Vercellini Paolo, Frontino Giada, Pietropaolo Giuliana, Gattei Umberto, Daguati Raffaella, Crosignani Pier Giorgio
Clinica Ostetrica e Ginecologica I, Istituto Luigi Mangiagalli, University of Milan, Milan, Italy.
J Am Assoc Gynecol Laparosc. 2004 May;11(2):153-61. doi: 10.1016/s1074-3804(05)60190-9.
"Deep endometriosis" includes rectovaginal lesions as well as infiltrative forms that involve vital structures such as bowel, ureters, and bladder. The available evidence suggests the same pathogenesis for deep infiltrating vesical and rectovaginal endometriosis (i.e., intraperitoneal seeding of regurgitated endometrial cells, which collect and implant in the most dependent portions of the peritoneal cavity and the anterior and posterior cul-de-sac, and trigger an inflammatory process leading to adhesion of contiguous organs with creation of false peritoneal bottoms). According to anatomic, surgical, and pathologic findings, deep endometriotic lesions seem to originate intraperitoneally rather than extraperitoneally. Also the lateral asymmetry in the occurrence of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomic differences of the left and right hemipelvis. Peritoneal, ovarian, and deep endometriosis may be diverse manifestations of a disease with a single origin (i.e., regurgitated endometrium). Based on different pathogenetic hypotheses, several schemes have been proposed to classify deep endometriosis, but further data are needed to demonstrate their validity and reliability. Drugs induce temporary quiescence of active deep lesions and may be useful in selected circumstances. Progestins should be considered as first-line medical treatment for temporary pain relief. However, in most cases of severely infiltrating disease, surgery is the final solution. Great importance must be given to complete and balanced counseling, as awareness of the real possibilities of different treatments will enhance the patient's collaboration.
“深部子宫内膜异位症”包括直肠阴道病变以及累及肠道、输尿管和膀胱等重要结构的浸润性病变形式。现有证据表明，深部浸润性膀胱和直肠阴道子宫内膜异位症具有相同的发病机制（即反流的子宫内膜细胞腹腔内种植，这些细胞聚集并植入腹膜腔最依赖部位以及直肠子宫陷凹和膀胱子宫陷凹，引发炎症过程，导致相邻器官粘连并形成假腹膜底部）。根据解剖学、手术和病理学发现，深部子宫内膜异位病变似乎起源于腹腔内而非腹腔外。输尿管子宫内膜异位症发生的侧方不对称也与月经反流理论以及左右半骨盆的解剖差异相符。腹膜型、卵巢型和深部子宫内膜异位症可能是单一来源疾病（即反流的子宫内膜）的不同表现形式。基于不同的发病机制假说，已提出多种深部子宫内膜异位症的分类方案，但需要更多数据来证明其有效性和可靠性。药物可使活跃的深部病变暂时静止，在特定情况下可能有用。孕激素应被视为缓解疼痛的一线药物治疗方法。然而，在大多数严重浸润性疾病的病例中，手术是最终解决方案。必须高度重视全面且平衡的咨询，因为了解不同治疗的实际可能性将增强患者的配合度。
