Rectovaginal endometriosis – endometriosis with intestinal involvement
Rectovaginal endometriosis belongs to the group of deep infiltrating endometriosis (TIE). When endometriosis lesions settle between the vagina and the bowel, it is called rectovaginal endometriosis. If endometriosis grows into organs or structures (such as the tissue between the bowel and vagina) and not just on them, it is called deep infiltrating endometriosis.
If the foci break through at least the outer bowel wall, i.e. grow into the bowel wall, it is called deep infiltrating endometriosis with bowel involvement or bowel involvement. It appears in about 25% of all endometriosis patients [5]. Endometriosis of the rectovaginal septum may present with or without intestinal infiltration. Both forms can affect the patient’s fertility and quality of life. Affected patients often complain of extremely severe pain, especially pain during sexual intercourse (dyspareunia) and pain during defecation (dyschezia) [5]. Depending on the extent, treatment and therapy require special surgeons and urologists who, together with gynecologists, remove the harmful tissue during surgery.
Symptoms of rectovaginal endometriosis
In addition to the classic symptoms of endometriosis, rectovaginal endometriosis is often noticed via other symptoms such as infertility and extreme pain during and outside of menstruation [2].
The following symptoms may occur:
- Pain and difficulty with defecation (dyschezia).
- Pain during sexual intercourse (dyspareunia), which may also lead to loss of libido due to the severe pain
- Bloated abdomen – the so-called “endobelly” can also appear in other forms of endometriosis and lead to severe pain
- rectal bleeding with the cycle
- severe abdominal pain
- nausea
- back pain especially in the lower part
- bowel emptying disorders such as diarrhea and constipation
- rarely, intestinal obstruction may occur
Diagnosis
Due to the general variety of symptoms of endometriosis, a diagnosis of intestinal endometriosis is difficult to make.
Initially, only a tentative diagnosis can be made by observing the symptoms and ranking the pain on a pain scale.
Especially in rectovaginal endometriosis, the so-called rectovaginal palpation is important in the diagnosis. The physician palpates the vagina and rectum simultaneously with one finger each. This allows a good assessment of the area in between, the site of rectovaginal endometriosis. An experienced examiner can find strong indications of rectovaginal endometriosis in this way.
An ultrasound may also be helpful. In the first step, the uterus and ovaries are examined. This is followed by an assessment of the mobility of the ovaries and the so-called “sliding sign” – the mobility of the uterus. Due to the rectovaginal adhesions, the mobility can be limited, this can be assessed directly in the ultrasound. In a further step, the assessment of an involvement of the posterior and anterior compartments, the bladder and the intestine is then performed [5]. Endosonography of the rectum can also provide information.
Depending on the findings, an MRI can provide additional information about the extent of endometriosis adhesions. In particular, if it is to be checked whether the endometriosis has already penetrated the bowel wall, an MRI can provide information about possible interventions, such as bowel resection, prior to surgical intervention[3]. However, a negative finding does not definitively rule out rectovaginal endometriosis.
Sometimes a colonoscopy is also performed, but since endometriosis usually sits on the outside of the bowel and grows in, an inconspicuous colonoscopy is also not a rule-out of bowel endometriosis in general.
However, reliable information about exactly where rectovaginal endometriosis is located, whether it has so far only been located on the outer wall of the bowel or has already broken through it, can only be determined with surgical intervention by laparoscopy [3]. In some cases, foci were not visible on ultrasound and endosonography and the full extent of endometriosis could only be detected during laparoscopy. Thus, the decision about possible bowel resection can also be made only intraoperatively [3]. Therefore, the procedure in case of an infestation near the bowel or on the bowel should be discussed in the education before every endometriosis operation in order to develop an “if-then” plan with the surgeon.
Treatment
Several factors must be considered in the treatment and therapy of endometriosis with bowel involvement [5]:
- Age of the patient
- Possible desire to have children
- Extent of endometriosis
- Impairment of adjacent organ
- Complaints such as pain
If endometriosis of the rectum is a purely incidental finding without symptoms, surgical therapy is not absolutely necessary according to the guidelines. As a rule, however, rectovaginal endometriosis in particular does cause problems and pain.
Due to the involvement of other organs such as the intestine, the therapy should be performed in a specialized center in order to involve other special departments such as intestinal surgeons.
Surgery is often necessary, especially for rectovaginal endometriosis that causes a lot of pain. The pain can be relieved by medication, but the endometriosis does not disappear. The hormone preparations that patients also take for other forms of endometriosis can be administered, such as progestins, combined pills, a, GnRH agonists/antagonists or levenorgestrel-releasing IUD [5]. Small studies have shown symptom improvement with vaginal hormone rings in particular, so this is also an individual option.
Surgical removal of the endometriosis lesions is often the treatment of choice for symptomatic endometriosis with bowel involvement. Surgical therapy is the best option to improve pain and fertility in the long term [4].
Nevertheless, this should always be discussed individually with the appropriate center.
In particular, if the bowel wall has deep-infiltrating endometriosis, bowel resection may be the option. Surgery that also involves organs such as the bladder, ureters, and bowel requires a well-trained, experienced team of gynecologists, surgeons, and urologists to perform the procedure in such a way that the patient wakes up from anesthesia with the least amount of damage.
Good to know!
With every operation, but especially if the bowel is involved, the “if-then” scenarios must always be discussed in the explanation. The extent of the endometriosis will only become apparent during the operation and by then you will already be asleep. This means that in every consultation it is discussed how to proceed if the intestine is affected. An operation on the intestine, during which a piece of intestine may also be removed, involves certain risks. It should be emphasized that, depending on the surgeon’s assessment, a temporary artificial anus can be inserted. This can then be “put back” after some time, so of course does not remain permanently. However, since this naturally has an influence on the time after the operation, this should be discussed with the doctor. If there is endometriosis in the intestine, should the operation be continued directly to remove everything or should the whole thing be planned in a second operation so that the extent and risk can be discussed with you in more detail beforehand? This decision is very individual, so let yourself be informed in detail and perhaps think about it beforehand.
After the operation
If the bowel wall has not yet been breached and the endometriosis could be removed from the outer bowel wall, there is no need for bowel resection. If part of the bowel was also removed, an artificial bowel outlet may be placed for a few weeks or months to allow the operated areas to heal.
Resection increases fertility in many patients. According to one study, 44.6% of women of childbearing potential were able to conceive after bowel resection for deep infiltrating bowel endometriosis. In addition, laparoscopic colorectal resection for endometriosis is associated with symptom relief and significant improvement in quality of life [1]. As before surgery, patients are counseled individually regarding possible drug therapy, such as progestin. In addition, a healthy diet geared to endometriosis is recommended.
References
- Daraï E, Bazot M, Rouzier R, Houry S, Dubernard G. Outcome of laparoscopic colorectal resection for endometriosis. Curr Opin Obstet Gynecol. 2007 Aug;19(4):308-13. doi: 10.1097/GCO.0b013e328216f6bc. PMID: 17625410.
- Donnez J, Nisolle M, Gillerot S, Smets M, Bassil S, Casanas-Roux F. Rectovaginal septal adenomyotic nodules: a series of 500 cases. Br J Obstet Gynaecol. 1997 Sep;104(9):1014-8. doi: 10.1111/j.1471-0528.1997.tb12059.x. PMID: 9307527.
- Mangler, M, Medrano, N, Lanowska M, Bartley, J, Schneider, A, Köhler, C. Preoperative diagnosis of bowel involvement in rectovaginal endometriosis. in Obstetrics Gynecology 2007; 67 – A30.
- Mangler, M., Loddenkemper, C., Lanowska, M., Bartley, J., Schneider, A., Köhler, C. A combined surgical approach to the therapy of rectovaginal endometriosis based on histological findings. Journal of Gynecologic Endocrinology 2008; 2 (2) (issue for Austria). Gablitz.
- Tiringer, D, Husslein, H, Küssel, L, Wenzl, R. Diagnosis and therapy of “rectovaginal” or deep infiltrating “intestinal” endometriosis. 37th ed. 1/2019.
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