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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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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
 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.
 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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