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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
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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
   
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.
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Cullen 1917 Netter 1954
Kuhn 1982 Vercellini 2000
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Koninckx Types I, II and III - 1992
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"High Septum" Cullen 1917, Netter 1954, Adamyan 1993,
Umaria 2001
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"Deep Septum"
Kuhn 1982,
Vercellini 2000,
Martin 2001
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Adamyan Illustrations 1993
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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.
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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
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Addendum
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.
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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.
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References
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Adamyan L: Additional
international perspectives. In Nichols DH (ed): Gynecologic and Obstetric
Surgery. St. Louis: Mosby Year Book, 1993, pp 1167-1182
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Chen TF, Collier DSJ,
Everett WG, et al: Endometriosis of the rectovaginal septum treated by anterior
resection. Ann Chir Gynaecol 78:324-326, 1989
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Cullen TS: Adenomyoma
of the recto-vaginal septum. Johns Hosp Bull 321:343-348, 1917
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Koninckx PR, Martin
DC: Deep endometriosis: a consequence of infiltration or retraction or possibly
adenomyosis externa? Fertil Steril 58:924-928, 1992
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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
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Kuhn R, Hollyock V:
Observations on the anatomy of the rectovaginal pouch and septum. Obstet Gynecol
59:445-447, 1982
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Martin DC, Batt RE:
Retrocervical, Rectovaginal Pouch and Rectovaginal Septum Endometriosis. J Am
Assoc Gynecol Laparosc 8:12-17, 2001
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Netter FH: Volume 2,
Reproductive System. In Oppenheimer E (ed): Ciba Collection of Medical
Illustrations. Summitt, NJ: Ciba Pharmaceutical Company, 1954
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Possover M, Diebolder
H, Plaul K, et al: Laparoscopically assisted vaginal resection of rectovaginal
endometriosis. Obstet Gynecol 96:304-307, 2000
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Umaria N and Olliff JF: Imaging features of pelvic endometriosis. B J
Radiol 74, 556-562, 2001
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Vercellini P, Aimi G,
Panazza S, et al: Deep endometriosis conundrum: evidence in favor of a
peritoneal origin. Fertil Steril 73:1043-1046, 2000
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Endometriosis
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
ObGyn.net
EndoZone
Dr. David
Redwine
Dr. Mark
Perloe
Dr. Andrew Cook
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