The diagnosis and treatment of deep infiltrating endometriosis

Abstract

Background: Endometriosis and adenomyosis uteri are the most common benign disorders affecting girls and women after uterine myomas (fibroids), with a prevalence of roughly 5% to 15%. There have been many advances in diagnostic assessment and in our understanding of the disease over the past decade. Steady improvements in treatment have been accompanied by heightened consciousness of the diagnosis among the affected women and the doctors who care for them.

Methods: A selective literature search was carried out in the Cochrane and PubMed databases using the key words "endometriosis," "deep infiltrating endometriosis," "endometriosis AND diagnostics," "endometriosis AND surgical therapy," "endometriosis AND endocrine treatment," and others. The AWMF and ESHRE guidelines were also taken in account.

Results and conclusion: The main manifestations are primary or secondary dysmenorrhea, bleeding disturbances, infertility, dysuria, pain on defecation (dyschezia), cycle-dependent or (later) cycle-independent pelvic pain, nonspecific cycle-associated gastrointestinal or urogenital symptoms. Cycle-associated problems of urination and/or defecation that are due to endometriosis are most common in young, premenopausal women. Whenever such manifestations are present, endometriosis should be considered in the differential diagnosis, and evidence for it should be sought in the clinical history, physical examination, and ultrasound findings. If endometriosis is histologically confirmed and is of the deeply infiltrating kind, the recommended management today is to refer the patient to an endometriosis center.

Figure 1

According to the concept of tissue injury and repair, the uterus develops from the interacting tissues of the archimetra and the neometra (7). With the onset of ovarian function, uterine contractility increases, with ensuing tissue injury in the region of the fundocornual raphe. The repair processes that come into play in the basal layer of the endometrium cause local hyperestrogenism, which, in turn, leads to uterine dysperistalsis. A vicious circle arises, in which endometrial tissue is either sloughed off (transtubal transport, leading to endometriosis) or else undergoes intensified proliferation, penetrating into the myometrium (the beginning of adenomyosis). The illustration is reproduced with the kind permission of Prof. Dr. med. Gerhard Leyendecker. COX-2, cyclooxygenase-2; PGE2, prostaglandin E2; OT, oxytocin; ERalpha, estrogen receptor alpha

Figure 2

Typical varieties of deep infiltrating endometriosis:

Figure 3

Typical infiltration of the posterior vaginal fornix. Such findings can be seen only if the cervix is correctly positioned with the speculum during the gynecological examination

Case illustration

A 23-year-old woman presented with severe abdominal pain and was found to have factor VII deficiency and endometriosis. A transvaginal laparoscopic anterior resection of the rectum (TLARR) was performed as the treatment of choice.

eFigure1

Endometriosis with transmural infiltration extending toward the urothelium

eFigure 2

Extrinsic type of ureteric endometriosis