Deep infiltrating endometriosis: Evaluation and management

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Management options: Factor in the variables

DIE can involve the ureters and bladder, the retrocervical and rectovaginal spaces, the appendix, and the bowel. Lesions can be single or multifocal. Although our institutions’ imaging with MRI and TVUS is highly accurate, we additionally recommend the use of colonoscopy (with directed biopsies if appropriate) to evaluate patients who present with rectal bleeding, large endometriotic rectal nodules, or have a family history of bowel cancer.

While many studies have found that surgical resection of DIE improves pain and quality of life, surgery can have significant complications.12 Observation is adequate for asymptomatic patients with DIE. Medical treatment may be offered to patients with mild pain (there is no evidence of a reduction in lesion size with medical therapy). In cases of surgical treatment, we encourage the involvement of a multidisciplinary surgical team to reduce complications and optimize outcomes.

Patients with DIE, significant pain (VAS score, >7), and multiple failed in vitro fertilization treatments are candidates for surgery. When bowel endometriosis is noted on imaging, factors such as size, depth, number of lesions, circumferential involvement, and distance from the anal verge are all used to determine the surgical approach. Rectosigmoid lesions smaller than 3 cm can be treated more conservatively—for example, with shaving or anterior resection with manual repair using disk staplers. Segmental resection generally is indicated for rectosigmoid lesions larger than 3 cm, involvement deeper than the submucosal layer, multiple lesions, circumferential involvement of more than 40%, and the presence of obstructed bowel symptoms.13,14

In patients with DIE who present with both infertility and pain, antimüllerian hormone level and TVUS follicular count are used to evaluate ovarian reserve. As surgical treatment may further reduce ovarian reserve in patients with DIE and infertility, we counsel them regarding assisted reproductive technology options before surgery.

CASE Resolved

After thorough discussion, Mary opts to try a different combination oral contraceptive pill formulation. The pills improve her pain symptoms significantly (VAS score, 4), and she decides to forgo surgery. She will be followed up closely on an outpatient basis with serial TVUS imaging.

Individualize management based on patient parameters

Imaging has been used for the nonsurgical diagnosis of DIE for many years, and this practice increasingly is being accepted and adopted. A presumptive nonsurgical diagnosis of endometriosis can be made based on the clinical signs and symptoms obtained from a thorough history and physical examination, in addition to the absence of imaging findings for ovarian and deep endometriosis.

According to guidelines from major ObGyn societies, such as the American College of Obstetricians and Gynecologists and the European Society of Human Reproduction and Embryology, empiric medical therapy (including combination oral contraceptives, progesterone-containing formulations, and gonadotropin-releasing hormone agonists) can be considered for patients with presumed endometriosis presenting with pain.15

When surgery is chosen, the surgeon must obtain crucial information on the characteristics of the lesion(s) and involve a multidisciplinary team to achieve the best outcomes for the patient.

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