What is Deep Infiltrating Endometriosis?

When endometriosis lesions surpass superficial deposits and extend into organs, medical professionals diagnose it as deep infiltrating endometriosis (DIE). However, comprehending the intricacies of this condition and its treatment can be challenging. In this article, we will delve into the locations where deep infiltrating endometriosis can arise and elucidate why it often poses complexities for surgeons.

Defining Deep Infiltrating Endometriosis

During your research, you have likely encountered the term “deep infiltrating endometriosis”, often abbreviated as DIE. Depending on the locations and extent of endometriosis lesions, distinct types are identified. Apart from ovarian (endometriosis on the ovaries), peritoneal endometriosis (lesions on the abdominal lining), and the presence of endometrial glands and stromal cells within the uterine muscles, deep infiltrating endometriosis stands out as a separate category [1].

Deep infiltrating endometriosis possesses the following defining feature:

  • It transcends superficial layers, frequently breaching the peritoneum [2].
  • It extends into neighboring tissues or organs, embedding itself more profoundly [2].
  • The infiltration is marked by a depth of at least 0.5 cm [2].

Sites of Occurrence for Deep Infiltrating Endometriosis

Deep infiltrating endometriosis exhibits a predilection for specific areas within the body. Patients diagnosed with the following conditions may be dealing with the deep infiltrating form of this condition:

  • Bowel Endometriosis [1]
  • Douglas Space Endometriosis (This involves the region between the rectum and uterus/vagina.) [1]
  • Vaginal Endometriosis [1]
  • Pelvic Walls Endometriosis
  • Nerve-Related Endometriosis (This includes the sciatic nerve.) [4]
  • Ureteral Endometriosis
  • Bladder Endometriosis

Good to Know!

For those eager to delve deeper into the classifications of endometriosis, including the ENZIAN classification system, we invite you to peruse our informative post titled “Endometriosis Classifications – rASRM, ENZIAN and #ENZIAN – Endometriosis.”

Distinguishing Symptoms of Deep Infiltrating Endometriosis

While endometriosis often presents with lower abdominal pain, menstrual irregularities, digestive issues, back pain, and fertility challenges, the symptoms can markedly differ when the condition progresses to deep infiltrating endometriosis. Lesions that penetrate deeper into the tissue can lead to a range of distinctive symptoms. For instance, if the intestines are affected, endometriosis might trigger episodes of diarrhea. Similarly, when endometriosis lesions extend into the sciatic nerve, the repercussions can be far-reaching. Beyond sensory disruptions, such as those experienced in the legs, individuals might also contend with persistent pain [3]. Therefore, it is crucial not to dismiss symptoms that do not neatly align with typical endometriosis indicators. If you have previously received an endometriosis diagnosis and are grappling with unconventional pain, sensory issues, or gastrointestinal disturbances like diarrhea, it is imperative to consult your gynecologist. Moreover, if you have not yet been diagnosed with endometriosis, communicating these symptoms to your gynecologist can potentially establish a symptom pattern that aids in expediting an accurate diagnosis.

Navigating Complex Cases: The Role of Imaging Techniques

As the intricacy of a medical case deepens, the spectrum of investigative procedures broadens. Among these, magnetic resonance imaging (MRI) emerges as a pivotal tool, furnishing precise images that prove indispensable in planning surgeries for exceedingly intricate scenarios [5].

Moreover, if there is suspicion of deep infiltrating endometriosis or if endometriosis affecting the ovaries has been confirmed, a comprehensive approach includes conducting ultrasound scans of both kidneys [6].

Employing vaginal or rectal ultrasound can yield valuable insights as well. Such scans have the potential to unveil previously undetected nodules, contributing to a more comprehensive diagnostic picture. In tandem with this, preliminary palpation examinations via the vagina and intestines are conducted [1].

Throughout this process, your healthcare provider will offer a clear roadmap delineating the specific examination and treatment protocols tailored to your unique needs.

Good to Know!

When nerves or delicate organ structures become entwined, the expertise of a highly seasoned physician is paramount. Such proficiency is consistently found within endometriosis centers, which serve as reliable bastions of experience and knowledge. While hormone-containing medications may be considered as a supplementary approach to surgical treatment, relying solely on them for deep infiltrating endometriosis is often suboptimal due to their limited effectiveness. In contrast, surgical intervention can notably enhance both pain management and overall quality of life [7].

In a Nutshell

Deep infiltrating endometriosis transcends superficial boundaries, extending at least 0.5 cm into neighboring tissues or organs. This expansion can give rise to supplementary symptoms, encompassing gastrointestinal issues and nerve-related pain. The varied locations where deeply infiltrating endometriosis can arise include the intestine, bladder, sciatic nerve, and vagina, among others. The diagnosis is facilitated by the ENZIAN classification, coupled with meticulous imaging and palpation assessments. Often, addressing deeply infiltrating endometriosis necessitates surgical intervention to enhance the overall quality of life. However, this endeavor can be intricate due to the potential deep-seated nature of the nodules, demanding the expertise of a specialized surgeon.


  1. German Society of Gynecology and Obstetrics: Guideline Program. Diagnosis and therapy of endometriosis. August 2020.
  2. Koninckx PR, Martin DC. Deep endometriosis: a consequence of infiltration or retraction or possibly adenomyosis externa? Fertil Steril. 1992 Nov;58(5):924-8. doi: 10.1016/s0015-0282(16)55436-3. PMID: 1426377.
  3. Prof. Dr. med. Marc Possover: Die Endometriose des Ischias-Nervs und der Sakralwurzeln
  4. Tuttlies F, Keckstein J, Ulrich U, Possover M, Schweppe KW, Wustlich M, Buchweitz O, Greb R, Kandolf O, Mangold R, Masetti W, Neis K, Rauter G, Reeka N, Richter O, Schindler AE, Sillem M, Terruhn V, Tinneberg HR. ENZIAN-Score, eine Klassifikation der tief infiltrierenden Endometriose [ENZIAN-score, a classification of deep infiltrating endometriosis]. Zentralbl Gynakol. 2005 Oct;127(5):275-81. German. doi: 10.1055/s-2005-836904. PMID: 16195969.
  5. Medeiros LR, Rosa MI, Silva BR, Reis ME, Simon CS, Dondossola ER, da Cunha Filho JS. Accuracy of magnetic resonance in deeply infiltrating endometriosis: a systematic review and meta-analysis. Arch Gynecol Obstet. 2015 Mar;291(3):611-21. doi: 10.1007/s00404-014-3470-7. Epub 2014 Oct 7. PMID: 25288268.
  6. Palla VV, Karaolanis G, Katafigiotis I, Anastasiou I. Ureteral endometriosis: A systematic literature review. Indian J Urol. 2017 Oct-Dec;33(4):276-282. doi: 10.4103/iju.IJU_84_17. PMID: 29021650; PMCID: PMC5635667
  7. Garavaglia E, Inversetti A, Ferrari S, De Nardi P, Candiani M. Are symptoms after a colorectal segmental resection in deep endometriosis really improved? The point of view of women before and after surgery. J Psychosom Obstet Gynaecol. 2018 Dec;39(4):248-251. doi: 10.1080/0167482X.2018.1445221. Epub 2018 Mar 8. PMID: 29514537.
Benachrichtige mich bei
Inline Feedbacks
Zeige alle
Dipl.-Ges.oec. Jennifer Ann Steinort