Clinical diagnosis and treatment of bowel endometriosis and the distribution characteristics of lesions

Background Bowel endometriosis (BE) is a complex condition that can present with diverse clinical manifestations, impacting the quality of life for affected individuals. This retrospective case series aimed to investigate the clinical characteristics, diagnosis, treatment, and lesion distribution of BE.

Eighty-eight patients with pathologically confirmed BE who underwent surgery at Shanghai Rui-jin Hospital between January 2013 and September 2024 were retrospectively reviewed. Clinical features, diagnostic methods, treatment approaches, lesion distribution, and their association with adenomyosis were analyzed.

Among the 88 patients, 70.5% had unilateral and/or bilateral endometriotic cysts, and 44.4% of those with ureteral involvement had such cysts. Pelvic MRI demonstrated a positive predictive value of 88.2% (60/68), and endoscopic ultrasound (EUS) showed a positive predictive value of 90.2% (37/41) for preoperative diagnosis of BE. Following surgery, all patients reported relief or disappearance of symptoms, with postoperative symptom improvement rates of 100% for dysmenorrhea, chronic pelvic pain, dyspareunia, and dyschezia.

Pelvic MRI is recommended for preoperative evaluation of BE, and EUS may be a valuable adjunct in patients with gastrointestinal symptoms to exclude malignancy. CT urography should be considered in cases with suspected ureteral involvement requiring further anatomical clarification. Multidisciplinary collaboration is essential for individualized surgical planning and optimal management of BE. Similar content being viewed by others

Endometriosis is a prevalent gynecological condition, characterized by the growth of tissue that resembles endometrial tissue and responds to hormonal changes [1]. The incidence of endometriosis in women of childbearing age is 5%-15% [2]. Bowel endometriosis (BE) refers to endometriosis implants affecting the intestines. Endometriosis can be found superficially on the intestines or invading the lumen of the intestines. BE is a type of deep infiltrating endometriosis (DIE) that is defined as a depth of invasion > 5 mm into the wall of the intestines, most commonly, in the sigmoid colon or rectum, and the incidence is up to 37% among patients with DIE [3]. The mechanism of BE is unclear and may stem from a combination of factors, including iron-induced oxidation and antioxidant imbalance, abnormal estrogen metabolism, abnormal immune system function and abnormal genetically related signaling pathways in the ectopic endometrial microenvironment [4]. Patients often experience common gynecological symptoms (dysmenorrhea, chronic pelvic pain, dyspareunia), which may be accompanied by different degrees of intestinal symptoms, including diarrhea, constipation, dyschezia, and blood in the stool [5]. Endometriosis remains difficult to diagnose, and there are no biomarkers currently available for detecting or ruling out the condition [6]. Endometriosis is primarily diagnosed with surgical visualization, ideally with laparoscopy, and confirmed with pathological diagnosis [1]. Imaging is believed to be of little use, though ultrasound accuracy in diagnosing pelvic endometriosis has improved in recent years [7]. To date, the treatment of BE is still mainly based on surgical resection of the lesion [8]. In addition to involving the intestine, BE often involves internal heterogeneous lesions in other parts of the body, and the treatment involves multidisciplinary collaboration. The operation is difficult, and the complication rate is high [9]. Although several prior studies have investigated the role of imaging in the preoperative diagnosis of BE [10,11,12], they are often limited by small sample sizes, heterogeneous patient populations, or focus on single-modality assessments without integrating imaging findings with lesion distribution or surgical outcomes. To date, a clear consensus on the diagnostic value of imaging modalities, especially when stratified by lesion location or complexity, has not been established. Therefore, this study aimed to explore the lesion distribution, clinical diagnosis, and treatment characteristics of BE, particularly, the effectiveness of preoperative imaging. Assessing the distribution of lesions is crucial for determining the type of surgery and treatment plan. We hope that the results will aid in developing a more efficient management plan and offer diagnostic and treatment guidance for clinical practices of BE patients.

This was a retrospective, single-center case series that included all consecutive patients who underwent surgical treatment for BE at the Department of Gynecology, Rui-jin Hospital, Shanghai Jiao Tong University School of Medicine between January 2013 and September 2024. Eligible patients were identified through a review of the hospital’s electronic medical records and pathology database. The inclusion criteria were: (1) patients who underwent laparoscopic or open surgery for suspected BE; (2) patients with an intraoperative clinical diagnosis of BE confirmed by postoperative histopathological results; and (3) patients whose final pathological examination indicated BE [13]. This study was approved by the ethics committee of Rui-jin Hospital, Shanghai Jiaotong University. Due to the retrospective nature of the study, informed consent was waived (KY2022-126). Surgical procedures were performed according to standard techniques as described in the literature [14]. Briefly, the choice of surgical technique—including shaving, discoid excision, or segmental bowel resection—was based on the size, depth, and location of the intestinal lesions, as well as multidisciplinary discussion and patient preference. The aim was complete removal of endometriotic lesions with preservation of organ function where possible. Data was collected from electronic medical records retrospectively. The postoperative pathological results of all patients were reviewed and recorded. Pathologically involved sites included the left and right uterosacral ligaments, left and right fallopian tubes, left and right ureters (including the para-ureteral regions), left and right ovaries, vagina, cervix (including the back of the cervix), pelvic peritoneum, bladder and intestine (including the rectum, sigmoid colon, appendix, anus, etc.). There were no missing data in this study. Adenomyosis was diagnosed based on clinical symptoms, imaging findings (transvaginal ultrasound and/or magnetic resonance imaging), and confirmed by histopathology when surgical specimens were available. The diagnostic criteria included: (1) typical clinical symptoms (such as menorrhagia, severe dysmenorrhea, and infertility); (2) imaging features on ultrasound (globularly enlarged uterus, heterogeneous myometrial echotexture with small cystic areas, or a thickened and irregular junctional zone) or MRI (diffuse or focal low-signal-intensity areas within the myometrium on T2-weighted images); and (3) histopathological confirmation, defined as the presence of ectopic endometrial glands and stroma at least one low-power field (approximately 2.5 mm) from the endometrial–myometrial junction [15, 16]. The preoperative examination of all patients routinely included biannual gynecological examination, vagino-recto-abdominal examination, and serum CA125 tests. Transvaginal ultrasonography, pelvic magnetic resonance imaging, Endoscopic ultrasound (EUS), and CT urography were performed if needed (Fig. 1). All data were independently reviewed by two investigators. Disagreements were resolved by discussion; no statistical indicator for interobserver agreement was calculated. After surgery, patients were followed up at the outpatient clinic of our hospital at 1 month, 6 months and 1 year; gynecological examinations, pelvic ultrasounds and serum CA125 tests were conducted. For preoperative and postoperative pain quantification, a digital numerical rating scale (NRS) was adopted, and the degree of pain was divided into 5 levels according to the NRS score: 0 indicated no pain, 1–3 indicated mild pain, 4–6 indicated moderate pain, 7–9 indicated moderately severe pain, and 10 indicated severe pain. Routine reviews were repeated annually after 1 year of follow-up. The follow up was concluded on December 31st, 2024. Pain relief was defined as a decrease of more than 50% in postoperative pain compared to preoperative levels. Recurrence was defined as pain reaching or exceeding the preoperative measurement after experiencing relief. Patient satisfaction was categorized into three levels based on the reduction in NRS scores for each symptom: totally satisfied (> 80%), mostly satisfied (50%-80%), and dissatisfied (< 50%). Statistical analyses were performed using the Statistical Package for the Social Sciences (IBM SPSS version 25, IBM Corp, Windows). The continuous data were expressed as the mean ± standard deviation (x ± s), preoperative and postoperative NRS scores were analyzed by paired t-tests, and categorical data are expressed as percentages. A two-sided P < 0.05 was considered statistically significant.

General information The average age of the 88 patients was 38.51 ± 7.67 years (20–61 years). Among them, 56 (63.6%) had dysmenorrhea, 52 (59.1%) had chronic pelvic pain, five (5.7%) had dyspareunia, and 23 (26.1%) had dyschezia. 21 patients (23.9%) required pain medication, while another 12 (13.6%) faced secondary infertility and 12 (13.6%) dealt with abnormal uterine bleeding. 24 patients (27.3%) experienced diarrhea and 25 (28.4%) reported constipation. Preoperative imaging and diagnostic evaluation The consistency rate between the postoperative pathological diagnosis and preoperative imaging diagnosis of BE was 75.0%, while the consistency rate between the postoperative pathological diagnosis and intraoperative diagnosis of BE was 97.7%. All patients underwent transvaginal ultrasonography and bimanual/trimanual examination, with positive rates of 72.7% (64/88) and 83.0% (73/88), respectively. Pelvic MRI had a positive rate of 88.2% (60/68), and EUS had a positive rate of 90.2% (37/41) for preoperative diagnosis. CT urography indicated ureteral obstruction prior to surgery in 21.4% (3/14) of BE patients. Details are summarized in Table 1; Fig. 1. Surgical management All patients received complete surgical excision of BE lesions (Fig. 2). The surgical approach was individualized according to lesion location, size, and depth, and followed established guidelines for management of bowel endometriosis. Specifically, 52 patients (59.1%) underwent limited excision, including shaving excision of the intestinal wall (44 patients) or disc (full-thickness) excision of the lesion (8 patients). Segmental bowel resection with reanastomosis was performed in 34 patients (38.6%), typically for larger or multifocal lesions or those involving the muscularis or submucosa. One patient (1.1%) underwent appendectomy for appendiceal endometriosis, and one patient (1.1%) had anal mass resection for anal involvement. No patients received non-excisional or ablative (e.g., laser or cauterization) treatments. There were 79 patients who underwent laparoscopic surgery, 8 who underwent open surgery, and 1 who underwent anorectal surgery. The distribution of ectopic endometrial lesions is summarized in Table 2. All patients had a postoperative pathological diagnosis of BE (Fig. 3). There were 13 patients had intraoperative ureteral endometriosis; one required ureteral resection and bladder reimplantation. Fifteen had posterior vaginal fornix endometriosis (all underwent lesion resection), eight had cervical endometriosis (hysterectomy), 62 had ovarian cysts (cystectomy), 59 had sacral ligament DIE lesions (lesion resection), nine had tubal endometriosis (salpingectomy), and 59 had adenomyosis (with 17 hysterectomies and 42 adenomyomectomies). Postoperative complications No intraoperative or postoperative complications, such as intestinal fistula, anastomotic leakage, anastomotic bleeding, or stenosis, occurred in any patient. One patient experienced recurrence 8 months after surgery following prior hysteromyomectomy and intestinal wall resection. Lesion distribution The distribution of patients’ lesions is summarized in Table 2. Lesion size ranged from 0.7 cm to 7 cm. The probability of BE comorbid with unilateral and/or bilateral endometriotic cysts was 70.5%. Among patients with BE and ureteral involvement, 44.4% had unilateral and/or bilateral endometriotic cysts. Distribution of lesions in patients with BE and adenomyosis According to postoperative pathological results, 59 patients had both BE and adenomyosis. The distribution characteristics of their lesions and rectal endometriosis combined with adenomyosis are summarized in Table 2. Rectal endometriosis accounted for the largest proportion of all BE cases (81.8%, 72/88). Lesion distribution of rectal endometriosis The combinations of endometrial lesions at different sites used for the analysis of rectal endometriosis are detailed in Table 3. Among patients with rectal endometriosis, 50 (69.4%) also had adenomyosis. Outcomes and follow-up Among the 88 patients, 68 (77.3%) received adjuvant therapy with gonadotropin-releasing hormone agonists (GnRH-a) (rASRM [17] stage IV and AAGL [18] stage IV) for 6 months postoperatively. No patients were lost to follow-up. The average follow-up duration was 23.46 ± 14.03 months (range: 6–60 months). According to the satisfaction survey, 71 patients (80.7%) were totally satisfied with their postoperative pain and gastrointestinal symptom relief, and 17 patients (19.3%) were basically satisfied. No patients (0%) were dissatisfied. Details are summarized in Table 4. For the 34 patients who underwent segmental bowel resection, recovery time for intestinal symptoms (diarrhea, constipation, distention) was longer than for the remaining 54 patients during follow-up. After more than 6 months of postoperative outpatient follow-up, 12 patients met the fertility requirements. Patients were advised to consult the Department of Reproductive Medicine before pregnancy. Six patients became pregnant, one of whom conceived naturally, and five of whom conceived by in vitro fertilization-embryo transfer (IVF-ET). Pain and symptom relief All patients experienced varying degrees of relief or resolution of dysmenorrhea, dyschezia, dyspareunia, and chronic pelvic pain at 1 month and 6 months after surgery, with statistically significant decreases in pain scores (P < 0.05), as shown in Table 5.

This study demonstrates the diverse clinical manifestations of BE and highlights the high diagnostic accuracy of pelvic MRI and EUS in the preoperative assessment of BE. A strong coexistence of adenomyosis and rectal endometriosis was observed, and postoperative outcomes were favorable, with substantial relief of pain and gastrointestinal symptoms. Diagnosis and preoperative examination of BE Accurate preoperative assessment is essential for optimal management of BE. Our findings align with recent studies demonstrating that pelvic MRI offers high sensitivity and specificity, with reported positive predictive values above 85% for BE detection [10]. MRI not only differentiates BE from colorectal malignancy but also provides detailed mapping of lesion infiltration depth and extent, which is crucial for surgical planning [19]. EUS, as shown in our cohort and recent prospective studies, is particularly valuable for detecting lesions infiltrating the muscularis propria and for distinguishing endometriosis from primary intestinal neoplasms [20]. EUS also enables targeted biopsy when malignancy is suspected and allows for precise preoperative localization [21]. However, EUS should be reserved for patients with gastrointestinal symptoms suggestive of BE, rather than being used routinely. For suspected urinary tract involvement, CT urography remains valuable to define ureteral anatomy and obstruction, supporting findings from recent cohorts showing its utility for surgical planning [22]. Surgical treatment of BE Surgical treatment for BE should be tailored to the location, extent, and depth of intestinal wall invasion. Current guidelines recommend limited excision (shaving or disc excision) for lesions < 3 cm in diameter, < 7 mm in depth, and involving < 50% of the bowel circumference, to preserve vascular and neural integrity and optimize postoperative intestinal function [23]. Segmental resection with reanastomosis is indicated for larger, multifocal, or deeply invasive lesions, or those in the sigmoid colon or involving the submucosa or mucosa, to prevent deformity and stenosis [24]. In our cohort, all patients underwent complete excision of BE lesions, with surgical modality determined according to these principles. No intraoperative or postoperative complications such as fistula, bleeding, or stenosis were observed, underscoring the safety of multidisciplinary, guideline-based management. Consistent with prior studies, thorough resection was associated with significant pain relief and improved quality of life [25, 26]. However, segmental resection carries a documented risk of complications (up to 18%), emphasizing the importance of individualized surgical planning [27]. Lesion distribution and comorbidities Our findings confirm the high prevalence of ovarian endometriotic cysts in BE patients (70.5%), and a 44.4% comorbidity with ureteral involvement, aligning with previous studies [28]. These patterns underscore the need for comprehensive preoperative assessment, including evaluation of the uterosacral ligaments, ureters, and pelvic peritoneum, especially in patients with known DIE or ovarian endometriomas. Surgical management of BE with concomitant ureteral DIE is particularly challenging and may require multidisciplinary expertise and thorough preoperative planning, as well as detailed informed consent regarding the possibility of vital organ involvement. BE and adenomyosis The coexistence of BE and adenomyosis was observed in 67.1% of patients in this study, with 69.4% of those with rectal endometriosis also having adenomyosis. This is consistent with pathological studies indicating a possible homology between DIE and exophytic adenomyosis [28], and with imaging studies showing a higher prevalence of adenomyosis among endometriosis patients [29, 30]. These findings further support the interconnected pathogenesis of DIE and adenomyosis. Fertility outcomes Several patients in our series achieved pregnancy after surgery, including both natural conception and IVF-ET. This highlights the potential for fertility preservation and improvement following comprehensive surgical management of BE, particularly in patients with severe symptoms or infertility. Surgical intervention, when appropriately indicated and performed with fertility-preserving techniques, can play a pivotal role in reproductive outcomes for women with BE. Non-surgical management and long-term follow-up Optimal management of BE requires a combination of surgical and medical approaches. Medical therapy, including gonadotropin-releasing hormone agonists (GnRH-a), progestins (such as dienogest), and combined oral contraceptives, can control the progression of endometriotic lesions but is not curative. Long-term management is essential, as symptom recurrence is common if therapy is discontinued. In this study, 68 patients received postoperative GnRH-a therapy, four received oral contraceptives, one received oral letrozole, and 15 patients who underwent definitive surgery did not require further medication. Recent evidence confirms that both GnRH-a and dienogest effectively reduce postoperative pain and recurrence risk, with dienogest offering a well-tolerated long-term option suitable throughout the reproductive years [31]. GnRH-a is generally limited to short-term use due to side effects, while dienogest may be continued until conception is desired. For recurrent endometriomas, early progestin therapy may reduce the need for repeat surgery, and in select cases, surgery or ultrasound-guided aspiration may be considered [19], followed by continued hormonal therapy [32]. Radical surgery may be appropriate for patients with no fertility desire, severe symptoms, or suspected malignant transformation [33]. Follow-up is recommended every 3–6 months and should include symptom assessment, gynecological examination, pelvic ultrasound, ovarian tumor markers, and evaluation of ovarian function. Recurrence rates for DIE range from 4% to 25% and are related to the thoroughness of the initial surgery and adherence to long-term management protocols [34]. Strengths and limitations This study adds to the current literature by providing a comprehensive overview of surgical and medical management outcomes in a contemporary cohort of BE patients. Our findings highlight the high diagnostic accuracy of MRI and EUS in preoperative assessment, underscore the frequent coexistence of adenomyosis and rectal endometriosis, and demonstrate favorable postoperative outcomes with a multidisciplinary, guideline-based approach. Moreover, our results support the role of individualized, fertility-preserving interventions and long-term medical management in optimizing both symptom control and reproductive outcomes for women with BE. However, this study has several limitations. First, as a retrospective, single-center analysis, there is potential for selection bias, and the findings may reflect a relatively homogenous patient population. Second, the use of different imaging modalities across patients could introduce diagnostic inconsistencies and bias. Third, the duration of follow-up may not be sufficient to fully capture long-term recurrence rates, as longer-term data are increasingly emphasized in recent studies. Fourth, pain scores relied on patient self-report, which is inherently subjective and susceptible to recall bias. Fifth, patient satisfaction was assessed with a non-validated, single-question approach rather than standardized patient-reported outcome measures, possibly limiting reliability and comparability. Additionally, although data extraction and imaging interpretation were performed independently by two investigators, no formal statistical measurement of interobserver agreement, such as the intraclass correlation coefficient (ICC), was conducted. This omission may limit the assessment of reproducibility and reliability of imaging findings. Future prospective, multicenter studies with standardized imaging protocols, validated patient-reported outcome measures, formal assessment of interobserver agreement, and longer follow-up are warranted to confirm and extend these findings.

BE is a rare type of DIE that seriously affects women’s quality of life. If unilateral and/or bilateral ovarian endometriotic cysts are found on preoperative examination, the risk of intestinal and ureteral involvement in patients with adenomyosis is significantly increased. Pelvic MRI should be considered for preoperative evaluation of BE, and EUS may be useful in selected patients with gastrointestinal symptoms to exclude malignancies. CT urography may be considered in patients with suspected ureteral involvement when further anatomical clarification or exclusion of other urinary tract pathologies is needed. The lesion type and the patient’s age and fertility needs should be determined, and a multidisciplinary surgical team should cooperate with the patient to develop an individualized surgical plan, that can effectively relieve symptoms and improve quality of life. Surgical removal of BE nodules may include resection of intestinal surface lesions, discectomy or segmental bowel resection of intestinal lesions. Regular postoperative follow-up and pharmacotherapy can be provided to achieve an optimal response and reduce the recurrence rate. Data availability The research data used to support the findings of this study were supplied by Prof.Liu under license and so cannot be made freely available. Requests for access to these data should be made to Prof.Liu (Email: [email protected]). Abbreviations - BE: - Bowel Endometriosis - EUS: - Endoscopic Ultrasound - NRS: - Numerical Rating Scale

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The authors thank the Rui-jin Hospital, Shanghai Jiao Tong University School of Medicine for their assistance with this research. Funding This study has been supported by research grants awarded by Shanghai Municipal Health Commission (No.202340093) to establish the cohort and follow up. Author information Authors and Affiliations Contributions All authors contributed to the study conception and design. HNJ, WWF, HL contributed to the planning, conduction and report of the work. HNJ, HL contributed to the conception and design of the work. HNJ, WWF contributed to the acquisition of analysis and interpretation of the results. All authors have read and approved the manuscript. Corresponding authors Ethics declarations Ethics approval and consent to participate The study was approved by the Institutional Review Board of Rui-jin Hospital, Shanghai Jiaotong University (KY2022-126). The requirement for informed consent was waived by the Institutional Review Board of Rui-jin Hospital, Shanghai Jiaotong University because of the retrospective nature of the study. I confirm that all methods were performed in accordance with the relevant guidelines. All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. About this article Cite this article Jiao, H., Feng, W. & Liu, H. Clinical diagnosis and treatment of bowel endometriosis and the distribution characteristics of lesions. BMC Women's Health 26, 62 (2026). https://doi.org/10.1186/s12905-025-04248-3 Received: Accepted: Published: Version of record: DOI: https://doi.org/10.1186/s12905-025-04248-3