endometriosis as a common cause of pelvic pain · 9. solid fibrotic masses of endometriosis are...
TRANSCRIPT
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ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN
M.Basta Nikolić, S. Stojanović, O. Nikolić, T. Mrđanin, D. Donat, V. Žigić
Center for Radiology, Clinical Center of VojvodinaNovi Sad
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Chronic pelvic pain (CPP)
• Presence of pain >6m localized to the anatomic pelvis
• Severe enough to cause functional disability and require medical or surgical treatment
• Cause of ~40% laparoscopies and 10-15% hysterectomies
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CAUSE OF CPP
1. Gyn and Obs
2. Urologic
3. GI
4. Vascular
5. MS
6. Neuro
7. Psychological
1/3 endometriosis
1/3 adhesions
Neis KJ,Neis F. Chronic pelvic pain: cause, diagnosis and therapy from a gynaecologist’s and an endoscopist’s point of view. Gynecol Endocrinol.2009;25(11):757-761.
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ENDOMETRIOSIS
-presence of functional endometrial glands and stroma outside the uterine cavity
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• Infertility• pelvic pain
• Unusual symptoms• gastrointestinal involvement: catamenial diarrhoea,
rectal bleeding and constipation• vesical involvement: urgency, frequency, haematuria• thoracic involvement: pleuritic chest pain,
pneumothorax, pleural effusions or cyclic haemoptysis• asymptomatic: especially if disease is isolated to the
peritoneum
SYMPTOMS
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AETHIOPATHOGENETIC MECHANISMS OF ENDOMETRIOSIS-ASSOCIATED CPP
• Nociceptive
• Inflammatory
• Neuropathic mechanisms
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• metastatic theory
• metaplastic theory
• induction theory
PATHOGENESIS
radiopedia.org
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PREVALENCE
• 1 in 10 women
• Strongly linked to infertility
• 25-50% of infertile women have endometriosis
• 30-50% of women with endometriosis is infertile
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• OVARIAN
• SUPERFICIAL
• DEEP
LOCATION
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SUPERFICIAL ENDOMETRIOSIS
• superficial plaques scattered across the peritoneum, ovaries and uterine ligaments
DEEP PELVIC ENDOMETROSIS
• subperitoneal invasion by endometriotic lesions that exceeds 5 mm in depth and comprises nodules, cysts and secondary scarring
Antônio Coutinho, et al. MR Imaging in Deep Pelvic Endometriosis: A Pictorial EssayRadioGraphics 2011 31:2, 549-567
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• Most common: ovaries, pelvis, peritoneum
• Less common: C section scar, deep subperitoneal tissue, GI tract, bladder, chest, subcutaneous tissue
• Most common sites of pelvic involvement: Douglas pouch, uterosacral ligaments and torus uterinus
LOCATION
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• ULTRASOUND
TRANSABDOMINAL
TRANSVAGINAL
TRANSRECTAL
• MRI
• CT
• CLASSIC RADIOLOGICAL METHODS
COLONOGRAPHY, ENTEROCLISIS, CHEST X RAY...
IMAGING
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ENDOMETRIOSIS
TRANSVAGINAL US TRANSRECTAL US
• OVARIES
• URINARY BLADDER
• RECTOVAGINAL
• UTEROSACRAL
• RECTOSYGMOID
BAZOT M ET AL.; DEEP PELVIC ENDOMETRIOSIS: MR IMAGING FOR DIAGNOSIS AND
PREDICTION OF EXTENSION OF DISEASE; RADIOLOGY 2004.
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ULTRASONOGRAPHY
• Good for endometriomas
• Homogenous hypoechoic lesion
• No Doppler signal
• Unilocular
• May be multiple
• Poor for peritoneal implants
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ENDOMETRIOMA
“CHOCOLATE” CYST
TRANSVAGINAL US MACROSCOPICALLY
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THICK SEPTATIONS
TRANSVAGINAL US MACROSCOPICALLY
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MRI
radiopaedia.org
• T1
– hyperintense
– high SI T1 FS
• T2
– hypointense -shading sign
– T2 dark spot sign
• DWI
– variable restricted diffusion
• T1C+
– may have wall enhancement
– the presence of an enhancing mural nodule is suggestive of malignant transformation
METHOD OF CHOICE!
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• haemorrhagic “powder burn” lesions appear bright on T1 fat saturated sequences
• small solid deep lesions– may be hyperintense on T1 and hypointense on T2
• adhesions and fibrosis
MRI CHARACTERISTICS OF ENDOMETRIOSIS
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uterosacral involvement
• irregular margins
• asymmetry
• nodularity and thickening
• altered T2 signal: isointense (50%), hypointense (40%) or hyperintense (10%) cf. myometrium
vaginal involvement
• loss of hypointense signal of posterior vaginal wall on T2WI
• thickening, nodules and/or masses
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M Bazot et al. Accuracy of magnetic resonance imaging and rectal endoscopic sonography for the prediction of location of deep pelvic endometriosis. Human reproduction , 2007; 22:. 1457-63.
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BLEEDING FOCI IN VAGINA
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Pouch of Douglas
– partial to complete obliteration
– suspended or lateralisedfluid collections
Rectovaginal septum
– nodules or masses that passed through the lower border of the posterior lip of the cervix
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Gastrointestinal tract
rectal wall thickening
anterior displacement of the rectum
abnormal angulation
loss of fat plane between uterus and bowel
inflammatory response due to repeated haemorrhage can lead to adhesions, strictures and bowel obstruction
Urinary tract
– bladder
• localised or diffuse bladder wall thickening
• signal intensity abnormality, nodules or masses usually located at the level of the vesicouterine pouch
• involvement of bladder mucosa is rare
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KISSING OVARIES
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• chest
– catamenial pneumothorax
– haemothorax
– lung nodules
• cutaneous tissues
– nodules
• malignant transformation
– solid enhancing components
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PULMONARY ENDOMETRIOSIS- CATAMENIAL SY
CHEST X RAY THORACIC CT
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ENDOMETRIOSIS OF ANTERIOR ABDOMINAL
WALL
US CONTRAST CT
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Hematosalpinx
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Hydrosalpinx
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SENSITIVITY SPECIFICITY
UTEROSACRAL LIGAMENT 86 % 77 %
VAGINA 80 % 93%
RECTOVAGINAL SEPTUM 80 % 97 %
BOWEL 88 % 98 %
ENDOMETRIOSIS
ACCURACY OF MRI IN DIFFERENT LOCALIZATIONS 1
1. BAZOT M ET AL.; DEEP PELVIC ENDOMETRIOSIS: MR IMAGING FOR DIAGNOSIS AND
PREDICTION OF EXTENSION OF DISEASE; RADIOLOGY 2004.
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• VISUALIZATION OF SMALL PERITONEAL IMPLANTS
• VISUALIZATION OF ADHESIONS
1. DIRECT – PRESENCE OF FLUID ON BOTH SIDES
2. INDIRECT
-ANGULATION OF BOWEL LOOPS
-ELEVATION OF POSTERIOR VAGINAL FORNIX
-CHANGE OF UTERUS AND OVARIES POSITION
-TRIANGULAR PULLING OF ANTERIOR RECTAL WALL
LIMITATIONS OF MRI EXAMINATION
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LAPAROSCOPY-GOLDEN STRANDARD!
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12/7/2017 41
� Total rate of recurrence of endometriosis after operative
treatment is:
30-40%
� Paolo Vercellini Surgery for endometriosis-Associated infertility: a pragmatic approach. Human Reproduction, Vol.24, No.2 pp. 254–269, 2009.
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Up to 10 years for diagnosis!!!
Every woman who has endometriosis knows another one with the same problem.
Every doctor has different opinion
and advice. However, satisfactory
treatment is still a distant dream
for many patients!
PROBLEMS
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What to say?Sometimes difficult to
diagnose
Right choice of therapy-does it exist?
„Find a way to send them to someone else“
„Remember one among all colleagues who you do not like“
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• ADDITIONAL SEQUENCES
1. FAT SUPPRESSED
2. GRADIENT ECHO
3. SUSCEPTIBILITY WEIGHTED 1 : 93 % SENSITIVITY
100 % SPECIFICITY
• INTRAVAGINALLY - US GELLY
• INTRARECTAL - CONTRAST OR WATER
• INTRAMUSCULAR – ANTIPERISTALTIC AGENS
ENHANCEMENT OF MRI EXAMINATION
1. TAKEUCHI ET AL.; SUSCEPTIBILITY WEIGHTED MRI OF ENDOMETRIOMA: PRELIMINARY RESULTS; AJR 2008.
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1. Multiple T1- Hyperintense adnexal cysts are specific for endometriomas
2. Female pelvis MR imaging protocols should include T1-weighted Fat-suppressed sequences
3. Low SI of adnexal masses on STIR MR images is not specific for mature cystic teratoma and does not exclude endometrioma
Ten Imaging Pearls
MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675–1691
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4. Benign endometriomas show restricted diffusion
5. Hematosalpinx should be considered specific for pelvic endometriosis
6. Obstruction of antegrade menstrual flow increases the risk for endometriosis
7. Decidualized endometriosis may mimic ovarian malignancy in pregnant women
MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675–1691
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8. Endometriomas can transform into clear cell or endometrioid epithelial ovarian carcinomas
9. Solid fibrotic masses of endometriosis are common and easily overlooked
10. Solid invasive endometriosis of the posterior uterus can mimic posterior segmental adenomyosis
MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675–1691
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CONCLUSION
• Consider endometriosis
in the presence of gynecological symptoms such as dysmenorrhoea,pelvic pain, dispareunia, infertility and fatigue in the presence of any of the above
Or in women of reproductive age with non-gynecological cyclical symptoms (dyschezia,dysuria, haematuria, rectal bleeding, shoulder pain)
• MR is the imaging method of choice
• Laparoscopy is the golden standard of both diagnosis and treatment
G.A.J. Dunselman et al. ESHRE guideline: management of women with endometriosis , Human Reproduction, 2014; 29 (3): 400–412.
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