Rectal endometriosis is a benign overgrowth of the endometrium in the distal part of the large intestine. Usually develops a second time after the spread of endometriosis to the ovaries and peritoneum. It is manifested by constant pain in the lower abdomen, false urges, stool disorders, impurities of mucus and blood in the feces. Symptoms occur a few days before the start of menstruation and persist until it ends. The disease is diagnosed on the basis of a characteristic clinical picture, general and gynecological examination data, ultrasound, irrigoscopy, rectoromanoscopy and other studies. Treatment – drug therapy, excision of foci of ectopic endometrium.
N80.5 Intestinal endometriosis
Rectal endometriosis is a type of extragenital endometriosis, in which local endometrial growths occur in the rectum. It usually develops due to the spread of endometriosis from the female genital organs to the peritoneum and further to the rectum. It is extremely rarely diagnosed as an independent process. Experts suggest that cases of damage to the rectum in the absence of endometriosis in the area of the female genital organs and peritoneum are caused by hematogenous proliferation of endometrial cells.
Rectal endometriosis is the most common form of intestinal endometriosis, accounting for about 70% of the total number of lesions of the large intestine. It can cause perforation of the intestine and the development of intestinal obstruction. According to researchers, rectal endometriosis is detected in 1-2% of women of reproductive age. Usually patients under the age of 40 suffer, in some cases the disease develops in the menopausal period. Treatment is carried out by specialists in the field of proctology, gastroenterology, gynecology and endocrinology.
The direct cause of the development of endometriosis of the rectum is contact or hematogenous (less often) spread and subsequent implantation of cells of the uterine mucosa into the serous membrane of the rectum. Predisposing factors are:
- diseases of the female genital organs (endometritis, salpingoophoritis);
- multiple abortions;
- increased estrogen levels due to ovarian pathology, liver disease, obesity, diabetes mellitus;
- chronic stress and insufficient physical activity play a certain role.
Unlike chronic proctitis, endometriosis of the rectum affects not the inner, but the outer part of the organ. Endometrial cells grow into the serous membrane and can spread to the muscular layer of the intestine, forming one or more islands or multiple foci. Multiple areas of rectal endometriosis occur when uterine epithelial cells with menstrual blood are thrown through the fallopian tubes or when an endometrioid cyst ruptures.
In the initial stages of endometriosis of the rectum, the islets of the endometrium located on the serous membrane of the organ visually resemble bluish stripes or small spots. Subsequently, plaques or nodules are formed in place of stripes and spots, surrounded by scars diverging in the form of rays. With the progression of endometriosis of the rectum, the endometrium either grows deep into the muscle layer, or spreads through the serous layer and circularly covers the intestine. In this case, the wall of the rectum thickens, its lumen narrows. When all layers germinate, outgrowths resembling polyps appear on the mucous membrane.
There is no connective tissue capsule, areas of endometriosis of the rectum gradually pass into the normal tissue of the organ. Histological examination in the center of such areas reveals scars, altered muscle fibers and bubbles with reddish or brownish fluid. The vesicles are formed by a glandular epithelium resembling endometrioid tissue. The ratio of stroma and epithelial cells in rectal endometriosis can vary significantly.
Areas resembling a normal endometrium, islands with a pronounced predominance of stroma, or zones with almost complete absence of stroma and glandular tissue growths may be detected. The researchers note that the change in the ratio between the listed elements often causes difficulties in diagnosing “endometriosis of the rectum”. Some scientists point out that with the predominance of stroma, there is an increased risk of transformation of endometriosis into sarcoma.
The clinical symptoms of endometriosis of the rectum are determined by cyclic changes in the foci of the endometrium. Signs of the disease occur a few days before the onset of menstruation, persist during menstruation, and then disappear. The severity of the manifestations of endometriosis of the rectum depends on the depth of germination of ectopic tissue. When the serous layer or the serous membrane and the superficial layers of the muscles are affected, patients complain of localized or diffuse pain in the rectum, anus or perineum. Pain syndrome can be combined with increased motor skills, bloating and diarrhea.
With the germination of deep muscle layers and the intestinal mucosa, the intensity of pain increases. Patients with endometriosis of the rectum complain of constipation, bloating and difficult discharge of gases. Often there is pain during sexual intercourse. Over time, the symptoms of rectal stenosis come to the fore: ribbon-like feces, the need for manual assistance with bowel movements, impurities of blood and mucus in the feces. During menstruation, bloody diarrhea is possible.
With pronounced intestinal obstruction, patients suffering from endometriosis of the rectum are sometimes hospitalized in surgical departments. With the predominance of diarrhea and false urges, hospitalization in infectious departments with suspected dysentery and other intestinal infections is possible. Anemia is not characteristic (except in cases when intestinal endometriosis is combined with menorrhagia or metrorrhagia).
The diagnosis of endometriosis of the rectum is established during a consultation with a proctologist based on the history of the disease, complaints, examination data and the results of additional studies. Since extragenital endometriosis in the vast majority of cases develops a second time, against the background of damage to the female genital organs, consultation of a gynecologist, obstetric and gynecological anamnesis data, results of gynecological examination and diagnostic techniques used in the process of detecting diseases of the female reproductive system are of great importance in the process of diagnosing endometriosis of the rectum.
- Objective data. Suspicion of endometriosis of the rectum occurs when there is a regular increase in pain and the appearance of bloody diarrhea or bloody discharge from the anus during menstruation. During the general examination, soreness may be detected during palpation of the lower abdomen. The area of the anus is usually not changed (except in cases of prolonged existence of the disease with the development of rectal stenosis).
- Gynecological examination. During gynecological examination, some patients with endometriosis of the rectum have foci of endometriosis in the vagina. During bimanual vaginal examination, adhesions and scarring of the uterus and fallopian tubes may be detected. To clarify the nature and prevalence of pathological changes, ultrasound of the pelvic organs and transvaginal echography are performed.
- Proctological examination. The data of the finger rectal examination depend on the prevalence of endometriosis of the rectum. With deep and / or extensive foci, infiltration and narrowing of the intestine can be determined. During rectoscopy, polypoid growths are sometimes detected. Contrast X–rays in the presence of such growths reveal filling defects, and with stenosis – signs of narrowing of the intestine. The most informative is endoscopy with biopsy.
- Instrumental methods. With superficial endometriosis of the rectum, information about the state of the intestinal wall, the presence and prevalence of ectopic endometrial sites is obtained by laparoscopy. When the intestinal wall sprouts, the use of rectoromanoscopy is effective. Both methods should be prescribed on the eve or during menstruation, when foci of endometriosis of the rectum become more noticeable. Along with the above studies, CT scans of the pelvic organs are used to assess the prevalence of the process.
Differential diagnosis of endometriosis of the rectum is carried out with dysentery and colorectal cancer. Endometriosis is indicated by the duration of the disease, the cyclical nature of clinical manifestations, the relationship between exacerbations and the menstrual cycle, as well as the presence of foci of endometriosis in the female genital organs, peritoneum, navel, etc.
Treatment of rectal endometriosis
The basis of conservative treatment consists of measures to correct the hormonal background. In addition, antibacterial drugs, antiviral agents and immunocorrectors are used in the course of therapy. Patients are referred for physiotherapy. In the absence of the effect of conservative therapy, widespread endometriosis of the rectum, severe forms of combined genital and extragenital endometriosis, surgical intervention is indicated. Before surgery, patients are prescribed hormone therapy for 3-6 months to reduce the size of pathological foci and minimize blood loss.
Surgical tactics for endometriosis of the rectum are determined individually, depending on the localization and prevalence of the process. With small foci, resection of the affected areas is possible. With multiple genital and extragenital zones of ectopic epithelium, hysterectomy with removal of appendages (adnexectomy), excision of affected areas in the area of other organs and resection of pathological foci in the rectum with suturing of the resulting defects is indicated.
An indication for emergency intervention in endometriosis of the rectum is intestinal obstruction. When detecting signs of peritonitis, specialists in the field of surgical proctology perform the imposition of a colostomy, and subsequently perform reconstructive operations.