Management of bowel dysfunction after pelvic surgery for endometriosis

Abstract

Introduction

Bowel dysfunction is a common and debilitating condition affecting patients with endometriosis. Despite the extent of surgery, symptoms may persist or arise, often overlapping with low anterior resection syndrome (LARS) or irritable bowel syndrome (IBS) typical features. This review aims to summarize the multifactorial pathophysiology and current therapeutic options for postoperative bowel dysfunction after endometriosis surgery.

Methods

A structured narrative review was conducted through a comprehensive search for studies published between 2000 and 2025. Inclusion criteria focused on postoperative functional outcomes and treatments (medical, rehabilitative and interventional) effectiveness. The available evidence is limited and largely extrapolated from related conditions such as LARS and neurogenic bowel dysfunction.

Results

The complex pathophysiology of postoperative dysfunction involves preoperative visceral hypersensitivity, surgical disruption of pelvic autonomic nerves, reduced rectal compliance, and pelvic floor dyssynergia. While dietary interventions (e.g., low-FODMAP diet) and pharmacological treatments (laxatives, antidiarrheals, or neuromodulators) serve as first-line therapies, they are often insufficient for severe symptoms. Emerging evidence supports the use of transanal irrigation (TAI) for mechanical emptying and sacral neuromodulation (SNM) for refractory sensorimotor disorders. Functional rehabilitation, including pelvic floor physiotherapy and manual therapy, represents a further opportunity to influence specific symptoms.

Conclusions

Postoperative bowel dysfunction in endometriosis management requires a transition from rigid treatment protocols to a multidisciplinary, symptom-oriented approach. The support of specialized nursing, physiotherapy, and advanced interventions like TAI and SNM is essential. Future prospective studies using standardized outcome measures are needed to better define these therapeutic pathways and improve patient quality of life.

Introduction

Bowel symptoms are frequently reported in patients with endometriosis (up to 37%) [1, 2], and they may persist, newly occur, or worsen after surgery, even in the absence of major postoperative complications or disease recurrence. In particular, constipation and tenesmus may increase in up to 27% [3, 4]. While more extensive procedures, particularly segmental colorectal resection, have traditionally been considered at higher risk for postoperative bowel dysfunction, increasing evidence suggests that gastrointestinal impairment is also common following conservative surgery and may already be present preoperatively due to the pathophysiology of deep endometriosis itself [2]. Therefore, the attribution of postoperative bowel dysfunction just to the extent of surgical resection remains controversial, and the optimal management of these symptoms still represents an unmet clinical need.

Postoperative bowel dysfunction after surgery for endometriosis includes a broad spectrum of symptoms that closely remind a low anterior resection syndrome (LARS), a condition well described in rectal cancer surgery. These symptoms include increased stool frequency, urgency, clustering, impaired continence, and difficulty postponing bowel movements. However, recent evidence suggests that LARS-like symptoms are already present in a significant proportion of women with untreated colorectal endometriosis, highlighting the multifactorial pathophysiology of gastrointestinal dysfunction in these patients and complicating the interpretation of postsurgical outcomes [5, 6].

The mechanisms underlying bowel dysfunction after endometriosis surgery are not completely understood, involving a combination of factors including disruption of autonomic pelvic nerves, altered rectal reservoir function, changes in bowel anatomy, postoperative fibrosis, and persistent visceral hypersensitivity. Moreover, baseline gastrointestinal function, extent of surgery, and surgical technique appear to influence long-term functional outcomes, despite existing studies reporting heterogeneous results, partly due to differences in follow-up duration, outcome measures, and study design [6–10].

Despite increasing awareness of bowel dysfunction in patients with endometriosis, there is currently no standardized approach to its management in women that underwent a surgical treatment. Therapeutic strategies range from dietary and pharmacological interventions to pelvic floor rehabilitation, neuromodulation or, at last, surgical revision. Evidence supporting these treatments is fragmented across different disciplines and clinical decision-making is often extrapolated from literature on functional bowel disorders or colorectal cancer surgery rather than endometriosis-specific data.

Therefore, this paper aims to provide a comprehensive overview of postoperative bowel dysfunction following surgery for endometriosis and to critically summarize the available evidence on current therapeutic options. Through the integration of gynecological, gastroenterological, colorectal, and pelvic floor literature, this review seeks to support a multidisciplinary, patient-centered approach to the management of gastrointestinal dysfunction after endometriosis surgery and to identify gaps for future research.

Methods

Due to the lack of high-quality studies with adequate evidence, a formal systematic review was not feasible. Therefore, we conducted a structured narrative review based on a comprehensive and systematic literature search, aiming to summarize the current evidence and the potential opportunity on the management of bowel dysfunction following surgery for endometriosis, with or without colonic resection.

A comprehensive literature search was performed by two independent reviewers using a common database (PubMed, Medline, Embase, Web of Science) including studies published from January 2000 to December 2025. In the search phase, no restrictions were applied on study design to identify all relevant data in this emerging and heterogeneous field. The search strategy combined Medical Subject Headings (MeSH) terms and free-text keywords related to endometriosis, bowel surgery, postoperative gastrointestinal dysfunction, and treatment strategies.

The main search terms included combinations of the following: “endometriosis,” “bowel endometriosis,” “colorectal endometriosis,” “bowel resection,” “shaving,” “discoid resection,” “segmental resection,” “postoperative bowel dysfunction,” “gastrointestinal function,” “low anterior resection syndrome,” “constipation,” “fecal incontinence,” “pelvic floor dysfunction,” “rehabilitation,” and “treatment.”

Reference lists of relevant articles and reviews were also manually screened to identify additional pertinent studies.

Studies were considered eligible if they included women undergoing surgery for endometriosis, reported postoperative gastrointestinal or bowel functional outcomes, evaluated treatments (conservative, rehabilitative, medical, neuromodulation, or surgical) for bowel dysfunction, and were original research articles, systematic reviews, or consensus statements published in English. Case reports, conference abstracts without full text, and studies exclusively addressing oncologic colorectal surgery were excluded.

After removal of duplicates, titles and abstracts of 297 articles were screened for relevance, followed by full-text evaluation of selected articles. In the end, 24 studies were identified, of which 8 concerned postoperative outcomes, 10 addressed management issues, and 6 focused on specific treatments. Due to the heterogeneity of study designs, outcome measures, and follow-up durations, a quantitative meta-analysis was not performed. A formal assessment of risk of bias was not performed, as this is not mandatory for scoping or narrative reviews and the objective of this work was to map the available evidence rather than to assess treatment effectiveness. Findings were synthesized narratively and organized thematically according to types of bowel dysfunction and therapeutic strategies reported. Areas of limited or inconsistent evidence were identified to highlight gaps for future research.

Postoperative bowel dysfunction was evaluated according to the definitions and assessment tools used in the included studies. When available, validated patient-reported outcome measures such as the Gastrointestinal Quality of Life Index (GIQLI), the low anterior resection syndrome (LARS) score, the Wexner score, and the Knowles–Eccersley–Scott Symptom (KESS) questionnaire were considered, together with symptom-based clinical outcomes.

Results

Patophisiology

Bowel dysfunction after surgery for endometriosis is multifactorial and reflects both disease-related alterations and surgery-induced changes affecting bowel anatomy, motility, neural pathways, and pelvic floor function. Understanding these mechanisms is essential to guide management strategies, as different pathophysiological mechanisms may require distinct therapeutic approaches.

Preoperative factors

Women with deep infiltrating endometriosis involving rectum and sigmoid colon frequently reported chronic gastrointestinal symptoms, including abdominal pain, bloating, altered stool consistency, constipation, diarrhea, or alternation between the two [11, 12].

These symptoms often resemble those seen in irritable bowel syndrome (IBS), and several studies have demonstrated a higher prevalence of IBS-like symptoms in patients with endometriosis [13–16] compared with controls, suggesting shared pathophysiological mechanisms such as visceral hypersensitivity, chronic inflammation, and altered motility patterns. A possible association between the two conditions, which could overlap in some patients, has also been hypothesized. This overlap may complicate the interpretation of postoperative outcomes, as a substantial proportion of bowel symptoms may be refractory to surgical management if they are driven primarily by functional and nociceptive mechanisms not only related to endometriosis rather than by fixed mechanical obstruction.

Moreover, LARS-like symptoms, including urgency, fragmentation of defecation, and altered stool frequency, have been reported in a substantial proportion of women even before surgical treatment. This suggests that bowel dysfunction in this population is, at least in part, intrinsic to the disease itself rather than exclusively a consequence of surgical intervention [5, 17].

In addition, chronic pelvic pain syndromes, including endometriosis, are frequently associated with central sensitization, a condition in which the central nervous system exhibits heightened responsiveness to sensory input that can amplify pain perception. Persistent alterations in pain, somatosensory, and visceral processing pathways can sustain gastrointestinal symptoms independently of structural abnormalities and may contribute to symptom persistence even when surgical resection is technically successful and in absence of disease recurrence.

Surgical factors

Surgical treatment of bowel endometriosis ranges from conservative approaches such as rectal shaving to discoid resection to more extensive segmental colorectal resection. While the extent of surgery has traditionally been considered a primary determinant of postoperative bowel dysfunction, recent evidence suggests that this relationship is not so straightforward. In fact, even if segmental resection has been associated with higher rates of postoperative constipation and reduced quality of life particularly due to reduced rectal reservoir capacity, compared with conservative techniques, the difference in functional outcomes from preoperative baseline scores is less pronounced [2]. This observation further underscores the importance of the complex interplay between disease-related dysfunction and surgery-induced changes rather than the extent of resection alone.

Among the potential surgery-related mechanisms related to postoperative dysfunction, disruption of autonomic pelvic nerves, reduced rectal reservoir capacity, postoperative fibrosis, altered sensory function, and induced changes in gut motility (permanent or temporary) have been suggested.

Postoperative bowel and pelvic floor dysfunction

After surgery, symptoms like urgency, increased stool frequency, fragmentation of defecation, and impaired ability to defer evacuation are often reported, remembering again LARS, suggesting that, beyond inflammatory mechanisms, postoperative dysfunction may also reflect disturbances in rectal reservoir function, sensory modulation, and autonomic neural integrity. In fact, disruption of the intricate network of pelvic autonomic nerves by direct surgical trauma or by postoperative fibrosis can impair rectal compliance and neural control of defecation.

However, LARS-like symptoms have been reported even following more conservative procedures, indicating that factors such as surgical dissection within the mesorectal plane, peri-rectal fibrosis, and subtle neural impairment may contribute to altered bowel function independently of the length of bowel removed [17].

From a pathophysiological standpoint, if preoperative symptoms are predominantly driven by hypersensitivity and inflammatory mechanisms resembling functional bowel disorders, postoperative symptoms share features with disorders of impaired rectal storage and neural control (Table 1). This is also confirmed in patients who develop postoperative severe refractory constipation in which, despite the limited evidence available, they appear to share pathophysiological mechanisms with neurogenic sensorimotor and autonomic dysfunction similar to neurogenic bowel disorders [18, 19].

Table 1.

Pathophysiological and clinical analogies between endometriosis-related bowel dysfunction, irritable bowel syndrome (IBS), low anterior resection syndrome (LARS), and neurogenic bowel

Feature	Endometriosis (preop)	Endometriosis (postop)	IBS	LARS	Neurogenic bowel
Mechanism	Inflammation, hypersensitivity	Reservoir dysfunction, partial denervation	Brain–gut dysregulation	Loss of reservoir, denervation	Neurological injury
Pain	Cyclical	May persist	Defecation-related	Minimal	Variable
Urgency	Occasional	Frequent	Possible	Very common	Common
Frequency	Variable	Increased	IBS-D	Very frequent	Common
Slow transit constipation	Possible	Frequent	IBS-C	Rare	Common
Clustering	Rare	Frequent	Rare	Typical	Common
Incontinence	Rare	Possible	Rare	Frequent	Common
Evacuation disorders	Common	Possible	IBS-C	Less typical	Common
Rectal function	Preserved	Often reduced	Preserved	Reduced	Variable
Sensory changes	Hypersensitivity	Altered	Hypersensitivity	Altered	Variable
Pelvic floor dysfunction	Hypertonicity common	Frequent dysfunction	Possible	Possible	Common
Central sensitization	Common	May persist	Common	Less prominent	Depends on lesion level
Analogy	IBS-like	LARS/neurogenic-like	Functional	Post-surgical	Neurological

Persistent or newly developed pelvic floor dysfunction may further contribute to postoperative symptoms. Dyssynergic defecation, hypertonic pelvic floor musculature, and impaired coordination between abdominal pressure and anal sphincter relaxation are common in women with pelvic pain and usually lead to obstructed defecation or incomplete evacuation.

Taken together, postoperative bowel dysfunction after surgery for endometriosis should be considered the result of a multifactorial process involving:

1. Pre-existing disease-related bowel impairment

2. Pain-related central sensitization

3. Surgical modification of rectal anatomy and neural pathways

4. Concomitant pelvic floor dysfunction

5. Persistent visceral hypersensitivity

Given the multifactorial nature of postoperative bowel dysfunction after endometriosis surgery, management should be tailored to the predominant pathophysiological mechanism rather than based solely on the type of surgical procedure. This is why understanding these mechanisms is essential to guide management strategies, as each of these requires specific treatment, without which the outcomes may be limited or ineffective. However, although all the described mechanisms are biologically plausible, direct evidence in this specific population remains limited.

A preliminary mechanism-oriented therapeutic framework is proposed in Table 2.

Table 2.

Mechanism-oriented therapeutic approach to bowel dysfunction after endometriosis surgery

Pathophysiological pattern	Clinical features	First-line	Second-line	Advanced options
IBS-like (hypersensitivity)	Pain, bloating, variable stool, defecation-related symptoms	Diet (e.g., low-FODMAP), soluble fiber, antispasmodics	Neuromodulators, psychological therapies	Multidisciplinary pain management
LARS-like (reservoir dysfunction)	Urgency, ↑ frequency, clustering, poor deferment	Antidiarrheals (e.g., loperamide), diet	Pelvic floor rehab, biofeedback, TAI	SNM, PTNS
Evacuation disorder (dyssynergia)	Straining, incomplete evacuation, digital maneuvers	Pelvic floor rehab, biofeedback	Laxatives, suppositories/enemas	Botulinum toxin (selected cases)
Slow-transit constipation	Infrequent stools, hard stools, bloating	Osmotic laxatives, fiber (if tolerated)	Prokinetics/secretagogues	TAI (refractory cases)
Fecal incontinence	Urgency incontinence, leakage	Diet, bulking agents, loperamide	Pelvic floor rehab, biofeedback	SNM, bulking agents
Mixed phenotype	Overlapping symptoms	Individualized approach	Combined therapies	Multidisciplinary referral

Treatments

Given the heterogeneous pathophysiology underlying postoperative symptoms, no single therapeutic strategy is always effective. Moreover, even if the treatment selection should be guided by the predominant symptoms pattern, in clinical practice, patients often present with overlapping phenotypes, making a stepwise multimodal strategy often required (Table 3).

Table 3.

Comparative overview of therapeutic options for postoperative bowel dysfunction after endometriosis surgery

Intervention	Consider if (best candidates)	What to expect
Rehabilitation (± PTNS)	• Mild–moderate dysfunction • Pelvic floor dyssynergia • Early postoperative phase • Pelvic pain/myofascial component • Motivated patients	• Gradual improvement • ↑ coordination, ↓ urgency/pain • Variable effect in severe cases • Requires adherence
Transanal irrigation (TAI)	• Incomplete evacuation, clustering • Refractory constipation • LARS-like phenotype • Suspected impaired rectal emptying • Failure of medical therapy	• Predictable bowel emptying • ↓ clustering, ↓ incomplete evacuation • Possible ↓ urgency/incontinence • Requires training and long-term use
Sacral neuromodulation (SNM)	• Refractory urgency/incontinence • Neurogenic-like dysfunction • Failure of conservative treatments • No major obstruction • Suitable for implantation	• Early response (test phase) • ↓ urgency and incontinence • Possible effect on evacuation • Requires device follow-up
Surgical revision/diverting stoma	• Severe refractory symptoms • Structural complications • Major QoL impairment • Failure of all other options • Selected, well-informed patients	• Potential symptom control • Definitive solution (stoma) • High impact on QoL • Surgical risks

Moreover, an important but often overlooked aspect is the preoperative assessment of gastrointestinal symptoms. Many patients already present with bowel complaints before surgery, making it essential to distinguish pre-existing dysfunction from true postoperative sequelae to better target treatments.

Dietary and lifestyle interventions

Growing evidence indicates that lifestyle and dietary factors in patients with endometriosis play an important complementary role in symptom management and may influence disease progression, even after surgery. This is why dietary and nutritional modification should represent a reasonable first-line approach, particularly in patients with IBS-like symptoms. Although high-quality evidence for postoperative endometriosis populations is limited, general principles derived from functional gastrointestinal disorders and non-surgical endometriosis could be applied.

The most compelling evidence for managing postoperative GI symptoms comes from the implementation of a low-FODMAP diet. Recent randomized controlled trials, such as the EndoFOD study, have demonstrated that a 28-day low-FODMAP intervention leads to a significant reduction in the severity of GI symptoms in approximately 72% of women with endometriosis [20]. It has been supposed that reducing the intake of fermentable short-chain carbohydrates in the diet can minimize luminal distension and osmotic pressure in the gut, directly addressing the bloating and pain that surgery might not alleviate [21].

In the prospective study by Moore et al., women with endometriosis and coexisting IBS experienced greater symptom improvement with a low-FODMAP diet compared with IBS patients without endometriosis, suggesting a potentially heightened dietary sensitivity in this population [22]. However, after colorectal surgery for deep endometriosis, the pathophysiology may shift toward a more neuropathic and motility-driven pattern resembling LARS or neurogenic bowel. In these patients, dietary measures alone are often insufficient, particularly in the presence of severe constipation, clustering, or fecal incontinence. Despite this, optimization of fiber intake, adequate hydration, regular meal timing, physical activity, and avoidance of individual trigger foods remain reasonable components of multimodal management [23, 24].

Postsurgical recovery is also influenced by the state of the gut microbiota. Endometriosis is often associated with intestinal dysbiosis, and a pro-inflammatory environment may persist even after the primary lesions are excised [25].

The interaction between the microbiota and the estrobolome (the collection of bacterial enzymes capable of metabolizing and modulating the systemic circulation of estrogens) suggests that dietary interventions aimed at restoring microbial balance, such as the Mediterranean diet, characterized by high intake of anti-inflammatory nutrients, fiber, and antioxidants, or the use of specific probiotics, are essential for long-term maintenance and prevention of symptomatic recurrence [26, 27].

The successful management of postsurgical bowel symptoms has a significant impact on quality of life. In fact, dietary interventions may reduce not only physical pain but also significantly improve mental health outcomes and social functioning, which are often severely impaired in the postoperative period due to persistent GI distress [28, 29].

As previously stated, most evidence for dietary interventions is derived from non-operated endometriosis or endometriosis/IBS populations and should therefore be interpreted with caution.

Pharmacological therapy

Pharmacological treatment represents a key component in the multimodal management of bowel dysfunction after surgery for endometriosis. However, drug therapy should be individualized according to the predominant symptom pattern and pathophysiological phenotype and should usually be considered as supportive rather than curative. This is because, obviously, visceral hypersensitivity, impaired motility, or rectal/neorectal reservoir dysfunction will benefit from different treatments [30].

In patients with urgency, increased stool frequency, diarrhea, or LARS-like symptoms, antidiarrheal agents such as loperamide are commonly used to improve stool consistency and reduce urgency episodes. Bile acid sequestrants may be considered in selected cases (i.e., ileal involvement or extensive pelvic surgery) where bile acid malabsorption could be suspected, although evidence in endometriosis populations is very limited.

In patients with constipation osmotic laxatives (e.g., polyethylene glycol) are typically used as first-line therapy due to stool hydration and bowel movements improvement. However, a subset of patients, particularly those with suspected rectal sensorimotor dysfunction, dyssynergia, or pelvic floor hypertonia, may show limited response to conventional laxatives alone. In these cases, escalation to secretagogues or prokinetic agents may be considered, even if with unsupported results in the literature. As occurs in mixed constipation or obstructed defecation, this confirms the issue of a medical therapy that must be supplemented with additional therapeutic solutions (enemas, rehabilitation, irrigation, neuromodulation, etc.).

As shown in IBS or chronic pelvic pain syndrome literature, in patients with prominent visceral pain and hypersensitivity, neuromodulators such as low-dose tricyclic antidepressants or serotonin/norepinephrine reuptake inhibitors may be beneficial, modulating gut–brain signalling and potentially reducing pain amplification.

Again, pharmacologic therapy alone is often insufficient in patients with significant reservoir dysfunction or evacuation disorders, and early integration with rehabilitative strategies should be considered.

There is no evidence that other medical treatments, such as probiotics, steroids, mesalazine, vitamin, or butyric acid may have a role in these patients. Pharmacological therapy should be individualized, and while agents such as secretagogues or prokinetics may be considered, evidence in this specific population remains limited.

Functional rehabilitation

A multimodal rehabilitative approach (rehabilitate means to restore function) plays an increasingly stronger role in the management of dysfunction related to endometriosis. However, even if most of the current literature mainly focuses on pain relief with interesting results [29], data specifically focusing on bowel function remain scarce.

As preliminarily suggested from case reports and small pilot studies, osteopathic and manual therapy approaches have demonstrated potential benefits in pain and quality of life also in randomized trials [31, 32], as well as physical activity and exercise (flexibility and strength training, cardiovascular fitness, yoga) [33, 34].

To date, numerous rehabilitative techniques have been explored, including kinesiotherapy, visceral manual therapy, electrotherapy, laser, neuromuscular electrical stimulation, magnetic stimulation, posterior tibial nerve stimulation, and mind–body intervention, with promising results [35–37]. These options appear particularly useful in patients with prominent myofascial pain, central sensitization, or musculoskeletal contributors to pelvic pain. Moreover, acupuncture has also demonstrated potential benefits [38–40] and could be considered in these patients.

Unfortunately, an important limitation of the current literature is the relative lack of focus on gastrointestinal outcomes. Most available studies evaluate pain, sexual function, scar management, or overall quality of life rather than bowel function specifically.

However, only one randomized controlled trial has specifically assessed bowel outcomes following pelvic floor muscle physiotherapy in women with deep infiltrating endometriosis [41], with limited evidence on a significant impact of pelvic floor physiotherapy on bowel function. These results are consistent with those relating to the rehabilitative treatment of LARS, in which the potential benefits are not always confirmed in randomized controlled trials [42–45]. Moreover, even if pelvic floor muscle training (PFMT) combined with biofeedback was reported to be more effective than PFMT alone and both interventions delivered alone were superior to standard conservative support, another potential limitation of the current literature is the lack of well-defined and standardized practices in the various studies, thus limiting the reproducibility of any positive results.

Therefore, from a clinical perspective, rehabilitation should be considered a complementary component of the therapeutic management, particularly in patients with overlapping pelvic floor dysfunction, myofascial pain, or mixed symptom patterns [46]. However, in patients with predominant LARS-like symptoms or severe constipation suggestive of rectal sensorimotor impairment, a physiotherapy approach alone is unlikely to be sufficient and should be integrated into a broader bowel-focused management strategy.

Transanal irrigation

Transanal irrigation (TAI) has emerged as an effective strategy for bowel management in patients with evacuation disorders, fecal incontinence, LARS, and neurogenic bowel dysfunction. By facilitating controlled rectal emptying through the instillation of water into the rectum and distal colon, TAI aims to restore a more predictable bowel habit and reduce symptoms related to incomplete evacuation, urgency, and clustering.

When offered to these patients, TAI was associated with high satisfaction and a reduction in pain and LARS-like symptoms [47].

Although evidence specifically addressing women undergoing surgery for endometriosis is currently weak, the pathophysiological overlap with conditions such as low anterior resection syndrome and neurogenic bowel provides a strong rationale for its use in selected patients [48, 49], with outcomes superior to those of conservative therapy and rehabilitation [50]. In particular, TAI may be beneficial in those patients presenting with severe constipation refractory to laxatives, impaired rectal sensation, clustering and incomplete evacuation, urgency or fecal incontinence episodes, and mixed patterns of evacuation dysfunction.

Besides a primarily mechanical mechanism of action, regular irrigation promotes rectal emptying, reduces stool retention, and may improve rectal sensory response over time, with positive consequences both functional and on quality of life.

Even if clinical experience from colorectal and neurogenic populations suggests that TAI is generally safe and well tolerated, appropriate pretreatment evaluation, patient education program, and specific training are essential to optimize adherence and outcomes, reducing the potential risk of complications [51, 52].

Sacral neuromodulation

Sacral neuromodulation (SNM) represents an established therapeutic option for refractory functional bowel disorders, including fecal incontinence, LARS, and some form of constipation associated with evacuation disorders [53, 54]. Its role in patients with bowel dysfunction after surgery for endometriosis is emerging but remains poorly studied.

From a pathophysiological point of view, SNM may be particularly relevant in this population because postoperative bowel symptoms often suggest altered rectal sensorimotor function and pelvic autonomic nerve impairment. As discussed above, some patients appear to modify a preoperative IBS-like phenotype to a LARS/neurogenic bowel pattern after surgery, a context in which neuromodulation became biologically plausible.

Evidence specifically addressing SNM after endometriosis surgery is limited. However, studies evaluating the role of SNM for defecatory disorders after pelvic surgery and included patients after endometriosis surgery, demonstrated clinically meaningful improvement in bowel function [54]. In this context, 66% of patients reported positive outcomes and were definitively implanted, and the results were maintained after a mean follow-up period of > 5 years.

Positive results on bowel symptoms have also been reported in studies evaluating the efficacy of SNM in the treatment of bladder voiding dysfunction following surgery for endometriosis [55].

Taken together, the currently available evidence suggests that SNM may be considered in selected patients with refractory bowel dysfunction after endometriosis surgery, particularly when clinical features suggest a neuropathic or sensorimotor disorder and when conservative and rehabilitative strategies, including transanal irrigation, have failed. In these patients, neuropathic or sensorimotor dysfunction refers to impaired rectal sensation, altered compliance and disrupted autonomic innervation affecting bowel control.

However, further studies are needed to identify some predictors of response to SNM, the best pathological phenotypes, and to clarify the interaction between pelvic nerve injury, central sensitization, and bowel outcomes and how SNM could modulate them.

Discussion

Postoperative bowel dysfunction after surgery for deep endometriosis is increasingly recognized as a relevant issue but still poorly considered. Although surgical management of bowel endometriosis has improved substantially, functional outcomes (especially bowel) have received less attention [2, 4, 54, 55]. Only limited and methodologically weak literature is available, consisting mainly of small observational studies with heterogeneous endpoints, often focused more on pain than on bowel function. For these reasons, findings from this review still should be interpreted with caution. This highlights the need for more robust functional research in this population.

From a clinical point of view, while patients with endometriosis frequently exhibit IBS-like symptoms, they may develop features resembling neurogenic bowel dysfunction after surgery (especially if extensive), with several analogies with LARS. This evolution likely reflects the multifactorial impact of surgery, including autonomic denervation, altered rectal compliance, and pre-existing visceral hypersensitivity [56–58].

Given this complexity, single treatments rarely allow complete symptom control. Available data suggest that drugs, rehabilitation techniques, transanal irrigation, and sacral neuromodulation (and in very selected cases surgical revision) may each benefit a subset of patients, but none is often effective when used alone, supporting the value of a multimodal management strategy [59].

Besides the need for multimodal treatment, there is also a need for multidisciplinary involvement (gynecologists, colorectal surgeons, pelvic floor physiotherapists, gastroenterologists, and specialized nurses), with therapeutic pathways that should move away from rigid vertical algorithms toward more flexible, patient-centered models in which different treatments can be combined according to the predominant symptom profile and the patient’s preferences [60, 61] (Fig. 1).

Fig. 1.

From pyramid to rhombus. Beyond a classical stepwise vertical progression to a horizontal and multimodal approach where shared decision-making and patient involvement are part of the success of the treatment. Targeted drug therapies, transanal irrigation and rehabilitation are presented as same-level second-line options, to be chosen after a shared and tailored decision (rehabilitative options include physiotherapy, biofeedback, physical therapies, PTNS, and acupuncture)

This is why shared decision-making plays a central role in this context. In functional and chronic diseases, expectations and quality of life of patients are often more important than symptoms, and the available treatments need an active involvement to be truly effective.

Conclusions

Postoperative bowel dysfunction after surgery for endometriosis is an underestimated condition with an often complex therapeutic pathway. While several therapeutic options are available, none can currently be considered standard of care for this specific population. The limited evidence available and the need to manage various therapeutic options often require treatment to be personalized. Rehabilitative techniques, transanal irrigation, and sacral neuromodulation may represent effective solutions that must be available in centers that treat these patients.

Further prospective studies using standardized bowel outcomes measures are urgently needed. Until stronger evidence becomes available, multidisciplinary care and shared decision-making remain essential to optimizing functional results and patient satisfaction.

Author contribution

J.M. and S.O. wrote the main manuscript text and tables. Both authors reviewed the manuscript.

Funding

No funding for the present manuscript.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.