"Ask Dr. Cook" is a series of questions and answers regarding endometriosis. The current subject and answer can be found on Current Ask Dr. Cook web page. The questions may represent a summary of questions I have been asked by several different patients. I hope you find this information helpful. If you have a question you would like answered, please Submit A Question.

What Causes Adhesions?

Question:
My doctor tells me I have extensive adhesions of my pelvic organs and my intestine. I am in a lot of pain. I have gone through a couple of surgeries to get rid of the adhesion, but it seems to keep coming back and if anything the pain is getting worse. Is there anything that can be done to help me out?

Answer:
Yes, fortunately your situation can be helped. There are recent medical advances that make it more likely that you can permanently get rid of your adhesions and pain. In this section I will discuss the common causes of adhesions. This is part two of a three part series. Also see part 1"What Are Adhesions?" and part 3 "How Are Adhesions Treated?".

Scar tissue usually results from previous trauma to the tissue. The most common causes of scar tissue formation are endometriosis, past infection, and previous surgery.

Endometriosis is traumatic to the surrounding tissue. Every month the endometrial implants are stimulated hormonally and bleed internally when a woman has her period. The endometrial implant itself and the recurrence bleeding are very irritating to the inside lining of the body (peritoneum). The body forms scar tissue is response to endometriosis in an effort to (1) heal the damaged tissue and (2) wall off the disease trying to protect the rest of the body. If you remember our discussion last week, as scar tissue matures, it shortens. Over time this cycle of irritation and scar tissue formation results more and more normal tissue getting pulled into this adhesive mass. Similar to material pulled up into a curtain pleat. This area is commonly located on the utero-sacral ligaments and can involve the uterus, bowel, and vagina. Clinically the patient may notice pain with periods, lower back pain, pain with intercourse (deep penetration) and pain with bowel movements. She may even notice pain radiating down her leg(s). A special situation that places a patient at risk of extensive adhesion formation is an endometrioma. An endometrioma is a collection of endometriosis in the ovary. If an endometrioma becomes large enough, it can rupture, spilling its contents into the pelvic cavity. This substance is very irritating to the body an is a setup for extensive adhesion formation.

The most common pelvic or abdominal infectious causes of adhesion formation, are pelvic inflammatory disease (PID) and appendicitis. PID is an infection of the fallopian tubes, which is different from the routine vaginal infection. A patient with PID, usually but not always, has severe pelvic pain and is often hospitalized for I.V. antibiotics. Appendicitis does not usually cause pelvic infections. An uncommon but sever situation that can result in adhesions is an unrecognized hole in the bowel during surgery. If a hole is made in the bowel during surgery, not recognized and left open, the patient can get very sick over the next week and massive adhesions can result.

By definition, surgery is traumatic to tissue and thus can result in scar tissue formation. By far and away the most important factor in preventing post-operative scar tissue formation is good surgical technique. How the surgeon handles the tissue is very important. If the tissue is handled roughly, squeezed tightly with instruments, rubbed with dry cloths, or coagulated (burned) with electrosurgery, scar tissue formation is more likely. I will never forget my first experience in the animal microsurgery laboratory. I was amazed to watch a piece of tissue I had picked up with a set of surgical tweezers die off, one of the first steps in scar tissue formation. All I had done was pick up the tissue! I learned then that even what seemed to be normal actions could have devastating results on surgical outcome.

Updatede October 29, 2005