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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
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Updated information is at
UTMG 2006

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Glenn Ann Martin, Ph.D.
Clinical Psychologist

 

Rectovaginal Pouch of Douglas

Abstracted from: Martin DC, Batt RE. 
Retrocervical, rectovaginal pouch, and rectovaginal septum endometriosis.
J Am Assoc Gynecol Laparosc 8:12-17, 2001
 

This material was updated for the 25th Annual Meeting of the Japanese Society of Endometriosis in Osaka 24 and 25 January 2004.  There is a contrast between Adamyan Staging and true rectovaginal septum endometriosis.

Rectovaginal Pouch of Douglas and Rectovaginal Septum

 

 Your ALT-Text here The rectovaginal (RV) pouch covers part of the vagina and rectum and its base is the upper limit of the RV septum.

The RV pouch is not the RV septum.  The RV septum extends from the depth of the pouch to the top of the perineal body.

 Your ALT-Text here The depth of the RV pouch extends to the middle one third of the vagina in 93% of women.  Shortening of the RV pouch and elongation of the RV septum with RV pouch involvement appears to be related to contraction of the pouch.  This increases with increasing Adamyan stage.

 

Adamyan Retrocervical Staging

 

Dr. Leila Adamyan of Moscow has proposed a staging system with retrocervical endometriosis as Stage I with no vaginal involvement while Stage II involves the vagina.  This observation agrees with other author's observations that deep retrocervical and rectovaginal nodules tend to invade the vagina and not the rectum.  Adamyan Stage III involves the vagina and rectum and has cul-de-sac distortion while Stage IV includes cul-de-sac obliteration.  Stages I and II have no cul-de-sac distortion and are compatible with deep Mullerian or Koninckx Type III endometriosis.  Stages III and IV have significant cul-de-sac distortion and/or obliteration.  These appear to be a combination of Koninckx Type I and II. 

 

Note:  Although this 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. See Osaka 2004

 

           

 

These are photographs of stage I with endometriosis limited to the retrocervical area.  This is confirmed by placing a probe in the vagina between the endometriosis and the rectum.  The probe changes the light reflection and makes the endometriosis easier to see.

 

   

 

 

Adamyan Retrocervical Staging

 

Dr. Leila Adamyan of Moscow has proposed a staging system with retrocervical endometriosis as Stage I with no vaginal involvement while Stage II involves the vagina.  This observation agrees with other author's observations that deep retrocervical and rectovaginal nodules tend to invade the vagina and not the rectum.  Adamyan Stage III involves the vagina and rectum and has cul-de-sac distortion while Stage IV includes cul-de-sac obliteration.  Stages I and II have no cul-de-sac distortion and are

 

Update on Rectovaginal Septum (January 2004)

 

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.  Additional information is at the page for the 25th Annual Meeting of the Japanese Society of Endometriosis.

 

 

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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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Koninckx PR, Martin DC: Treatment of deeply infiltrating endometriosis. Curr Opinion Obstet Gynecol 6: 231-241, 1994

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

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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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