Endometriosis can invade organs that are near the uterus which can include the bowel and the urinary bladder. This type of endometriosis is called, “deeply infiltrating” or “deeply infiltrative endometriosis” [DIE] because it is found deep within the tissue or organ. Fortunately this happens rarely, or in approximately 1-five percent of women with endometriosis. The treatment of deeply infiltrating endometriosis is can be challenging because it doesn’t always respond to medical therapy such as oral contraceptive pills or GnRH agonists. In the following article, you will learn the basic about the symptoms of deeply infiltrative endometriosis when the urinary bladder and the bowel are involved, as well as surgical treatment options.
The ureters carry urine from the kidneys to the urinary bladder, where the urine is stored. The kidneys are located above the pelvis. The portion of the ureter that lies above the pelvic area is rarely affected by endometriosis. However, the portion of the ureter that lies below the pelvic area and the urinary bladder can be affected by endometriosis in approximately 1% of patients.
The symptoms are not always exactly the same for every woman, but often include one or more of the following: urinary frequency and urgency, blood in the urine, pelvic pain and possibly flank pain (pain in the lower side of the back). In rare cases patients have no symptoms, but their ureter may become completely closed over time which can result in loss of function of that kidney.
A pelvic ultrasound may help in the diagnosis, but a more accurate way of diagnosing urinary tract endometriosis is by a CT urogram or an MRI urogram. These similar tests involve injecting intravenous contrast material (a type of dye) into the urinary bladder. A series of photos are taken by the scanner while the dye moves through the bladder and ureter. The pictures are then reconfigured into a three dimensional image so that the entire urinary tract can be clearly seen. The image helps the doctor to see the ureter and urinary bladder and to look for endometriosis.
Medical management is not usually helpful to treat endometriosis of the urinary tract, thus surgery is recommended. If endometriosis is invading the ureter, that part of the ureter needs to be removed and the ends of the ureters are then sewn together. It is more common however, to see scar tissue constricting or squeezing the ureter. This can be treated by removing the scar tissue without having to cut the ureter. If the endometriosis is invading a large segment of the ureter it may not be possible to put the ureter back together again. In these extremely rare cases the bladder may need to be moved towards the ureter and the ureter is then reinserted into the bladder in a location that is closer to the damaged ureter. If the ureter needs to be cut, a ureteral stent has to be placed through the bladder and into the ureter. The stent is basically a very narrow plastic tube that is placed along the entire length of the ureter from the kidney to the bladder. The stent carries urine from the kidneys to the bladder and this protects the ureter during the healing process. The stent is typically in place for six weeks and can be removed in the office using a cystoscope, which is a long hollow instrument that has a tiny camera lens on the end of it. The cystoscope is inserted into the bladder through the urethra to check for any inflammation and endometriosis.
If endometriosis is invading the urinary bladder the affected area will need to be surgically removed. Most of the time, the bladder will need to be opened and then sewn closed. In these cases a Foley catheter will be inserted and left in the bladder for about one week to allow the bladder to heal without getting swollen with urine.
Endometriosis can affect any portion of the bowel, but the most common location is in the pelvis. The portion of the bowel in the pelvis is the sigmoid colon and the rectum, which are the two lowest segments of the gastrointestinal tract. The rectum is approximately 7-8 cm long and runs from the anus up to where it transitions into the sigmoid colon. The sigmoid colon sits towards the left side of the pelvis and extends up long the left side of the abdomen. The space between the upper vagina and the rectum is called the cul-de-sac. It is very common to see endometriosis lesions in the cul-de-sac. Endometriosis here often causes fusion of the rectum and the vagina which can result in severe pain with intercourse or with bowel movements.
Bowel endometriosis can cause symptoms such as pelvic pain, constipation, diarrhea, abdominal bloating, pain with bowel movements, pain with intercourse and occasionally bloody stools. However some women with endometriosis do not have any symptoms.
There are several options for the diagnosis of endometriosis. Pelvic ultrasound can detect endometriosis of the rectum and the lower sigmoid colon. This is a preferred diagnostic test since it is inexpensive, nonsurgical, and available in most hospitals. However, ultrasound has its limitations. It may not detect endometriosis which may be higher up in the gastrointestinal tract and it requires extra training by a technician in order to adequately identify endometriosis lesions. Rectal ultrasound is another option however, this is not as widely used because of patient discomfort and limited views higher in the pelvis. A CAT scan or a pelvic MRI are other widely used options. While the MRI is more expensive, it may have a slightly better resolution to detect endometriosis and is not associated with radiation exposure. A colonoscopy is occasionally used, but this is rare since endometriosis is usually not growing through the entire GI tract.
Treatment of endometriosis of the GI tract is surgical since medical treatment is usually not effective. Most of the time, the endometriosis lesion is not growing through the entire wall of the bowel and can be resected (cut out) and then the bowel wall is sutured together again. However, if the endometriosis is growing through the entire wall of the bowel or if the endometriosis is involved in a large segment of the bowel it is not possible to repair the bowel wall adequately. In these rare cases, the part of the bowel that is affected by endometriosis needs to be surgically removed. Most of the time, the bowel can be sutured back together again. Occasionally however there maybe concern that the connected area may not heal properly and in these cases, patients may need to have the bowel contents diverted away from the surgical area. This means that a loop of bowel is pulled out to the outside of the abdomen through the abdominal wall. The bowel contents will temporarily drain into a “colostomy” bag that is placed on the outside of the body. The procedure is called an ileostomy or colostomy depending on which segment of the bowel is pulled out. In about 6-8 weeks, the ileostomy or colostomy is disconnected and then reattached to the “inside” of the body, only after the affected bowel has had a chance to heal.
In summary, deeply infiltrative endometriosis is a rare form of endometriosis that will usually require surgical removal. Surgery for this condition is challenging and should only be done by surgeons who are experienced in performing these types of procedures.
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