’s pain.
How It is Managed and Treated
Individuals experiencing symptoms of adhesions may consider laparoscopic surgery as a treatment option. An advantage of this procedure is that it requires only a small incision, which is why it is often referred to as “keyhole surgery.” Laparoscopy is particularly preferred for infertility surgery because it lowers the risk of new adhesions forming.
Laparoscopic adhesiolysis, which is the surgical removal of adhesions using a laparoscope, greatly improves the quality of life for women with chronic pelvic pain caused by adhesions. This procedure yields similar results to more invasive surgeries in managing extensive adhesions. But it can be time-consuming, taking around two to four hours and technically challenging. Adhesion barriers, which are commercially available products, can be placed during the surgery to help reduce the formation of new adhesions.
Following adhesiolysis, an additional treatment known as adjuvant treatment, often using products like intercoat, is beneficial in preventing the development of intrauterine adhesions.
Most women who undergo laparoscopic adhesiolysis:
- are discharged on the same day as the procedure without the need for major abdominal incisions
- experience minimal complications
- typically resume their normal activities within one week of the procedure
Laparoscopic adhesiolysis provides a promising approach to recognising and managing adhesions, allowing individuals to recover quickly.
Adhesions are also treated using pharmaceutical drugs or by inserting a physical barrier directly at the site. The latter approach is considered more effective as it directly targets the problem area. This method has become widely adopted in healthcare worldwide. However, the currently available commercial adhesion barriers have some drawbacks.
One commonly used barrier is prone to brittleness and tearing before it can be properly deployed. But once it comes into contact with a wet surgical tool, it becomes sticky and adheres to the tissues effectively. Another barrier option is only approved for use in specific applications where there is no bleeding involved, such as gynaecological surgeries. This barrier has a structure with tiny pores that can lead to adhesion in areas where there is blood present.
Recognising these limitations and considering alternative options that can overcome these shortcomings is important in managing adhesions.
Adhesions often do not show any symptoms in many cases. But if symptoms occur, the most common one is chronic abdominal pain. As such, seek immediate medical advice from a gynaecologist in Singapore for proper diagnosis and treatment.