Frozen Pelvis in Deep Infiltrating Endometriosis


What it a frozen pelvis?

  • The term, “frozen pelvis” is not an official medical term, but an unofficial condition meaning that the organs of the pelvis are densely adhered to each other due to deeply infiltrating endometriosis; and these organs, typically, are the rectum, bladder and ureters, uterus, and even large and small bowel.
  • The tubes and ovaries and ligaments of the pelvis may be involved as well.
  • The criterium for “deeply infiltrating endometriosis--DIE” (the official medical term) is that there must be solid endometriosis infiltrating more than 5 mm into the floor of the pelvis, which typically represents the cornerstone of the adherent organs.
  • The organs that are densely adhered, using “adhesions,” have nerves that develop within these adhesions, contributing to pain which begins with the inflammatory process of the endometriosis.

How common is Deep Infiltrating?

  • In the USA, endometriosis occurs in 2-10% of women, and 14% of these are diagnosed with DIE.
  • Deeply infiltrating endometriosis (DIE) is usually found in Stage III (“moderate”) and Stage IV (“severe”) endometriosis; as such, there may also be ovarian endometriosis as a mass (an “endometrioma”).
  • At Advanced Endometriosis Center, since we specialize in the condition, a significant percentage of our patients have DIE.

What are the symptoms?

  • Pain is present in 80% of patients. This can be either painful period cramping or pain with sexual intercourse, making it prohibitive.
  • Infertility in 50% or more.

What causes it?  

  • The severity of endometriosis is not due to any one cause, but genetic, familial, immune and autoimmune, embryonic, and abnormal endocrine hormonal causes have all been implicated in a complex combination of causes.

What are the possible complications?

  • Infertility, of course. The more involved the endometriosis, the more inflammatory interference with conception and ovulation there is.
  • Obliteration of the pelvic space between the rectum and the uterus, called the “cul-de-sac.” Structural abnormalities interfere with the normal business of the different organs, from conception to bowl and bladder function.
  • Sexual problems not only affecting the feasibility of intercourse (and with it, fertility), but relationships in general.
  • Pain can become so severe as to provoke the “nuclear option,” surgically removing all of the reproductive organs, which is tragic in those wanting to keep pregnancy options open. (See Dr. Bozdogan’s statement, below.) 

How is DIE diagnosed?

  • GYN history, with a special emphasis on previous endometriosis, pain, painful periods, family and fertility history, etc.
  • GYN physical exam to elicit any trigger points of pain in the vagina or pelvis. A frozen pelvis, consisting of an obliteration of the pelvic space between the rectum and the uterus, usually can be palpated by exam.
  • Cultures to rule out any STD causes of pelvic pain and/or painful intercourse.
  • Ultrasound, especially if ovarian endometriosis (an “endometrioma”) is suspected. It is accurate at identifying an obliterated cul-de-sac, as well.

The only official way to diagnose endometriosis is via definitive surgical identification and removal for biopsy the actual endometriosis tissue. This is done via either laparoscopy or—better, robotic surgery—to not only thoroughly evaluate the inner abdomen/pelvis, but also offer the option of surgical treatment at the same time (excising endometriosis and/or separating adhesed organs.)

  • With a diagnosis officially established, a frozen pelvis can be discerned by exam if endometriosis were to recur or progress. This, of course, depends on the skill of the examiner, and at Advanced Endometriosis Center, we specialize in this diagnostic approach. 

How is DIE treated? 

The treatment is surgical.

Since this complication is a manifestation of late stage endometriosis, a patient with DIE is well past the conservative remedies of hormonal manipulation. Endometriosis can be excised and its anatomical distortion remedied using robotic excision.

Occasionally a diagnostic laparoscopy is done for pelvic pain or infertility and a surprise endometriosis can present with this late stage complication, requiring more than a simple laparoscopic surgery.  

A note from Dr. Bozdogan about DIE: 

According to Dr. Bozdogan:

“Although a frozen pelvis has been building for some time, I consider it an emergency. The pain and infertility—and the bowel issues—are simply unacceptable. Allowing it to continue even one more day is cruel and can only result in things getting worse. Because you have a right to an anatomy the way it was meant to be, when surgery is planned I go into it equipped to handle anything, because a frozen pelvis will throw every conceivable difficulty my way. This requires the unapparelled dexterity of the robotic manipulation instruments and the excellent visibility access of magnification views from any angle. This can only be done via the da Vinci robot, so it is my go-to protocol for tackling this difficult surgery. You deserve this, because I am not in favor of the “nuclear option,” which in most cases is unnecessary and resorted to by those less skilled to deal with difficult cases!”


A “frozen pelvis”—or, deeply infiltrating endometriosis (DIE) is an end-stage of the disease, characterized by not only the pain and infertility associated with endometriosis in general, but also serious dysfunction of organs of the pelvis involved in adhesions and obliteration of normal anatomical spaces. It is serious and devastating physically, psychologically, and emotionally. It is a threat to fertility and to the sexual relationship between partners. Surgery is indicated and, due to the anatomic complexity of the condition, an experienced surgeon such as Dr. Bozdogan is critical for taking advantage of his experience, skills, and technological expertise. These are available to you simply by making an appointment.

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