Endometriosis is known to negatively impact sexual function; however, limited research has explored whether classification systems can help pinpoint specific anatomical locations associated with sexual dysfunction. This study was necessitated by the paucity of literature on classification systems that allow clinicians to associate specific symptoms of sexual dysfunction with particular locations of deep infiltrating endometriosis (DIE).
This study aimed to investigate whether the Enzian and revised American Society for Reproductive Medicine (rASRM) classification systems can predict sexual dysfunction based on the localization and extent of DIE.
A clinical study was conducted with 77 women with histologically confirmed DIE. Data were collected from gynecological consultations and surgical reports classified using the rASRM and Enzian systems. Sexual function was assessed using the Female Sexual Function Index. Statistical analyses included Fisher’s exact test, Mann-Whitney test, and Student’s t-test.
The primary outcome was to examine the relationship between endometriosis localization, disease extent, and sexual dysfunction as indicated by the two classification systems under investigation.
A possible association was identified between sexual dysfunction and Enzian B classification (p = 0.013*), implicating involvement of the sacrouterine ligaments, cardinal ligaments, or pelvic sidewall. No significant association was found between sexual dysfunction and rASRM scores. A correlation between the number of endometriosis locations and the presence of sexual dysfunction was also observed (p = 0.015*). However, it is important to note that patients classified as Enzian B may have had additional, undocumented lesions in other locations not identified through available medical records, imaging, or surgical reports. These unidentified lesions could have influenced their sexual dysfunction, representing a potential confounding factor in our analysis.
These findings suggest that the localization of DIE may contribute to sexual dysfunction, but further validation is required before drawing clinical conclusions regarding surgical interventions.
This is the first study to explore the ability of a classification system to pinpoint sexual dysfunction in endometriosis to a particular anatomical location, providing novel insights into DIE’s impact on sexual health. However, variability in referral sources, the potential for undocumented lesions, and a small sample size for cases of sexual dysfunction may limit the generalizability of these findings.
Disease localization, particularly in the uterosacral ligaments and pelvic sidewall, may contribute to sexual dysfunction, offering potential guidance for clinical evaluation. However, further research is necessary to validate these associations while accounting for potential confounding factors.

© The Author(s) 2025. Published by Oxford University Press on behalf of The International Society for Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.