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Tubal Reversal
Reproductive Surgery
Dr Martin
Tubal Requests

Dan C. Martin, MD
UT Medical Group, Inc.

University of Tennessee Health Science Center (UTHSC)

UTHSC Academic Office

Daniel Clyde Martin, M.D.
UT Medical Group, Inc.
Infertility and Gynecology
Reproductive Surgery
Germantown Office Building
7945 Wolf River Boulevard
Suite 320
Germantown, Tennessee
TN 38138-1733

(901) 347-8331
(901) 347-8188 fax
Directions to Office

Updated information is at
UTMG 2006

Click for information on:
Glenn Ann Martin, Ph.D.
Clinical Psychologist

Retrocervical and Rectovaginal Endometriosis

Dan C. Martin, M.D.

Presented at the

25th Annual Meeting

of the

Japanese Endometriosis Society

Osaka, Japan

25 January 2004

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The terminology used for rectovaginal endometriosis can be difficult due to anatomic understanding.  Vaginal surgeons and urogynecologists know that the Pouch of Douglas extends to the middle third of the vagina in most women. However, Netter drew this in a retrocervical location in 1954.  In addition, many authors (Cullen 1917, Adamyan 1993, Umaria 2001) discuss a retrocervical position of endometriosis as being in the septum.  The septum is not generally retrocervical in normal anatomy.



 Cullen 1917     Netter 1954           Kuhn 1982             Vercellini 2000




Koninckx Types I, II and III - 1992




"High Septum" Cullen 1917, Netter 1954, Adamyan 1993, Umaria 2001




"Deep Septum" Kuhn 1982, Vercellini 2000, Martin 2001




Adamyan Illustrations 1993




Adamyan Retrocervical Stages, Martin 2001

The illustrations of my 2001 paper agree with the original Adamyan illustrations for Stages III and IV but not for Stages I and II.  Although my 2001 paper discussed retrocervical and rectovaginal as separate areas, this was for discussion of the concepts and not to add a new staging system.  I use the Adamyan Staging System for retrocervical endometriosis.  But the Adamyan system does not include involvement of the septum. 

The 2001 paper abstract is at: Recto-Vaginal Pouch Endometriosis.



Endometriosis in the Rectovaginal Septum

Involvement of the septum is probable with endometriosis extension into the lower 1/2 to 1/3 length of the vagina.  Endometriosis has extended to the lower 1/2 of the vagina in the illustration.  Extension into the lower 1/2 is associated with an increased risk of rectovaginal fistula after anastomosis.  Extension to this level is rare and may occur in no more than 1 in 75,000 to 1 in 750,000 women.

The Adamyan Staging System for retrocervical endometriosis does not include involvement of the septum.  Involvement of the septum may be called Adamyan Stage V or a new terminology may be needed.

Presented at the25th Annual Meeting of the Japanese Endometriosis Society.

Osaka, Japan, 25 January 2004




The anatomy of the pelvis can vary in individuals.  But, in general, the perineal body is at the vulva and the lower 1/3 of the vagina.  The septum starts in the lower 1/3 of the vagina and extends to the middle 1/3.  The Pouch of Douglas extends past the upper 1/3 and to the middle 1/3 of the vagina.



Deep Infiltration of Endometriosis is Associated with an Increased Risk of Rectovaginal Fistula by Jennifer Swoboda and Dan Martin won the  First prize resident's paper award at the Annual Meeting of the AAGL November, 2004.  The announcement is on page 23 at AAGL 2004.

Summaries and posters are at AAGL 2004, Deep Infiltration of Endometriosis is Associated with an Increased Risk of Rectovaginal Fistula and Rectovaginal Fistulas and Pelvic Abscess after Resection of Rectovaginal Endometriosis.





Adamyan L: Additional international perspectives. In Nichols DH (ed): Gynecologic and Obstetric Surgery. St. Louis: Mosby Year Book, 1993, pp 1167-1182


Chen TF, Collier DSJ, Everett WG, et al: Endometriosis of the rectovaginal septum treated by anterior resection. Ann Chir Gynaecol 78:324-326, 1989


Cullen TS: Adenomyoma of the recto-vaginal septum. Johns Hosp Bull 321:343-348, 1917


Koninckx PR, Martin DC: Deep endometriosis: a consequence of infiltration or retraction or possibly adenomyosis externa? Fertil Steril 58:924-928, 1992


Koninckx PR, Cornillie FJ: Infiltrating endometriosis: infiltration, retraction or adenomyosis externa? In Martin DC (ed): Atlas of Endometriosis. London: Gower Med Publ, 1993, pp 9.1-9.8


Kuhn R, Hollyock V: Observations on the anatomy of the rectovaginal pouch and septum. Obstet Gynecol 59:445-447, 1982


Martin DC, Batt RE: Retrocervical, Rectovaginal Pouch and Rectovaginal Septum Endometriosis. J Am Assoc Gynecol Laparosc 8:12-17, 2001


Netter FH: Volume 2, Reproductive System. In Oppenheimer E (ed): Ciba Collection of Medical Illustrations. Summitt, NJ: Ciba Pharmaceutical Company, 1954


Possover M, Diebolder H, Plaul K, et al: Laparoscopically assisted vaginal resection of rectovaginal endometriosis. Obstet Gynecol 96:304-307, 2000


Umaria N and Olliff JF:  Imaging features of pelvic endometriosis. B J Radiol 74, 556-562, 2001


Vercellini P, Aimi G, Panazza S, et al: Deep endometriosis conundrum: evidence in favor of a peritoneal origin. Fertil Steril 73:1043-1046, 2000



    Endometriosis: Emerging Research and Intervention - NIH 2002

    Endometriosis on DanMartinMD.com 

    Laparoscopic Appearance of Endometriosis - 1988 Slide Set  

    Laparoscopic Appearance of Endometriosis - 1990 Color Atlas

    Laparoscopic Appearance of Endometriosis - 1991 Lecture Supplement

    Endometriosis Association  



    Dr. David Redwine 

    Dr. Mark Perloe 

    Dr. Andrew Cook 

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