Deep Pelvic Endometriosis: Sites of Involvement, Symptoms and Treatment
Deep pelvic endometriosis may affect the uterosacral ligaments and parametrium, rectovaginal region, bladder, ureters and, in some cases, pelvic nerve structures.
Symptoms can vary depending on the anatomical location of the disease. For this reason, assessing the location and extent of endometriosis is an important part of treatment planning.
Uterosacral ligaments and parametrium
Deep pain during sexual intercourse and pain affecting the lower back, hip or sacral region may occur.
Rectovaginal region
Painful bowel movements, particularly around menstruation, as well as rectal pain or discomfort may occur.
Bladder
Symptoms may include pain when the bladder is full or during urination, urinary frequency and, rarely, blood in the urine.
Ureters
Ureteric endometriosis may not always cause noticeable symptoms. In some cases, obstruction of urinary flow may lead to dilation of the kidney (hydronephrosis), making appropriate assessment important.
Pelvic nerve structures
Endometriosis lesions located close to or involving pelvic nerves may be associated with pain radiating to the hip or leg, sometimes resembling sciatic pain.
The presence of these symptoms alone does not establish a diagnosis of endometriosis, as similar symptoms may occur with other conditions.
Diagnosis and Mapping
Assessment of deep pelvic endometriosis includes determining which anatomical areas may be affected.
Clinical examination: The pelvic floor, uterosacral ligaments and other relevant pelvic areas are assessed.
Transvaginal ultrasound (TVUS): May be used to evaluate endometriosis involving the rectovaginal region and posterior pelvic compartment.
Magnetic resonance imaging (MRI): Can assist in assessing the parametrium, ureters, bladder and other deep pelvic structures.
Additional investigations: When bladder or ureteric involvement is suspected, further urological or other appropriate investigations may be considered.
Treatment Approach
Treatment is individualized according to the severity of symptoms, location and extent of disease, organs involved, previous treatment and reproductive plans.
Medical Treatment
Hormonal treatments may be used in some patients to manage pain and other symptoms associated with endometriosis. Treatment is selected according to the patient's individual clinical circumstances.
Surgical Treatment
Surgery may be considered for selected patients. When surgery is indicated, the surgical approach is planned according to the location of disease and the organs involved.
For bowel endometriosis, different surgical approaches such as shaving, disc resection or segmental resection may be considered.
When the bladder or ureters are affected, the surgical approach is determined according to the characteristics and extent of involvement.
In advanced disease involving organs such as the bowel, bladder or ureters, assessment involving other relevant surgical specialties may be required.
Surgical Planning
Assessment of the location and extent of disease before surgery is an important part of planning surgery for deep pelvic endometriosis.
Preservation of relevant anatomical structures and organ function is considered during surgical planning. Depending on the location of disease, assessment involving different surgical specialties and additional measures may be considered when appropriate.
Rehabilitation and Quality of Life
For some patients, pelvic floor physiotherapy, dietary adjustments based on individual symptoms, gradual return to physical activity and psychosocial support may be considered as part of the overall management plan.
These supportive approaches do not replace appropriate medical or surgical treatment.
Frequently Asked Questions
What can cause sciatica-like pain?
Endometriosis lesions located close to or involving pelvic nerve structures may be associated with pain radiating to the hip or leg.
Disc resection or segmental resection: how is the approach chosen?
The surgical approach is determined by considering factors such as the location and depth of the lesion, the extent of bowel-wall involvement and the presence of stenosis.
Will I need a stoma?
The need for a stoma depends on the extent of disease and the characteristics of the bowel surgery required. If this is a possibility, it is discussed with the patient before surgery.
Can deep pelvic endometriosis recur?
Endometriosis is a chronic condition, and symptoms or signs of disease may recur following treatment. Follow-up and any additional treatment are planned according to the patient's clinical circumstances.
How does a pregnancy plan affect treatment?
Age, ovarian reserve, the location and extent of disease, previous treatment and other infertility factors are considered when determining the timing of surgery and assisted reproductive treatment.