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What You Need To Know About Rectovaginal Endometriosis: Symptoms, Treatment, and Prognosis

Posted on March 16, 2022
Medically reviewed by
Dan Martin, M.D.
Article written by
Kristopher Bunting, M.D.

Rectovaginal endometriosis (RVE) is a severe form of endometriosis, a painful chronic condition where endometrial-like cells (cells like the lining of the uterus) grow outside of the uterus. RVE is a type of deep infiltrating endometriosis. Deep infiltrating endometriosis invades deep into the peritoneum, the lining that covers organs in the pelvis and abdomen. RVE can occur in any stage of endometriosis, but large rectovaginal lesions are common in stage 4 endometriosis — the most severe stage.

RVE is less common than other forms of endometriosis. It affects between 4 percent and 37 percent of people with endometriosis, depending on the data source. RVE can involve both the vagina and the rectum, as well as the surrounding tissue in the pelvis. To be more specific, RVE can involve the rectovaginal septum, the wall of tissue that separates the vagina from the rectum inside the body. It usually involves the rectovaginal cul-de-sac, the empty space between the vagina and rectum above the rectovaginal septum.

RVE can spread and invade nearby body parts, including the ligaments that help hold the uterus in place and the ureters, the tubes that connect the kidneys to the bladder. Like other types of endometriosis, RVE can cause severe pain, infertility, and menstrual problems.

Signs and Symptoms of Rectovaginal Endometriosis

Symptoms of RVE are the same as other forms of endometriosis, but they tend to be more severe. Severity of symptoms can vary throughout the menstrual cycle as estrogen levels fluctuate.

Common symptoms seen with RVE include:

  • Chronic pelvic pain
  • Abdominal pain
  • Lower back pain
  • Heavy menstrual periods (menorrhagia)
  • Painful menstrual periods (dysmenorrhea)
  • Pain during sexual intercourse (dyspareunia)
  • Pain during urination (dysuria)
  • Pain during bowel movements (dyschezia)
  • Constipation
  • Bloating
  • Nausea and vomiting
  • Infertility or difficulty getting pregnant

Diagnosis of Rectovaginal Endometriosis

A diagnosis of endometriosis generally requires laparoscopic surgery, but vaginal biopsy can sometimes be used. Other steps to diagnose endometriosis include a thorough family and personal medical history, physical exam (including a pelvic exam), blood and other laboratory tests, and imaging studies.

Medical History

A careful and thorough medical history can identify potential symptoms of endometriosis. It can also help identify if other family members have endometriosis. Having family members with endometriosis increases your risk of developing the condition.

Physical Exam

A physical exam can identify nodules and tenderness that may be endometriosis lesions. A pelvic exam may also be performed to find potential abnormalities of the reproductive tract and rectovaginal septum.

Blood Tests

Standard blood tests, including a complete blood count, are needed to rule out other possible conditions.

Imaging

Imaging studies are used to help locate endometrial lesions. The primary imaging method used to look for these lesions is ultrasound. Pelvic ultrasound, transvaginal ultrasound, and transrectal ultrasound are all used to identify potential lesions.

Colonoscopy may also be performed. CT and MRI imaging are sometimes used to identify lesions, but they are more likely to be used before surgery to look for anatomic abnormalities caused by endometriosis.

Laparoscopy

The standard for diagnosis of endometriosis is laparoscopic surgery to visually identify lesions. Surgeons can also use laparoscopic surgery to collect tissue for biopsies, which can positively identify endometrial tissue. Surgery can also be therapeutic; surgical removal of lesions is part of the treatment of endometriosis.

What Causes Rectovaginal Endometriosis?

The causes of rectovaginal and other types of endometriosis are poorly understood. What is known is that both genetic and environmental factors play a role in the development of disease. Several processes are suspected to cause endometriosis, but research has yet to prove a single cause.

It is most likely that a variety of genetic and environmental factors work together in the development of endometriosis. Biological mechanisms including inflammation, the immune system, and estrogen and progesterone receptors may be involved. Research is ongoing to understand the pathogenesis of endometriosis.

Risk factors for endometriosis include:

  • A family history of endometriosis
  • Early onset of menstruation
  • Late menopause
  • Not having delivered a child

Rectovaginal Endometriosis Treatment

Treatment of RVE includes pain management, hormonal therapy, and surgical removal of endometriosis lesions and adhesions.

Pain Management

Chronic and recurring pain from RVE can be debilitating. Many over-the-counter and prescription pain medications can be used to manage pain. Nonsteroidal anti-inflammatory drugs such as ibuprofen can help pain. Other pain medications, including opioid painkillers, may be used to help control the severe pain of RVE.

Hormonal Therapy

Endometriosis lesions respond to estrogen. They grow and spread when estrogen levels are high, just as normal endometrial tissue does. Drugs called gonadotropin-releasing hormone (GnRH) antagonists like Orilissa (elagolix) can treat endometriosis by lowering estrogen levels. GnRH agonists like Lupron (leuprolide) work in the same way. Danocrine (danazol) is a synthetic hormone related to testosterone that alters hormone levels and reduces endometriosis symptoms.

Hormonal therapies are effective at reducing pain and other symptoms of endometriosis — even the severe pain associated with RVE.

Hormonal contraceptives, such as birth control pills and hormonal intrauterine devices, are often used to treat endometriosis. Oral contraceptives are usually not effective against the severe symptoms of RVE.

Surgery

Surgery, including laparoscopic surgery or laparotomy, is used to diagnose RVE, to remove or destroy endometriosis lesions, and to treat adhesions. Surgical excision, electrosurgery, and laser resection are minimally invasive surgery options that are used to remove lesions.

Because RVE is a deeply invasive type of endometriosis, tissue containing lesions may need to be removed. In some cases, sections of bowel must be removed, and the remaining bowel must be rejoined.

Surgery to remove the uterus (hysterectomy) or ovaries (oophorectomy) can be a treatment option for severe endometriosis. However, there are drawbacks to each procedure. Both options cause permanent infertility, and an oophorectomy can increase a person’s risk for cardiovascular disease.

Overall, surgery has proven to be an effective way to relieve bowel symptoms, pain, and pain with sex (dyspareunia) in many people with RVE.

Complications of Rectovaginal Endometriosis

RVE can cause bowel obstruction. Bowel surgery for endometriosis can have several severe complications, including rectovaginal fistulas and adhesions.

Rectovaginal Fistulas

Rectovaginal fistulas are essentially holes that connect the interiors of the vagina and rectum. These holes allow fecal material to enter the vagina. Rectovaginal fistulas can lead to vaginal discharge, chronic vaginal and urinary tract infections, irritation of the vagina and vulva, and bowel incontinence.

Adhesions

Endometriosis causes inflammation that can lead to scarring of the peritoneum, the lining that covers organs in the pelvis and abdomen. This scarring can cause the formation of painful adhesions between organs, or scarring that makes internal organs stick to one another.

In addition to causing pain, adhesions can deform organs such as the fallopian tubes (contributing to infertility) or the intestines (leading to intestinal blockages). Adhesions can also obstruct the fallopian tubes, bowel, ureters, and blood vessels in the pelvis and abdomen, cutting off blood flow (ischemia) and causing tissue death (necrosis). Severe complications caused by adhesions, such as bowel necrosis, can be a medical emergency.

Rectovaginal Endometriosis Outlook

RVE is considered the most severe kind of endometriosis. It can cause serious complications and significant pain. Effective treatments can improve symptoms while also addressing the underlying disease. While surgical treatment is usually necessary to alleviate symptoms, studies have shown that hormonal therapies can significantly improve severe symptoms — including pain — by controlling estrogen levels. Together, surgery and hormonal treatments can effectively reduce symptoms, help prevent severe complications, and significantly improve quality of life for people with RVE.

Talk With Others Who Understand

MyEndometriosisTeam is the social network for people with endometriosis and their loved ones. On MyEndometriosisTeam, more than 124,500 members come together to ask questions, give advice, and share their stories with others who understand life with endometriosis.

Are you living with rectovaginal endometriosis? Share your experience in the comments below, or start a conversation by posting on your Activities page.

References
  1. Endometriosis — Johns Hopkins Medicine
  2. Diagnosis, Management, and Long-Term Outcomes of Rectovaginal Endometriosis — International Journal of Women’s Health
  3. Diagnosis and Treatment of Rectovaginal Endometriosis: An Overview — Acta Obstetricia et Gynecologica Scandinavica
  4. Retrocervical, Retrovaginal Pouch, and Rectovaginal Septum Endometriosis — The Journal of the American Association of Gynecologic Laparoscopists
  5. Endometriosis of the Retrocervical Septum Is Proposed To Replace the Anatomically Incorrect Term Endometriosis of the Rectovaginal Septum — Human Reproduction
  6. Endometriosis: Diagnosis and Treatment — Mayo Clinic
  7. Family Incidence of Endometriosis in First-, Second-, and Third-Degree Relatives: Case-Control Study — Reproductive Biology and Endocrinology
  8. Pelvic Exam: About — Mayo Clinic
  9. Complete Blood Count (CBC): About — Mayo Clinic
  10. Current Biomarkers for the Detection of Endometriosis — Chinese Medical Journal
  11. CA 125 Relatively Specific for Diagnosing Endometriosis — American Family Physician
  12. Ultrasound: About — Mayo Clinic
  13. Transvaginal Ultrasound — Mayo Clinic
  14. Computed Tomography (CT) Scan — Johns Hopkins Medicine
  15. Magnetic Resonance Imaging (MRI) — Johns Hopkins Medicine
  16. Diagnostic Laparoscopy — UCSF Health
  17. Biopsies — Johns Hopkins Medicine
  18. Genetic Factors Contribute to the Risk of Developing Endometriosis — Human Reproduction
  19. Environmental Risk Factors for Endometriosis: A Critical Evaluation of Studies and Recommendations From the Epidemiologic Perspective — Current Epidemiology Reports
  20. Involvement of Immune Cells in the Pathogenesis of Endometriosis — The Journal of Obstetrics and Gynaecology Research
  21. Theories on the Pathogenesis of Endometriosis — International Journal of Reproductive Medicine
  22. Endometriosis: Symptoms and Causes — Mayo Clinic
  23. Medical Treatment for Rectovaginal Endometriosis: What Is the Evidence? — Human Reproduction
  24. Rectovaginal Fistula: Symptoms and Causes — Mayo Clinic
  25. Abdominal Adhesions — National Institute of Diabetes and Digestive and Kidney Diseases
  26. Abdominal Adhesions: A Practical Review of an Often Overlooked Entity — Annals of Medicine and Surgery

All updates must be accompanied by text or a picture.
Dan Martin, M.D. is the scientific and medical director of the Endometriosis Foundation of America. Learn more about him here.
Kristopher Bunting, M.D. studied chemistry and life sciences at the U.S. Military Academy, West Point, and received his doctor of medicine degree from Tulane University. Learn more about him here.

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