Intestinal endometriosis: how it affects women’s quality of life

Endometriosis is a benign gynecological condition where endometrial cells are found outside the uterus, behaving similarly to those in the uterine lining. The condition can be aggressive due to its infiltrative nature and the inflammatory response around the lesions (1,2). Approximately 6–15% of women in their reproductive years are affected by endometriosis, which is associated with significant physical and emotional morbidity, severely impacting quality of life (3). Symptoms such as dysmenorrhea, chronic pelvic pain, dyspareunia, dyschezia, dysuria, and infertility can negatively affect daily activities, including household tasks, sexual function, work, appetite, physical activities, sleep, and social interactions, ultimately reducing overall productivity (4).

Deep intestinal endometriosis involves the infiltration of the intestinal muscular layer by endometrial tissue. It occurs in 5–12% of women with endometriosis and is among the most severe forms, contributing to chronic pelvic pain and infertility, significantly impairing quality of life (4). The sigmoid colon and/or rectum are the most commonly affected regions, observed in approximately 70–93% of cases (5). Common intestinal symptoms include abdominal bloating, diarrhea, constipation, abdominal pain, tenesmus, and dyschezia. These symptoms are often exacerbated during menstruation but do not always correlate with the extent of endometrial infiltration into the intestinal wall (6).

Women with pelvic endometriosis often experience visceral pelvic hypersensitivity, and some symptoms may overlap with conditions such as irritable bowel syndrome, which is more prevalent among those with endometriosis. Therefore, not all intestinal symptoms can be solely attributed to endometriotic lesions, although cyclical patterns are typical when symptoms are correlated with these lesions. Potential explanations for intestinal symptoms include microbleeds, inflammation of the intestinal wall, adhesions between the rectum and other pelvic structures, or rectal stenosis (6).

Surgical treatment for intestinal endometriosis can be either conservative or radical. Conservative approaches involve techniques like rectal shaving, where lesions are excised without opening the intestinal lumen, or disc excision involving full-thickness removal around the lesion. Radical surgery includes segmental colorectal resection, removing the affected segment of the rectum (7). Both approaches effectively alleviate painful symptoms, but radical surgery carries risks of serious complications such as damage to local nerves and the potential onset of new symptoms that can further impact quality of life (6).

Rectal shaving offers good improvement in intestinal function, low complication rates, and favorable fertility outcomes. However, the risk of recurrence due to microscopic disease remains. It is particularly suitable for women not desiring pregnancy who will enter amenorrhea post-treatment. Both rectal shaving and disc resection do not require mobilization of the colon or mesocolon sectioning. Shaving preserves intestinal function and sensory-motor capabilities, while disc resection minimally reduces the rectal reservoir volume (7,8).

Some authors advocate for radical surgery due to its effectiveness in pain control, lower recurrence rates, and acceptable postoperative complication rates (9). Complications of segmental intestinal resection mirror those of colorectal surgeries for other indications, including rectovaginal fistulas, anastomotic leaks, and urinary dysfunction, all of which can worsen quality of life. Colorectal resection may additionally lead to rectal denervation, anastomotic stenosis, reduced rectal reservoir capacity, altered intestinal motility, increased intracolonic pressure affecting anal sphincter function, and long-term fecal urgency and incontinence due to multifactorial postoperative intestinal dysfunctions (7).

Thus, determining the correct surgical approach for rectosigmoid endometriosis (the so-called “gray zone”) is challenging and studies suggest that conservative surgery would be the best option as it presents similar results with lower complication rates (10,11).

Recent studies indicate that women with deep colorectal endometriosis may experience intestinal and bladder dysfunctions preoperatively, with a 40% risk of abnormal bowel movements regardless of the surgical technique chosen (12,13). Despite treatments, endometriosis can significantly diminish quality of life, impacting various aspects, including sexual function (14). Surgical and clinical interventions may improve clinical outcomes and quality of life, but certain surgical approaches can affect intestinal function, potentially limiting overall improvements in quality of life.

In conclusion, endometriosis, particularly in its deep intestinal form, poses a significant challenge due to its aggressive and infiltrative nature. Affecting a notable percentage of women in their reproductive years, it leads to substantial physical and emotional morbidity. The condition severely impacts daily life, with symptoms that include chronic pelvic pain, gastrointestinal disturbances, and infertility. Treatment options, ranging from conservative surgical techniques to radical interventions, offer varying degrees of symptom relief and risks. While conservative methods like rectal shaving can preserve intestinal function and offer lower complication rates, radical surgeries may provide more definitive pain control but come with higher risks of postoperative complications. Ultimately, the management of intestinal endometriosis requires a tailored approach that considers the severity of symptoms, the patient’s fertility desires, and the potential impact on quality of life. Comprehensive, individualized treatment strategies are essential to effectively address the multifaceted challenges posed by this condition.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine. The article has undergone external peer review.

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-26/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-26/coif). The authors have no conflicts of interest to declare.

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