Deep infiltrating endometriosis - Dr.Shiva Harikrishnan

When the endometriosis tissue growing outside the uterus spreads deep inside the tissue of organs close to or inside the pelvic cavity, including the bowel, urinary bladder, intestine, vagina, etc it is called DIE – Deep infiltrating endometriosis. It penetrates more than 5mm into the peritoneal tissues. DIE is rare and usually found only in 1% of women with endometriosis, but the issue is that it may not always respond positively to treatment.

The clumps of scar tissue formed as a healing process after bleeding due to inflammation of endometriosis tissue is called adhesions. These adhesions may bind the organs together.

In this manner, DIE invasion can cause a frozen pelvis, where endometriosis that has progressed deep between organs, locks them together and prevents or restricts their movement. This can cause extreme pain, especially during ovulation, intercourse, and menstrual period.

Symptoms of DIE

The presence or absence of these symptoms does not indicate the severity of the situation as women with mild symptoms can have a severe form of endometriosis and vice versa too. DIE usually affects areas rich in nerve endings which can cause irritation and pain. The symptoms also vary based on where it has been affected.

-Symptoms of endometriosis in the reproductive tract include pain with mensuration or Dysmenorrhea, pain during intercourse or dyspareunia, and infertility.

-Symptoms for endometriosis in the urinary tract – When the ureter below the pelvic area is affected, it is known as Urinary Tract endometriosis. Some of the symptoms include increased urine frequency, urgency to pass urine, pelvic or lower back pain, burning sensation when passing urine, and presence of blood in the urine. In some cases, the symptoms will not be there, but the ureter will become closed causing a loss of function of the kidney.

-Symptoms for endometriosis in the bowel – Endometriosis in the bowel can cause fusion of the rectum and vagina. This can cause severe pain during intercourse or bowel movements. Abdominal pain, bloating, constipation, diarrhoea, and blood in stool are a few other symptoms. Some do not have any symptoms at all.

Diagnosis for DIE

A combination of the techniques like pelvic exam, ultrasound scan, MRI, laparoscopy, or biopsy will be used for locating and identifying the severity of the issue.

Management of DIE

Treatment for DIE will vary based on what is the problem that needs to be solved, that is if it is to relieve pain, decrease the growth of the endometriosis tissues, for fertility, remove the endometrial tissues, or to avoid it from coming back. Hormone treatment may be provided to limit the production of oestrogen which encourages the endometriosis tissue to grow. But complete management using medicines or hormone tablets is not possible in most cases.

Laparoscopy to remove the lesions and scar tissue is a common procedure. But it also depends on the magnitude of how much endometriosis has spread.

In severe cases, an incision will be necessary. As the surgery can be complicated it is necessary to have a highly specialized surgeon perform the procedure. This is because an incomplete resection will result in the patient coming again for another surgery. The surgery will provide relief for a few years but there are chances the disease may recur. Treatment via surgical methods also depends on the location of endometrial tissue that needs to be removed.

Urinary tract endometriosis treatment 

The affected part of the ureter needs to be removed and the rest is sewn back. In some cases, the scar tissue only can be removed.

In rare cases when endometriosis has affected a large section of the ureter cutting and re-joining the ureter will not work. Instead, the urinary bladder will have to be moved closer to the ureter and the ureter is inserted into the bladder. During the procedure, a urinary stent will be placed along the length of the ureter from the kidney to the bladder. This stent will be carrying the urine until the ureter heals. The stent will be removed after 6 weeks using a cystoscope.

If the urinary bladder has been affected by endometriosis, the affected area will be removed, and the rest sewn together. In this case, a catheter will be used for one week till the bladder heals.

Bowel Endometriosis Treatment 

If the endometriosis has affected the bowel, depending upon the depth and the size of the nodule of endometriosis, we have to do a shaving of the rectal wall, a discoid excision, or a complete resection of the bowel with an end-to-end anastomosis. There is no need for a colostomy. We will involve the colorectal surgeon; it will be multidisciplinary care.


In cases where the symptoms are not present, and infertility is not an issue the doctors may wait to see what needs to be done. For more details kindly contact us.



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