Advances in bowel endometriosis: epidemiology, pathogenesis, diagnosis, treatment, and future perspectives

Abstract Bowel endometriosis (BE), the most common extra-pelvic manifestation of endometriosis and one of the most challenging subtypes of deep infiltrating endometriosis (DIE), is defined by endometrial glands and stroma infiltrating the bowel wall with involvement of the muscularis propria. Rectosigmoid involvement accounts for approximately 90% of all intestinal lesions. BE causes progressive pelvic pain, severe gastrointestinal dysfunction, and subfertility, substantially impairing the physical and psychological well-being of women of reproductive age. This narrative review comprehensively summarizes recent advances in the epidemiology, multifactorial pathogenesis (retrograde menstruation, coelomic metaplasia, immune dysregulation, neuroinvasion, gut microbiota, and somatic driver mutations), clinical presentation and quality-of-life impact, multimodal imaging strategies (International Deep Endometriosis Analysis [IDEA], enhanced ultrasonography, magnetic resonance imaging [MRI], endoscopic ultrasonography), individualized treatment (hormonal therapy, shaving, discoid resection, segmental resection), and multidisciplinary team (MDT) management of BE. We additionally discuss classification/staging systems (the ENZIAN score), surgical decision-making algorithms including ultrasound-guided classification (UBESS) and degree of muscular infiltration, complementary and nutritional therapies, fertility preservation, long-term prognosis and recurrence (including persistent symptoms despite surgery), and future precision-medicine directions, accompanied by a graded appraisal of the quality of available evidence. A particular focus is placed on delayed diagnosis, which remains a major contributor to disease burden. Similar content being viewed by others Author information Authors and Affiliations Corresponding author Ethics declarations Competing interests The authors declare no competing interests. Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. About this article Cite this article Ye, Q., Li, Y. & Li, X. Advances in bowel endometriosis: epidemiology, pathogenesis, diagnosis, treatment, and future perspectives. Reprod Biol Endocrinol (2026). https://doi.org/10.1186/s12958-026-01623-z Received: Accepted: Published: DOI: https://doi.org/10.1186/s12958-026-01623-z