Endometriosis: Clinical and Anatomical Considerations

  • Sukhbir S. SinghEmail author


Endometriosis is one of the most challenging diseases to diagnose and manage in gynecology today. It is a common condition and has been reported to have an overall prevalence of 5–10% in the general population [1, 2]. In females with pelvic pain and infertility, endometriosis is known to have a higher prevalence of 50% and 25–40%, respectively [3, 4].



Dr. S. Singh would like to acknowledge his local team for making it possible to provide great multidisciplinary care that includes nursing support, expert imaging, and great surgical care. Drs. Margaret Fraser, Shauna Duigenan, and Vincent Della Zazzera provide local expert imaging for complex endometriosis cases. Our fellows Drs. Michael Suen, Cici Zhu, and Maris Yap-Garcia provide surgical and clinical care. Our residents, Drs. Heather Stone and Devon Evans, worked on educational material to help advance our teaching of surgical approaches. Shannen McDonald, Karen Deme, Kelly Lacombe, Monique Newman, and Ottawa Hospital staff help support our patients through their journey. Our surgical team includes Drs. Kristina Arendas, Innie Chen, Karine Lortie, and Hassan Shenassa. Our interdisciplinary team of surgeons includes Drs. S. Gilbert (Thoracics), S. Tadros (General Surgery), and The Ottawa Hospital Urology and Colorectal Services. Finally, our research team including Dr. Teresa Flaxman, Ms. Erica Nichols, Carly Cooke, Suzanah Wojcik, and Cairina Frank help with our endometriosis research program.

Supplementary material

Video 1.1

Scar endometriosis—An example of a post cesarean section incisional endometriosis nodule resulting in cyclical left lower quadrant pain and a palpable mass. (Courtesy of Dr. S. Singh) (MP4 123088 kb)

Video 1.2

Excision of superficial endometriosis—An educational video. (Courtesy of Dr. M. Suen) (MP4 332944 kb)

Video 1.3

Surgical approach to endometriosis of the posterior cul-de-sac. (Courtesy of Dr. D. Evans and M. Suen) (WMV 261723 kb)

Video 1.4

Video demonstrating excision of an invasive bladder nodule. (Courtesy of Dr. S. Singh) (MOV 799350 kb)


  1. 1.
    Vercellini P, Vigano P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014;10(5):261–75.CrossRefGoogle Scholar
  2. 2.
    Viganò P, Parazzini F, Somigliana E, Vercellini P. Endometriosis: epidemiology and aetiological factors. Best Pract Res Clin Obstet Gynaecol. 2004;18(2):177–200.CrossRefGoogle Scholar
  3. 3.
    Giudice LC. Clinical practice. Endometriosis. N Engl J Med. 2010;362(25):2389–98.CrossRefGoogle Scholar
  4. 4.
    Somigliana E, Vigano P, Benaglia L, Busnelli A, Berlanda N, Vercellini P. Management of endometriosis in the infertile patient. Semin Reprod Med. 2017;35(1):31–7.PubMedGoogle Scholar
  5. 5.
    Bulun SE. Endometriosis. N Engl J Med. 2009;360(3):268–79.CrossRefGoogle Scholar
  6. 6.
    Nnoaham KE, Hummelshoj L, Webster P, d'Hooghe T, de Cicco NF, de Cicco NC, et al. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril. 2011;96(2):366–73. e8CrossRefGoogle Scholar
  7. 7.
    Singh SS, Suen MW. Surgery for endometriosis: beyond medical therapies. Fertil Steril. 2017;107(3):549–54.CrossRefGoogle Scholar
  8. 8.
    Aredo JV, Heyrana KJ, Karp BI, Shah JP, Stratton P. Relating chronic pelvic pain and endometriosis to signs of sensitization and myofascial pain and dysfunction. Semin Reprod Med. 2017;35(1):88–97.CrossRefGoogle Scholar
  9. 9.
    Kuznetsov L, Dworzynski K, Davies M, Overton C, Committee G. Diagnosis and management of endometriosis: summary of NICE guidance. BMJ. 2017;358:j3935.CrossRefGoogle Scholar
  10. 10.
    Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De Bie B, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014;29(3):400–12.CrossRefGoogle Scholar
  11. 11.
    Sinaii N, Plumb K, Cotton L, Lambert A, Kennedy S, Zondervan K, et al. Differences in characteristics among 1,000 women with endometriosis based on extent of disease. Fertil Steril. 2008;89(3):538–45.CrossRefGoogle Scholar
  12. 12.
    Parazzini F, Esposito G, Tozzi L, Noli S, Bianchi S. Epidemiology of endometriosis and its comorbidities. Eur J Obstet Gynecol Reprod Biol. 2017;209:3–7.CrossRefGoogle Scholar
  13. 13.
    Guerriero S, Condous G, van den Bosch T, Valentin L, Leone FP, Van Schoubroeck D, et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol. 2016;48(3):318–32.CrossRefGoogle Scholar
  14. 14.
    Fraser MA, Agarwal S, Chen I, Singh SS. Routine vs. expert-guided transvaginal ultrasound in the diagnosis of endometriosis: a retrospective review. Abdom Imaging. 2015;40(3):587–94.CrossRefGoogle Scholar
  15. 15.
    Ceccaroni M, Clarizia R, Alboni C, Ruffo G, Bruni F, Roviglione G, et al. Laparoscopic nerve-sparing transperitoneal approach for endometriosis infiltrating the pelvic wall and somatic nerves: anatomical considerations and surgical technique. Surg Radiol Anat. 2010;32(6):601–4.CrossRefGoogle Scholar
  16. 16.
    Knabben L, Imboden S, Fellmann B, Nirgianakis K, Kuhn A, Mueller MD. Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical classification. Fertil Steril. 2015;103(1):147–52.CrossRefGoogle Scholar
  17. 17.
    Abrao MS. Pillars for surgical treatment of bowel endometriosis. J Minim Invasive Gynecol. 2016;23(4):461–2.CrossRefGoogle Scholar
  18. 18.
    Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update. 2015;21(3):329–39.CrossRefGoogle Scholar
  19. 19.
    Parr G, Leyland N. The hockey stick sign in appendiceal endometriosis. J Obstet Gynaecol Can. 2010;32(5):421.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.University of OttawaOttawaCanada
  2. 2.Shirley E. Greenberg Women’s Health CentreThe Ottawa HospitalOttawaCanada
  3. 3.Ottawa Hospital Research InstituteOttawaCanada

Personalised recommendations