Rectovaginal Lesions Research Articles

The etiology of major, acquired female urogenital and rectovaginal lesions in Port Harcourt, Nigeria

Introduction: New and emerging trends in the causation of urogenital and rectovaginal lesions, and changing patterns of behavior of female patients with the diseases were observed. The aim of this study is to determine the risk factors and etiology of these diseases. Methods: This was a cross-sectional observational study of records of consecutive female patients operated on at the University of Port Harcourt Teaching Hospital (UPTH), Nigeria, with major urogenital and rectovaginal lesions from 01/01/2018 to 31/12/2022. Each patient’s records, sociodemographic data, clinical assessment, laboratory investigations, diagnosis, and intraoperative findings were studied and recorded. Data obtained were analyzed with simple statistics, and presented in charts prose, and tables. Results: Twelve major cases were found and studied. Their age statistics (in years) were as follows: mean age, 38.6±11.5; median, 34; and age range of 25 to 68. Ten of them were within the childbearing age (15-45 years). One patient had a uterocutaneous fistula with subcutaneous endometriosis. Another had anorectal carcinoma with rectovesical and rectouterine fistulas. One had uterovesical fistulas with menouria (Youssef’s syndrome), and the fourth had uterovesical fistula with a perineal tear. Four patients had uterovaginal prolapse, and 4 had vesicovaginal fistulas. Obstetric and gynecological trauma and sexual battery accounted for nine of 12 cases. The patients had high-risk pregnancies but had antenatal care and labor managed by either traditional birth attendants or primary healthcare staff at peripheral institutions. Conclusion: Most of the risk and etiological factors of the lesions were found modifiable. Appropriate measures have been suggested for the management and prevention of the lesions.

The etiology of major, acquired female urogenital and rectovaginal lesions in Port Harcourt, Nigeria

The etiology of major, acquired female urogenital and rectovaginal lesions in Port Harcourt, Nigeria

Medical management of deeply infiltrating endometriosis - 7 year experience in a tertiary endometriosis centre in London

BackgroundDeeply infiltrating endometriosis has an estimated prevalence of 1% in women of reproductive age. Ninety percent have rectovaginal lesions but disease may also include the bowel, bladder and ureters. Current practice often favours minimally invasive surgical excision; however, there is increasing evidence that medical management can be as effective as long as obstructive uropathy and bowel stenosis are excluded. Our objective was to establish the proportion of women with deeply infiltrating endometriosis successfully managed with hormonal therapies within our tertiary endometriosis centre in West London. Secondary analysis was performed on anonymised data from the Trust’s endometriosis database.ResultsOne hundred fifty-two women with deeply infiltrating endometriosis were discussed at our endometriosis multidisciplinary meeting between January 2010 and December 2016. Seventy-five percent of women underwent a trial of medical management. Of these, 44.7% did not require any surgical intervention during the study period, and 7.9% were symptomatically content but required interventions to optimise their fertility prospects. Another 7.0% were successfully medically managed for at least 12 months, but ultimately required surgery as their symptoms deteriorated. 26.5% took combined oral contraceptives, 14.7% oral progestogens, 1.5% progestogen implant, 13.2% levonorgestrel intrauterine device, 22.1% gonadotrophin-releasing hormone analogues, and 22.1% had analogues for 3–6 months then stepped down to another hormonal contraceptive. All women who underwent serial imaging demonstrated improvement or stable disease on MRI or ultrasound.ConclusionsMedical treatments are generally safe, well tolerated and inexpensive. More than half (52.6%) of women were successfully managed with medical therapy to control their symptoms. This study supports the growing evidence supporting hormonal therapies in the management of deeply infiltrating endometriosis. The findings may be used to counsel women on the likely success rate of medical management.

"Per vaginam" topical use of hormonal drugs in women with symptomatic deep endometriosis: a narrative literature review.

We aim to provide a comprehensive overview of the role of the vagina as a route for drug delivery and absorption, with a particular focus on the use of vaginal hormonal compounds for the treatment of deep infiltrating symptomatic endometriosis. A MEDLINE search through PubMed was performed to identify all published studies in English language on vaginal hormonal treatments for symptomatic endometriosis. Main advantages of the vaginal route include avoidance of the hepatic-first pass metabolic effect, the possibility of using lower therapeutic dosages, and the reduction of side effects compared with the oral administration. Studies on endometriosis treatment mainly focused on the use of vaginal danazol (n=6) and the contraceptive vaginal ring (n=2). One pilot study evaluated the efficacy of vaginal anastrozole in women with rectovaginal endometriosis. Most investigations evaluated the vaginal use of hormonal agents in women with deep infiltrating endometriosis/rectovaginal endometriosis. Overall, a substantial amelioration of pelvic pain symptoms associated with endometriosis was observed, particularly of dysmenorrhea. A significant reduction in rectovaginal endometriotic nodule dimensions measured at ultrasound examination was detected by some but not all authors. The vaginal route represents a scarcely explored modality for drug administration. High local hormonal concentrations might achieve a greater effect on endometriotic lesions compared with alternative routes. Future studies should focus on the use of the vagina for delivering target therapies particularly in patients with deeply infiltrating rectovaginal lesions.

Lesions of the Rectovaginal Septum-A Review

Background: The female rectovaginal septum may become involved by a variety of mass-like lesions, which may be challenging to providers who treat women. Objectives: To review the scope of lesions affecting the rectovaginal septum. Methods: A literature review was conducted. A Medline search was used, using the terms Vaginal diseases, Vaginal neoplasms, Rectal diseases, and Rectal neoplasms. Results: Reported lesions of the rectovaginal septum were reviewed. Many of these lesions can be mistaken for each other clinically. Conclusions: A review of the scope of rectovaginal lesions is presented to assist in developing a differential diagnosis if a patient with such a lesion is encountered. (J GYNECOL SURG 31:303)

Lesions of the Round Ligament and Canal of Nuck—It Is Not Always an Inguinal Hernia: A Review

Abstract Background: Lesions arising in the round ligament and canal of Nuck are uncommon and may prove challenging to clinicians. Objectives: To review the scope of lesions affecting the round ligament and canal of Nuck. Materials and Methods: A literature review was conducted. A Medline search was used, using the terms round ligament, canal of Nuck, and uterine neoplasms. Results: Reported lesions of the round ligament and canal of Nuck were reviewed. Many of these lesions can be mistaken for each other clinically. Conclusions: A review of the scope of rectovaginal lesions is presented to assist in developing a differential diagnosis if a patient with such a lesion is encountered. (J GYNECOL SURG 31:245)

Matrix metalloproteinase-27 is expressed in CD163+/CD206+ M2 macrophages in the cycling human endometrium and in superficial endometriotic lesions.

Matrix metalloproteinases (MMPs) are key enzymes involved in extracellular matrix remodelling. In the human endometrium, the expression and activity of several MMPs are maximal during the menstrual phase. Moreover, MMPs are thought to be involved in the pathogenesis of endometriosis and cancers, in particular with invasion and metastasis. We recently reported that MMP-27 is a unique MMP with an intracellular retention motif. We investigated the expression and cellular localization of MMP-27 in the cycling human endometrium and in endometriotic lesions. MMP-27 mRNA was detected throughout the menstrual cycle. Despite large interpatient variations, mRNA levels increased from the proliferative to the secretory phase, to peak during the menstrual phase. MMP-27 was immunolocalized in large isolated cells scattered throughout the stroma and around blood vessels: these cells were most abundant at menstruation and were identified by immunofluorescence as CD45(+), CD163(+) and CD206(+) macrophages. CD163(+) macrophages were also abundant in endometriotic lesions, but showed different patterns in ovarian or peritoneal endometriotic lesions (co-labelling for CD206 and MMP-27) and rectovaginal lesions (no co-labelling). In conclusion, MMP-27 is expressed in a subset of endometrial macrophages related to menstruation and in ovarian and peritoneal endometriotic lesions.

Medical Treatments for Endometriosis-Associated Pelvic Pain

The main sequelae of endometriosis are represented by infertility and chronic pelvic pain. Chronic pelvic pain causes disability and distress with a very high economic impact. In the last decades, an impressive amount of pharmacological agents have been tested for the treatment of endometriosis-associated pelvic pain. However, only a few of these have been introduced into clinical practice. Following the results of the controlled studies available, to date, the first-line treatment for endometriosis associated pain is still represented by oral contraceptives used continuously. Progestins represent an acceptable alternative. In women with rectovaginal lesions or colorectal endometriosis, norethisterone acetate at low dosage should be preferred. GnRH analogues may be used as second-line treatment, but significant side effects should be taken into account. Nonsteroidal anti-inflammatory drugs are widely used, but there is inconclusive evidence for their efficacy in relieving endometriosis-associated pelvic pain. Other agents such as GnRH antagonist, aromatase inhibitors, immunomodulators, selective progesterone receptor modulators, and histone deacetylase inhibitors seem to be very promising, but there is not enough evidence to support their introduction into routine clinical practice. Some other agents, such as peroxisome proliferator activated receptors-γ ligands, antiangiogenic agents, and melatonin have been proven to be efficacious in animal studies, but they have not yet been tested in clinical studies.

Differential expression of steroidogenic enzymes according to endometriosis type

To evaluate, in peritoneal, ovarian, and rectovaginal endometriotic lesions, expression of steroidogenic enzymes involved in the activation and inactivation of estrogens: 17β-hydroxysteroid dehydrogenase type 1 (HSD17B1) and 2 (HSD17B2), estrone sulfotransferase (EST), and steroid sulfatase (STS). Academic gynecology research unit. Retrospective study. Disease-free (n = 41) patients and patients with endometriosis (n = 79) were included for quantitative polymerase chain reaction (q-PCR) (15 disease-free, 33 endometriosis) and immunohistochemistry (26 disease-free, 46 endometriosis) studies. Q-PCR and immunohistochemistry. Evaluation of mRNA and protein expression. Glandular HSD17B1, HSD17B2, and STS protein expression were demonstrated. HSD17B2 mRNA values were higher in the secretory phase of the menstrual cycle in the endometrium of disease-free women, but not in the eutopic endometrium of patients with endometriosis. HSD17B1 mRNA was equally expressed in the various tissues investigated, and EST mRNA was expressed at low levels in the different lesion types. HSD17B2 mRNA expression was decreased in ovarian and rectovaginal endometriosis compared with eutopic endometrium, while STS mRNA was increased in rectovaginal lesions compared with ovarian lesions. Ratios between pro- and antiestrogenic enzymes (STS/EST and HSD17B1/HSD17B2) were more in favor of estrogens in ovarian and rectovaginal endometriosis. In endometriosis development, local activation of estrogens appears to be important. STS and HSD17B1 inhibitors may therefore prove useful to treat the disease.

Nerve Fibers are Absent in Disease-Free and Eutopic Endometrium, but Present in Endometriotic (Especially Deep) Lesions

Objective Detection of nerve fibers in endometrial biopsies was recently proposed as a noninvasive diagnostic tool for endometriosis. However, their occurrence in the functional layer of endometrium still remains controversial. Nerve fibers were found to be present in endometriotic lesions themselves, which may account for some of the pain experienced by patients, but their origin is not clear. The objective of the present study was to reevaluate the presence of nerve fibers in endometrium and in different types of endometriotic lesions. Patients and Methods Nerve fiber density (PGP9.5 immunohistochemical analysis), unmyelinated nerve fiber presence (neurofilament immunohistochemical detection) and nerve growth factor expression were evaluated in endometrial (disease free: n = 20; endometriotic: n = 26) and endometriotic (peritoneal lesions: n = 11; ovarian lesions: n = 16; rectovaginal lesions: n = 27) samples. Results Endometrial biopsies were found to be mostly negative for nerve fibers. Nerve fiber density was higher in deep nodular lesions than in peritoneal (p<0.01) or ovarian (p<0.001) lesions. Around 30% of PGP9.5-positive nerve fibers were confirmed by neurofilament staining. Nerve growth factor expression was detected at higher levels in the stroma of deep-infiltrating lesions (p<0.05). Conclusions No nerve fibers were detected in endometrial biopsies (from healthy or endometriosis patients). However, nerve fibers were detected in endometriotic lesions. Most of them were found to be unmyelinated, suggesting they could be implicated in pain. Deep nodular lesions may be more neuroattractive through the action of nerve growth factor.

Role of Surgery in Endometriosis-Associated Subfertility

Analysis of published series reveals that no more than a fourth of subfertile patients undergoing surgery for peritoneal endometriotic implants, rectovaginal endometriotic lesions, or recurrent endometriomas achieved conception spontaneously. First-line surgery for ovarian endometriotic cysts appears associated with a better reproductive performance, that is, a mean postoperative pregnancy rate of ∼50%. At the same time, excision of endometriomas paradoxically seems to induce gonadal damage. With the exception of peritoneal disease, no randomized trials are available to assess the effect of surgery in subfertile women with endometriosis. Therefore, it is not possible to define the absolute benefit increase of the treatment of ovarian and rectovaginal lesions. The decision to undergo surgery for endometriosis-associated subfertility must be shared with the woman after detailed information and taking into account several additional conditions, such as presence of pain, large or complex adnexal masses, bowel or ureteral stenosis, and coexisting infertility factors. When considering surgery, a therapeutic equipoise should be reached that includes demonstrated benefits, potential morbidity, and costs of treatment alternatives. Particularly in case of recurrent endometriosis, in vitro fertilization should generally be preferred to surgery. The role of surgery in endometriosis-associated subfertility includes temporary pain relief in symptomatic women desiring a spontaneous conception.

Pregnancy outcome in women with peritoneal, ovarian and rectovaginal endometriosis: a retrospective cohort study

We retrospectively assessed pregnancy outcome in 419 women who achieved a first spontaneous singleton pregnancy after surgery for endometriosis. A miscarriage was observed in 87 of 419 women (20.8%) and an ectopic pregnancy in eight (1.9%). Among the remaining 324 women, 14 (4.3%) experienced gestational hypertension/pre-eclampsia, 38 (11.7%) had a preterm delivery, five (1.5%) had placental abruption and 12 (3.7%) had placenta praevia. The incidence of placenta praevia was 7.6% in 150 women with rectovaginal lesions, 2.1% in 69 with ovarian endometriomas plus peritoneal implants, and 2.4% in 100 women with peritoneal implants only, whereas no case was observed in 100 women with ovarian endometriomas only.

Anterior Resection of a Rectal Endometriotic Nodule

Study Objective: Deeply infiltrating endometriosis includes rectovaginal lesions that might greatly alter the quality of life (dysmenorrhea, dispareunia, dyschezia, rectorragy). The indications for colorectal resection are controversial because of the risk of complications. We present a video showing our technique of an anterior rectal endometriotic nodule resection with a circular stapler in a patient with catamenial dyschezia. For the anterior rectal resection we used circular stapler (DST Series™ EEA™ of 31 mm, Autosuture ®). This device places a circular, double staggered row of titanium staples and resects the excess tissue, creating a circular anastomosis. The instrument is activated by squeezing the handle firmly as far as it will go. A study analysing the circular stapler approach is ongoing. Primary results show lower operative time, blood loss and complications. This technique of discoid bowel resection may allow us to have less invasive treatment with better outcomes. Study Objective: Deeply infiltrating endometriosis includes rectovaginal lesions that might greatly alter the quality of life (dysmenorrhea, dispareunia, dyschezia, rectorragy). The indications for colorectal resection are controversial because of the risk of complications. We present a video showing our technique of an anterior rectal endometriotic nodule resection with a circular stapler in a patient with catamenial dyschezia. For the anterior rectal resection we used circular stapler (DST Series™ EEA™ of 31 mm, Autosuture ®). This device places a circular, double staggered row of titanium staples and resects the excess tissue, creating a circular anastomosis. The instrument is activated by squeezing the handle firmly as far as it will go. A study analysing the circular stapler approach is ongoing. Primary results show lower operative time, blood loss and complications. This technique of discoid bowel resection may allow us to have less invasive treatment with better outcomes.

Comparison of contraceptive ring and patch for the treatment of symptomatic endometriosis

To evaluate the efficacy and tolerability of a contraceptive vaginal ring and transdermal patch in the treatment of endometriosis-associated pain. Patient preference cohort study. Academic center. Two-hundred and seven women with recurrent moderate or severe pelvic pain after conservative surgery for symptomatic endometriosis. Continuous, 12-month treatment with a vaginal ring supplying 15 mcg of ethinyl E and 120 mcg of etonogestrel per day or a transdermal system delivering 20 mcg of ethinyl E and 150 mcg norelgestromin per day. Satisfaction with treatment. One-hundred and twenty-three women preferred the ring, and 84 preferred the patch. Forty-four ring users (36%) and 51 patch users (61%) withdrew. Thirty-six of 79 subjects (46%) in the ring group and 14 of 33 (42%) in the patch group shifted from continuous to cyclic use because of irregular bleeding. Pain symptoms were reduced by both treatments, with the ring being more effective than the patch in patients with rectovaginal lesions. According to an intention-to-treat analysis, 88 of 123 ring users (72%) and 40 of 84 patch users (48%) were satisfied with the treatment received. Patients who preferred the ring were significantly more likely to be satisfied and to comply with treatment than those who chose the patch. Both systems were associated with poor bleeding control when used continuously.

OC24: The role of magnetic resonance imaging and transvaginal ultrasonography in patients with an adnexal mass and chronic pelvic pain or infertility

Objectives: Previously we showed that sonovaginography is an accurate ultrasonographic tool in the assessment of rectovaginal endometriosis. The aim of this study was to compare the diagnostic accuracy of sonovaginography and NMR in the diagnosis of rectovaginal endometriosis. Methods: This was a longitudinal prospective study in which 28 women with rectovaginal endometriosis suspected from the medical history and/or pelvic examination were enrolled. The study group underwent transvaginal ultrasonography and sonovaginography was performed in the same session as follows: an assistant inserted a Foley catheter into the vagina and an ultrasound probe covered with a specific balloon to swell the vagina. The balloon was filled with water (mean 40 mL) and soon after 60–180 mL saline solution was inserted through the Foley catheter to fill the vagina in order to create an acoustic window through the vagina to detect rectovaginal lesions. Within a mean of 30 days after the examination patients were scheduled for pelvic NMR. Once all the diagnostic tests had been performed, patients underwent laparoscopic surgery to enucleate the endometriotic lesion, which was sent for pathological examination. Results: Twenty-three (82.1%) patients had rectovaginal endometriotic lesions. The sensitivity of sonovaginography was 91.7%, specificity 75%, PPV 95.6% and NPV 60%; the area under the receiver-operating characteristic (ROC) curve was 0.87. In comparison, NMR had a sensitivity of 73.9%, specificity 60%, PPV 89.5% and NPV 33.3%, with an area under the ROC curve of 0.67. The procedure was well tolerated with a median visual analogue scale score of 2 (range, 0–8). Conclusions: Sonovaginography is a well tolerated procedure, with higher accuracy than NMR in the detection of rectovaginal endometriosis.

Deep Endometriosis: Definition, Pathogenesis, and Clinical Management

“Deep endometriosis” includes rectovaginal lesions as well as infiltrative forms that involve vital structures such as bowel, ureters, and bladder. The available evidence suggests the same pathogenesis for deep infiltrating vesical and rectovaginal endometriosis (i.e., intraperitoneal seeding of regurgitated endometrial cells, which collect and implant in the most dependent portions of the peritoneal cavity and the anterior and posterior cul-de-sac, and trigger an inflammatory process leading to adhesion of contiguous organs with creation of false peritoneal bottoms). According to anatomic, surgical, and pathologic findings, deep endometriotic lesions seem to originate intraperitoneally rather than extraperitoneally. Also the lateral asymmetry in the occurrence of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomic differences of the left and right hemipelvis. Peritoneal, ovarian, and deep endometriosis may be diverse manifestations of a disease with a single origin (i.e., regurgitated endometrium). Based on different pathogenetic hypotheses, several schemes have been proposed to classify deep endometriosis, but further data are needed to demonstrate their validity and reliability. Drugs induce temporary quiescence of active deep lesions and may be useful in selected circumstances. Progestins should be considered as first-line medical treatment for temporary pain relief. However, in most cases of severely infiltrating disease, surgery is the final solution. Great importance must be given to complete and balanced counseling, as awareness of the real possibilities of different treatments will enhance the patient's collaboration.

Deep endometriosis conundrum: evidence in favor of a peritoneal origin

Objective: To determine whether the depth and volume of the pouch of Douglas differs in patients with endometriosis with and without deep lesions and to compare them with subjects with a healthy pelvis or with diseases other than endometriosis. Design: Prospective, comparative study. Setting: Tertiary care and referral center for patients with endometriosis. Patient(s): Women undergoing laparoscopy for infertility, pelvic pain, or adnexal anomalies (deep endometriotic rectovaginal lesions in 16 cases, endometriosis without deep lesions in 127 cases, miscellaneous anomalies in 35 cases, and normal pelvis in 26 cases). Intervention(s): Douglas pouch depth measurement from the upper border of uterosacral ligaments to its base with a calibrated probe and volume assessment by a fluid-filling technique. Main Outcome Measure(s): Douglas pouch depth and volume. Result(s): Mean (±SD) Douglas pouch depth and volume measurements were 3.6 ± 1.6 cm and 41.6 ± 19.3 mL in women with deep endometriosis, 5.3 ± 0.8 cm and 67.2 ± 18.1 mL in those with peritoneal and ovarian lesions only, 5.2 ± 0.9 cm and 67.6 ± 12.6 mL in those with miscellaneous conditions, and 5.5 ± 0.8 cm and 65.8 ± 10.9 mL in those with normal pelvis. Conclusion(s): Reduced Douglas pouch depth and volume in women with deep endometriosis suggest that such lesions develop not in the rectovaginal septum but intraperitoneally and that burial by anterior rectal wall adhesions creates a false bottom, giving an erroneous impression of extraperitoneal origin.

Expression of interstitial collagenase (matrix metalloproteinase-1) is related to the activity of human endometriotic lesions

Objective: To determine whether interstitial collagenase (matrix metalloproteinase-1), known to play a pivotal role in the initiation of menstruation, contributes to the pathogenesis of endometriosis. Design: Serial sections of peritoneal red and black endometriotic lesions, ovarian endometriotic cysts, and rectovaginal adenomyotic nodules were analyzed by in situ hybridization for the expression of matrix metalloproteinase-1 by silver staining for the integrity of the fibrillar extracellular matrix and by immunolabeling for the abundance of sex steroid receptors. Setting: Academic hospital and research laboratory. Patient(s): Premenopausal women undergoing laparoscopy for endometriosis. Intervention(s): Biopsy of endometriotic lesions, combined with endometrium whenever possible. Main Outcome Measure(s): Expression of matrix metalloproteinase-1 messenger RNA (mRNA). Result(s): Matrix metalloproteinase-1 mRNA was expressed focally in red peritoneal and ovarian endometriosis irrespective of the phase of the menstrual cycle but was not detectable in black peritoneal and rectovaginal lesions. Foci of matrix metalloproteinase-1 expression closely correlated with matrix breakdown and with the absence of P receptors in adjacent epithelial cells. Conclusion(s): Correlation of matrix metalloproteinase-1 expression with activity of endometriotic tissue suggests its involvement in tissue remodeling and bleeding, and possibly in the secondary shedding and reimplantation of endometriotic lesions.