Deep Endometriosis

What is Deep Endometriosis?

Deep infiltrating endometriosis (DIE) is defined as the penetration of endometriosis foci into the walls of the organs in the lower abdomen. Deep infiltrative endometriosis is a special type. Endometriosis foci of 1 to 2 cm, which usually will not cause any symptoms under normal conditions, may present with very severe pain when they are located in deep areas, and the diagnosis can often be missed in this patient group. Endometriosis subgroups can be classified as peritoneal endometriosis, ovarian endometriosis, deep endometriosis (in the urinary tract, gastrointestinal tract, and between the vagina and anal region) and endometriosis outside the peritoneum.

What are the symptoms of Deep Endometriosis?

In patients with deep endometriosis, it has been shown that cells similar to the intrauterine lining epithelium are located more than 5 mm deep in the intra-abdominal membrane, and these cells are very active, causing increased inguinal pain, pain in intercourse, pain in the rectum, rectal bleeding and urinary tract symptoms. The characteristics of groin pain vary according to the location of deep endometriosis. Menstrual pain, rectal pain and urinary tract complaints can be very severe. Diarrhea, rectal bleeding and constipation may occur in some cases. In endometriosis located between vagina and anus, the nodule may be highly inflammatory. It can be very hard to separate these nodules from neighboring organs. These nodules can also lead to intestinal and urinary tract obstructions.

How can Deep Endometriosis be diagnosed?

Deep endometriosis may not be recognized unless it is very severe and widespread. In the 1990s, the diagnosis of deep endometriosis was largely made by laparoscopy. Difficulties in diagnosis still remain. Preoperative diagnostic methods in the diagnosis of deep endometriosis can be listed as: rectovaginal examination during the menstrual cycle, ultrasonography, pelvic MRI, double contrast enema, rectosigmoidoscopy, IVP and tm markers (Ca 125).

Treatment of Deep Endometriosis

Hormonal therapy (progestins or GnRHa) is effective in reducing pain. When the treatment is stopped, the probability of pain recurrence is high. The main treatment for endometriosis between vagina and anus is surgery. Appropriate bowel cleansing is required before laparoscopic treatment. The patient should be informed about the surgical procedure and its outcome. Surgical removal of all nodules is the preferred treatment method in patients with endometriosis between the vagina and anus. The use of 2 to 3-month period cutting needles in the pre-operative period not only simplifies the surgery but also reduces the recurrence rate of the disease.

Drug treatment alone is insufficient due to high recurrence rates. The main aim should be to cause the least harm to the patient when selecting the type of surgery. The surgeon should use whichever technique he/she is more experienced in. The goals of surgery are to make the lesion visible, to remove it completely, to take measures to prevent adhesion formation.

In conclusion, nodule removal in deep endometriosis or between vagina and anus is one of the most sensitive laparoscopic surgical procedures. The surgeon must be experienced in advanced laparoscopic surgery, bowel surgery and urinary tract, so these types of operations may require teamwork. The success of the surgery, the reduction of symptoms and the increase in the quality of life are closely related to the experience of the surgical team and the complete removal of the lesions.

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