Retrocervical endometriosis is an extraperitoneal form of external genital endometriosis with localization of the pathological process in the tissue between the posterior surface of the cervix and the rectum. It is manifested by pelvic pain, dyspareunia, contact bleeding from the vagina, bloody-mucous discharge from the rectum during menstruation. It is diagnosed by gynecological examination, transvaginal ultrasound, MRI, CT, rectoromanoscopy, colonoscopy, laparoscopy. Treatment is combined with the appointment of hormone therapy, immunomodulators, analgesics, enzymes, laparoscopic removal of endometriod foci or radical interventions.
Deep infiltrative retrocervical endometriomas are the third most common variant of endometriosis, more often than other forms are complicated by the spread to neighboring pelvic organs (rectosigmoid colon, peritoneum, ureters, bladder). Pathology is diagnosed mainly in women over 35 years of age with dishormonal conditions, inflammatory diseases of the reproductive organs, invasive gynecological interventions, complicated course of labor. The relevance of timely diagnosis is due to the high invasiveness of the endometrioid process with metastic lesion of the pelvic organs, obliteration of the uterine space and subsequent infertility.
The etiology of the spread of endometrioid growths on the post-cervical tissue has not been definitively established. Four main theories of the occurrence of the disease have been proposed, markers have been identified, in the presence of which the probability of developing endometriosis in the retrocervical space increases significantly. According to experts in the field of obstetrics and gynecology, pathology is caused by:
- Implantation of viable endometrial elements. Morphologically and functionally, the tissue of endometrioid heterotopias is similar to the endometrium. Implantation is possible after invasive interventions, severe labor, retrograde withdrawal of menstrual blood due to intense loads (shaping, sex, etc.), the presence of obstructive vaginal septa, hymen atresia.
- Genetic factors. The detection of infiltrative endometriosis in several generations of women in the family indicates the possibility of inheritance of the disease. However, the specific chromosome and gene responsible for the occurrence of endometrioid foci have not yet been determined. Perhaps the disease is polygenic, and its onset is provoked by damaging factors.
- Incomplete embryogenesis. The authors of the embryonic theory believe that the foci of endometriosis in the retrocervical tissue are formed from the embryonic paramesonephral ducts, which served as the basis for the formation of the genitals. The theory is confirmed by the detection of pathology in non-menstruating girls and its combination with abnormalities in the development of the reproductive system.
- Mesothelial metaplasia. The source of endometriodic tissue can be cells of the embryonic coelomic mesothelium that persist between mature peritoneal cells and in the transition zone between the endometrium and myometrium. Their activation is facilitated by retrograde entry into the retrocervical space of degenerating epithelial tissue during menstruation.
The risk group includes women with genital infections (colpitis, endocervicitis, endometritis), hormonal disorders caused by ovarian dysfunction in chronic oophoritis, adnexitis, cysts, sclerocystic syndrome, pituitary-hypothalamic disorders. The probability of detecting endometriosis increases with a decrease in immunity or the development of autoimmune processes.
The manifestations of retrocervical endometriosis are caused by cyclic changes occurring in pathological foci and the invasive spread of the process to neighboring organs (vagina, rectum). The researchers suggest that the formation of the primary focus becomes possible due to a decrease in local immunity – insufficient activity of T—lymphocytes, especially T-suppressors. The further spread of endometrioid cells is most likely carried out by contact, lymphogenic and hematogenic pathways. Compensatory activity of B-lymphocytes increases in the affected area, the level of immunoglobulins (IdA, IgG) increases, autoantibodies to endometrioid foci appear over time, which induces the adhesive process.
Highly differentiated heterotopias with retrocervical localization have receptors for estrogens and progesterone. During the menstrual cycle, the same changes occur in them as in the endometrium — proliferation, secretion, desquamation with the decay of the epithelium and hemorrhages into closed cavities. Low-differentiated foci are represented by cystic glands with low cylindrical or cubic epithelium, insensitive to hormonal influences. The connection of the disease with endocrine regulation is confirmed by a temporary decrease in the size of growths during lactation and their regression in the postmenopausal period.
The key criterion in the systematization of forms of retrocervical endometriosis is the degree of prevalence of the process. This approach allows you to more accurately predict the course of the disease and choose the optimal treatment method in terms of volume. There are four stages of pathology:
- Stage 1 – single endometrioid foci of small size are determined.
- Stage 2 – against the background of the germination of heterotopias in the cervix and the wall of the vagina, small cystic changes are formed.
- Stage 3 – there is a lesion with endometriosis of the serous membrane of the rectum, sacro-uterine ligaments.
- Stage 4 – the rectal mucosa is involved in the process, the peritoneum is infiltrated, adhesions have formed in the pelvis.
Symptoms of retrocervical endometriosis
There are no symptoms at the initial stages of the disease. As the size of endometriod foci increases, complaints arise of aching or shooting pains in the rectum, which radiate into the vagina, perineum, external genitalia, sacrum, lower back, inner thigh. The intensity of pain increases on the eve of menstruation, in its first days. Sexual contacts become painful. The germination of the walls of adjacent organs is indicated by the appearance or intensification of pain during defecation, contact bleeding after sex, mucous or bloody discharge from the anus during menstruation.
In almost half of cases, retrocervical endometriosis is complicated by infertility, the main cause of which is the adhesive process in the pelvic cavity. Additional blood loss during menstruation leads to the formation of chronic iron deficiency anemia. Extremely rarely endometrioid heterotopias are malignized. The narrowing of the intestine due to the ingrowth of the focus of endometriosis is accompanied by the occurrence of constipation up to intestinal obstruction. In far-reaching cases, the germination of the ureters and bladder leads to a violation of the passage of urine. Severe pain syndrome reduces a woman’s performance on the eve and in the first days of menstruation, becomes the basis for the appearance of persistent neurotic disorders — emotional lability, subdepressive reactions, hypochondria, carcinophobia.
The tasks of the diagnostic stage in case of suspected retrocervical endometriosis are the detection of endometrioid formations in the fiber separating the rectum and cervix, determining the extent of the process, the involvement of other organs and the peritoneum in it. To make a diagnosis, traditional physical methods are supplemented with modern instrumental ones. The most informative:
- Gynecological examination. On palpation, large foci of endometriosis are determined in the area of the posterior vaginal arch as soft-elastic volumetric formations. Examination in mirrors reveals the germination of heterotopia in the form of contact bleeding cyanotic areas. It is possible to limit the mobility of the uterus and appendages. Vaginal examination is usually supplemented with rectovaginal examination and colposcopy.
- Transvaginal ultrasound of the pelvic organs. The method visualizes the volumetric formations of the retrocervical region. Endometrioid foci are rounded, with an inhomogeneous echostructure, fuzzy borders and an uneven contour. Their sizes are usually 0.5-5.0 cm. Since sonography does not detect the spread of endometriosis to the ligaments of the uterus and pelvic walls, in addition to ultrasound, tomography is often prescribed.
- CT, MRI of the pelvis. The layered study and 3D modeling of the structure of pelvic organs is aimed at detecting the invasion of endometriodic growths into adjacent organs — the cervix, vaginal walls, rectum. On the tomogram, a possible narrowing of the intestinal lumen is easily detected. The value of the data obtained is especially high when choosing between organ-preserving and radical surgical interventions.
- Endoscopic methods. During rectoromanoscopy, colonoscopy, the condition of the mucosa of the rectum and sigmoid colon is objectively assessed, possible sites of endometriosis germination from retrocecal fiber are determined. The condition of the peritoneum is clarified by diagnostic laparoscopy. The key advantage of endoscopy is the possibility of targeted biopsy of questionable tissues for their histological examination.
Differential diagnosis of post-cervical endometrioma is performed with other variants of endometriosis, cancer of the rectum, cervix, vagina, ovaries, retrocervical abscesses, erythroplakia of the cervix. If there are indications, the patient, in addition to the gynecologist, is examined by specialized specialists — oncologist, proctologist, surgeon, endocrinologist, urologist.
The most effective is a combined approach with the appointment of pathogenetic drug therapy and surgical removal of post-cervical endometrioid growths. When choosing the method and scope of the operation, the patient’s age, her reproductive plans, the stage of the process and the degree of infiltration of surrounding organs are taken into account. Drug treatment without surgical intervention with careful monitoring of the process can be recommended only to women during menopause, when there is a possibility of regression of foci. Pharmaceuticals are usually used to suppress the growth of ectopia during routine preparation for surgery. Patients with endometriosis of the retrocervical space are recommended:
- Hormone therapy. It is possible to prescribe combined progestogen-estrogenic drugs, progestins, antigonadotropins, gonadotropin releasing factor agonists. The use of drugs that affect the secretion of sex hormones makes it possible to suppress cyclic changes in endometrioma tissues and stop its growth.
- Other pathogenetic agents. Since endometriosis is often combined with disorders in the immune system, patients are shown immunomodulators that increase the effectiveness of protective forces and reduce the likelihood of an autoimmune response. Enzymes are used to prevent the development of adhesions in the area of the endometrioid focus.
- Symptomatic drugs. To relieve severe pain syndrome, nonsteroidal anti-inflammatory drugs that increase the sensitivity threshold of pain receptors in the lesion, and antispasmodics that reduce muscle cell spasm in the intestinal wall are recommended. Taking into account the presence of anemia, most patients are prescribed iron preparations.
Laparoscopy is the optimal method of surgical treatment of retrocervical endometriosis. The use of modern technology makes it possible to excise foci not only from the cervical fiber, but also within healthy tissues from the walls of the rectum and other hollow organs without the risk of violating their integrity. During laparoscopic operations, it is possible to detect and remove heterotopias from the abdominal cavity in time, which were not detected at the diagnostic stage. The use of anti-adhesive gels and barriers in the postoperative period minimizes the risk of adhesions between the pelvic organs. Organ-preserving interventions ensure the restoration of the patient’s reproductive function. Radical operations (hysterectomy, extirpation of the uterus with appendages, resection of the rectum) are used in extreme cases with common forms of the disease.
Prognosis and prevention
The use of modern surgical techniques in combination with hormone therapy has reduced the risk of relapses in retrocervical endometriosis to 3-4%, restore childbearing function and significantly improve the quality of life of patients. Prevention of the disease provides for the restriction of physical activity during menstruation, the rejection of unjustified invasive interventions (abortions, diagnostic curettage, pertubation of the fallopian tubes), careful management of childbirth and compliance with the technique of gynecological operations. To detect the disease in the early stages, when treatment is more effective, regular examinations by a gynecologist and ultrasound screening are recommended, especially for patients with a history of heredity, pathological childbirth, diathermoexcision and diathermocoagulation of the cervix, and other surgical interventions on reproductive organs.