Advanced Endometriosis with a Large Bowel Nodule Managed Laparoscopically Using the NOSE Technique: a Case Report and Review of Literature

Advanced Endometriosis with a Large Bowel Nodule Managed Laparoscopically Using the NOSE Technique: a Case Report and Review of Literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Advanced Endometriosis with a Large Bowel Nodule Managed Laparoscopically Using the NOSE Technique: a Case Report and Review of Literature Leonard Ssebwami, Spire John Bosco Kiggundu, Ivan Paul Kato, Julius Ceasar Luyimbaazi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6961775/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Like any other advanced operable disease, advanced endometriosis presents a complex surgical experience to both the patient and the surgical team. This requires advanced surgical skills and the intra-operative time may be prolonged. This exposes the patient to prolonged anesthesia, prolonged carbon dioxide pneumoperitoneum and their associated complications. Consequently, this translates into a slightly increased recovery time and prolonged hospital stay. Case presentation We present a 28-year nulliparous black African diagnosed with advanced endometriosis; Enzian classification P-3 O-2/0 T-3/3 A-0 B-0/0 C-3 FA and was successfully managed laparoscopically using the NOSE technique a rarely performed modality of treatment in this setting. Conclusion Accurate and early diagnosis of endometriosis prevents progression to advanced disease, thereby saving the patientsfrom the burden of extensive and complex surgery. This paper presents an example of a critical diagnostic delay encountered by some endometriosis patients in Uganda. Improving the index of suspicion and diagnostic skills competency especially of performing transvaginal ultrasound scan among gynecology caregivers, coupled with community sensitization about the disease symptoms is paramount in minimizing diagnostic delay. Obstetrics & Gynecology Endometriosis Enzian classification Bowel surgery Laparoscopy Minimal access surgery NOSE technique Figures Figure 1 Figure 2 Background Endometriosis denotes the presence of functional endometrial stroma and glands outside the endometrial cavity ( 1 ). This ectopic endometrial tissue responds to cyclic menstrual hormone changes just like the normal endometrium in the uterine cavity. The symptoms of the disease result from the cyclic hormonal response of the ectopic endometrial tissue and include dysmenorrhoea, dyspareunia, dyschasia and infertility; however the disease may be asymptomatic ( 2 ). The chronicity of the symptoms of endometriosis has been associated with lower quality of life encompassing the physical and mental aspects. The disease affects women of reproductive age group and presents with a varying spectrum of manifestation depending on the location of the ectopic endometrial tissue ( 3 ). Economicaly, the disease affects productivity of women, resulting from the interrupted work performance from the catamenial symptoms ( 4 ). The true prevalence of the disease is unknown as estimates are affected by the need for mainly surgical diagnostic methods and on characteristics of the study population but is estimated to be around 5–10% ( 5 ).While the disease is prevalent in a remarkable number of populations, it is under diagnosed and thus under reported. This is partially due to limited investigative capacity and a low index of suspicion among gynaecological care givers ( 6 ). Recent literature has documented up to an estimated seven different consultations from different clinicians prior to an accurate diagnosis globally and this could even be higher among the resource constrained countries ( 7 ). Even when the diagnosis has been made, the disease presents one of the most perplexing moments to the team, which may sometimes necessitate a multidisciplinary intervention. Case report We present a 28 year nulliparous black African who presented with an eight year history of dysmenorrhea, dyspareunia, primary infertility and cyclic diarrhea. She was referred from a lower health facility, having been managed conservatively for pelvic inflammatory disease, ovarian cyst and tubo-ovarian mass with worsening symptomatology. She reported to having been subjected to a number of transabdominal ultrasound scans that revealed recurrent bilateral tubo-ovarian cysts. She was referred to the Henrob laparoscopic hospital in Kampala for further evaluation by a laparascopic gynaecologist. Physical assessment was generally unremarkable. Transvaginal ultrasound scan showed an anteverted anteflexed normal size uterus measuring (5.1x7.5x4.2) cm with asymmetrical myometrial thickening of the posterior myometrium in relation to the anterior myometrium with a ratio of 2:1 respectively. There were multiple hyperechoic islands seen in the myometrium and the endometrium was of normal echopattern with 1.5 cm thickness and a clear junctional zone. A thickened left uterosacral ligament was seen but with no nodule. The right uterosacral ligament was normal. The left ovary had a well defined thick walled mass seen in the left adnexia with ground glass echo pattern measuring (4.7x5.3) cm. The mass was fixed to the right ovary, uterus, pelvic side wall, uterosacral ligament and the lower bowel with a negative sliding sign. The right ovary was enlarged to 28ml and fixed to the left ovary, uterus, pelvic side wall, uterosacral ligament and rectum with a negative sliding sign. There was a tubular cystic mass seen in the right adnexia measuring (1.55x 5.3) cm. There was fibrosis at the torus with complete obliteration of the pouch of Douglas. There was an anterior rectal wall nodule at 8cm from the anal verge measuring (5.2x2.1) cm. This is shown in Fig. 1 . The posterior vaginal septum and recto-vaginal space appeared normal. The urinary bladder wall appeared normal with no nodules. The vesico-uterine space, ureters, kidneys appeared normal with no hydronephrosis. An Enzian classification was accordingly made, P-3 O-2/0 T-3/3 A-0 B-0/0 C-3 FA. Cystoscopy revealed normal urinary bladder mucosa with normal ureteric orifice. Hysteroscopy showed a normal endometrial cavity with visible patent bilateral ostia. Laparoscopy showed a frozen pelvis with a left endometrioma of 6cm in diameter and kissing ovaries adherent to the body of the uterus and left uterosacral ligaments. This is shown in Fig. 2 . The patient was counseled about the diagnosis, management and prognosis. She consented for an endometriosis surgery. Cystectomy was done for both ovaries, unraveled the frozen pelvis and did peritonectomy, plicated the ovaries onto the anterior abdominal wall for seven days. Nodulectomy at the torus and uterosacral ligaments was done. Debulking surgery for adenomyosis, resection and anastomosis of the rectal nodule about 5cm, tested with dye for patency and post operatively there was remarkable improvement. Histology showed colon tissue with an infiltrate of endometrial stroma and glands without atypia. Discussion Our patient presented with advanced endometriosis disease that had never been diagnosed despite the fact that she was seeking for care and being managed at a number of health facilities. In her case, the index diagnosis of endometriosis was made after eight years from the onset of symptoms. This delay between onset of symptoms and accurate diagnosis of endometriosis is similar to previous literature that revealed an average delay of seven years, though other studies have documented quite longer delay of up to ten years ( 8 ). This delay has been partly attributed to the fact that the symptoms of the disease mimic a number of disease pathologies, thus leading to misdiagnosis, but also the diagnosis requires extra skills of transvaginal ultrasound scan coupled with minimal access surgery skills ( 9 ) which may be missing in a number of health workers. Our patient presented with complaints of dysmenorrhea, dyspareunia, diarrhea and infertility. This is in tandem with previous literature that reported majority of patients present with pelvic pain, infertility and gastrointestinal symptoms as it was with our patient ( 10 ). After a century of intensive research, endometriosis remains a disease with a delayed diagnosis, mainly because non-invasive tools are not available for early stage diagnosis of the condition. Although bowel endometriosis is rare and is noted in about 10 to 30% of all patients with endometriosis ( 11 ). The disease typically has a special preference for the terminal colon, particularly the sigmoid and rectum ( 12 ). Endometriosis remains a disease with a delayed diagnosis, mainly because non-invasive tools are not available for early stage diagnosis of the condition ( 13 ). Our patient had a long spell of unclear diagnoses partly because of limited specialized doctors and the diagnostics. The lack of a gold standard staging system is a concerning issue in the treatment of endometriosis ( 14 ).This is even worse in the developing world including here in Uganda. We applied the Enzian classification to stage the disease, one of the most reliable staging systems that were developed as a supplement to the revised American Society for Reproductive Medicine score, to provide a detailed description of the retroperitoneal structures. Irrespective of the surgical technique, minimal access surgery has demonstrated to be superior to open surgery in the management of bowel endometriosis ( 15 ). Previous studies have documented lower rates of complications associated with laparoscopic resection of recto-sigmoid nodules at 15.7% compared to 26.6% at open laparotomy ( 2 ). This patient was managed using the NOSE colectomy technique, one of best approaches in surgical management of such patients. Compared to the traditional methods of laparoscopic bowel resection, the NOSE technique has been documented to be safer, have a shorter recovery time, and is associated with shorter intraoperative time. Conclusion Accurate and early diagnosis of endometriosis prevents progression to advanced disease, thereby saving the patient the burden of extensive and complex surgery. This paper presents an example of a critical diagnostic delay encountered by some endometriosis patients in Uganda. Improving the index of suspicion and diagnostic skills competency especially of performing transvaginal ultrasound scan among gynaecology care givers, coupled with community sensitization about the disease symptoms is paramount in minimizing diagnostic delay. Abbreviations NOSE: Natural Orifice Specimen Extraction TVS : Transvaginal Ultrasound Scan Declarations Acknowledgement We acknowledge and thank the patient who consented to have this work published, and also to all the hospital staffs who participated either directly or indirectly in the management of this patient. Consent for publication An informed written consent to publish this work was obtained from the patient. Availability of data and materials Not applicable. Conflict of interest The authors report no conflict of interest in this work. Funding None received. Author contributions LS and IPK participated in the conceptualization and literature search. SJBK, JCL and GKK made substantial contribution in case discussion. ALL authors revised and approved the final manuscript. References Cunningham FG, Leveno KJ, Bloom SL, Dashe JSH, BL CB (2018) Williams Obstetrics, 25th edn. McGraw-Hill Education Saunders PTK, Whitaker LHR, Horne AW, Endometriosis (2024) Improvements and challenges in diagnosis and symptom management. Cell Reports Med. ;5(6):101596. Available from: https://doi.org/10.1016/j.xcrm.2024.101596 Chauhan S, More A, Chauhan V, Kathane A, Endometriosis (2022) A Review of Clinical Diagnosis, Treatment, and Pathogenesis. Cureus 14(9):1–8 Id MA, Lawson K, Wood A, Smith CA, Abbott J (2019) The cost of illness and economic burden of endometriosis and chronic pelvic pain in Australia: A national online survey. PLoS ONE 14(10):1–12 Basarir H, Naci H, Rahmioglu N (2023) Prevalence, diagnostic delay and economic burden of endometriosis and its impact on quality of life: results from an Eastern Mediterranean population. Eur J Public Health 34(2):244–252 Smorgick N, As-sanie S, Marsh CA, Smith YR, Quint EH (2014) Original Study Advanced Stage Endometriosis in Adolescents and Young Women. J Pediatr Adolesc Gynecol. ;27(6):320–3. Available from: http://dx.doi.org/10.1016/j.jpag.2013.12.010 Eisenberg VH, Weil C, Chodick GSV (2018) Epidemiology of endometriosis: a large population-based database study from a healthcare provider with 2 million members. BJOG 125(18):55–62 Corte P, De, Klinghardt M, Stockum S, Von, Heinemann K (2025) Time to Diagnose Endometriosis: Current Status, Challenges and Regional Characteristics — A Systematic Literature Review. BJOG Int J Obstet Gynaecol 25(132):118–130 Griffiths MJ, Horne AW, Gibson DA, Roberts N, Saunders PTK (2024) Endometriosis: recent advances that could accelerate diagnosis and improve care. Trends Mol Med 30(9):875–889 Carranco R, Rivero M, Torres M, Alverde M, Gonzalez M, Salazar F et al (2023) Severe Endometriosis with Intestinal Invasion: A Case Report and Literature Review. J Surg Tech Proced Rem Publ 7(2):1–3 Kondo H, Hirano Y, Ishii T, Hara K, Obara N, Wang L et al (2020) Intestinal endometriosis treated by laparoscopic surgery: case series of 5 patients. Surg Case Rep 6(49):4–9 Yong PJ, Bedaiwy MA, Alotaibi F, Anglesio MS (2021) Pathogenesis of bowel endometriosis. Best Pract Res Clin Obstet Gynaecol 71:2–13 Brosens I, Gordts S, Benagiano G (2026) Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion. Hum Reprod 28(8):2026–2031 Lee S, Koo Y, Lee D, Koo Y (2021) Classification of endometriosis. Yeungnam Univ J Med 38(1):10–18 Jago CA, Nguyen DB, Flaxman TE, Singh SS (2021) Bowel surgery for endometriosis: A practical look at short- and long-term complications. Best Pract Res Clin Obstet Gynaecol 71:144–160 Additional Declarations The authors declare potential competing interests as follows: The authors report no conflict of interest in this work. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6961775","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":475529859,"identity":"9c0bb089-bcd4-4774-a487-a0a3df346b48","order_by":0,"name":"Leonard Ssebwami","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYDCCA3CSsRFI2sAYxGlpAJJpMAZRWsDkYSQuDsB3+wDzxx8VdxL7px1uOPCh4rzd2nYgg6HGJhqXFslzCWzSPGeeJc64ndhwcMaZ28nbziQCtRxLy23AocXgDAMbM2Pb4dwGoJbDvG23k80OALUwNhzGp4X5489/h3Png7T8bTuXbHb+IUEtDBK8QAUbQFoY2w7Ymd0gYIvkGcY2aZ5jz+o3gvzScyY5wewG0JYEPH7hO8N8+OOPmjvGcrfTHz74UWFnb3YeyPhQY4NTCyjiULiJYG4CTuVYgD0pikfBKBgFo2BkAACPtXOkNIRMTQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0000-9443-8684","institution":"Department of Obstetrics and Gynaecology, Hoima Regional Referral Hospital, Hoima, Uganda Department of Obstetrics and Gynaecology, Henrob Laparoscopy Hospital, Kampala, Uganda Department of Obstetrics and Gynaecology, Kampala International University Western Campus, Bushenyi, 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nodule measuring (5.2x2.1) cm, white arrow \u003cstrong\u003eB-\u003c/strong\u003eLaparoscopic view showing a frozen pelvis with kissing ovaries and the sigmoid colon trapped between the ovaries and the uterus, upper back arrow-left ovary, lower black arrow-uterus, upper small white arrow-sigmoid colon, big white arrow-right ovary.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6961775/v1/1e91651838381af4c729f448.png"},{"id":85619302,"identity":"01d3c153-ed92-4766-8e65-deca2d9cda11","added_by":"auto","created_at":"2025-06-29 14:56:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":176192,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA- \u003c/strong\u003eHysteroscopy showing a normal endometrial cavity \u003cstrong\u003eB-\u003c/strong\u003eSite of anastomosis following resection of bowel nodule \u003cstrong\u003eC-\u003c/strong\u003eApplication of a staple on the proximal segment of the rectum at laparoscopy\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6961775/v1/462636d4bb22626cd2b6cd2e.png"},{"id":85619306,"identity":"1097aa4e-289e-4e21-b29d-108fab248112","added_by":"auto","created_at":"2025-06-29 14:56:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1464668,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6961775/v1/b7d58f01-4cda-493f-8e53-7f3f80ea9481.pdf"}],"financialInterests":"The authors declare potential competing interests as follows: The authors report no conflict of interest in this work.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAdvanced Endometriosis with a Large Bowel Nodule Managed Laparoscopically Using the NOSE Technique: a Case Report and Review of Literature\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eEndometriosis denotes the presence of functional endometrial stroma and glands outside the endometrial cavity (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This ectopic endometrial tissue responds to cyclic menstrual hormone changes just like the normal endometrium in the uterine cavity. The symptoms of the disease result from the cyclic hormonal response of the ectopic endometrial tissue and include dysmenorrhoea, dyspareunia, dyschasia and infertility; however the disease may be asymptomatic (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The chronicity of the symptoms of endometriosis has been associated with lower quality of life encompassing the physical and mental aspects. The disease affects women of reproductive age group and presents with a varying spectrum of manifestation depending on the location of the ectopic endometrial tissue (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Economicaly, the disease affects productivity of women, resulting from the interrupted work performance from the catamenial symptoms (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The true prevalence of the disease is unknown as estimates are affected by the need for mainly surgical diagnostic methods and on characteristics of the study population but is estimated to be around 5\u0026ndash;10% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).While the disease is prevalent in a remarkable number of populations, it is under diagnosed and thus under reported. This is partially due to limited investigative capacity and a low index of suspicion among gynaecological care givers (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Recent literature has documented up to an estimated seven different consultations from different clinicians prior to an accurate diagnosis globally and this could even be higher among the resource constrained countries (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Even when the diagnosis has been made, the disease presents one of the most perplexing moments to the team, which may sometimes necessitate a multidisciplinary intervention.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eWe present a 28 year nulliparous black African who presented with an eight year history of dysmenorrhea, dyspareunia, primary infertility and cyclic diarrhea. She was referred from a lower health facility, having been managed conservatively for pelvic inflammatory disease, ovarian cyst and tubo-ovarian mass with worsening symptomatology. She reported to having been subjected to a number of transabdominal ultrasound scans that revealed recurrent bilateral tubo-ovarian cysts. She was referred to the Henrob laparoscopic hospital in Kampala for further evaluation by a laparascopic gynaecologist. Physical assessment was generally unremarkable. Transvaginal ultrasound scan showed an anteverted anteflexed normal size uterus measuring (5.1x7.5x4.2) cm with asymmetrical myometrial thickening of the posterior myometrium in relation to the anterior myometrium with a ratio of 2:1 respectively. There were multiple hyperechoic islands seen in the myometrium and the endometrium was of normal echopattern with 1.5 cm thickness and a clear junctional zone. A thickened left uterosacral ligament was seen but with no nodule. The right uterosacral ligament was normal. The left ovary had a well defined thick walled mass seen in the left adnexia with ground glass echo pattern measuring (4.7x5.3) cm. The mass was fixed to the right ovary, uterus, pelvic side wall, uterosacral ligament and the lower bowel with a negative sliding sign. The right ovary was enlarged to 28ml and fixed to the left ovary, uterus, pelvic side wall, uterosacral ligament and rectum with a negative sliding sign. There was a tubular cystic mass seen in the right adnexia measuring (1.55x 5.3) cm. There was fibrosis at the torus with complete obliteration of the pouch of Douglas. There was an anterior rectal wall nodule at 8cm from the anal verge measuring (5.2x2.1) cm. This is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The posterior vaginal septum and recto-vaginal space appeared normal. The urinary bladder wall appeared normal with no nodules. The vesico-uterine space, ureters, kidneys appeared normal with no hydronephrosis. An Enzian classification was accordingly made, P-3 O-2/0 T-3/3 A-0 B-0/0 C-3 FA. Cystoscopy revealed normal urinary bladder mucosa with normal ureteric orifice. Hysteroscopy showed a normal endometrial cavity with visible patent bilateral ostia. Laparoscopy showed a frozen pelvis with a left endometrioma of 6cm in diameter and kissing ovaries adherent to the body of the uterus and left uterosacral ligaments. This is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe patient was counseled about the diagnosis, management and prognosis. She consented for an endometriosis surgery. Cystectomy was done for both ovaries, unraveled the frozen pelvis and did peritonectomy, plicated the ovaries onto the anterior abdominal wall for seven days. Nodulectomy at the torus and uterosacral ligaments was done. Debulking surgery for adenomyosis, resection and anastomosis of the rectal nodule about 5cm, tested with dye for patency and post operatively there was remarkable improvement. Histology showed colon tissue with an infiltrate of endometrial stroma and glands without atypia.\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eOur patient presented with advanced endometriosis disease that had never been diagnosed despite the fact that she was seeking for care and being managed at a number of health facilities. In her case, the index diagnosis of endometriosis was made after eight years from the onset of symptoms. This delay between onset of symptoms and accurate diagnosis of endometriosis is similar to previous literature that revealed an average delay of seven years, though other studies have documented quite longer delay of up to ten years (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This delay has been partly attributed to the fact that the symptoms of the disease mimic a number of disease pathologies, thus leading to misdiagnosis, but also the diagnosis requires extra skills of transvaginal ultrasound scan coupled with minimal access surgery skills (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) which may be missing in a number of health workers. Our patient presented with complaints of dysmenorrhea, dyspareunia, diarrhea and infertility. This is in tandem with previous literature that reported majority of patients present with pelvic pain, infertility and gastrointestinal symptoms as it was with our patient (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). After a century of intensive research, endometriosis remains a disease with a delayed diagnosis, mainly because non-invasive tools are not available for early stage diagnosis of the condition. Although bowel endometriosis is rare and is noted in about 10 to 30% of all patients with endometriosis (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The disease typically has a special preference for the terminal colon, particularly the sigmoid and rectum (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Endometriosis remains a disease with a delayed diagnosis, mainly because non-invasive tools are not available for early stage diagnosis of the condition (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Our patient had a long spell of unclear diagnoses partly because of limited specialized doctors and the diagnostics.\u003c/p\u003e \u003cp\u003eThe lack of a gold standard staging system is a concerning issue in the treatment of endometriosis (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).This is even worse in the developing world including here in Uganda. We applied the Enzian classification to stage the disease, one of the most reliable staging systems that were developed as a supplement to the revised American Society for Reproductive Medicine score, to provide a detailed description of the retroperitoneal structures. Irrespective of the surgical technique, minimal access surgery has demonstrated to be superior to open surgery in the management of bowel endometriosis (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Previous studies have documented lower rates of complications associated with laparoscopic resection of recto-sigmoid nodules at 15.7% compared to 26.6% at open laparotomy (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This patient was managed using the NOSE colectomy technique, one of best approaches in surgical management of such patients. Compared to the traditional methods of laparoscopic bowel resection, the NOSE technique has been documented to be safer, have a shorter recovery time, and is associated with shorter intraoperative time.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAccurate and early diagnosis of endometriosis prevents progression to advanced disease, thereby saving the patient the burden of extensive and complex surgery. This paper presents an example of a critical diagnostic delay encountered by some endometriosis patients in Uganda. Improving the index of suspicion and diagnostic skills competency especially of performing transvaginal ultrasound scan among gynaecology care givers, coupled with community sensitization about the disease symptoms is paramount in minimizing diagnostic delay.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eNOSE:\u0026nbsp;\u003c/strong\u003eNatural Orifice Specimen Extraction\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTVS\u003c/strong\u003e: Transvaginal Ultrasound Scan\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge and thank the patient who consented to have this work published, and also to all the hospital staffs who participated either directly or indirectly in the management of this patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn informed written consent to publish this work was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflict of interest in this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLS and IPK participated in the conceptualization and literature search. SJBK, JCL and GKK made substantial contribution in case discussion. ALL authors revised and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCunningham FG, Leveno KJ, Bloom SL, Dashe JSH, BL CB (2018) Williams Obstetrics, 25th edn. McGraw-Hill Education\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaunders PTK, Whitaker LHR, Horne AW, Endometriosis (2024) Improvements and challenges in diagnosis and symptom management. Cell Reports Med. ;5(6):101596. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.xcrm.2024.101596\u003c/span\u003e\u003cspan address=\"10.1016/j.xcrm.2024.101596\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChauhan S, More A, Chauhan V, Kathane A, Endometriosis (2022) A Review of Clinical Diagnosis, Treatment, and Pathogenesis. Cureus 14(9):1\u0026ndash;8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eId MA, Lawson K, Wood A, Smith CA, Abbott J (2019) The cost of illness and economic burden of endometriosis and chronic pelvic pain in Australia: A national online survey. PLoS ONE 14(10):1\u0026ndash;12\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBasarir H, Naci H, Rahmioglu N (2023) Prevalence, diagnostic delay and economic burden of endometriosis and its impact on quality of life: results from an Eastern Mediterranean population. Eur J Public Health 34(2):244\u0026ndash;252\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmorgick N, As-sanie S, Marsh CA, Smith YR, Quint EH (2014) Original Study Advanced Stage Endometriosis in Adolescents and Young Women. J Pediatr Adolesc Gynecol. ;27(6):320\u0026ndash;3. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/j.jpag.2013.12.010\u003c/span\u003e\u003cspan address=\"10.1016/j.jpag.2013.12.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEisenberg VH, Weil C, Chodick GSV (2018) Epidemiology of endometriosis: a large population-based database study from a healthcare provider with 2 million members. BJOG 125(18):55\u0026ndash;62\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorte P, De, Klinghardt M, Stockum S, Von, Heinemann K (2025) Time to Diagnose Endometriosis: Current Status, Challenges and Regional Characteristics \u0026mdash; A Systematic Literature Review. BJOG Int J Obstet Gynaecol 25(132):118\u0026ndash;130\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGriffiths MJ, Horne AW, Gibson DA, Roberts N, Saunders PTK (2024) Endometriosis: recent advances that could accelerate diagnosis and improve care. Trends Mol Med 30(9):875\u0026ndash;889\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarranco R, Rivero M, Torres M, Alverde M, Gonzalez M, Salazar F et al (2023) Severe Endometriosis with Intestinal Invasion: A Case Report and Literature Review. J Surg Tech Proced Rem Publ 7(2):1\u0026ndash;3\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKondo H, Hirano Y, Ishii T, Hara K, Obara N, Wang L et al (2020) Intestinal endometriosis treated by laparoscopic surgery: case series of 5 patients. Surg Case Rep 6(49):4\u0026ndash;9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYong PJ, Bedaiwy MA, Alotaibi F, Anglesio MS (2021) Pathogenesis of bowel endometriosis. Best Pract Res Clin Obstet Gynaecol 71:2\u0026ndash;13\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrosens I, Gordts S, Benagiano G (2026) Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion. Hum Reprod 28(8):2026\u0026ndash;2031\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee S, Koo Y, Lee D, Koo Y (2021) Classification of endometriosis. Yeungnam Univ J Med 38(1):10\u0026ndash;18\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJago CA, Nguyen DB, Flaxman TE, Singh SS (2021) Bowel surgery for endometriosis: A practical look at short- and long-term complications. Best Pract Res Clin Obstet Gynaecol 71:144\u0026ndash;160\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Endometriosis, Enzian classification, Bowel surgery, Laparoscopy, Minimal access surgery, NOSE technique","lastPublishedDoi":"10.21203/rs.3.rs-6961775/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6961775/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLike any other advanced operable disease, advanced endometriosis presents a complex surgical experience to both the patient and the surgical team. This requires advanced surgical skills and the intra-operative time may be prolonged. This exposes the patient to prolonged anesthesia, prolonged carbon dioxide pneumoperitoneum and their associated complications. Consequently, this translates into a slightly increased recovery time and prolonged hospital stay.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe present a 28-year nulliparous black African diagnosed with advanced endometriosis; Enzian classification P-3 O-2/0 T-3/3 A-0 B-0/0 C-3 FA and was successfully managed laparoscopically using the NOSE technique a rarely performed modality of treatment in this setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccurate and early diagnosis of endometriosis prevents progression to advanced disease, thereby saving the patientsfrom the burden of extensive and complex surgery. This paper presents an example of a critical diagnostic delay encountered by some endometriosis patients in Uganda. Improving the index of suspicion and diagnostic skills competency especially of performing transvaginal ultrasound scan among gynecology caregivers, coupled with community sensitization about the disease symptoms is paramount in minimizing diagnostic delay.\u003c/p\u003e","manuscriptTitle":"Advanced Endometriosis with a Large Bowel Nodule Managed Laparoscopically Using the NOSE Technique: a Case Report and Review of Literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-29 14:48:13","doi":"10.21203/rs.3.rs-6961775/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"85b6036e-e531-45a4-8a83-7f3ff19634f4","owner":[],"postedDate":"June 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50496385,"name":"Obstetrics \u0026 Gynecology"}],"tags":[],"updatedAt":"2025-06-29T14:48:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-29 14:48:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6961775","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6961775","identity":"rs-6961775","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}