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Endometriosis: Treatment of rectovaginal and bowel disease

Endometriosis: Treatment of rectovaginal and bowel disease
Literature review current through: Jan 2024.
This topic last updated: Dec 08, 2022.

INTRODUCTION — Endometriosis is the presence of endometrial glands and stroma at extrauterine sites throughout the pelvis and beyond. Endometriosis lesions can be superficial, ovarian, or deep. Endometriosis lesions that invade into the rectovaginal space and/or bowel are forms of deep infiltrating endometriosis (DIE). The invasive nature of these implants causes significant pain, bowel dysfunction, and treatment challenges.

This topic will review the medical and surgical treatment of rectovaginal and bowel endometriosis. General principles of endometriosis, the presentation of rectovaginal and bowel endometriosis, and urinary tract endometriosis (another form of DIE) are presented separately.

(See "Endometriosis in adults: Pathogenesis, epidemiology, and clinical impact".)

(See "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease".)

(See "Endometriosis of the bladder and ureter".)

TREATMENT CONSIDERATIONS — In creating a treatment plan, the clinician and patient must consider the patient's symptoms, the anatomic location of disease, and the risks and benefits of both medical and surgical therapies.

Patient symptoms — Treatment of bowel or rectovaginal disease is indicated if characteristic symptoms are present (deep dyspareunia, dyschezia, cyclic rectal bleeding) and rectovaginal endometriosis is identified on evaluation. Treatment of bowel endometriosis is indicated for nonspecific gastrointestinal symptoms (eg, rectal bleeding, constipation, bloating) only if other etiologies of these symptoms have been excluded. (See "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease", section on 'Differential diagnosis'.)

Urgent surgical treatment is indicated in the rare instances in which a woman presents with bowel or ureteral obstruction. By contrast, women who are asymptomatic or who have mild symptoms that are not bothersome are managed expectantly.

Anatomic location of disease — 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. The surgical treatments, and the risks and complications, differ for these two locations. As an example, women with rectovaginal nodules that require an ultra-low rectal anastomosis (distance from the lower margin of resected segment from the anal verge <5 cm) have a higher risk of postoperative anastomotic leakage and may require protective temporary colostomy/ileostomy. In contrast, primary anastomosis is typically performed following resection of bowel lesions that are more than 5 cm from the anal verge. Both rectovaginal and bowel endometriosis typically coexist with other sites of disease. Thus, to appropriately counsel a woman regarding her treatment options, the clinician must discuss the full distribution of lesions and the clinical implications of the location of those lesions [1]. (See "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease", section on 'Diagnostic evaluation'.)

Choice of medical or surgical treatment — The main therapeutic options for symptomatic rectovaginal or bowel endometriosis are systemic medical therapy or surgical treatment. Randomized trials directly comparing medical and surgical treatment for symptom and disease resolution are lacking; thus, the optimal treatment is not known. While both therapies can be effective at reducing symptoms, the risk profiles differ. Choosing a treatment plan is based as much on risk tolerance and patient goals as it is on treatment efficacy. In a parallel cohort study, 87 women affected by colorectal endometriosis, but without severe sub-occlusive symptoms, chose either medical (low-dose oral contraceptive or a progestin) or surgical treatment using a standardized shared decision-making process. At 12-month follow-up, both groups reported similar treatment satisfaction (total satisfaction rates of 78 and 76 percent for the medical and surgery groups, respectively). However, significant between-group differences favoring medical treatment were observed for the symptoms of diarrhea, dysmenorrhea, nonmenstrual pelvic pain, and health-related quality of life [2].

In observational studies, the overall rates of improvement in pain symptoms are 70 percent or higher for either medical or surgical treatment, but these studies do not give information about severity of disease, and most do not provide long-term data [3-8]. Unfortunately, there are few data regarding the effectiveness of medical therapy in treating pelvic pain specifically in women with rectovaginal or bowel endometriosis, and there is only one study on relief of gastrointestinal symptoms [6]. However, the effectiveness of medical therapy for general pelvic endometriosis-related pain is well established. (See "Endometriosis: Treatment of pelvic pain", section on 'Medical treatment options'.)

Medical therapy – Advantages of medical therapy include that it treats all sites of disease simultaneously, can have ancillary benefits (eg, provide birth control), is generally well tolerated, and has relatively few side effects. In addition, medical treatment of rectovaginal or bowel endometriosis avoids the risks associated with surgery. (See 'Complications' below.)

The disadvantages of medical therapy are that it must be continued until menopause (when endometriosis typically regresses), it is not effective in all women, it may take longer to achieve an effect, and discontinuation can result in symptoms recurrence [4,9]. In addition, women who are trying to conceive must stop hormonal medications since they interfere with ovulation and are potentially teratogenic. In a cohort study of women with deep dyspareunia from deeply infiltrating endometriosis (urinary and rectovaginal), nearly one-third of women had an inadequate response to medical therapy and required surgical management (although 60 percent of women treated medically were satisfied) [10]. In addition, this study reported that women who received medical treatment with progestin therapy had a more gradual response compared with women who underwent surgery, although the measured treatment outcomes (frequency of intercourse per month and treatment satisfaction) were the same at 12 months for women with rectovaginal disease.

Surgical therapy – Surgical therapy provides treatment that is directly correlated to patient symptoms, provides long-term pain relief, and is associated with improved quality of life [3,11]. In a prospective cohort study of nearly 250 women followed for two years after surgical resection of endometriosis from the rectovaginal septum, only 4 percent of women reported pain and 1 percent reported dyspareunia [12]. The major disadvantages include morbidity, surgical complication, and potential bowel dysfunction. (See 'Complications' below and 'Long-term bowel dysfunction' below.)

OUR APPROACH — Consistent with statements from international committees, our approach is to maximize medical therapy and minimize surgical intervention, particularly repeat surgeries [13,14]. Management of rectovaginal or bowel endometriosis is aimed at resolving symptoms; thus, we offer all patients empiric treatment with regularly scheduled office visits, a bowel regimen (such as with polyethylene glycol 3350), and pain management with nonsteroidal anti-inflammatory drugs. (See "Endometriosis: Treatment of pelvic pain", section on 'Nonsteroidal anti-inflammatory drugs'.)

For individuals who require additional treatment, we initially offer hormone-based medical therapy because it is effective in more than half of patients and avoids the risk of surgical complications, such as genital tract fistulae, bladder dysfunction, or bowel anastomotic leakage [10]. In patients with nodules located above the midrectum, medical treatment may provide a substantial improvement of symptoms and avoid the risks of surgery. Candidates for medical therapy include those with bowel lumen stenosis of less than 60 percent, lesion infiltrates of less than 50 percent of the bowel circumference, and diameter of the largest nodule of less than 3 cm [15-17]. Surgery is a reasonable choice for patients who are willing to accept the risks of surgery and who prefer to avoid chronic medical therapy, patients who have failed medical therapy, or patients who cannot receive medical therapy. Asymptomatic individuals can be observed [18]. Exceptions to this approach include patients with bowel or ureteral obstruction; this group requires immediate surgical correction. (See "Endometriosis: Treatment of pelvic pain", section on 'Medical treatment options' and 'Complications' below and "Endometriosis of the bladder and ureter", section on 'Surgery'.)

While it is generally accepted that women with a rectovaginal nodule are more likely to achieve complete relief of symptoms (deep dyspareunia, dyschezia) following surgical treatment than with medical therapy, in our opinion, this benefit is not outweighed by the high risk of major postoperative complications [11]. However, this approach is somewhat surgeon-dependent. Our approach to the management of bowel endometriosis according to the patient's symptoms is presented in the algorithm (algorithm 1). However, a review of 122 studies concluded that women with significant pain (as defined by a visual analog score ≥7) benefited from proceeding directly with surgery and created a surgical treatment algorithm based on the depth and size of rectal disease [15]. Our concern with proceeding directly to surgery is that many omen with endometriosis undergo several surgeries, and the risk of surgical complications increases with repeat procedures due to multiple exposures to surgical risk and development of scar tissue [19]. (See 'Medical treatment' below and 'Surgical treatment' below.)

Of note, neither surgical nor pharmacologic therapy for rectovaginal or bowel endometriosis is effective for the treatment of infertility [20]. For women with endometriosis and infertility, we offer treatments focused on resolving the infertility, including surgical removal of endometriosis at other anatomic sites with restoration of normal anatomy or assisted reproduction techniques. (See 'Infertility' below and "Endometriosis: Treatment of infertility in females", section on 'Our approach'.)

MEDICAL TREATMENT — Options for medical therapy include estrogen-progestin or progestin-only hormonal treatment, gonadotropin-releasing hormone agonists, danazol, and aromatase inhibitors.

Efficacy — Medical therapy for rectovaginal or bowel endometriosis appears to be effective in many patients, but it requires further study to understand the subgroups who benefit most. Available studies report a promising effect on pain symptoms, with 60 to 90 percent of patients noting considerable improvement or complete relief [4-8,10].

Patients desiring hormonal treatment for rectosigmoid endometriosis are counseled regarding the potential relief of intestinal symptoms (approximately 70 percent), potential need for surgery for treatment failure (approximately 10 percent), and potential development of bowel obstruction (1 to 2 percent) [21]. For patients with lesions exclusively infiltrating the midrectum (ie, cases of true rectovaginal endometriosis), the probabilities of intestinal symptom relief and potential need for surgery are approximately 80 and 3 percent, respectively.

The limitations of the studies to date are that they have been conducted almost exclusively in women with rectovaginal disease who have recurrent or persistent symptoms following conservative surgery (uterus and ovaries were not removed). The efficacy rate for primary medical treatment of rectovaginal or bowel disease is not known because women whose symptoms are adequately managed medically do not proceed with further evaluation or surgery to diagnose and treat intestinal disease. In addition, as surgical treatment encompasses both conservative and definitive surgery (removal of endometriosis only versus removal of endometriosis plus uterus and ovaries), it is not clear as to which surgery medical therapy should be compared with when assessing efficacy. Lastly, more data are needed regarding the efficacy of medical treatment of lesions beyond the rectum and on women with gastrointestinal, rather than pelvic, symptoms. (See "Endometriosis: Surgical management of pelvic pain", section on 'Conservative versus definitive surgery'.)

Some experts have postulated that medical therapy would be less effective because it treats the lesion but not the surrounding fibrosis. Such fibrosis almost always accompanies deep endometriosis and likely contributes to pain, and certainly to bowel obstruction [22]. On the other hand, medical treatment likely results in reduced stimulation of pain fibers by decreasing intra- and perilesional inflammation and production of prostaglandins and cytokines.

Estrogens and progestins — Studies of progestin-only and estrogen-progestin treatments have reported both reduction and resolution of pain symptoms associated with rectovaginal endometriosis [5,6,23-25]. However, the optimal hormonal combinations or routes of treatment to reduce symptoms of rectovaginal or bowel endometriosis are not known. In our practice, we use progestin-only as a first-line treatment (eg, oral norethindrone acetate [NETA] 2.5 mg orally per day) [26,27]. NETA and dienogest are the progestins that have been more extensively evaluated for the treatment of endometriosis. A study of 90 women consecutively treated with NETA followed by dienogest (and discontinuation of NETA) reported similar satisfaction rates between the groups (71 and 72 percent were either satisfied or very satisfied, respectively) [28]. Side effects were experienced by 55 percent of women in the NETA group and 41 percent of women in the dienogest group, the most frequent being weight gain, spotting, and decreased libido. However, due to the limited compliance with dienogest therapy as a result of the high cost of this drug, the overall effectiveness was higher with NETA.

However, as both the combined estrogen-progestin and progestin-only regimens have been associated with reduced symptoms, treatment with a combined hormonal contraceptive is a reasonable option. In a trial of 90 women with rectovaginal endometriosis comparing estrogen-progestin therapy with NETA treatment, both groups reported a substantial reduction in dysmenorrhea, deep dyspareunia, nonmenstrual pelvic pain, and dyschezia at 12 months of treatment [5].

Other treatment options appear to include the contraceptive vaginal ring, transdermal patch, and levonorgestrel-releasing IUDs, although supporting data are limited. In a prospective study of 59 women with rectovaginal endometriosis that compared treatment with the contraceptive vaginal ring (15 micrograms ethinyl estradiol and 120 micrograms etonogestrel per day) with the patch (20 micrograms ethinyl estradiol and 150 micrograms norelgestromin per day), the ring was associated with a significantly greater improvement in dysmenorrhea, while improvement in dyspareunia and chronic pelvic pain was similar for the two preparations [23]. A different study of nearly 150 women with rectovaginal endometriosis who elected treatment with a desogestrel-only pill or the vaginal ring reported similar outcomes for reduction of lesion volume, discontinuation of therapy, and subsequent surgery, but patient satisfaction was higher for the pill than the ring [29]. Lastly, a small study (n = 11) reported that the use of the levonorgestrel intrauterine device was associated with improvement in dysmenorrhea, pelvic pain, and dyschezia in women with rectovaginal endometriosis [7]. Thus, selection of hormonal product (estrogen-progestin or progestin-only) and route of delivery (pill, patch, ring, injection, implant, or intrauterine device) depends largely on patient preferences. (See "Contraception: Counseling and selection".)

Relief of gastrointestinal symptoms of bowel endometriosis with medical therapy has not been well studied. In a prospective study of 40 women with rectosigmoid endometriosis who were still symptomatic following surgery and were treated with norethisterone (2.5 mg per day) reported treatment was associated with significant improvements in diarrhea, intestinal cramping, passage of mucus with stool, and cyclic rectal bleeding at 12 months of follow-up [6]. Constipation was improved only in women who had cyclic symptoms. No significant improvement was reported for abdominal bloating or the feeling of incomplete evacuation.

Other medical therapy — Treatment of rectovaginal or bowel endometriosis with hormonal medications other than estrogen and progestins have been investigated in limited studies. Gonadotropin-releasing hormone (GnRH) agonists, danazol, and aromatase inhibitors (AI) have each been evaluated in one study and reported to improve symptoms in women with rectovaginal endometriosis [8,9,30]. However, long-term use of these agents is generally avoided since GnRH agonists and AI result in menopausal symptoms and a decrease in bone density, and danazol treatment is associated with androgenic side effects (danazol does not decrease bone density). (See "Endometriosis: Treatment of pelvic pain", section on 'Agonists' and "Endometriosis: Treatment of pelvic pain", section on 'Danazol' and "Endometriosis: Treatment of pelvic pain", section on 'Aromatase inhibitors'.)

Patient follow-up — Women with rectovaginal or bowel endometriosis who are treated with medical therapy should undergo periodic evaluations for disease progression. Studies have reported that lesions decrease in size during medical therapy [5,7,8,30], but rare reports of disease progression raise concern for the risk of the development of ureteral involvement [31]. Progressive disease resulting in bowel obstruction has not been reported.

In our practice, we follow patients on medical therapy with physical examination and imaging. At each visit, we perform a bimanual examination, with rectovaginal examination if appropriate, and a transvaginal ultrasound, according to the following schedule:

Every three to four months for the first year

Every six to eight months for the next two years

Followed by yearly evaluation

We also obtain a urinary tract ultrasound to exclude hydronephrosis every six months for two years, then yearly.

SURGICAL TREATMENT

Preoperative planning — A multi-disciplinary surgical approach is typically required as these patients can have deep endometriosis lesions of the rectosigmoid colon, bowel, bladder, and ureters [32]. Surgical treatment of rectovaginal or bowel endometriosis is guided by the location, size, and depth of infiltration of the endometriotic lesions. When surgery for the removal of bowel disease is chosen, we remove all sites of endometriosis found throughout the pelvis. Surgery is typically performed with laparoscopy, but laparotomy can be required depending upon the anatomic site of disease, the complexity of the procedure, and the surgeon's laparoscopic skills. Successful treatment of symptoms appears to depend upon surgical experience [33,34].

Patient counseling involves a careful discussion of the risks of bowel resection if such surgery necessary to fully remove the endometriosis lesions. We specifically discuss the potential need for a temporary colostomy/ileostomy in cases of very low nodules and the risks of anastomotic leak requiring reoperation and possible temporary colostomy/ileostomy, rectovaginal fistula, postoperative ileus or obstruction, and pelvic abscess. Rectal resection is complicated by rectovaginal fistula in up to 10 percent of women [35-38]. If rectal wall infiltration is suspected, the surgeon should discuss the potential for this complication with the patient and explain the treatment that fistula formation can require. Many women prefer to live with residual dyschezia than to risk a vaginal passage of feces or a colostomy. In order to reduce the risk of rectovaginal fistula formation, some surgeons perform a temporary preventive ileostomy at first-line surgery [39,40]. (See 'Complications' below.)

The role of mechanical bowel preparation for these women is debated [41,42]. In our practice, we ask women to consume a fiber-free diet for three days prior to surgery and to drink 3 to 4 liters of polyethylene glycol solution the night prior to surgery. However, this approach is not universal.

Thromboprophylaxis and antibiotic prophylaxis is the same as for women undergoing surgery for general endometriosis. (See "Endometriosis: Surgical management of pelvic pain", section on 'Preoperative preparation'.)

Conservative or definitive surgery — The surgical approach to endometriosis may be either conservative or definitive. Conservative surgical treatment consists of excising the symptomatic endometriotic lesions, while leaving surrounding structures intact. For endometriosis in general, definitive surgery includes hysterectomy and bilateral salpingo-oophorectomy with removal of symptomatic lesions at other sites (eg, peritoneum, bowel). In our practice, definitive surgery is typically reserved for women who have failed medical and conservative surgical treatment because of the associated morbidity of hormone loss [14]. (See "Endometriosis: Surgical management of pelvic pain", section on 'Conservative versus definitive surgery'.)

Nerve-sparing technique — The surgical treatment of deep endometriosis requires dissection in close proximity to the course of the hypogastric nerve, inferior hypogastric plexus, and splanchnic pelvic nerve, all of which contribute autonomic innervation to the pelvic organs. Iatrogenic damage to these neural structures can cause postoperative urinary retention, constipation, and reduced sexual arousal (lubrication and swelling of the vagina). As the feasibility and efficacy of a surgical technique that eradicates endometriosis but spares the autonomic nerve fibers has been demonstrated, we have adopted this approach [43-45]. A detailed knowledge of the pelvic anatomy is required in order to dissect the healthy tissue surrounding the disease while visualizing and sparing the pelvic nerves, especially along the course of the ureter in proximity to the parametrium and along the lateral aspect of the uterosacral ligaments. When possible, this procedure has been reported to significantly improve postoperative urinary function compared with a conventional technique and to significantly improve sexual function [44,45].

The main limitation of this technique is that nerve-sparing surgery is neither feasible nor effective when endometriotic neural infiltration and resultant functional impairment are already present.

Rectovaginal endometriosis — Surgical treatment of rectovaginal endometriosis involves dissection of the rectovaginal space and removal of the endometriotic nodule(s). If infiltration of the rectal or vaginal walls is present, resection and repair of these structures may be required. In addition, as rectovaginal disease is often associated with obliteration of the posterior cul-de-sac or with lesions of the uterosacral ligaments, these sites may require posterior cul-de-sac adhesiolysis and/or ablation or resection of the uterosacral ligaments [46].

Surgical procedure — The surgical procedure is typically performed laparoscopically. The basic steps for surgical treatment of rectovaginal disease are as follows:

Explore and delineate the posterior pelvic anatomy – The surgeon explores the accessible portion of the pelvic posterior cul-de-sac, identifies the ureters bilaterally, and develops the pararectal spaces.

Dissect the rectum off the posterior vaginal fornix – To identify the vaginal apex, the surgeon inserts examining fingers or an instrument, such as an end-to-end anastomosis sizer, into the vagina to elevate the posterior vaginal fornix and the rectum (figure 1). The surgeon's other hand or an instrument is used from within the pelvis to dissect the rectum from the posterior aspect of the uterus and posterior vaginal wall. This technique allows the surgeon to use both visual and tactile information to ensure a precise plane of dissection, thereby minimizing the risk of bowel injury. We use cold scissors in order to avoid thermal injury to the rectum and use selective bipolar coagulation to control bleeding.

Open the vaginal fornix – The posterior vaginal wall is then grasped, typically using delicate laparoscopic grasping forceps, at each corner. This allows direct inspection of the endometriotic lesion and a precise estimate of the need for further rectal detachment. Dissection of the para-rectal space may be necessary to visualize the lesion and its depth of invasion.

Excise the endometriotic lesions – We dissect the adjacent normal tissue off the lesion. Once free margins around the lesion are reached both laterally and caudally, the endometriotic plaque is excised. This may require removal of part of the vaginal wall to completely remove the endometriotic lesion. If the lesion is not completely excised, symptoms are likely to persist. Resection of the lesion is usually performed using a V-shaped incision that follows the original shape of the lower posterior cul-de-sac.

Assess the anterior rectal wall – In the presence of kinking, stenosis, or infiltration of the rectal wall by the endometriotic nodule, an intraoperative consultation from a bowel surgeon is required to determine the treatment approach.

Reattach the vagina to the cervix – In our practice, we use a T-shaped suture (ie, a short vertical suture of the caudal portion of the vaginal incision), followed by a transverse suture of the posterior vaginal wall to the cervix, using 3-0 polyglactin (Vicryl) sutures. During a laparoscopic procedure, this step is performed vaginally.

In contrast to the above approach, some surgeons perform a low anterior rectal resection with primary repair. In our practice, we limit colorectal resection in women with rectovaginal disease to two clinical situations: (1) those with nodules requiring extensive opening of the rectum, for which suturing may result in iatrogenic stenosis and (2) those with fibrotic and unhealthy tissue margins at increased risk of suture dehiscence.

Supporting data — The above approach is supported by studies reporting that rectal shaving reduces pain and rectal segmental resection does not appear to offer better pain control than nodule excision and may result in adverse gastrointestinal symptoms and higher complication rates [3,47].

A meta-analysis that evaluated surgical outcomes and complications after colorectal surgery for endometriosis reported the following [48]:

Mean complication rates The mean complication rates for rectal shaving, excision of endometriotic disc, and segmental bowel resection were 2.2, 9.7, and 9.9 percent, respectively.

Risk of rectovaginal fistula – Rectal shaving was associated with lower risk of rectovaginal fistula compared with disc excision (odds ratio 0.19, 95% CI 0.10-0.36) and segmental colorectal resection (OR 0.26, 95% CI 0.15-0.44). Disc excision and segmental excision had similar risks for rectovaginal fistula (OR 1.07, 95% CI 0.70-1.630).

Risk of anastomotic leakage – While rectal shaving was associated with less anastomotic leakage compared with disc excision (OR 0.22, 95% CI 0.06-0.73), outcomes were similar for rectal shaving and segmental resection (OR 0.32, 95% CI 0.10-10.10) and disc excision and segmental resection (OR 0.32, 95% CI 0.30-1.58).

Anastomotic stenosis – Disc excision was associated with reduced risk of anastomotic stenosis compared with segmental resection (OR 0.15, 95% CI 0.05-0.48).

In a retrospective study of women who underwent either colorectal resection (25 women) or nodule excision (16 women) and were followed over an average of 26 months, pain improvement was similar for the two groups but the women who underwent segmental resection were more likely to develop frequent stools, defined as ≥3 per day (52 versus 19 percent) [39].

In a different retrospective study of 77 women with deeply infiltrating lesions of the rectum, women who underwent lesion shaving, compared with women who underwent colorectal resection, reported better Gastrointestinal Quality of Life Index values, lower Knowles Eccersley Scott Symptom scores for postoperative constipation, and improved anal continence [49]. While 9 percent of women managed with rectal shaving experienced a rectal recurrence, an additional 11 women would have had to undergo colorectal resection rather than lesion shaving to avoid one recurrence.

Limitations of these studies include the variable number of included individuals and the lack of randomly assigned trial design.

Follow-up — Following resection of rectovaginal endometriosis, we advise patients to avoid sexual intercourse for eight weeks. We see patients for a routine follow-up visit approximately six weeks postoperatively. Instructions for patients following gynecologic surgery can be found separately. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)

Bowel endometriosis — Bowel endometriosis at sites other than the rectosigmoid is treated surgically by excising the lesion. There are no universal guidelines as to which excision technique is optimal and the surgical management of bowel endometriosis is a point of clinical controversy [16]. Given the available data, we perform the smallest resection required to excise the lesion.

The extent of resection depends upon the lesion's depth of infiltration and size, as well as the surgeon's preference. Techniques include bowel resection or nodule excision [16]. Methods of nodule excision include bowel shaving (without opening the bowel wall) or discoid resection (ie, removing the nodule and surrounding rectal wall) [50]. Additional details of these surgical techniques include [11,16]:

Shaving or superficial excision – This may be performed only for lesions that do not invade beyond the serosa. Electrosurgical or laser techniques are typically used for this type of procedure [51]. The integrity of the bowel must be assessed after shaving/superficial excision is performed. Damage to the bowel muscularis requires repair or resection of the damaged area.

Discoid full thickness bowel excision and repair – The lesion and full thickness of the surrounding bowel wall are excised. The bowel wall is then closed with manual suture in two layers.

Segmental bowel resection and anastomosis – The lesion and bowel segment are resected, followed by bowel anastomosis. Indications for bowel resection include stenosis, multifocal lesions, sigmoid involvement, and lesions >3 cm or involving more than 50 percent of the bowel wall circumference [52]. Consistent with the anatomic distribution of the disease, over 90 percent of segmental bowel resections performed in women with endometriosis are of the rectosigmoid [3]. (See "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease", section on 'Distribution of disease'.)

There are limited data to guide the choice of resection technique and the comparative studies are not randomly assigned trials. When choosing a surgical approach, issues to consider include efficacy of pain relief, risk of repeat surgery, and risk of complication. Retrospective studies suggest that complete pain relief and avoidance of a repeat endometriosis surgery is more likely in women who undergo segmental or discoid resection compared with shaving [53-55]. However, complication rates appear to increase with the extent of resection, but the data are not consistent [56]. In a systematic review of surgical treatment of deep colorectal endometriosis that included 49 studies with nearly 3900 women, the majority of patients underwent segmental bowel resection and anastomosis (71 percent), followed by shaving/superficial procedures (17 percent) and discoid excision (10 percent) [11].

Unfortunately, complete excision may be difficult to determine with gross visualization. In a systematic review of women who underwent bowel resection for colorectal endometriosis, six studies reported that 20 percent of specimens had margins that were positive for endometriosis [11].

Incidental bowel endometriosis — Rectovaginal disease is more commonly diagnosed preoperatively than disease of other bowel sites. Rectovaginal disease typically presents with characteristic symptoms (eg, dyschezia) and a presumptive diagnosis can be made preoperatively with physical examination and imaging that identify rectovaginal endometriosis lesions. In contrast, bowel lesions beyond the rectosigmoid junction are associated with nonspecific symptoms. These lesions are typically found incidentally during diagnostic laparoscopy for pelvic pain or infertility and can be confirmed with biopsy. (See "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease", section on 'Diagnosis'.)

In our practice, we do not biopsy all bowel lesions that are discovered incidentally. For such lesions, we remove only those that are small in diameter (<2 cm) and that can be removed without entering the bowel muscularis or lumen. Removal of lesions that require bowel wall excision or bowel resection is performed only in patients who have been counseled about the procedure, have given informed consent, and have undergone a proper preoperative bowel preparation. For this reason, some women with bowel endometriosis have a two-stage procedure: one surgery for diagnosis and another for treatment. A systematic review of surgical treatment for colorectal endometriosis reported that nearly 60 percent of women had undergone a previous surgery for endometriosis [11]. However, a careful preoperative evaluation should limit the frequency of this two-procedure approach.

For women who require surgical treatment of endometriosis and who do not have bowel symptoms, we treat other sites first and do not ablate or remove bowel disease as part of a primary procedure. This approach is usually successful at relieving general symptoms of endometriosis (pelvic pain, dysmenorrhea, infertility). It also avoids the potentially morbid extensive pelvic dissection or bowel resection required for surgical treatment of rectovaginal or bowel endometriosis. If symptoms persist, surgical treatment of bowel disease may be performed as a follow-up procedure. (See "Endometriosis: Surgical management of pelvic pain".)

Complications — Complications vary by whether the procedure was rectovaginal dissection or bowel resection. The complications of these procedures are the same as for other pelvic dissection or bowel resection procedures.

In a literature review of 36 primarily retrospective studies, surgical treatment of rectovaginal endometriosis was associated with major complications in 3 to 10 percent of patients [33]. Urinary retention was the most frequently reported complication, possibly due to denervation of the bladder. Bladder dysfunction was found mostly, but not exclusively, in women who underwent colorectal resection. Rectovaginal fistula was reported in up to 10 percent of women. The same review evaluated 49 studies of surgical treatment of colorectal endometriosis and reported complications associated with bowel resection and anastomosis [11]. In studies of bowel resection only, the complication rates in order of frequency were rectovaginal fistula (2.7 percent), anastomotic leakage (1.5 percent), and abscess (0.3 percent). Summary data were not given for less extensive resection of bowel lesions. However, a different systematic review of 30 studies on the complications of bowel resection for endometriosis reported an overall complication rate of 22.2 percent and a severe intestinal complication rate of 6.4 percent [3].

Outcome

Pain symptoms — Surgical treatment results in improvement of pain symptoms, based upon consistent results from retrospective case series [12,35,36,47,54,57-69]. It is difficult to quantify the extent and duration of pain relief, since outcome measures used by studies have been heterogeneous [33]. In a prospective cohort study in which 105 infertile women were treated either with rectovaginal dissection and excision of the endometriotic nodule (with low anterior rectal resection in some women) via laparotomy or expectant management, women in the surgery group had significantly lower rates of moderate to severe pain symptoms than those in the expectant management group at two years of follow-up [59]. Women who underwent surgery reported the following outcomes when compared with women in the expectant management group: dysmenorrhea (61 versus 75 percent), deep dyspareunia (27 versus 52 percent), and dyschezia (22 and 43 percent). The two groups reported similar rates of nonmenstrual pelvic pain postoperatively.

Overall, for all sites of rectovaginal or bowel endometriosis, substantial postoperative short-term pain relief is reported by approximately 70 to 90 percent of the patients [3]. However, at one-year follow-up, approximately 50 percent of the women needed analgesics or hormonal treatments [62,67,70]. The reported recurrence of symptoms at two to five years after surgery varies from 4 to 54 percent [3,65,68,71]. A subset may require additional surgery. (See 'Need for repeat surgery' below.)

Long-term bowel dysfunction — Surgery is offered to treat symptoms of rectovaginal or bowel endometriosis, including diarrhea, constipation, rectal bleeding, proctitis, tenesmus, and pain. However, surgery to remove bowel endometriosis may incompletely treat or may worsen bowel symptoms [39,70]. For these reasons, surgery for deep infiltrating endometriosis is typically only considered for women with severe symptoms.

In a cohort study of women who underwent segmental bowel resection and were matched with control women who underwent endometriosis surgery that did not include a bowel resection, at a median of 10 years of follow-up, a larger proportion of case women reported new bowel symptoms compared with women who underwent control surgery (58 versus 14 percent) [72]. Women who underwent bowel resection also reported more abdominal pain, incomplete bowel movements, and false alarms on the Patient Assessment of Constipation Symptoms Questionnaire.

Infertility — Surgical treatment of rectovaginal endometriosis does not appear to improve fertility based on studies of conception rates [59,71,73,74]. Given these data, we counsel patients that surgical treatment of rectovaginal or bowel endometriosis is indicated for the treatment of pain symptoms but will not appear to improve reproductive prognosis [20].

Need for repeat surgery — After initial surgical resection of rectovaginal or bowel endometriosis, approximately 20 percent of women will require additional conservative or definitive surgery because of pain relapse [53,60,75,76]. Risk factors for repeat surgery include younger age, elevated body mass index, and positive margins for endometriosis at the time of initial bowel resection [71,77,78]. In one study of 81 women followed for a median of 53 months after an initial surgery for bowel endometriosis, 13 percent underwent repeat surgery, all of whom had confirmed endometriosis [78]. In this study, surgical margins positive for endometriosis at the time of the first surgery were the strongest risk factor for undergoing future surgery.

Postoperative therapy — For women who do not desire immediate pregnancy, postoperative medical therapy to suppress endometriosis is generally advised, although supporting data are limited [32,79,80]. As deep endometriosis often occurs with other forms of the disease, prolonged postoperative therapy should be strongly considered for the prevention of the formation of endometriomas and dysmenorrhea recurrence [81]. The European Society for Human Reproduction and Embryology advocates for postoperative use of combined hormonal contraception or a levonorgestrel intrauterine device (LNG IUD) for at least 18 to 24 months for secondary prevention of endometriosis-associated dysmenorrhea [14].

We typically offer postoperative patients hormonal suppression with combined hormonal contraceptive pills because of ease of access, low cost, and provision of contraception.

Supporting data for the LNG IUD come from two small trials reporting improvements in visual analogue measurements of dysmenorrhea pain with postoperative LNG IUD use compared with expectant management [82].

In addition to medical therapy, women with chronic pain symptoms can benefit from treatment modalities targeting chronic pain syndromes including medication, physical therapy, behavioral medicine, and neuromodulation. These nonmedical treatments are presented in detail separately. (See "Approach to the management of chronic non-cancer pain in adults".)

By contrast, women who desire pregnancy receive appropriate counseling and treatment to achieve pregnancy as soon as possible [16].

Medical treatment options are presented in detail separately. (See "Endometriosis: Treatment of pelvic pain", section on 'Medical treatment options' and "Endometriosis: Long-term treatment with gonadotropin-releasing hormone agonists".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Endometriosis".)

SUMMARY AND RECOMMENDATIONS

In creating a treatment plan, the clinician and patient must consider the patient’s symptoms, the anatomic location of disease, and the risks and benefits of both medical and surgical therapies. Treatment of bowel or rectovaginal disease is indicated if characteristic symptoms are present (deep dyspareunia, dyschezia, cyclic rectal bleeding) and rectovaginal endometriosis is identified on evaluation. Treatment of bowel endometriosis is indicated for nonspecific gastrointestinal symptoms (eg, rectal bleeding, constipation, bloating) only if other etiologies of these symptoms have been excluded. (See 'Patient symptoms' above.)

The main therapeutic options are medications for symptom control, systemic hormone-based medical therapy, or surgery. Treatment selection is based on the woman's symptoms and preferences as well as the clinician's judgment regarding the optimal approach. Exceptions include women with bowel or ureteral obstruction; these women require immediate surgical correction (algorithm 1). (See 'Choice of medical or surgical treatment' above.)

We offer medication for symptom control to all women with rectovaginal or bowel endometriosis. These treatments include nonsteroidal anti-inflammatory drugs for pain and laxatives or bulking agents to treat constipation. (See 'Our approach' above.)

A trial of medical therapy is appropriate for most women who do not have an immediate surgical indication, such as bowel obstruction or perforation. Clinical trials comparing the efficacy of the two approaches are lacking, and surgical therapy has inherent risks, such as genital tract fistulae, bladder dysfunction, or bowel anastomotic leakage. Additionally, hormone-based medical therapy is effective in more than half of women. (See 'Our approach' above.)

Surgery is a reasonable choice for women who are willing to accept the risks of surgery and who prefer to avoid chronic medical therapy, women who have failed medical therapy, or women who cannot receive medical therapy. (See 'Our approach' above.)

For women who desire medical treatment, we suggest progestin-only agents as first-line treatment (eg, oral norethindrone acetate 2.5 mg per day) (Grade 2C). However, as both progestin-only and combined estrogen-progestin regimens have been associated with a reduction in symptoms, treatment with a combined hormonal contraceptive is a reasonable option. Additional medical treatment options include gonadotropin-releasing hormone agonists, danazol, and aromatase inhibitors. (See 'Medical treatment' above.)

Surgical treatment of rectovaginal or bowel endometriosis is guided by the location, size, and depth of infiltration of the endometriotic lesions. When surgery for the removal of bowel disease is chosen, we remove all sites of endometriosis found throughout the pelvis. A multi-disciplinary surgical approach is typically required as these patients can have deep endometriosis lesions of the rectosigmoid colon, bowel, bladder, and ureters. (See 'Preoperative planning' above.)

Surgical treatment of rectovaginal endometriosis involves dissection of the rectovaginal space and removal of the endometriotic nodule(s). If infiltration of the rectal or vaginal walls is present, resection and repair of these structures may be required. (See 'Rectovaginal endometriosis' above.)

Bowel endometriosis at sites other than the rectosigmoid is treated surgically by excising the lesion. Techniques include bowel resection or nodule excision. Retrospective studies suggest that complete pain relief is more likely in women who undergo segmental or discoid resection compared with nodule excision but complication rates appear to increase with increasing extent of resection. (See 'Bowel endometriosis' above.)

Surgical treatment of rectovaginal endometriosis is associated with major complications in 3 to 10 percent of patients. Long-term outcomes include recurrence of pain, bowel dysfunction, and need for repeat surgery. (See 'Complications' above and 'Outcome' above.)

For women who do not desire immediate pregnancy, postoperative medical therapy to suppress endometriosis is generally advised, although supporting data are limited. Women who desire pregnancy receive appropriate counseling and treatment to achieve pregnancy as soon as possible. (See 'Postoperative therapy' above.)

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Topic 110323 Version 17.0

References

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