Rectovaginal Endometriosis

I recently had a patient who was referred to me for treatment of pelvic pain and pain with intercourse. She had multiple prior surgeries for “endometriosis”. During one of her prior surgeries she was noted to have “adhesions of her rectum to the uterus.

On her office exam, there was a nodule behind the uterus that I could feel. It appeared to be pulling her rectum into the back side of the uterus. This is the third patient I have seen with this similar presentation and history.

During surgery, she was noted to have a nodule of endometriosis that pulled the rectum forward and blocked her normal “pelvic cul-de-sac” (the area between the uterus and the rectum. During dissection, this nodule was dissected off the uterus and the rectum and freed up. After identifying the rectum, ureters and uterine blood vessels, the nodule was removed.

When treating endometriosis surgically, it is important to use the physical examination to know what to expect at the time of surgery. It is also important for the surgeon to feel comfortable removing endometriosis in difficult areas such as over the ureters or bowel. There are many times endometriosis surgeries are performed and the surgeon takes a look and then stops the surgery because the endometriosis is too bad or in locations “too risky” to remove.

This patient is an ideal example of the necessity to know how to identify and adequately excise the endometriosis encountered during surgery.