1

DLLL INIIL1kA1ING LNDCML1kICSIS: A1nCGLNLSIS, DIAGNCSIS AND CLINICAL MANAGLMLN1

Cristina Maciel*, Hlder Ferreira**, Rosa Macedo***.
nospltol Cetol 5ooto Aotolo, ceotto nospltolot Jo lotto, lotto
A8S1kAC1:
ueeply lofllttotloq eoJomettlosls (ul) locloJes tectovoqlool lesloos os well os lofllttotlve fotms tbot lovolve
vltol sttoctotes socb os bowel, otetets, ooJ bloJJet tbot mlqbt qteotly oltet tbe poollty of llfe becoose of sevete polo
ot meosttootloo ooJ lotetcootse, ooJ pose pottlcolotly Jlfflcolt sotqlcol ptoblems. lt ls JloqooseJ lo 20X of womeo
wltb eoJomettlosls.
1be vost boJy of evlJeoce ovolloble lo tbe lltetotote sttooqly soppotts tbe lmploototloo tbeoty lo ul
potboqeoesls.
Altbooqb botmoool tteotmeot ls efflcleot wltb tespect to tbe polo, sotqety ls tbe tteotmeot of tefeteoce lo
tbls cootext. 1be complexlty ooJ motblJlty ossocloteJ wltb tbe sotqlcol ptoceJotes most be cooslJetote. Cteot
lmpottooce most be qlveo to complete ooJ bolooceJ coooselloq, os owoteoess of tbe teol posslbllltles of Jlffeteot
tteotmeots wlll eobooce tbe potleots collobototloo.
lt oppeots to be locteosloqly cleot tbot ul wlll be best tteoteJ lo o moltlJlsclpllooty ceotet.
_______________________________________________________________________________________________
IN1kCDUC1ICN
LndomeLrlosls ls an esLrogen-dependenL
lnflammaLory dlsease and lLs deflnlng feaLure ls Lhe
presence of endomeLrlum-llke Llssue ln slLes ouLslde
Lhe endomeLrlal cavlLy and uLerlne musculaLure.
1hese ecLoplc endomeLrlal lmplanLs are usually
locaLed ln pelvls, buL can occur nearly anywhere ln Lhe
body.
1he Lhree cllnlcally dlsLlncL forms of
endomeLrlosls are endomeLrloLlc lmplanLs on Lhe
surface of Lhe pelvlc perlLoneum and ovarles
(perlLoneal endomeLrlosls), ovarlan cysLs llned by
endomeLrlold mucosa (endomeLrlomas), and deeply
lnfllLraLlng endomeLrlosls (ulL).
1
ulL lncludes recLovaglnal leslons as well as
lnfllLraLlve forms LhaL lnvolve vlLal sLrucLures such as
bowel, ureLers, and bladder, whlch mlghL greaLly alLer
Lhe quallLy of llfe because of severe paln aL
mensLruaLlon and lnLercourse, and pose parLlcularly
dlfflculL surglcal problems.
2
_____________________________________________________________________
* Aluna do 6.ano do Mestrado em Medicina
** Interno Complementar de Ginecologia/Obstetrcia
*** Assistente Hospitalar Graduada de Ginecologia e Obstetrcia
ln Lhe presenL paper, Lhe anaLomlc and
paLhologlc evldence regardlng Lhe paLhogenesls of
lnfllLraLlng endomeLrlosls ls descrlbed. 1hls
consLlLuLes Lhe basls for Lhe developmenL of a
classlflcaLlon of deep dlsease. uesplLe exLenslve
research, Lhe opLlmal managemenL of endomeLrlosls
ls unclear. 1hls paper wlll revlew medlcal and surglcal
opLlons for LreaLlng women wlLh ulL.
kLVALLNCL
1he overall Lrue prevalence of endomeLrlosls
ls unknown, prlmarlly because surgery ls Lhe only
rellable meLhod for dlagnosls and generally ls noL
performed on women wlLhouL sympLoms or physlcal
flndlngs LhaL sLrongly suggesL Lhe posslblllLy. 1he
prevalence of asympLomaLlc endomeLrlosls ls
approxlmaLely 4 ln women havlng surgery for
elecLlve sLerlllzaLlon. MosL esLlmaLes of prevalence of
endomeLrlosls have ranged beLween 3 and 20
among women wlLh pelvlc paln and beLween 20 and
40 among lnferLlle women, a general prevalence
ranglng beLween 3 and 10 ln reproducLlve-aged
women ls llkely.
3
kLVILW Ak1ICLL
2
ulL ls dlagnosed ln 20 of women wlLh
endomeLrlosls. Moreover, bowel endomeLrlosls ls
found ln 3 Lo 12 of paLlenLs wlLh endomeLrlosls.
4
A1nCGLNLSIS
1he eLlology and paLhology of Lhe dlsease has
been argued abouL slnce Lhe flrsL deLalled paLhologlc
descrlpLlon ln 1860 by karl lrelherr von 8oklLansky.
uesplLe Lhe passage of Llme and exLenslve
lnvesLlgaLlon, Lhe exacL paLhogenesls of Lhls enlgmaLlc
dlsorder remalns unknown.
1wo physlopaLhologlcal hypoLheses are Lhe
mosL ofLen proposed Lo explaln Lhe paLhogenesls of
endomeLrlosls. 1he flrsL Lheory ls LhaL of reLrograde
mensLruaLlon ln whlch Lhe leslons would be secondary
Lo lmplanLaLlon and prollferaLlon of regurglLaLed
endomeLrlal cells ln an ecLoplc slLuaLlon (Sampson,
1927). 1he second Lheory ls LhaL of meLaplasla
(Meyer, 1919), elLher of Lhe celomlc meLaplasla or
Mullerlan remnanLs meLaplasla.
3
ketrograde Menstruat|on
lnlLlally proposed by Sampson ln Lhe 1920s,
Lhe Lheory of reLrograde mensLruaLlon ls boLh
lnLulLlvely aLLracLlve and supporLed by mulLlple llnes
of sclenLlflc evldence, alLhough no slngle mechanlsm
can explaln all cases of endomeLrlosls. Accordlng Lo
Lhls Lheory, ecLoplc endomeLrlum ls sloughed vla
paLenL falloplan Lubes lnLo Lhe perlLoneal cavlLy
durlng mensLruaLlon. lndeed, Lhe unlversallLy of Lhls
phenomenon ls supporLed by Lhe flndlng of mensLrual
blood ln Lhe perlLoneal fluld of up Lo 90 of healLhy
women wlLh paLenL falloplan Lubes undergolng
laparoscopy durlng Lhe perlmensLrual perlod of Lhe
cycle.
6
lurLher supporL for Lhls eLlology ls derlved
from sLudles of obsLrucLed or compromlsed ouLflow
LracLs. ln adolescenL glrls wlLh congenlLal ouLflow
obsLrucLlon, Lhe prevalence of endomeLrlosls ls hlgh.
1he vlablllLy of Lhe reLrogradely mensLruaLed
endomeLrlal cells ls of paramounL lmporLance for Lhe
plauslblllLy of Lhe LransplanLaLlon Lheory. 1hls has
been mosL eleganLly addressed by Lhe experlmenLs of
8ldley and Ldwards.
1he anaLomlc dlsLrlbuLlon of endomeLrloLlc
leslons also favors Lhe reLrograde mensLruaLlon
Lheory. Superflclal lmplanLs are more ofLen locaLed ln
Lhe posLerlor comparLmenL of Lhe pelvls and ln Lhe
lefL hemlpelvls. rlmary and recurrenL ovarlan
endomeLrlomas are slgnlflcanLly more ofLen locaLed
on Lhe lefL ovary ln conLrasL Lo Lhe dlsLrlbuLlon of non
endomeLrloLlc benlgn ovarlan cysLs, whlch do noL
dlsplay a predllecLlon for sldedness.
DIL pathogenes|s
A large observaLlonal sLudy
3
suggesL LhaL Lhe
anaLomlcal dlsLrlbuLlon of pelvlc ulL leslons presenLs a
double asymmeLry. elvlc ulL leslons are more
frequenLly observed ln Lhe posLerlor pelvlc
comparLmenL and are mosL ofLen locaLed on Lhe lefL
slde. lurLhermore, abdomlnal ulL leslons are far less
frequenL Lhan pelvlc ulL leslons, and unllke Lhese,
Lhey are mosL ofLen locaLed ln Lhe rlghL slde of Lhe
abdomlnal cavlLy (appendlx and lleocaecum [uncLlon).
All Lhese observaLlons plead ln favour of Lhe
Lheory of regurglLaLlon and Lhe lmporLance of
perlLoneal flow paLLerns ln ulL paLhogenesls. WlLh Lhe
paLlenL sLandlng erecL, under Lhe effecL of gravlLy,
mensLrual blood reflux accumulaLes ln Lhe boLLom of
Lhe ouch of uouglas, whlch ls Lhe mosL dependanL
porLlon of Lhe abdomlno-pelvlc cavlLy.
1he effecL of gravlLy also explalns why pelvlc
ulL leslons are more frequenLly observed Lhan
abdomlnal ulL leslons and why lnLesLlnal ulL leslons
are preferenLlally locaLed on Lhe recLum and Lhe
recLo-slgmold [uncLlon. 1he far lower frequency of
deep bladder endomeLrlosls compared wlLh
uLerosacral llgamenL, vaglnal and recLal ulL can be
explalned by Lhe anaLomy, because Lhe lower llmlL of
Lhe veslco-uLerlne pouch ls locaLed well above Lhe
lower llmlL of Lhe pouch of uouglas, whlch lles
opposlLe Lhe mlddle Lhlrd of Lhe posLerlor vaglnal
wall.
1he more Lhe uLerus ls reLroverLed, whlch
makes lL easler for Lhe perlLoneal llquld Lo flow from
Lhe anLerlor comparLmenL Lowards Lhe posLerlor
comparLmenL, Lhe more Lhe ulL leslons wlll be found
posLerlorly.
7
1he anaLomlcal dlfferences beLween lefL and
rlghL hemlpelvls, because of Lhe presence of Lhe
slgmold colon on Lhe lefL, could explaln why pelvlc ulL
leslons (as superflclal and ovarlan leslons) are
observed more frequenLly on Lhe lefL pelvlc slde wall.
1he close anaLomlcal relaLlonshlp beLween Lhe
slgmold colon and Lhe lefL adnexa forms a barrler Lo
pelvlc dlffuslon of mensLrual blood reflux, resulLlng ln
an anaLomlcal slLuaLlon LhaL could encourage
adheslons and growLh of regurglLaLed endomeLrlal
cells on Lhe lefL pelvlc slde wall.
8esulLs of research lnLo Lhe flow of perlLoneal
fluld supporL Lhe hypoLhesls LhaL perlLoneal llquld
plays a parL, LogeLher wlLh regurglLaLed endomeLrlal
cells, ln ulL paLhogenesls.lour predomlnanL slLes have
been ldenLlfled for Lhe preferenLlal, repeaLed or
arresLed flow of perlLoneal fluld: (l) Lhe pelvlc cavlLy
and especlally Lhe ouch of uouglas, (ll) Lhe rlghL
lower quadranL aL Lhe LermlnaLlon of Lhe small bowel
mesenLery (caecum and lleocaecum [uncLlon), (lll) Lhe
superlor aspecL of Lhe slgmold mesocolon, and (lv) Lhe
rlghL paracollc guLLer (Meyers, 1973). !usL as for
superflclal leslon, Lhe anaLomlcal dlsLrlbuLlon of ulL
3
leslons correlaLes wlLh Lhe paLhways for Lhe
perlLoneal fluld flow.
8
lour oLher observaLlons plead ln favour of
regurglLaLlon playlng a role for Lhe dlfferenL Lypes of
endomeLrloLlc leslons. llrsLly, unllke Lhose paLlenLs
presenLlng endomeLrlosls wlLhouL deep leslons, Lhose
wlLh ulL have a slgnlflcanLly reduced uouglas pouch
depLh.
9
1hls obllLeraLlon of Lhe pouch of uouglas ls
secondary Lo Lhe lnflammaLory process subsequenL Lo
perlLoneal lmplanLaLlon of regurglLaLed endomeLrlal
cells, whlch glves Lhe false lmpresslon LhaL deep
leslons are of reLroperlLoneal orlgln. MagneLlc
resonance lmaglng clearly shows LhaL ulL orlglnaLes
from Lhe reLrocervlcal area and noL from Lhe
recLovaglnal sepLum.
10
llrsLly, Lhe Lerm 'recLovaglnal
sepLum endomeLrlosls' ls lncorrecL ln Lhe anaLomlcal
sense as ulL leslons are lnlLlally locaLed above Lhe
upper border of Lhe recLovaglnal sepLum.
Secondly, no perlLoneal and/or ovarlan endomeLrloLlc
leslons are seen afLer Lubal llgaLlon, and Lhe raLe of
endomeLrlosls recurrence aL 24 monLhs ls slgnlflcanLly
less lmporLanL when endomeLrlal ablaLlon ls
assoclaLed wlLh laparoscoplc LreaLmenL of
endomeLrlosls.
1hlrdly, perlLoneal fluld represenLs a speclflc
mlcroenvlronmenL LhaL could play a role ln Lhe
paLhogenesls of endomeLrlosls. Several sLudles have
shown LhaL ovulaLlon ls more frequenL on Lhe rlghL
slde. CreaLer exposure Lo progesLerone ln Lhe rlghL
hemlpelvls could conLrlbuLe ln Lhls parL of Lhe pelvls
Lo seL up an lnapproprlaLe mlcroenvlronmenL for
lmplanLaLlon of endomeLrloLlc cells and for developlng
ulL.
lourLhly, Lhe asymmeLrlc naLure of pelvlc
vascularlzaLlon, because of Lhe enLrance of Lhe lefL
ovarlan veln lnLo Lhe homolaLeral renal veln raLher
Lhan lnLo Lhe vena cava, explalns why varlcocele
occurs more frequenLly on Lhe lefL slde. 1hls venous
sLasls on Lhe lefL slde could glve rlse Lo local varlaLlon
ln blood sLream facLors LhaL would affecL Lhe
developmenL of ulL, whlch ls more dependenL on
plasma levels Lhan Lhe lnfluence of Lhe perlLoneal
llquld.
ln concluslon, Lhe vasL body of evldence
avallable ln Lhe llLeraLure, sLrongly supporL Lhe
lmplanLaLlon Lheory ln ulL paLhogenesls and LhaL Lhe
role of Lhe perlLoneal llquld ls essenLlal for
undersLandlng Lhe anaLomlcal dlsLrlbuLlon of ulL
leslons.
3
erlLoneal, ovarlan, and deep endomeLrlosls
may be dlverse manlfesLaLlons of a dlsease wlLh a
slngle orlgln l.e., regurglLaLed endomeLrlum.
6
Mo|ecu|ar mechan|sms
1hough reLrograde mensLruaLlon explalns Lhe
physlcal dlsplacemenL of endomeLrlal fragmenLs lnLo
Lhe perlLoneal cavlLy, addlLlonal sLeps are necessary
for Lhe developmenL of lmplanLs. lL ls Lhe propenslLy
for lmplanLaLlon LhaL besL accounLs for Lhe dlsparlLy
beLween Lhe 90 prevalence of reLrograde
mensLruaLlon and Lhe nearly 10 prevalence of Lhe
dlsease.
Cne of Lwo mechanlsms could explaln Lhe
successful lmplanLaLlon of refluxed endomeLrlum onLo
Lhe perlLoneal surface: molecular defecLs or
lmmunologlc abnormallLles (or boLh). ln
endomeLrlosls, Lhe euLoplc endomeLrlum exhlblLs
mulLlple subLle buL blologlcally lmporLanL molecular
abnormallLles, lncludlng Lhe acLlvaLlon of oncogenlc
paLhways (e.g., Lhe Wlngless-Lype MM1v lnLegraLlon
slLe famlly member wot or Lhe raL sarcoma vlral
oncogene homologue kos) or blosynLheLlc cascades
favorlng lncreased producLlon of esLrogen, cyLoklnes,
prosLaglandlns, and meLalloproLelnases. When Lhe
euLoplc endomeLrlum, blologlcally dlsLlncL Llssue,
aLLaches Lo mesoLhellal cells, Lhe magnlLude of Lhe
molecular abnormallLles ls ampllfled drasLlcally,
enhanclng Lhe survlval of Lhe lmplanL. A posslble
second mechanlsm of lmplanL survlval enLalls a fallure
of Lhe lmmune sysLem Lo clear lmplanLs from Lhe
perlLoneal surface. 8oLh mechanlsms may conLrlbuLe
Lo Lhe developmenL of endomeLrlosls.
1
CLASSIIICA1ICN CI DLL LNDCML1kICSIS
8ased on dlfferenL paLhogeneLlc hypoLheses,
several schemes have been proposed Lo classlfy deep
endomeLrlosls, buL furLher daLa are needed Lo
demonsLraLe Lhelr valldlLy and rellablllLy.
lL seems lnsLlncLlve Lo lnclude deep
endomeLrlosls ln sLage 4 of Lhe revlsed Amerlcan
SocleLy for 8eproducLlve Medlclne (AS8M)
classlflcaLlon. Powever, lnfllLraLlve forms are noL
speclflcally addressed ln Lhe AS8M scheme, whlch was
devlsed malnly wlLh Lhe ob[ecL of sLraLlfylng paLlenLs
wlLh dlfferenL reproducLlve prognoses.
konlnckx and MarLln were Lhe flrsL Lo deflne
deep endomeLrlosls. 1hey dlsLlngulshed posLerlor cul-
de-sac and recLovaglnal leslons ln Lhree dlfferenL
subgroups: Lype l, conlcally shaped, developed from
lnfllLraLlon, Lype ll, deeply locaLed, covered by
exLenslve adheslons, probably formed by reLracLlon,
and Lype lll, Lhe mosL severe, one or more spherlcal
nodules locaLed ln Lhe recLovaglnal sepLum wlLh Lhe
largesL dlmenslon under Lhe perlLoneum, posslbly Lo
be consldered as adenomyosls exLerna.
11
Adamyan classlfled speclflcally reLrocervlcal
endomeLrlosls ln four sLages accordlng Lo exLenL of
Lhe dlsease. AL sLage l, endomeLrloLlc leslons are
conflned Lo Lhe recLovaglnal cellular Llssue ln Lhe area
of Lhe vaglnal vaulL. AL sLage ll, endomeLrloLlc Llssue
4
lnvades Lhe cervlx and peneLraLes Lhe vaglnal wall,
causlng flbrosls and small cysL formaLlon. AL sLage lll,
leslons spread lnLo Lhe uLerosacral llgamenLs and Lhe
recLal serosa. AL sLage lv, Lhe recLal wall, recLoslgmold
zone, and recLouLerlne perlLoneum are compleLely
lnvolved, and Lhe recLouLerlne pouch ls LoLally
obllLeraLed.
MarLln and 8aLL dlfferenLlaLed among
reLrocervlcal, recLovaglnal pouch, and recLovaglnal
sepLum endomeLrlosls. 8eLrocervlcal endomeLrlosls
lncludes leslons ln Lhe anLerlor aspecL of Lhe uouglas
pouch, posLerlor vaglnal fornlx, and reLroperlLoneal
area behlnd or beneaLh Lhe cervlx wlLh no recLal
lnvolvemenL. ln recLovaglnal endomeLrlosls, recLal and
vaglnal walls, as well as boLh vaglnal and recLal
aspecLs of Lhe posLerlor cul-de-sac are lnvolved.
8ecLovaglnal sepLum endomeLrlosls refers Lo lsolaLed,
Lrue subperlLoneal leslons wlLhouL conLlnulLy wlLh
uouglas pouch leslons. Accordlng Lo Lhe proponenLs
of Lhls scheme, lL ls dlfflculL Lo deLermlne Lrue
recLovaglnal sepLum lnvolvemenL, also because
recLovaglnal and recLovaglnal sepLum leslons may be
assoclaLed.
MosL recenLly a classlflcaLlon sysLem for deep
endomeLrlosls based on Lhe anaLomlcal locaLlon of
Lhe leslon wlLh a recommended preferred surglcal
LreaLmenL for each locaLlon has been developed.
12-13
DIL: A1nCLCG AND SI1LS CI INVCLVLMLN1
MarLln eL al., (1989) and laLer Cornlllle eL al.
(1990) suggesLed LhaL endomeLrlosls should be
classlfled accordlng Lo Lhe depLh of lnvaslon lnLo
superflclal (<1 mm), lnLermedlaLe (24 mm), deep (>3
mm) and very deep (>10 mm).
12
ulL ls deflned by Lhe presence of endomeLrlal
lmplanLs, flbrosls and muscular hyperplasla under Lhe
perlLoneum, and can lnvolve, ln descendlng order of
frequency,Lhe uLerosacral llgamenLs, Lhe recLoslgmold
colon, Lhe vaglna and Lhe bladder.
7
8ecLovaglnal endomeLrlosls accounLs for 3
Lo 10 of women wlLh endomeLrlosls and ls
characLerlsed by Lhe presence of palpable
endomeLrloLlc nodules deep ln Lhe connecLlve Llssue
of Lhe pelvls, whlch show profound flbrosls and
flbromuscular hyperplasla.
14
MulLlfocallLy ls a ma[or characLerlsLlc of ulL
leslons.
13
kLC1CVAGINAL LNDCML1kICSIS: CCNIUSICN
A8CU1 NAMLS
Cullen's orlglnal name for deep pelvlc dlsease
was adenomyoma of Lhe recLovaglnal sepLum (Cullen,
1920).
12
lL ls now recognlzed LhaL endomeLrlosls only
rarely lnvolves Lhe Lrue recLovaglnal sepLumand much
more frequenLly lnvolves Lhe overlylng recLovaglnal
pouch.
9
. A varleLy of oLher descrlpLlons has been used
Lo descrlbe Lhe anaLomlcal locaLlon of Lhese leslons
and lncludes cul-de sac endomeLrlosls (MarLln eL al.,
1989), obllLeraLlon of Lhe cul-de-sac (8edwlne, 1991)
and recLocervlcal endomeLrlosls (Adamyan eL al.,
1993, erry eL al., 1993), 1hese Lhree Lerms were
comblned Lo produce an anaLomlcally preclse buL
hardly conclse cul-de-sac obllLeraLlon secondary Lo
reLrocervlcal deep flbroLlc endomeLrlosls (8elch eL al.,
1991).
CLher Lerms LhaL have also been used lnclude
pelvlc wall-lnfllLraLlng endomeLrlosls (khare eL al.,
1996), recLovaglnal sepLum adenomyoLlc nodules
(uonnez eL al., 1997), reLroperlLoneal adenomyosls
(uonnez, 2001) and recLovaglnal endomeLrlosls
(kavallarls eL al., 2003).lrom Lhls revlew lL ls noL
lmmedlaLely obvlous whaL Lhese leslons should be
called or how we should descrlbe Lhelr locaLlons.
12
CLINICAL ILA1UkLS CI DIL
LndomeLrlosls exhlblLs a broad specLrum of
cllnlcal manlfesLaLlons: can be asympLomaLlc, belng
lncldenLally dlscovered aL laparoscopy or posLmorLem
examlnaLlon,
7
or a dlsorder of such severlLy LhaL Lhe
sufferers quallLy of llve ls desLroyed.
12
ulL ls known as
a severe and palnful modallLy of dlsease.
13
A causal assoclaLlon beLween severe
dysmenorrhoea and endomeLrlosls ls very probable.
1hls assoclaLlon ls lndependenL of Lhe macroscoplc
Lype of Lhe leslons (superflclal endomeLrlosls, cysLlc
ovarlan endomeLrlosls or ulL) or Lhelr anaLomlcal
locaLlons and may be relaLed Lo recurrenL cycllc
mlcro-bleedlng ln Lhe lmplanLs. LndomeLrlosls-relaLed
adheslons may also cause severe dysmenorrhoea.
Powever, pelvlc paln may be more common ln
women wlLh deep, lnfllLraLlng lmplanLs. 1here are
hlsLologlcal and physlopaLhologlcal argumenLs for Lhe
responslblllLy of ulL ln severe chronlc pelvlc paln
sympLoms. ulL-relaLed paln may be ln relaLlon wlLh
compresslon or lnfllLraLlon of nerves ln Lhe sub-
perlLoneal pelvlc space by Lhe lmplanLs.
16
1he lnLenslLy
of paln ln woman wlLh ulL correlaLes well wlLh Lhe
depLh and volume of lnfllLraLlon.
3
1he palnful sympLoms caused by ulL presenL
parLlcular characLerlsLlcs, belng speclflc Lo
lnvolvemenL of preclse anaLomlcal locaLlons (severe
deep dyspareunla, palnful defecaLlon) or organs
(funcLlonal urlnary LracL slgns, bowel slgns). 1hey can
Lhus be descrlbed as locotloo loJlcotloq polo.
1here ls a clear-cuL relaLlonshlp beLween
posLerlor ulL and deep dyspareunla, palnful
defecaLlon durlng menses wlLh lnvolvemenL of Lhe
posLerlor wall of Lhe vaglna, non-cycllc pelvlc paln and
funcLlonal bowel slgns wlLh bowel lnvolvemenL and
funcLlonal urlnary LracL slgns wlLh lnvolvemenL of Lhe
3
bladder. A prospecLlve sLudy, based on paLlenLs
operaLed by laparoscopy for chronlc pelvlc paln,
demonsLraLed LhaL palnful defecaLlon durlng menses
and severe dyspareunla were speclflcally connecLed Lo
ulL lnvolvlng Lhe posLerlor area compared Lo Lhe
oLher dlagnoses (oLher macroscoplc Lype of
endomeLrlosls or non-endomeLrlosls dlagnosls).
16
DIL and deep dyspareun|a
When dyspareunla ls referred Lo Lhe recLum
or lower sacrococcygeal area, lL suggesLs recLovaglnal
or uLerosacral llgamenL lnvolvemenL. ln parLlcular,
several sLudles correlaLed deep dyspareunla wlLh Lhe
presence of endomeLrlosls of Lhe uLerosacral
llgamenLs. 1hls correlaLlon ls conslsLenL wlLh Lhe
presence of a conslderable amounL of nerve Llssue
wlLhln Lhe uLerosacral llgamenLs, dyspareunla may be
relaLed Lo Lhe sLlmulaLlon of paln flbers by LracLlon of
scarred lnelasLlc Llssues and by pressure on
endomeLrloLlc nodules embedded ln flbroLlc Llssues.
uyspareunla has been assoclaLed wlLh a
negaLlve aLLlLude Loward sexuallLy, anxleLy and
avoldance of lnLercourse. Women wlLh dyspareunla,
noL surprlslngly, have lower frequency of lnLercourse
and lower levels of deslre and arousal and experlence
fewer orgasms.
17
Gastro|ntest|na| |nvo|vement |n DIL
8owel endomeLrlosls ls found ln 3 Lo 12 of
paLlenLs wlLh endomeLrlosls and colorecLum
represenLs 90 of all bowel locaLlons.
4
SympLoms range from recLal bleedlng,
urgency, pelvlc paln, severe dyschezla, bowel
cramplng and alLeraLlon ln bowel hablL from dlarrhea
Lo obsLrucLlon of Lhe colon.
18
SympLoms usually occur
cycllcally aL or abouL Lhe Llme of mensLruaLlon.
lnLesLlnal endomeLrlosls should be suspecLed ln
women of chlldbearlng age who presenL wlLh
gasLrolnLesLlnal sympLoms and a hlsLory of
endomeLrlosls.
6
MallgnanL change ln colonlc endomeLrlosls
has been documenLed. 1he raLe of progresslon ls
unknown buL ls uncommon.
12
Gen|tour|nary |nvo|vement |n DIL
1he urlnary LracL ls lnvolved ln 1 Lo 4 of
women wlLh endomeLrlosls of whlch around 90
lnvolve Lhe bladder. aLlenL presenLaLlon ln veslcal
endomeLrlosls ls qulLe varlable, and sympLoms may
conslsL of suprapublc dlscomforL, pelvlc paln,
dysmenorrheal, dysurla, urlnary frequency, urgency,
mlcroscoplc hemaLurla, and even cycllcal gross
hemaLurla.
6
MallgnanL LransformaLlon of bladder
endomeLrlosls alLhough rare has been descrlbed
repeaLedly and musL represenL a rlsk lf bladder leslons
remaln unLreaLed.
12
ureLeral endomeLrlosls ls
uncommon, wlLh an lncldence of less Lhan 0.1 of all
cases of endomeLrlosls. CbsLrucLlve uropaLhy LhaL
may lead Lo renal corLlcal aLrophy and severe loss of
renal funcLlon can occur wlLh Lhls Lype of leslon.
6
DIAGNCSIS CI DIL
LndomeLrlosls remalns dlfflculL Lo dlagnose,
wlLh a delay of 8-11 years beLween flrsL reporL of
sympLoms and recognlLlon of dlsease.
19
unforLunaLely, Lhe subsLanclal advances ln our
undersLandlng of Lhe paLhogenesls of endomeLrlosls
have noL yeL provlded any rellable nonlnvaslve
alLernaLlve Lo laparoscopy for dlagnosls of Lhe
dlsease.
3
hys|ca| exam|nat|on
ln endomeLrlosls physlcal examlnaLlon of Lhe
exLernal genlLalla ls Lyplcally normal. Cccaslonally,
speculum examlnaLlon may reveal Lyplcal blue-colored
lmplanLs or red prollferaLlve leslons LhaL bleed on
conLacL, boLh usually ln Lhe posLerlor fornlx. Whereas
dlsease ln women wlLh ulL lnvolvlng Lhe recLovaglnal
sepLum ls frequenLly palpable, lL ls much less ofLen
vlslble, and ln many Lhere ls no remarkable flndlngs.
3
Analysls of Lhe flndlngs on vaglnal
examlnaLlon ln sympLomaLlc paLlenLs wlLh presumed
endomeLrlosls suggesLs LhaL palpable lnduraLlon or
nodules ln Lhe posLerlor vaglnal fornlx and/or along
Lhe uLerosacral llgamenLs appears Lo be
paLhognomonlc slgns of deep endomeLrlosls.
12
1hese
leslons are Lender and pressure reproduces
sympLoms. 1he predlcLlve poslLlve value of such
Lenderness predlcLlng endomeLrlosls ls beLween 76
and 79 and Lhls rlses Lo 83 wlLh a speclflclLy of 92
lf focal Lenderness ls locaLed only ln Lhe uLerosacral
llgamenLs and cul de sac.
1he accuracy of Lhese flndlngs ls furLher
lncreased lf Lhe examlnaLlon ls performed durlng
mensLruaLlon. ueep lnvaslve endomeLrlosls ls
frequenLly assoclaLed wlLh ovarlan endomeLrlosls. 1he
co-exlsLence of Lhese Lwo condlLlons furLher lmproves
Lhe rellablllLy of Lhe cllnlcal dlagnosls.
ln summary, Lhe presence or absence of
palpable nodular or lnfllLraLlve leslons ls relaLed Lo Lhe
locaLlon and depLh of Lhe leslons and reflecLs Lhe
severlLy of Lhe paln and Lhe rlsks of severe
compllcaLlons.
12
Imag|ng stud|es
hyslcal examlnaLlon has a llmlLed capaclLy Lo
6
dlagnose and quanLlfy ulL and Lransvaglnal,
LransrecLal or recLal endoscoplc sonography as well as
magneLlc resonance lmaglng (M8l) has all been
recommended for lLs dlagnosls and for deLermlnlng lLs
locaLlon.
20
1he slgnlflcanL role of M8l ln Lhe dlagnosls of
endomeLrlosls ls relaLed Lo Lhe ldenLlflcaLlon of
lnLermlngled leslons ln Lhe presence of adheslons, and
also Lhe demonsLraLlon and evaluaLlon of sub-
perlLoneal leslons exLenL ln cases where Lhese leslon
cannoL be vlsuallzed by laparoscopy, wlLh accuracy,
senslLlvlLy and speclflclLy > 90 for deep
endomeLrlosls.
ln paLlenLs wlLh deep pelvlc endomeLrlosls,
cllnlcal and sonographlc resulLs may be normal or
poorly elucldaLlve, dlfflculLlng Lhe dlagnosls
deLermlnaLlon. ln Lhese cases, M8l ls essenLlal for an
accuraLe dlfferenLlal dlagnosls. 8ecause of lLs
mulLlplanar capaclLy and excellenL Llssue
characLerlzaLlon, M8l plays an essenLlal role ln Lhe
preoperaLlve evaluaLlon of paLlenLs wlLh deep pelvlc
endomeLrlosls.
21
Serum CA 12S
AlLhough women wlLh endomeLrlosls ofLen
have hlgh (greaLer Lhan 33 lu/mL) serum CA 123
concenLraLlons, serum CA 123 ls noL a senslLlve
lndlcaLor of Lhe dlsease. Powever, knowledge of an
elevaLed preoperaLlve CA 123 concenLraLlon may be
useful for selecLlng women who are aL hlgh rlsk for
bowel ln[ury because of dense pelvlc adheslons and
Lhus mosL llkely Lo beneflL from preoperaLlve bowel
preparaLlon.
3,7
Laparoscopy
Laparoscopy ls Lhe preferred Lechnlque for
dlagnosls slnce endomeLrlosls ls locaLed prlmarlly on
Lhe pelvlc organs. 1he opLlmal Llmlng of laparoscopy
aL a speclflc Llme ln Lhe mensLrual cycle ls unclear, buL
lL should noL be performed durlng or wlLhln Lhree
monLhs of hormonal LreaLmenL so as Lo avold under-
dlagnosls. ldeally, lf surgery ls performed for
dlagnosls, consenL ls obLalned for surglcal
resecLlon/ablaLlon of endomeLrlosls aL Lhe same
Llme.
3,7
1kLA1MLN1 CI DIL
Med|ca| treatment of DIL
lL ls well esLabllshed LhaL hormonal drugs do
noL cure endomeLrlosls buL only lnduce Lemporary
qulescence of acLlve leslons and LhaL ln mosL cases of
advanced dlsease, surgery ls Lhe flnal soluLlon.
Powever, Lhere are several slLuaLlons ln whlch
medlcal LreaLmenLs are sLlll useful. Some women who
have already undergone several operaLlons mlghL
prefer Lo avold furLher surgery buL need paln rellef,
and oLhers may wanL only Lo posLpone surgery
because of sLudy, work, or famlly problems.
lurLhermore, drugs may be chosen as an alLernaLlve
Lo surgery ln Lhe rare very dlfflculL cases ln whlch Lhe
rlsks of morbldlLy and compllcaLlons ouLwelgh Lhe
beneflLs of a radlcal operaLlon.
Long-Lerm paln rellef ls Lhe maln ob[ecLlve,
and greaL care should be pald Lo Lhe cholce of drug.
ulL has been LreaLed successfully wlLh danazol,
gonadoLropln-releaslng hormone analogs, progesLlns,
and esLrogen-progesLln comblnaLlons.
rogesLlns should be consldered as flrsL-llne medlcal
LreaLmenL for Lemporary paln rellef.
22
Conservat|ve surg|ca| treatment of DIL
ln mosL cases of severely lnfllLraLlng dlsease,
surgery ls Lhe LreaLmenL of reference.
13
Surglcal
LreaLmenL ls effecLlve for rellevlng pelvlc paln,
dyspareunla, and palnful defecaLlon.
2
ln general, deep endomeLrloLlc leslons should
noL always be LreaLed [usL because Lhey are Lhere.
lnLesLlnal and ureLeral focl LhaL cause progresslve
sLenosls consLlLuLe lndlspuLable reasons for operaLlng.
CLherwlse, surgery for asympLomaLlc ulL should noL
be consldered mandaLory ln all cases. 1he resulLs of
LreaLmenL for a benlgn condlLlon such as
endomeLrlosls are funcLlonal, and surglcal lndlcaLlons
should be based malnly on sympLoms and
nonresponse Lo medlcal Lheraples.
22
1he locaLlon of Lhe ulL leslons musL dlcLaLe
Lhe cholce of operaLlng Lechnlque. ln mulLlfocal cases,
several surglcal procedures musL be assoclaLed. lor
bladder ulL, Lhe sLandard LreaLmenL ls parLlal
cysLecLomy whlch can be performed by operaLlve
laparoscopy. lor ulL lnfllLraLlng Lhe uLerosacral
llgamenLs, lL has been shown LhaL laparoscoplc
surglcal resecLlon ls efflclenL. lor vaglnal ulL,
numerous auLhors have demonsLraLed LhaL operaLlve
laparoscopy ls efflclenL uslng varlous Lechnlques
(elecLrosurgery, sharp dlssecLlon or laser CC2,
excluslvely laparoscoplc procedure or laparoscoplcally
asslsLed vaglnal surgery).
1he dlfferenL Lopographlcal locaLlon of
uLerosacral llgamenLs and vaglnal ulL requlres speclflc
operaLlng Lechnlques. Leslons sLrlcLly locaLed on Lhe
uLerosacral llgamenLs requlre, ln Lhe ma[orlLy of
paLlenLs, ureLerolysls wlLhouL assoclaLed exeresls of
Lhe upper parL of Lhe posLerlor vaglnal wall. ln cases
of lsolaLed vaglnal ulL, dlssecLlon of Lhe laLero-recLal
fossae ls necessary ln >80 of cases and exeresls of
Lhe upper parL of Lhe posLerlor vaglnal wall ls
7
essenLlal. 1he reason for Lhls ls LhaL vaglnal ulL mosL
ofLen does noL lnfllLraLe Lhe recLovaglnal sepLum
whlch ls locaLed lower down buL raLher Lhe upper
Lhlrd of Lhe posLerlor vaglnal wall.
13
1he quesLlon of operaLlve Lechnlque ls far
more complex when Lhe dlgesLlve LracL ls lnvolved.
Surgery for recLovaglnal endomeLrlosls can be
complex and challenglng and ofLen lnvolves a
mulLldlsclpllnary Leam. 1here are several approaches
Lo be consldered, from shavlng Lhe dlsease off Lhe
recLal wall Lo carrylng ouL an exclslon of Lhe anLerlor
recLal wall or a segmenLal exclslon of Lhe recLum,
none of whlch has been accepLed as besL" pracLlce.
All Lhese procedures can be carrled ouL by elLher a
laparoscoplc, comblned or open approach.
18
ln women wlLh advanced sympLomaLlc
dlsease ln whom medlcal and conservaLlve surglcal
LreaLmenL falls, radlcal surglcal LreaLmenL
(hysLerecLomy and bllaLeral salplngo-oophorecLomy)
merlLs serlous conslderaLlon and dlscusslon.
3
DIL comp||cat|ons and recurrences
Surgery for deep endomeLrlosls ls assoclaLed
wlLh a relaLlvely hlgh rlsk of posLoperaLlve
compllcaLlons, such as de-novo or worsenlng voldlng
dysfuncLlon and recLovaglnal flsLula.
2
LndomeLrlosls ls a nonmallgnanL dlsease LhaL
usually affecLs young women wlLh hlgh expecLaLlons
ln Lerms of concepLlon and quallLy of llfe. ln Lhese
clrcumsLances, lnLraoperaLlve and posLoperaLlve
compllcaLlons are percelved and LoleraLed wlLh
dlfflculLy, and lncapaclLaLlng paln recurrence and
perslsLenL lnferLlllLy are parLlcularly frusLraLlng. A
Lhorough preoperaLlve dlagnosLlc lnvesLlgaLlon and
careful deLalled counsellng are of ma[or lmporLance.
lnvolvemenL of Lhe lnLesLlnal and urologlc sysLems
should be known ln advance, Lo schedule
lnLraoperaLlve consulLaLlon, lf necessary, and Lo
lnform Lhe woman abouL Lhe Lype of surgery requlred
and lLs poLenLlal sequelae.1hls wlll also help paLlenLs
and Lhelr famllles undersLand Lhe cllnlcal severlLy of
Lhe condlLlon, and balance Lhe rlsks and beneflLs of
Lhe proposed LreaLmenLs. ln parLlcular, as Lhe chances
of pregnancy afLer surgery may be llmlLed, an
alLernaLlve soluLlon mlghL be chosen such as ln vlLro
ferLlllzaLlon or adopLlon. Awareness of Lhe real
posslblllLles of dlfferenL LreaLmenLs wlll enhance Lhe
paLlenL's collaboraLlon.
22
8ecurrence or perslsLence of endomeLrlosls
afLer LreaLmenL ls one of Lhe mosL vexlng problems of
gynecology and ls based on Lhe known
unpredlcLablllLy of Lhe dlsease. LndomeLrlosls
recurrence raLes vary from 2 Lo 47. 1he hlghesL
recurrence raLe ls documenLed for deep lnfllLraLlve
endomeLrlosls, based on dlfflculLles ln esLlmaLlng Lhe
real borders of Lhe lnfllLraLe, as well as Lhe consclous
re[ecLlon of more aggresslve approaches Lo removal
of Lhe leslons, whlch are locaLed near vlLal organs.
23
1he surgeon should be aware of Lhe blo-
psychosoclal naLure of Lhe dlsease: Lhe surgeon who
only Lhlnks, for lnsLance, Lo eradlcaLe Lhe leslons of
endomeLrlosls, and who does noL conslder all llvlng of
Lhe paLlenL wlll ofLen have few successes and many
recurrences. 1he key Lo Laklng good charge ls
Lherefore Lo acL on boLh aspecLs: psychologlcal and
physlcal" (8odolphe Maheux, World LndomeLrlosls
AssoclaLlon).
24
1nL IU1UkL.
new developmenLs ln flber opLlc endoscopes
wlLh dlameLers less Lhan 1 mm have enabled a
gynecologlsL Lo dlagnose and sLage Lhe dlsease ln an
offlce seLLlng under local anesLhesla, posslbly aL
earller sLages.
23
1he developmenL of CenLers of Lxcellence"
for Lhe overall managemenL of severe endomeLrlosls
has been advocaLed ln recenL publlcaLlons. Worklng ln
con[uncLlon wlLh colorecLal and urologlcal surgeons
and Lhrough Lhe use of mulLldlsclpllnary Leam
meeLlngs approprlaLe case selecLlon can be made Lo
ensure LhaL Lhe correcL sklll base ls presenL for
curaLlve surgery.
14
kLILkLNCLS
1. 8ulun,SL. LndomeLrlosls. Mechanlsms of dlsease. n Lngl ! Med
2009,360:268-79.
2. Schenken, 8S. Cvervlew of Lhe LreaLmenL of endomeLrlosls. up-
Lo-daLe. 2008.
3. Speroff L, lrlLz MA. LndomeLrlosls. ln: Cllnlcal Cynecologlc
Lndocrlnology and lnferLlllLy (7
Lh
LdlLlon). LlpplncoLL Wllllams
&Wllklns, 2003:1103-133.
4. uaral L, eL al. LndomeLrlose recLal eL ferLlllLe. Cynecologle
CbsLeLrlque and lerLlllLe. 2008, 36
3. Chapron C, Chopln n, 8orghese 8 eL al. ueeply lnfllLraLlng
endomeLrlosls: paLhogeneLlc lmpllcaLlons of Lhe anaLomlcal
dlsLrlbuLlon. Pum 8eprod 2006, 21:1839-843.
6. 8urney 8C, Cludlce LC. 1he aLhogenesls of LndomeLrlosls. ln:
nezaLs CperaLlve Cynecologlc Laparoscopy and PysLeroscopy
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Lh
LdlLlon). nezhaL C, nezhaL l, nezhaL C (eds). Cambrldge
unlverslLy ress, 2008:231-37.
7. Schenken 8S. aLhogenesls, cllnlcal feaLure, and dlagnosls of
endomeLrlosls. up-Lo-daLe. 2008
8. !enklns S, Cllve uL, Paney Al. LndomeLrlosls: paLhogeneLlc
lmpllcaLlons of Lhe anaLomlc dlsLrlbuLlon. CbsLeL Cynecol
1986,67:333-38.
9. vercelllnl , Alml C, anazza S, vlncenLl S, lacreLa A ,
Croslgnanl C. ueep endomeLrlosls conundrum: evldence ln favor
of a perlLoneal orlgln. lerLll SLerll 2000,73:1043-046.
10. Chapron C, Llaras L, layeL , Poeffel C et ol. MagneLlc
resonance lmaglng and endomeLrlosls: deeply lnfllLraLlng
endomeLrlosls does noL orlglnaLe from Lhe recLovaglnal sepLum.
Cynecol CbsLeL lnvesL 2002, 33:204-08.
8
11. Abro MS, neme 8M, Averbach M. LndomeLrlose do sepLo
reLovaglnal: doena de dlagnsLlco e LraLamenLo especlflco.Arq
CasLroenLerol 2003. 40:192-97.
12. Carry 8. 1he endomeLrlosls syndromes: a cllnlcal classlflcaLlon
ln Lhe presence of aeLlologlcal confuslon and LherapeuLlc anarchy.
Pum 8eprod 2004,19:760-8.
13. Chapron C, lauconnler A, vlelra M eL al. AnaLomlcal
dlsLrlbuLlon of deeply lnfllLraLlng endomeLrlosls: surglcal
lmpllcaLlons and proposlLlon for a classlflcaLlon. Pum 8eprod
2003,18:137-61.
14. Slack A, Chlld 1, kennedy S eL al. urologlcal and colorecLal
compllcaLlons followlng surgery for recLovaglnal endomeLrlosls.
8!CC 2007,114:1278-282.
13. 8lbelro A, 8odrlgues lC, kehdl l eL al. Laparoscoplc resecLlon
of lnLesLlnal endomeLrlosls: a 3-year experlence. ! Mlnlm lnvaslve
Cynecol.2006,13:442-446.
16. lauconler A, Chapron C. LndomeLrlosls and pelvlc paln:
epldemlologlcal evldence of Lhe relaLlonshlp and lmpllcaLlons.
Pum 8eprod 2003, 11:393-606.
17. lerrero S, AbbamonLe LP, Clordano M eL al. ueep dyspareunla
and sex llfe afLer laparoscoplc exclslon of endomeLrlosls. Pum
reprod 2007,22:1142-148.
18. 8rouwer 8, Woods 8!. 8ecLal endomeLrlosls: resulLs of radlcal
exclslon and revlew of publlshed work. AnZ !. Surg. 2007, 77: 362-
371
19. PudellsL C, kecksLeln !, WrlghL !1. 1he mlgraLlng
adenomyoma: pasL vlews on Lhe eLlology of adenomyosls and
endomeLrlosls. lerLll SLerll 2008.
20. 8azoL M, Malzy , CorLez A eL al. Accuracy of Lransvaglnal
sonography and recLal endoscoplc sonography ln Lhe dlagnosls of
deep lnfllLraLlng endomeLrlosls.ulLrasound CbsLeL Cynecol 2007,
30: 994-1001.
21. !unlor AC, Llma CM, CouLlnho L eL al. MagneLlc resonance
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8ras 2008, 41:129-34
22. vercelllnl , lronLlno C, leLrlpaolo C eL al. ueep
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! Am Assoc Cynecolo Laparosc 2004, 11(2):133-61.
23. 8erker 8, Psu 1S, Lee kL eL al. Laparoscoplc LreaLmenL of
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Lh
LdlLlon). nezhaL C, nezhaL l, nezhaL C (eds).
Cambrldge unlverslLy ress, 2008:231-37.
24. 8elalsch !. 8eflecLlons on Lhe medlcal LreaLmenL of
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wldely used. 178-184