Beyond Excision: Why ESSI’s Enhanced Excision Protocol Includes Pelvic-Floor Botox at the Time of Surgery
Most endometriosis programs stop at lesion removal. We don’t. Here’s the science behind the protocol pioneered at ESSI — and why it changes the long game for patients with pelvic pain.
Endometriosis Surgical Specialists International (ESSI) | Clinical Education Series | internationalendo.com
THE TAKEAWAY:
Excision is necessary, but for many patients with endometriosis it is not sufficient. Pelvic-floor muscle spasm is present in nearly every patient with endometriosis-associated chronic pelvic pain, and it is a separate, treatable pain generator. The ESSI Enhanced Excision Protocol addresses both at once — complete excision of disease combined with EMG-informed pelvic-floor botulinum toxin under the same anesthetic. The result: a meaningful reduction in pain, opioid use, and disability for patients who had previously been told they had “run out of options.”
The Problem No One Talks About After Endometriosis Surgery
If you’ve had excision surgery for endometriosis and still have pain, you are not imagining it — and you are not alone. Endometriosis affects roughly 1 in 9 to 1 in 10 women of reproductive age, and even after the most meticulous surgical removal of disease, only about half of patients experience complete pain resolution. That number has not changed in decades, and it is the single most important fact in modern endometriosis care.
Why? Because endometriosis pain is rarely caused by one thing. There are typically two pain generators running in parallel: the visible disease itself, and the pelvic-floor muscles that have been clenched and guarding for years against that disease. Excision — even perfect excision — only addresses the first.
In a landmark NIH cohort, 100% of women with endometriosis-associated chronic pelvic pain were found to have pelvic-floor muscle spasm on standardized exam. That is not a coincidence — that is a second disease that has been hiding in plain sight.
How ESSI Responded: The Enhanced Excision Protocol
After years of operating on patients who were sent to us with the same story — “my excision was ‘successful,’ but I still hurt” — our team developed and refined what we now call the ESSI Enhanced Excision Protocol. It is, to our knowledge, the only protocol of its kind that combines, under a single anesthetic:
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Complete robotic-assisted excision of all visible and palpable endometriosis (no ablation, no “spot treatment”).
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Nerve-sparing dissection around the hypogastric and sacral plexuses informed by neuropelveology principles.
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Targeted pelvic-floor botulinum toxin (Botox) injection into areas of palpable spasm, performed at the time of surgery while the patient is anesthetized and the muscles can be precisely identified.
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Coordinated post-op rehabilitation with our physical-therapy partners so the muscles can finally relearn how to relax.
Most centers that perform excision do not offer pelvic Botox at all. The few that do, refer patients out — weeks or months later — to a separate provider for a second, separately billed procedure under a second anesthetic. By that point, many patients have already entrenched their pain pathways and lost ground. ESSI is, to the best of our knowledge, the only program globally that performs the two interventions simultaneously, by the same expert team, in a single coordinated procedure.
How the ESSI Enhanced Excision Protocol Differs
| Conventional Excision (most centers) | “Excision + Referral” Model | ESSI Enhanced Excision Protocol |
| Removes visible lesions; ablation common | Excision performed; pelvic-floor PT or Botox referred out, weeks or months later | Complete excision PLUS targeted, EMG-informed pelvic-floor Botox under the SAME anesthetic |
| Single mechanism addressed (peripheral lesions) | Two mechanisms addressed sequentially — with a gap during which pain often re-entrenches | Two mechanisms addressed simultaneously: peripheral disease AND myofascial/central pain driver |
| Patient often returns with persistent pain or dyspareunia | Multiple appointments, multiple co-pays, slower recovery | One operation, one recovery, no second anesthesia exposure, faster return to function |
| Reoperation rates remain high | Outcomes depend on whether the patient finds and accesses a qualified pelvic-floor specialist | Nerve-sparing dissection + neuromuscular treatment delivered by the same expert team |
The Science: What the Evidence Actually Shows
Adding Botox to excision is not an experiment. It is informed by Phase 2 randomized, placebo-controlled trial data conducted at the NIH Clinical Center (NCT01553201) and recently published in eClinicalMedicine by Tandon, Karp, Stratton and colleagues. Independent multicenter trials in Europe have replicated the signal in broader chronic pelvic pain populations.
In the NIH Phase 2 RCT, 73% of women receiving pelvic-floor Botox reported benefit at 1 month vs. 29% on placebo (p=0.027).
“The botulinum toxin injections were incredibly effective in decreasing pain levels, as well as patients’ use of pain medications, including opioids.”
— Pamela Stratton, M.D., Gynecologist, NIH/NINDS, co-lead investigator of the NIH RCT
In the open-label follow-up of that same NIH cohort, women who received pelvic-floor Botox had substantial reductions across every domain that matters: muscle spasm, pain on visual-analog scale, opioid and analgesic use, and self-reported disability.
Summary of Peer-Reviewed Evidence
| Source | Design / N | What it shows |
| Tandon, Karp, Stratton et al. (2025), eClinicalMedicine | Phase 2 RCT, double-masked, n=29 | 73% of Botox-treated patients reported benefit at 1 month vs. 29% on placebo (p=0.027); longer-lasting benefit (p=0.023) and greater % improvement (p=0.034) than placebo. |
| Stratton P, Khachikyan I et al. (2021), Fertility & Sterility | RCT primary outcome report | Pelvic-floor onabotulinumtoxinA reduced pain, opioid/analgesic use, and disability in women with surgically treated endometriosis and persistent pelvic-floor spasm. |
| Aredo JV, Heyrana KJ, Karp BI, Shah JP, Stratton P (2017/2021) | Cross-sectional, n=30 | 100% of women with endometriosis-associated CPP demonstrated pelvic-floor muscle spasm; widespread myofascial dysfunction supports central sensitization as a driver of post-excision pain. |
| van Reijn-Baggen et al. (2024), BJOG | Multicenter RCT | BoNT-A injection into pelvic-floor muscles produced significantly greater pain reduction and quality-of-life gains than placebo in women with refractory CPP and high-tone pelvic-floor dysfunction. |
| Aredo JV et al. (2017), Semin Reprod Med | Mechanistic review | Approximately half of patients have incomplete pain resolution after excision alone; persistent myofascial dysfunction and central sensitization are the principal drivers of treatment failure. |
Who Is the ESSI Enhanced Excision Protocol For?
Not every patient needs the enhanced protocol. We recommend evaluation for it when any of the following are part of your story:
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You have had previous excision surgery and pain has returned or never fully went away.
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You experience deep dyspareunia, painful bladder, painful bowel movements, or pain with sitting that does not match where the lesions are.
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You have been told your imaging is “normal” but you are still in significant pain.
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Pelvic-floor physical therapy alone has not been enough.
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You are heading into surgery and want to give yourself the best possible chance of lasting relief on the first attempt.
In Conversation: Drs. Vidali, Bagaria & Fernandez
We sat down with three of ESSI’s lead surgeons — Dr. Andrea Vidali (Founder, ESSI; reproductive endocrinologist and master excision specialist), Dr. Madhu Bagaria (dual-fellowship trained at Mayo Clinic and Emory; ESSI lead robotic excision specialist) and Dr. Osbert Fernandez (ESSI Miami; complex multi-organ disease) — to talk plainly about why this protocol exists and why it is different.
Moderator: Dr. Vidali, why does the Enhanced Excision Protocol exist? Excision was already considered the gold standard.
Dr. Vidali: Because excision, as well as it is performed, only treats one of the two diseases that hurt our patients. After 25 years of doing this, I can tell you the same story we hear every week: the patient had “successful” excision somewhere else, the operative report says everything was removed, and yet she still hurts. We learned that the pelvic floor itself was the missing piece. The muscles have been guarding for years. They do not unclench just because we removed the lesions. Someone has to teach them how, and Botox is one of the most direct ways to do that.
Dr. Bagaria: And what we see on exam is striking. I trained at Mayo and at Emory before ESSI, and I can confirm that nearly every patient with endometriosis-associated pelvic pain has palpable pelvic-floor spasm — the obturator internus, the levators, the coccygeus. The NIH data put a number on it: 100%. So the question is not whether the muscles are involved. The question is whether your surgeon is willing to do anything about it.
Moderator: Why do it at the same time as excision? Why not refer the patient to pelvic Botox afterward?
Dr. Fernandez: Because the patient is already asleep, and the muscles in spasm can be palpated under direct examination in a way they simply cannot in an awake clinic visit. You can map them. You can inject precisely, with EMG guidance, in the exact areas that have been guarding. And there is no second anesthetic. No second recovery. No second co-pay. For my Miami and South Florida patients, many of whom have already had two or three surgeries elsewhere, that matters a great deal.
Dr. Vidali: There is also a window of opportunity. After excision, the central nervous system has a brief period in which it can “reset”. If we let the muscles continue to spasm during that window, the brain re-learns the pain. If we relax them at that moment, the brain has a chance to learn something different. That is biology, not marketing.
Moderator: Dr. Bagaria, how is this different from what other top centers offer?
Dr. Bagaria: Most excellent excision centers do exactly that — excellent excision. Some refer to pelvic-floor PT. A handful refer to pelvic Botox in a separate office, weeks later. To my knowledge, no other program performs all of it in one operation, by the same surgical team, with the same understanding of the patient’s anatomy and her individual pain pattern. That continuity is the unique part.
Dr. Fernandez: And the philosophy underneath it matters. We are excision-only — we never ablate — and we operate with a neuro-navigation mindset. We are not just looking for red spots; we are mapping nerves, identifying the sacral roots, protecting the hypogastrics. The Botox piece is an extension of that same idea: treat the whole neuromuscular system, not just the surface.
Moderator: What do you say to a patient who has been told she has “run out of options”?
Dr. Vidali: I say: you have not run out of options. You have run out of providers who understand the full picture. The data on pelvic-floor Botox in this population are now Phase-2-RCT-quality. The mechanism is clear. And the surgical platform to deliver it correctly — in the same operation, with nerve-sparing technique, by surgeons who do this all day — exists. That is what ESSI is for.
Dr. Bagaria: And I want to add something for the patient herself: this is not in your head. The science is showing us, very clearly, that what you are feeling is real, it is measurable, and it is treatable. You deserve a plan that treats all of it.
Dr. Fernandez: Eres escuchada, y no estás sola. You are heard, and you are not alone.
If This Sounds Like You
If you have endometriosis-associated pain that has not responded to standard excision, you can request a virtual consultation with our team at internationalendo.com. Our coordinators will guide you through MRI review, intake, and — if you are a candidate — scheduling for the ESSI Enhanced Excision Protocol at our New York, New Jersey, or Miami centers.
You do not have to keep starting over. You deserve a protocol designed for the disease you actually have.
References
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Tandon HK, Karp BI, Aredo JV, Heyrana KJ, Sinaii N, Stratton P. Botulinum toxin for endometriosis-associated chronic pelvic pain: a randomised, double-masked, parallel, phase 2 trial. eClinicalMedicine. 2025; (NCT01553201).
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Stratton P, Tandon HK, Phan V, et al. Randomized, placebo-controlled trial of botulinum toxin for endometriosis-related chronic pelvic pain. Fertil Steril. 2021;116(3 Suppl):e52.
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Aredo JV, Heyrana KJ, Karp BI, Shah JP, Stratton P. Relating chronic pelvic pain and endometriosis to signs of sensitization and myofascial pain and dysfunction. Semin Reprod Med. 2017;35(1):88–97.
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Aredo JV, Heyrana KJ, Sinaii N, et al. Widespread myofascial dysfunction and sensitization in women with endometriosis-associated chronic pelvic pain: a cross-sectional study. PMC7979491.
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van Reijn-Baggen DA, et al. The efficacy of botulinum toxin A injection in pelvic floor muscles in chronic pelvic pain patients: a double-blinded RCT. BJOG. 2024 (PMC11704059).
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Yong PJ, Williams C, Bedaiwy MA, Allaire C. Pelvic pain comorbidities associated with quality of life after endometriosis surgery. Am J Obstet Gynecol. 2023;229(3):317.e1–317.e10.
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ACOG Committee Opinion 218. Chronic pelvic pain. Obstet Gynecol. 2020;135(3):e98–e109. ESHRE Endometriosis Guideline. Hum Reprod Open. 2022;hoac009.
