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Endometriosis of bowel or rectovaginal space

Nicola Berlanda, MD
Paolo Vercellini, MD
Luigi Fedele, MD
Section Editor
Tommaso Falcone, MD, FRCSC, FACOG
Deputy Editor
Kristen Eckler, MD, FACOG


Endometriosis is the presence of endometrial glands and stroma at extrauterine sites. These ectopic endometrial implants are usually located in the pelvis but can occur nearly anywhere in the body. Endometriosis appears to be the most frequent cause of chronic pelvic pain in women of reproductive age and may cause prolonged suffering and disability that negatively affect health-related quality of life [1].

Rectovaginal or bowel involvement is estimated to be present in 5 to 12 percent of women with endometriosis [2]. The rectosigmoid colon is the most common site of bowel endometriosis [2-5]. Bowel involvement typically coexists with disease at other sites. Thus, evaluation and management of colorectal disease must take into account full distribution of endometriotic lesions.

Bowel endometriosis can be thought of as two different entities, depending upon anatomic location: (1) rectovaginal endometriosis and (2) involvement of the bowel wall proximal to the rectosigmoid colon. Presenting symptoms, evaluation, and management differ somewhat for these two general locations.

Diagnosis and management of rectovaginal or bowel endometriosis are reviewed here. General principles of the treatment of endometriosis, as well as endometriosis of the urinary tract and thorax, are discussed separately. (See "Endometriosis: Treatment of pelvic pain" and "Endometriosis of the bladder and ureter" and "Clinical features, diagnostic approach, and treatment of adults with thoracic endometriosis".)


Pathogenesis — The three theories for the pathogenesis of endometriosis include: (1) spread of endometrial cells from retrograde menstruation; (2) lymphatic or hematogenous dissemination; and (3) coelomic metaplasia. (See "Endometriosis: Pathogenesis, clinical features, and diagnosis", section on 'Pathogenesis'.)


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Literature review current through: Nov 2016. | This topic last updated: Wed Apr 06 00:00:00 GMT+00:00 2016.
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  1. Howard FM. The role of laparoscopy in the evaluation of chronic pelvic pain: pitfalls with a negative laparoscopy. J Am Assoc Gynecol Laparosc 1996; 4:85.
  2. Weed JC, Ray JE. Endometriosis of the bowel. Obstet Gynecol 1987; 69:727.
  3. Redwine DB. Ovarian endometriosis: a marker for more extensive pelvic and intestinal disease. Fertil Steril 1999; 72:310.
  4. Bailey HR, Ott MT, Hartendorp P. Aggressive surgical management for advanced colorectal endometriosis. Dis Colon Rectum 1994; 37:747.
  5. Pereira RM, Zanatta A, Preti CD, et al. Should the gynecologist perform laparoscopic bowel resection to treat endometriosis? Results over 7 years in 168 patients. J Minim Invasive Gynecol 2009; 16:472.
  6. Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril 1997; 68:585.
  7. Hartmann D, Schilling D, Roth SU, et al. [Endometriosis of the transverse colon--a rare localization]. Dtsch Med Wochenschr 2002; 127:2317.
  8. COLLIER HA, GONZALES LL, BOSSERT LJ. Cyclic ascites as a manifestation of endometriosis. Report of a case. Obstet Gynecol 1962; 19:681.
  9. Meyers WC, Kelvin FM, Jones RS. Diagnosis and surgical treatment of colonic endometriosis. Arch Surg 1979; 114:169.
  10. Iaroshenko VI, Salokhina MB. [Endometriosis of the stomach]. Vestn Khir Im I I Grek 1979; 123:82.
  11. Meuleman C, Tomassetti C, D'Hoore A, et al. Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 2011; 17:311.
  12. Remorgida V, Ferrero S, Fulcheri E, et al. Bowel endometriosis: presentation, diagnosis, and treatment. Obstet Gynecol Surv 2007; 62:461.
  13. Somigliana E, Infantino M, Candiani M, et al. Association rate between deep peritoneal endometriosis and other forms of the disease: pathogenetic implications. Hum Reprod 2004; 19:168.
  14. Martin DC, Batt RE. Retrocervical, retrovaginal pouch, and rectovaginal septum endometriosis. J Am Assoc Gynecol Laparosc 2001; 8:12.
  15. Vercellini P, Carmignani L, Rubino T, et al. Surgery for deep endometriosis: a pathogenesis-oriented approach. Gynecol Obstet Invest 2009; 68:88.
  16. Khong SY, Bignardi T, Luscombe G, Lam A. Is pouch of Douglas obliteration a marker of bowel endometriosis? J Minim Invasive Gynecol 2011; 18:333.
  17. De Cicco C, Corona R, Schonman R, et al. Bowel resection for deep endometriosis: a systematic review. BJOG 2011; 118:285.
  18. Chapron C, Dubuisson JB, Chopin N, et al. [Deep pelvic endometriosis: management and proposal for a "surgical classification"]. Gynecol Obstet Fertil 2003; 31:197.
  19. Sangi-Haghpeykar H, Poindexter AN 3rd. Epidemiology of endometriosis among parous women. Obstet Gynecol 1995; 85:983.
  20. Strathy JH, Molgaard CA, Coulam CB, Melton LJ 3rd. Endometriosis and infertility: a laparoscopic study of endometriosis among fertile and infertile women. Fertil Steril 1982; 38:667.
  21. Kirshon B, Poindexter AN 3rd. Contraception: a risk factor for endometriosis. Obstet Gynecol 1988; 71:829.
  22. Mahmood TA, Templeton A. Prevalence and genesis of endometriosis. Hum Reprod 1991; 6:544.
  23. Wills HJ, Reid GD, Cooper MJ, Morgan M. Fertility and pain outcomes following laparoscopic segmental bowel resection for colorectal endometriosis: a review. Aust N Z J Obstet Gynaecol 2008; 48:292.
  24. Fedele L, Bianchi S, Zanconato G, et al. Is rectovaginal endometriosis a progressive disease? Am J Obstet Gynecol 2004; 191:1539.
  25. Vercellini P. Endometriosis: what a pain it is. Semin Reprod Endocrinol 1997; 15:251.
  26. Vercellini P, Frontino G, Pietropaolo G, et al. Deep endometriosis: definition, pathogenesis, and clinical management. J Am Assoc Gynecol Laparosc 2004; 11:153.
  27. Vercellini P, Trespidi L, De Giorgi O, et al. Endometriosis and pelvic pain: relation to disease stage and localization. Fertil Steril 1996; 65:299.
  28. Fauconnier A, Chapron C, Dubuisson JB, et al. Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril 2002; 78:719.
  29. Yantiss RK, Clement PB, Young RH. Endometriosis of the intestinal tract: a study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation. Am J Surg Pathol 2001; 25:445.
  30. De Ceglie A, Bilardi C, Blanchi S, et al. Acute small bowel obstruction caused by endometriosis: a case report and review of the literature. World J Gastroenterol 2008; 14:3430.
  31. Varras M, Kostopanagiotou E, Katis K, et al. Endometriosis causing extensive intestinal obstruction simulating carcinoma of the sigmoid colon: a case report and review of the literature. Eur J Gynaecol Oncol 2002; 23:353.
  32. Vercellini P, Aimi G, Panazza S, et al. Deep endometriosis conundrum: evidence in favor of a peritoneal origin. Fertil Steril 2000; 73:1043.
  33. Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod 2014; 29:400.
  34. Propst AM, Storti K, Barbieri RL. Lateral cervical displacement is associated with endometriosis. Fertil Steril 1998; 70:568.
  35. Guerriero S, Ajossa S, Orozco R, et al. Accuracy of transvaginal ultrasound for diagnosis of deep endometriosis in the rectosigmoid: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2016; 47:281.
  36. Bazot M, Lafont C, Rouzier R, et al. Diagnostic accuracy of physical examination, transvaginal sonography, rectal endoscopic sonography, and magnetic resonance imaging to diagnose deep infiltrating endometriosis. Fertil Steril 2009; 92:1825.
  37. Bazot M, Detchev R, Cortez A, et al. Transvaginal sonography and rectal endoscopic sonography for the assessment of pelvic endometriosis: a preliminary comparison. Hum Reprod 2003; 18:1686.
  38. Piketty M, Chopin N, Dousset B, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod 2009; 24:602.
  39. Thomassin I, Bazot M, Detchev R, et al. Symptoms before and after surgical removal of colorectal endometriosis that are assessed by magnetic resonance imaging and rectal endoscopic sonography. Am J Obstet Gynecol 2004; 190:1264.
  40. Bazot M, Bornier C, Dubernard G, et al. Accuracy of magnetic resonance imaging and rectal endoscopic sonography for the prediction of location of deep pelvic endometriosis. Hum Reprod 2007; 22:1457.
  41. Chapron C, Vieira M, Chopin N, et al. Accuracy of rectal endoscopic ultrasonography and magnetic resonance imaging in the diagnosis of rectal involvement for patients presenting with deeply infiltrating endometriosis. Ultrasound Obstet Gynecol 2004; 24:175.
  42. Biscaldi E, Ferrero S, Remorgida V, Rollandi GA. Bowel endometriosis: CT-enteroclysis. Abdom Imaging 2007; 32:441.
  43. Zwas FR, Lyon DT. Endometriosis. An important condition in clinical gastroenterology. Dig Dis Sci 1991; 36:353.
  44. Vercellini P, Barbara G, Abbiati A, et al. Repetitive surgery for recurrent symptomatic endometriosis: what to do? Eur J Obstet Gynecol Reprod Biol 2009; 146:15.
  45. Vercellini P, Crosignani PG, Somigliana E, et al. Medical treatment for rectovaginal endometriosis: what is the evidence? Hum Reprod 2009; 24:2504.
  46. Vercellini P, Pietropaolo G, De Giorgi O, et al. Treatment of symptomatic rectovaginal endometriosis with an estrogen-progestogen combination versus low-dose norethindrone acetate. Fertil Steril 2005; 84:1375.
  47. Ferrero S, Camerini G, Ragni N, et al. Norethisterone acetate in the treatment of colorectal endometriosis: a pilot study. Hum Reprod 2010; 25:94.
  48. Fedele L, Bianchi S, Zanconato G, et al. Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis. Fertil Steril 2001; 75:485.
  49. Razzi S, Luisi S, Calonaci F, et al. Efficacy of vaginal danazol treatment in women with recurrent deeply infiltrating endometriosis. Fertil Steril 2007; 88:789.
  50. Ferrero S, Camerini G, Seracchioli R, et al. Letrozole combined with norethisterone acetate compared with norethisterone acetate alone in the treatment of pain symptoms caused by endometriosis. Hum Reprod 2009; 24:3033.
  51. Practice Committee of American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis. Fertil Steril 2008; 90:S260.
  52. Vercellini P, Barbara G, Somigliana E, et al. Comparison of contraceptive ring and patch for the treatment of symptomatic endometriosis. Fertil Steril 2010; 93:2150.
  53. Vercellini P, Crosignani P, Somigliana E, et al. 'Waiting for Godot': a commonsense approach to the medical treatment of endometriosis. Hum Reprod 2011; 26:3.
  54. Roman H. Oral contraceptives and endometriosis. Hum Reprod 2011; 26:1600.
  55. Vercellini P, Crosignani PG, Somigliana E, et al. Reply: Oral contraceptives and the endometriosis domino effect. Hum Reprod 2011; [Epub ahead of print]:1.
  56. Fedele L, Bianchi S, Zanconato G, et al. Gonadotropin-releasing hormone agonist treatment for endometriosis of the rectovaginal septum. Am J Obstet Gynecol 2000; 183:1462.
  57. Vercellini P, Crosignani PG, Abbiati A, et al. The effect of surgery for symptomatic endometriosis: the other side of the story. Hum Reprod Update 2009; 15:177.
  58. Carmona F, Martínez-Zamora A, González X, et al. Does the learning curve of conservative laparoscopic surgery in women with rectovaginal endometriosis impair the recurrence rate? Fertil Steril 2009; 92:868.
  59. Vercellini P, Aimi G, Busacca M, et al. Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized, controlled trial. Fertil Steril 2003; 80:310.
  60. Roman H, Loisel C, Resch B, et al. Delayed functional outcomes associated with surgical management of deep rectovaginal endometriosis with rectal involvement: giving patients an informed choice. Hum Reprod 2010; 25:890.
  61. Ruffo G, Scopelliti F, Scioscia M, et al. Laparoscopic colorectal resection for deep infiltrating endometriosis: analysis of 436 cases. Surg Endosc 2010; 24:63.
  62. Donnez J, Squifflet J. Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules. Hum Reprod 2010; 25:1949.
  63. Mohr C, Nezhat FR, Nezhat CH, et al. Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis. JSLS 2005; 9:16.
  64. Duepree HJ, Senagore AJ, Delaney CP, et al. Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement. J Am Coll Surg 2002; 195:754.
  65. Darai E, Thomassin I, Barranger E, et al. Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis. Am J Obstet Gynecol 2005; 192:394.
  66. Dubernard G, Piketty M, Rouzier R, et al. Quality of life after laparoscopic colorectal resection for endometriosis. Hum Reprod 2006; 21:1243.
  67. Donnez J, Nisolle M, Casanas-Roux F, et al. Rectovaginal septum, endometriosis or adenomyosis: laparoscopic management in a series of 231 patients. Hum Reprod 1995; 10:630.
  68. Donnez J, Nisolle M, Gillerot S, et al. Rectovaginal septum adenomyotic nodules: a series of 500 cases. Br J Obstet Gynaecol 1997; 104:1014.
  69. Vercellini P, Pietropaolo G, De Giorgi O, et al. Reproductive performance in infertile women with rectovaginal endometriosis: is surgery worthwhile? Am J Obstet Gynecol 2006; 195:1303.
  70. Reich H, McGlynn F, Salvat J. Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis. J Reprod Med 1991; 36:516.
  71. Candiani GB, Vercellini P, Fedele L, et al. Conservative surgical treatment of rectovaginal septum endometriosis. J Gynecol Surg 1992; 8:177.
  72. Anaf V, Simon P, El Nakadi I, et al. Impact of surgical resection of rectovaginal pouch of douglas endometriotic nodules on pelvic pain and some elements of patients' sex life. J Am Assoc Gynecol Laparosc 2001; 8:55.
  73. Chapron C, Jacob S, Dubuisson JB, et al. Laparoscopically assisted vaginal management of deep endometriosis infiltrating the rectovaginal septum. Acta Obstet Gynecol Scand 2001; 80:349.
  74. Angioni S, Peiretti M, Zirone M, et al. Laparoscopic excision of posterior vaginal fornix in the treatment of patients with deep endometriosis without rectum involvement: surgical treatment and long-term follow-up. Hum Reprod 2006; 21:1629.
  75. Kristensen J, Kjer JJ. Laparoscopic laser resection of rectovaginal pouch and rectovaginal septum endometriosis: the impact on pelvic pain and quality of life. Acta Obstet Gynecol Scand 2007; 86:1467.
  76. Campagnacci R, Perretta S, Guerrieri M, et al. Laparoscopic colorectal resection for endometriosis. Surg Endosc 2005; 19:662.
  77. Fleisch MC, Xafis D, De Bruyne F, et al. Radical resection of invasive endometriosis with bowel or bladder involvement--long-term results. Eur J Obstet Gynecol Reprod Biol 2005; 123:224.
  78. Brouwer R, Woods RJ. Rectal endometriosis: results of radical excision and review of published work. ANZ J Surg 2007; 77:562.
  79. Fedele L, Bianchi S, Zanconato G, et al. Long-term follow-up after conservative surgery for rectovaginal endometriosis. Am J Obstet Gynecol 2004; 190:1020.
  80. Possover M, Diebolder H, Plaul K, Schneider A. Laparascopically assisted vaginal resection of rectovaginal endometriosis. Obstet Gynecol 2000; 96:304.
  81. Redwine DB, Wright JT. Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection. Fertil Steril 2001; 76:358.
  82. Nezhat C, Nezhat F, Pennington E. Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser. Br J Obstet Gynaecol 1992; 99:664.
  83. Mereu L, Ruffo G, Landi S, et al. Laparoscopic treatment of deep endometriosis with segmental colorectal resection: short-term morbidity. J Minim Invasive Gynecol 2007; 14:463.
  84. Nezhat C, Hajhosseini B, King LP. Laparoscopic management of bowel endometriosis: predictors of severe disease and recurrence. JSLS 2011; 15:431.
  85. Nirgianakis K, McKinnon B, Imboden S, et al. Laparoscopic management of bowel endometriosis: resection margins as a predictor of recurrence. Acta Obstet Gynecol Scand 2014; 93:1262.