Deep infiltrating endometriosis

Definition

• Deep infiltrating endometriosis is present when endometriotic tissue with fibrosis and hyperplasia infiltrates more than 5 mm beneath the peritoneum; lesions under 5 mm are regarded as superficial.
• Endometriosis is characterised by endometrial glands and stroma outside the uterine cavity and is an oestrogen-dependent inflammatory disease.

Classification

#ENZIAN classification

• The #ENZIAN classification describes compartment-based, including deep infiltrating form.
• Compartment P stands for peritoneal endometriosis.
• Compartments O and T stand for ovaries; T: tubo-ovarian junction.
• Compartments A, B, and C stand for vagina/rectovaginal space, sacrouterine lig., rectum.
• The suffix F (for “far”) denotes A: adenomyosis, B: bladder, U: ureter, I: bowel, O: other.
• The size of the lesions is coded in 3 grades: <1 cm, 1–3 cm, >3 cm.

Sites

• In endometriosis overall, the ovaries are most commonly involved, followed by the posterior broad ligament, the anterior and posterior cul-de-sac and the uterosacral ligaments; endometriotic nodules can also affect the bowel, ureter, bladder and urethra.

Occurrence & epidemiology

Epidemiology

• The prevalence of endometriosis is reported as about 10–18% in women of reproductive age and 20–50% in infertile women; the deep infiltrating form accounts for 15–30% of diagnosed cases.

Clinical features

• Typical are dysmenorrhoea, chronic pelvic pain and infertility.
• Depending on the site, deep dyspareunia, dyschezia or rectal bleeding during menses, and with bladder involvement dysuria and haematuria, may occur.
• On examination a thickened or nodular rectovaginal septum or nodules on the uterosacral ligaments may be palpable, although findings may also be normal.

Diagnosis

• In a meta-analysis, physical examination reached a pooled sensitivity of 71% and specificity of 69%, transvaginal ultrasound 76% and 94%, and MRI 82% and 87%.
• Additional techniques such as assessing pelvic organ mobility (sliding sign) and rectal water contrast improve the diagnostic performance of transvaginal ultrasound.

Keep learning in the app

Further reading (selection)

1. Comparison of physical examination, ultrasound techniques and magnetic resonance imaging for the diagnosis of deep infiltrating endometriosis: A systematic review and meta-analysis of diagnostic accuracy studies (Exp Ther Med 2020, PubMed Central)
2. StatPearls: Endometriosis
3. MSD Manual Professional: Endometriosis
4. DocCheck Flexikon, Endometriose

Cross-references