Deep Infiltrating Endometriosis

Definition
Endometriosis is a disease of the uterus in which
tissue from the uterine cavity becomes implanted
in the abdominal cavity and, rarely, metastasizes
to organs at a distance from the uterus
Any manifestation of endometriosis that is
located other than in the superficial tissues of the
rectovaginal septum and vaginal fornix, the pelvic
wall, parametrium, bowel, uterus, or urinary
bladder can be called deep infiltrating endo -
metriosis
 endometriosis should be classified according
to the depth of invasion into superficial (<1
mm), Intermediate (2-4 mm), deep (>5 mm)
and very deep (>10 mm)
 Epidemiology
prevalence of endometriosis is 5% to 15% among
all women of child-bearing age
20% to 48% of women suffering from infertility
No robust data are available concerning the
prevalence of deep infiltrating intestinal
endometriosis
Ureteric endometriosis, for example, has been
described in 0.1% to 0.4% of all cases of
endometriosis, while the overall prevalence of
urogenital endometriosis is said to be 1% to 2%
of the overall prevalence of endometriosis
 Etiology
transplantation
hypothesis, viable
endometrial cells enter
the abdominal cavity
through retrograde
menstruation and
become implanted
there (retrograde
menstruation)
 Clinical manifestation
Symptom
Pain:
Dysmenorrhea, which can be either primary or
secondary. Primary dysmenorrhea generally begins
shortly after the menarche, and it usually persists until
the menopause in affected women.
Position-dependent or -independent dyspareunia (with
or without loss of libido)
Dyschezia
Pelvic pain of both cyclic and acyclic chronic types

Uterine hemorrhagic disturbances

Primary or secondary sterility
 The intensity of pain in woman with DIE
correlates well with the depth and volume of
infiltration
Relationship between posterior DIE and deep
dyspareunia
Painful defecation during menses with
involvement of the posterior wall of the vagina
Urinary tract signs with involvement of the
bladder
Result :
The mean values obtained on the different scales of the SHOW-Q
showed poor sexual function (mean SHOW-Q total score
56.3822.74).
Satisfaction was the dimension most affected (mean satisfaction
score 55.6634.55),
followed by orgasm (mean orgasm score 56.9033.77).
Analyzing the impact of symptoms and lesions on sexual
function, we found that dyspareunia and vaginal DIE nodules
significantly affect sexual activity (P<0.05).
 Type of DIE
Koninckx and Martin were the first to define deep
endometriosis. They distinguished posterior
culde-sac and rectovaginal lesions in three
different subgroups:
type I, conically shaped, developed from infiltration;
type II, deeply located, covered by extensive
adhesions, probably formed by retraction; and
type III, the most severe, one or more spherical
nodules located in the rectovaginal septum with the
largest dimension under the peritoneum, possibly to
be considered as adenomyosis extern
Endometriosis of the bladder
painful, ineffective bladder contractions,
micro- or macrohematuria
The diagnostic assessment includes history-
taking, vaginal palpation, vaginal
ultrasonography with a full bladder, and
magnetic resonance imaging (MRI)
Invasive diagnostic techniques include
cystoscopy (biopsi) and laparoscopy
Ureteric endometriosis
Intrinsic
Rare, only 0.3% from all endometriosis
Symtom: nonspecific pelvic pain to flank pain, renal
obstruction (usually unilateral), and asymptomatic
hydronephrosis.
Diagnostic with laboratorium, renal ultrasound, MRI
Extrinsic
More common
Ureter is compressed by the shrinkage of
endometriosis tissue
Rectovaginal endometriosis
Eazy to see and palpated at rectovaginal septum.
Infiltration of intestine and sacrouterine ligament lead
to partial or complete obilteration of douglass pouch
Symtom: Severe pelvic pain; intestinal manifestations
(cycle-dependent intestinal hemorrhage); and
dyspareunia, sometimes leading to loss of libido, is
typical
Diagnostic: transrectal ultrasonography, in combination
with rectosigmoidoscopy, to determine whether the
mucosa is involved can be documented by MRI
 Serum CA 125 is not a sensitive indicator of
the disease. However, knowledge of an
elevated preoperative CA 125 concentration
may be useful for selecting women who are at
high risk for bowel injury because of dense
pelvic adhesions and thus most likely to
benefit from preoperative bowel preparation
 Management
Endocrine treatement
Endocrine pharmacotherapy can be used as a neo-
adjuvant or adjuvant measure, as well as for the
treatment of recurrences.
The following options are available at present:
a) gestagens
b) oral contraceptives
c) GnRH analogues
d) pain therapy
e) combinations of the above
 Management
Surgical
General principles
Laparoscopy is the gold standard for the
surgical treatment of endometriosis.
Remove all focus of endometriosis
(impossible)
DIE >10% case get to limphnode
DIE is surrounded by fibrotic layer
Not all endometriosis focus causing symptom
 Indication
patients who have failed clinical treatment,
have recurrent symptoms after stopping medical
treatment,
infertility related to endometriosis,
of the urinary tract or gastrointestinal tract, or
the presence of cyclic rectorrhagia
Techniques for rectosigmoid DIE: rectal shaving,
rectal shaving with mucosal skinning, discoid
resection and segmental resection.