Pelvic floor dysfunction and bowel symptoms in women with endometriosis


A study in the International Journal of Gynecology & Obstetrics found that transperineal ultrasound (TPU) signs of pelvic floor muscle hypertonia are more prevalent in endometriosis patients with chronic constipation than in those without.

This was particularly true in women affected by isolated ovarian endometriosis.1

The observational prospective cohort study enrolled 87 women with endometriosis scheduled for surgery at a hospital affiliated with the University of Bologna in Italy between September 2019 and October 2020. Overall, 33% of women had chronic constipation.

Women underwent TPU at rest and during Valsalva maneuver to assess levator-hiatal-area (LHA), antero-posterior diameter (APD), and levator ani muscle (LAM) coactivation.

Women with endometriosis and chronic constipation had a smaller LHA during Valsalva, less LHA and APD enlargement from rest to maximum Valsalva, and a higher frequency of LAM coactivation than women without chronic constipation.

In the ovarian endometriosis subgroup (48% of the cohort), women with chronic constipation,in contrast to those without chronic constipation,had smaller LHA at Valsalva, less enlargement of LHA and APD from rest to maximum Valsalva, and a higher prevalence of LAM coactivation: 65.5% vs. 18.9%.

In addition, 29% of patients in the ovarian subgroup reported chronic constipation.

However, in the DIE subgroup (52% of thecohort), of whom 38% presented with chronic constipation, TPU did not significantly differ between women who had or did not have chronic constipation.

“This study suggests a significant role of the pelvic floor in the pathophysiology of chronic constipation in women with ovarian endometriosis,” wrote the authors.

The authors acknowledged, though, that the ramifications of LAM coactivation are neither entirely understood nor is much known about the clinical significance and management.

Initial reports indicated that this phenomenon was quite common in nulliparous women with no particular clinical significance, yet its persistence appeared to have some connection to obstructed defecation.

Some subsequent studieshave concluded that women with endometriosis had identifiable signs of pelvic floor hypertonia at transperineal ultrasound, including LAM coactivation.

Recently, it was revealed that nulliparous women with LAM coactivation at term of pregnancy were more likely to have a longer second stage of labor, along with a less engaged fetal head.

The current study’s findings of the relationship between endometriosis and bowel symptoms may have significant clinical implications, according to the authors, but that the management of constipation in endometriosis patients remains challenging.

Some women may benefit from interventions targeting the pelvic floor hypertonia, such as physiotherapy, and ultrasound can help improve symptoms.

A pilot study published in the Journal of Sex & Marital Therapy in 2020 by the authors concluded that ultrasound visual feedback improved superficial and deep dyspareunia symptoms, and improved ultrasound signs of hypertonia in women with endometriosis.2

“We highly encourage the evaluation of this approach in women with endometriosis and bowel symptoms, especially in those with sonographic evidence of pelvic floor muscle hypertonia,” they wrote.


  1. Raimondo D, Cocchi L, Raffone A, et al. Pelvic floor dysfunction at transperineal ultrasound and chronic constipation in women with endometriosis. Int J Gynacol Obstet. Printed online January 7, 2022. doi:10.1002/ijgo.14088
  2. Del Forno S, Arena A, Alessandrini M, et al. Transperineal ultrasound visual feedback assisted pelvic floor muscle physiotherapy in women with deep infiltrating endometriosis and dyspareunia: a pilot study. J Sex Marital Ther. 2020; 46(7): 603- 611. doi:10.1080/0092623X.2020.1765057
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