Journal of the European Society for Gynaecological Endoscopy


Preoperative pain measurements in correlation to deep endometriosis classification with Enzian. Deep endometriosis classification in relation to pain

J. Metzemaekers1, M.D. Blikkendaal2, K.E. v. Nieuwenhuizen1, K. Bronsgeest1, J.P.T. Rhemrev2, M.J.G.H. Smeets2, J. English2, F.W. Jansen1, S. Both3, A.R.H. Twijnstra1

1 Department of Gynaecology, Leiden University Medical Center, Leiden, the Netherlands
2 Department of Gynaecology, Haaglanden Medisch Centrum-Bronovo, Den Haag, the Netherlands
3 Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
4 Department of Sexology & Psychosomatic Gynecology, Amsterdam UMC, Amsterdam, the Netherlands


Endometriosis, surgery, rASRM, Enzian, classification

Published online: Sep 30 2022


Background: Deep Endometriosis (DE) classification studies with Enzian never compared solitary (A, B, C, F), and combinations of anatomical locations (A&B, A&C, B&C, A&B&C), in correlation to pain. Therefore, the results of these studies are challenging to translate to the clinical situation.

Objectives: We studied pain symptoms and their correlation with the solitary and combinations of anatomical locations of deep endometriosis lesion(s) classified by the Enzian score.

Materials and Methods: A prospective multi-centre study was conducted with data from university and non-university hospitals. A total of 419 surgical DE cases were collected with the web-based application called EQUSUM (

Main outcome measures: Preoperative reported numeric rating scale (NRS) were collected along with the Enzian classification. Baseline characteristics, pain scores, surgical procedure and extent of the disease were also collected.

Results: In general, more extensive involvement of DE does not lead to an increase in the numerical rating scale for pain measures. However, dysuria and bladder involvement do show a clear correlation AUC 0.62 (SE 0.04, CI 0.54-0.71, p< 0.01). Regarding the predictive value of dyschezia, we found a weak, but significant correlation with ureteric involvement; AUC 0.60 (SE 0.04, CI 0.53-0.67, p< 0.01).

Conclusions:TPain symptoms poorly correlate with anatomical locations of deep endometriosis in almost all pain scores, with the exception of bladder involvement and dysuria which did show a correlation. Also, dyschezia seems to have predictive value for DE ureteric involvement and therefore MRI or ultrasound imaging (ureter and kidney) could be recommended in the preoperative workup of these patients.

What’s new? Dyschezia might have a predictive value in detecting ureteric involvement.