Deep pelvic endometriosis: clinical features, diagnosis, and treatment - a comprehensive review

Deep infiltrative endometriosis (DIE) is characterized by the infiltration of endometrial tissue into the pelvic organs, such as the rectovaginal septum, utero-ovarian, and uterosacral ligaments. Bowel involvement occurs in approximately 3.8-37% of cases, whereas urinary tract involvement is less common (1-6%). The pathophysiology of DIE includes deep infiltration of endometrial tissue into the peritoneum, with the gastrointestinal system being a common site. The pathogenesis of endometriosis involves hormonal functional changes in estrogen and progesterone receptors and the influence of immune factors like peritoneal macrophages, natural killer cells, and lymphocytes. Diagnostic methods, including transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI), play crucial roles in identifying and assessing endometriosis. Medical treatment options include oral contraceptives, progesterone pills and devices, and gonadotropin-releasing hormone (GnRH) analogs or antagonists. Surgical treatment options are shave excision, disc excision, and colorectal resection. This review provides a comprehensive overview of DIE, its pathophysiology, diagnostic methods, treatment options, as well as implications for fertility and pregnancy outcomes.