2/24/19
1
Endometriosis:sonographers’ guide for general practice
Jing Fang Monash Health
Endometriosis• Superficial endometriosis• Ovarian endometrioma• Deep infiltrating endometriosis (DIE)
• TVS is an accurate and reliable diagnostic tool for diagnosing DIE • Diagnostic performance similar to MRI
• Bowel preparation is NOT essential nor necessary for detection of DIE (Hudelist, et al., 2011)
• Endometriosis assessment should be incorporated into general practice • Benefits
Endometriosis Clinical indications• Pelvic pain• Irregular periods• Menorrhagia• Dysmenorrhea• Dyspareunia
Bowel• Dyschezia• Cyclical rectal bleeding
Bladder/Ureters• Dysuria • Cyclical hematuria
• Asymptomatic!!
Systematic approach to scanning for
deep infiltrating endometriosis Overview
1• Uterus and
adnexa
2• Pouch of
Douglas (POD)
3• Posterior pelvic
compartment
4• Anterior pelvic
compartment
2/24/19
2
1. Uterus & Adnexa• Anteverted and
retroflexed uterus• Association with POD
obliteration (Reid et al., 2013)
• Adenomyosis • Loss of junctional zone • Myo. cysts• Venetian blind
• Ovaries• Endometrioma: associated with 50% DIE
lesions (Chapron et al., 2009)
• Kissing ovaries
• 7 fold increase in association with bowel nodule• 3 fold increase in association with POD obliteration
1. Uterus & Adnexa
• Ovaries• Mobility
1. Uterus & Adnexa• Ovaries
• Mobility
1. Uterus & Adnexa
• Hydrosalpinx • Pseudo-peritoneal cysts
1. Uterus & Adnexa Overview
1• Uterus and
adnexa
2• Pouch of
Douglas (POD)
3• Posterior pelvic
compartment
4• Anterior pelvic
compartment
2/24/19
3
• POD – where is it?• Sliding sign
• What is it? • Non-obliteration
• Obliteration - partial or complete • accurate and sensitive
• 93% accuracy
• Positive sliding sign does not exclude DIE in the post compartment • 12% w/o POD obliteration had DIE
2. Pouch of Douglas• Sliding sign
• Anterior fornix
2. Pouch of Douglas
Animation courtesy of Karl Rombauts
2. Pouch of Douglas• Sliding sign
• Posterior fornix
2. Pouch of Douglas• Sliding sign
• Posterior fornix
2. Pouch of Douglas• Sliding sign – retroverted uterus
• Push and pull • Negative sliding sign:
• hard marker for high-grade endometriosis• Women with POD obliteration 3 times more likely to have bowel endometriosis (Khong et al.,
2011)
2. Pouch of Douglas
2/24/19
4
Overview
1• Uterus and adnexa
2• Pouch of Douglas
(POD)
3• Posterior pelvic
compartment
4• Anterior pelvic
compartment
Sites commonly affected by DIE:
• vaginal wall• posterior vaginal fornix• rectovaginal septum• uterosacral ligament• anterior rectum• anterior rectosigmoid
(Chapron et al., 2006; Chamie et al., 2010)
3. Posterior Compartment
Overall pooled sensitivity and specificity:• Vaginal endometriosis: 58% and 96% • Rectovaginal septum endometriosis: 49% and 98%• USL endometriosis: 53% and 93%
3. Posterior Compartment
• Vagina
• Thin and hypoechoic
• Techniques • Posterior fornix• Scan from left to right
3. Posterior Compartment
• Vaginal nodule
3. Posterior Compartment 3. Posterior Compartment• Mimic of vaginal nodule
2/24/19
5
• Rectovaginal Septum• space between the posterior vaginal wall and the anterior rectal wall
3. Posterior Compartment
• Rectovaginal septum• DIE involving just the RVS is
uncommon• Measurement:
• distance of the nodule from the anus
• Low-lying DIE lesions (<5-8cm from the anus) associated with significant post-operative complications
(Ruffo et al., 2010; Moawad, et al., 2013)
Image courtesy of Karl Rombauts
3. Posterior Compartment
3. Posterior Compartment• Vaginal nodule stuck to a bowel nodule forming a RV nodule
• Uterosacral ligaments (L&R)• insert at the level of internal os of
cervix just above the posterior vaginal fornix
• commonly involved in DIE
3. Posterior Compartment
• Uterosacral ligaments – technique• Posterior fornix• Sweep from right to left
Animation courtesy of Karl Rombauts
3. Posterior Compartment• Uterosacral ligaments – technique
3. Posterior Compartment
2/24/19
6
• USL nodule stuck to vagina
3. Posterior Compartment 3. Posterior Compartment• USL nodule stuck to vagina
3. Posterior Compartment• USL nodule stuck to vagina, ovary and a bowel nodule
3. Posterior Compartment• USL nodule stuck to vagina, ovary and a bowel nodule
• Bowel• Affect 4%-37% of women with
endometriosis (Remorgida et al., 2007)
• Anterior rectum, rectosigmoid and the sigmoid
• Isolated, multiple• 3 layers: muscularis, submucosal &
mucosal layer• TVS detection of bowel
endometriosis• 94% sensitive; 98% specific
(Hudelist et al., 2011)
3. Posterior CompartmentFocal nodule Echogenic focus within nodule
Bowel wall thickening and tethering to ovary Focal linear thickening of bowel wall
3. Posterior Compartment
2/24/19
7
3. Posterior Compartment• Bowel nodule
3. Posterior Compartment• Bowel nodule – multiple
3. Posterior Compartment• Bowel nodule – multiple
3. Posterior Compartment• Bowel - technique
• Low lying bowel lesions (5-8cm from anus)• Measurements taken in short sections & total distance is added
3. Posterior Compartment• Bowel – measuring distance of the nodule from anus
3. Posterior Compartment• Bowel nodule – measuring distance of the nodule from anus
2/24/19
8
3. Posterior Compartment• Bowel - pitfalls
3. Posterior Compartment• Bowel - pitfalls
Overview
1• Uterus and
adnexa
2• Pouch of
Douglas (POD)
3• Posterior pelvic
compartment
4• Anterior pelvic
compartment
• Bladder
• Most frequently affected with DIE in the anterior compartment
• Accuracy of TVS for diagnosis of DIE in the bladder: • Meta-analysis with overall pooled sensitivity
and specificity: 65% and 100% (Guerriero, S et al., 2015)
4. Anterior Compartment
• Bladder – normal
4. Anterior Compartment• Bladder nodule
4. Anterior Compartment
2/24/19
9
• Vesico-uterine pouch
• Sliding test - mobility of the VUP
• TV probe in the anterior fornix
4. Anterior Compartment• Vesico-uterine pouch – normal
4. Anterior Compartment
• Vesico-uterine pouch obliteration
4. Anterior Compartment• Vesico-uterine pouch obliteration
4. Anterior Compartment
• Ureters • endometriotic nodules infiltrate or compress the ureter à strictures• difficult to diagnose • r/o hydronephrosis
4. Anterior Compartment• Use the posterior fornix
• Extend the scan into the posterior and anterior compartments
• Be systemic
Summary
2/24/19
10
Acknowledgements• Dr. Sofie Piessens
• Karl Rombauts
References• Koninckx PR, Martin D. Treatment of deeply infiltrating endometriosis. Curr Opin Obstet Gynecol. 1994;6(3):231-41.• Kondo W, Bourdel N, Tamburro S, Cavoli D, Jardon K, Rabischong B, et al. Complications after surgery for deeply infiltrating pelvic
endometriosis. BJOG. 2011;118(3):292-8.• Guerriero S, Condous G, van den Bosch T, Valentin L, Leone FP, Van Schoubroeck D, et al. Systematic approach to sonographic
evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol. 2016;48(3):318-32.
• Hudelist G, English J, Thomas AE, Tinelli A, Singer CF, Keckstein J. Diagnostic accuracy of transvaginal ultrasound for non-invasive diagnosis of bowel endometriosis: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2011;37(3):257-63.
• Reid S, Lu C, Casikar I, Reid G, Abbott J, Cario G, et al. Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound technique: the sliding sign. Ultrasound Obstet Gynecol. 2013;41(6):685-91.
• Chapron C, Pietin-Vialle C, Borghese B, Davy C, Foulot H, Chopin N. Associated ovarian endometrioma is a marker for greater severity of deeply infiltrating endometriosis. Fertil Steril. 2009;92(2):453-7.
• Ghezzi F, Raio L, Cromi A, Duwe DG, Beretta P, Buttarelli M, et al. "Kissing ovaries": a sonographic sign of moderate to severe endometriosis. Fertil Steril. 2005;83(1):143-7.
• Khong SY, Bignardi T, Luscombe G, Lam A. Is pouch of Douglas obliteration a marker of bowel endometriosis? J Minim Invasive Gynecol. 2011;18(3):333-7.
• Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher-Lavenu MC, et al. Deeply infiltrating endometriosis: pathogeneticimplications of the anatomical distribution. Hum Reprod. 2006;21(7):1839-45.
• Chamié LP, Pereira RMA, Zanatta A, Serafini PC. Transvaginal US after Bowel Preparation for Deeply Infiltrating Endometriosis: Protocol, Imaging Appearances, and Laparoscopic Correlation. RadioGraphics. 2010;30(5):1235-49.
• Reid S, Lu C, Hardy N, Casikar I, Reid G, Cario G, et al. Office gel sonovaginography for the prediction of posterior deep infiltrating endometriosis: a multicenter prospective observational study. Ultrasound Obstet Gynecol. 2014;44(6):710-8.
• Ruffo G, Scopelliti F, Scioscia M, Ceccaroni M, Mainardi P, Minelli L. Laparoscopic colorectal resection for deep infiltrating endometriosis: analysis of 436 cases. Surg Endosc. 2010;24(1):63-7.
• Moawad NS, Caplin A. Diagnosis, management, and long-term outcomes of rectovaginal endometriosis. Int J Womens Health. 2013;5:753-63.
• Bazot M, Malzy P, Cortez A, Roseau G, Amouyal P, Darai E. Accuracy of transvaginal sonography and rectal endoscopic sonography in the diagnosis of deep infiltrating endometriosis. Ultrasound Obstet Gynecol. 2007;30(7):994-1001.
• Remorgida V, Ferrero S, Fulcheri E, Ragni N, Martin DC. Bowel endometriosis: presentation, diagnosis, and treatment. ObstetGynecol Surv 2007; 62: 461–470
• Hudelist G, Tuttlies F, Rauter G, Pucher S, Keckstein J. Can transvaginal sonography predict infiltration depth in patients with deep infiltrating endometriosis of the rectum? Hum Reprod. 2009;24(5):1012-7.
• Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher-Lavenu MC, et al. Deeply infiltrating endometriosis: pathogeneticimplications of the anatomical distribution. Hum Reprod. 2006;21(7):1839-45.
• Moro F, Mavrelos D, Pateman K, Holland T, Hoo WL, Jurkovic D. Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section. Ultrasound Obstet Gynecol. 2015;45(2):223-8.
• Pateman K, Holland TK, Knez J, Derdelis G, Cutner A, Saridogan E, et al. Should a detailed ultrasound examination of the complete urinary tract be routinely performed in women with suspected pelvic endometriosis? Hum Reprod. 2015;30(12):2802-7.