The role of pre-operative gonadotrophin-releasing hormone agonists (GnRHa) on pain, bowel and bladder symptoms in rectovaginal/colorectal endometriosis surgery: a multicenter cohort study.

BACKGROUND: The efficacy of medical and surgical treatment of endometriosis-associated pain is a source of ongoing controversy. There is a lack of evidence about gonadotropin-releasing hormone agonists (GnRHa) use on long-term pain control, bladder and bowel symptoms for patients having surgery for deep rectovaginal/colorectal endometriosis. OBJECTIVES: To assess the effect of preoperative GnRHa (pre-GnRHa) use on pain, bowel and bladder symptoms for patients undergoing surgery for deep rectovaginal/colorectal endometriosis. METHODS: The study evaluated data from the British Society for Gynaecological Endoscopy database, a large international multicentre prospective cohort of patients who underwent deep rectovaginal/colorectal endometriosis surgery between 2009-2021. We included 9433 patients from 101 accredited endometriosis centres. Multivariable logistic regression analysis was used to evaluate the association between pre-GnRHa use and postoperative pain, bowel and bladder symptoms at different time points, controlling for confounders like patient age, body mass index, smoking status, and hysterectomy. MAIN OUTCOME MEASURES: Rate of cyclical and non-cyclical pelvic and menstrual pain, bowel and bladder symptoms. RESULTS: The mean age of the patients was 36 years (18-55). Pre-GnRHa use was associated with significant postoperative improvement in premenstrual pain [odds ratio (OR): 0.30, 95% confidence interval (CI): -0.57 - -0.034, P=0.02*], menstrual pain (OR: 0.41/10, 95% CI: -0.7 - -0.13, P=<0.001*), non-cyclical pain (OR: 0.27/10, 95% CI: -0.5 - -0.04, P=0.021*) and lower backache (OR: 0.30, 95% CI: -0.532 - -0.087, P=0.006*) up to 12 months postoperatively. Moreover, bladder pain was significantly reduced in the pre-GnRHa group at 12 months (OR: 0.24, 95% CI: -0.451 - -0.039, P=0.01*). Significant improvements were observed in bowel symptoms including frequent bowel movements (OR: 0.10, 95% CI: -0.194 - -0.012, P=0.02*), incomplete emptying sensation (OR: 0.10, 95% CI: -0.196 - -0.023, P=0.01*), cyclical dyschezia (OR: 0.43, 95% CI: -0.724 - -0.142, P=0.003*) and non-cyclical dyschezia (OR: 0.28, 95% CI: -0.504 - -0.075, P=0.008*) up to 12 months. CONCLUSIONS: Pre-GnRHa use is associated with a significant reduction in postoperative menstrual pain and non-menstrual pain as well as improved bowel and bladder symptoms lasting up to two years. It is also valuable to improve the quality of life for patients undergoing surgery for deep rectovaginal/colorectal endometriosis. WHAT IS NEW?: This is the largest prospective international study evaluating pre-GnRHa use in deep rectovaginal/colorectal endometriosis surgery. It provides evidence supporting the role of pre-GnRHa as an adjuvant to surgical treatment, to reduce postoperative pain and improve bowel and bladder function.