How To Perform Ultrasonography in Endometriosis 2018

How to Perform
Ultrasonography in
Endometriosis
Stefano Guerriero
George Condous
Juan Luis Alcázar
Editors
123
How to Perform Ultrasonography
in Endometriosis
Stefano Guerriero
George Condous • Juan Luis Alcázar
Editors
How to Perform
Ultrasonography
in Endometriosis
Editors
Stefano Guerriero George Condous
Department of Obstetrics and Acute Gynaecology, Early Pregnancy
Gynecology and Advanced Endosurgery Unit
University of Cagliari Sydney Medical School Nepean
Cagliari University of Sydney
Italy Nepean Hospital
Sydney, Australia
Juan Luis Alcázar
Obstetrics and Gynecology Department
University of Navarra
Pamplona
Spain
ISBN 978-3-319-71137-9 ISBN 978-3-319-71138-6 (eBook)

https://doi.org/10.1007/978-3-319-71138-6
Library of Congress Control Number: 2018950453
© Springer International Publishing AG, part of Springer Nature 2018

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Preface
How to Perform Ultrasonography in Endometriosis is an international col-

laborative which brings together experts in the different fields of endometrio-
sis, with a special focus on imaging. This book primarily aims to give
sonologists, radiologists and sonographers a blueprint which enables them to
understand not only the different phenotypes and anatomical locations of
endometriosis but also the steps involved when performing an ultrasound-
based evaluation in a woman with potential underlying endometriosis.
Before the recent 2016 publication on the systematic approach to ultra-
sound in women with suspected endometriosis by the International Deep
Endometriosis Analysis (IDEA) group, there was significant heterogeneity in
the scientific literature in nomenclature, definitions and components of this
particular type of ultrasound scan. The dynamic ultrasound-based evaluation
of the pelvis in women with potential endometriosis is divided into four dis-
tinctive systematic steps as defined by the IDEA group. In this book, we have
taken each of the four steps and dissected every aspect of the ultrasound eval-
uation so that the reader is clearly guided and gets a clear understanding of
what is involved. The format of each chapter includes a ‘short update’, ‘how
we do it’, ‘technical tips’ and ‘future perspectives’ to thoroughly assist the
reader in the intricacies of all aspects of the patient evaluation. We have also
included where relevant pictorials, images and videos to illustrate different
aspects of the specific imaging evaluation being discussed.
Step one of the IDEA approach includes both assessment of the uterus and
ovaries. In this ‘how-to’, we go into great detail examining and explaining the
methodology behind uterine and myometrial evaluation as adopted by the
Morphological Uterus Sonographic Assessment (MUSA) group. We also
elaborate on the classification of ovarian endometrioma according to the
International Ovarian Tumor Analysis (IOTA) group.
Step two of the IDEA approach evaluates ‘soft markers’ including ovarian
mobility and site-specific tenderness. Again in this ‘how-to’, great insight is
given to this important dynamic aspect of the ultrasound-based evaluation.
Step three of the IDEA approach evaluates the status of the pouch of
Douglas (POD). This is explained in the ‘how-to’ with implementation of the
‘sliding sign’ which is also a dynamic part of the ultrasound-based
evaluation.
Step four of the IDEA approach evaluates the anterior and posterior com-
partments of the pelvis for the presence or absence of deep endometriosis. We
have allocated separate and detailed chapters in the ‘how–to’ on the ultrasound
v
vi Preface
evaluation of specific deep endometriosis anatomical locations, including the

bladder and ureters, the uterosacral ligaments, the posterior vaginal fornix
and the rectum–rectosigmoid–sigmoid.
We have also outlined extra-pelvic sites for endometriosis and discussed
other modified ultrasonographic techniques as well as additional radiological
techniques including magnetic resonance imaging.
In broadening the content of this ‘how-to’ book, we believed it was impor-
tant to include chapters on the clinical and anatomical considerations of
endometriosis, an up-to-date overview on medical and surgical management
strategies and currently available biomarkers being used and evaluated in
endometriosis. These evidence-based chapters give an update in these key
areas of the disease.
We hope that when reading this book you become well versed in the detail
involved in assessing women with endometriosis. The incredibly relevant
experience shared by the different co-authors throughout this ‘how-to’ com-
mentary should educate and expand your knowledge in this rapidly evolving
field of endometriosis imaging. The simplification of the IDEA approach
through pictorials, images and videos should empower you in your endeav-
ours to improve your diagnostic performance in endometriosis ultrasound. In
turn, this will enable you to not only map disease location but more impor-
tantly convey important information about the extent of disease. Enjoy.
Cagliari, Italy Stefano Guerriero

Sydney, New South Wales, Australia George Condous
Pamplona, Spain Juan Luis Alcazar
Contents
1 Endometriosis: Clinical and Anatomical Considerations�� 1

Sukhbir S. Singh
2 Medical and Surgical Management of Endometriosis�� 13
Errico Zupi, Lucia Lazzeri, and Caterina Exacoustos
3 Standardized Ultrasonographic Diagnostic Protocol to
Diagnose Endometriosis Based on the International Deep
Endometriosis Analysis (IDEA) Consensus Statement�� 27
Mathew Leonardi and George Condous
4 Uterine Evaluation Using a Diagnostic Protocol
Based on MUSA �� 37
Thierry Van den Bosch
5 Ovarian Endometriosis�� 47
Juan Luis Alcázar
6 Soft Marker Evaluation�� 57
Shannon Reid
7 Ultrasound in the Evaluation of Pouch of
Douglas Obliteration�� 63
Shannon Reid
8 Anterior Compartment Including Ureter�� 67
Luca Savelli and Maria Cristina Scifo
9 Uterosacral Ligament Endometriosis�� 77
Francesco Paolo Giuseppe Leone
10 Forniceal-Vaginal Deep Endometriosis�� 89
Stefano Guerriero, Gil Cohen, Silvia Ajossa, Ornella
Comparetto, Camilla Ronchetti, Bruno Piras, Alba Piras,
and Valerio Mais
11 Rectovaginal Septum Endometriosis�� 97
Gernot Hudelist and Kristine Aas-Eng
12 Rectum, Rectosigmoid, and Sigmoid Endometriosis�� 103
Manoel Orlando Goncalves, Leandro Accardo de Mattos,
and Mauricio S. Abrao
vii
viii Contents
13 Other Locations of Deep Endometriosis�� 121

Stefano Guerriero, Silvia Ajossa, Ornella Comparetto,
Camilla Ronchetti, Virginia Zanda, Bruno Piras,
Alba Piras, and Valerio Mais
14 Modified Ultrasonographic Techniques �� 133
Simone Ferrero, Umberto Leone Roberti Maggiore,
Fabio Barra, and Carolina Scala
15 Additional Radiological Techniques (MRI) �� 147
Federica Schirru, Stefano Guerriero, and Luca Saba
16 Biomarkers in Endometriosis �� 169
Vicki Nisenblat and M. Louise Hull
17 Clinical Cases and Videos. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Mauricio León, Hugo Sovino, and Juan Luis Alcazar
Index�� 191
List of Videos
Video 1.1 Scar endometriosis—An example of a post cesarean section inci-

sional endometriosis nodule resulting in cyclical left lower quad-
rant pain and a palpable mass. (Courtesy of Dr. S. Singh)
Video 1.2 Excision of superficial endometriosis—An educational video.
(Courtesy of Dr. M. Suen)
Video 1.3 Surgical approach to endometriosis of the posterior cul-de-sac.
(Courtesy of Dr. D. Evans and M. Suen)
Video 1.4 Video demonstrating excision of an invasive bladder nodule.
(Courtesy of Dr. S. Singh)
Video 5.1 In this video, acoustic streaming in a case of ovarian endometri-
oma can be observed. Note the movement of the cyst’s particles
Video 5.2 In this case, the adhesion of the ovary to the uterus is clearly
noted when moving the transvaginal probe back and forth
Video 5.3 In this case, the ovarian endometrioma is not attached to the uterus,
and we can observe the sliding of the cyst against the cervix
Video 5.4 This video corresponds to a case of endometrioma decidualiza-
tion during pregnancy. A highly vascularized cystic solid mass
can be seen. The cyst was surgically removed, and histologic
analysis proved it was a decidualized endometrioma
Video 6.1 Transvaginal ultrasound is used to demonstrate a mobile right
ovary (RO) along the right pelvic sidewall (RPSW) in the trans-
verse plane. EIV external iliac vessel
Video 6.2 Transvaginal ultrasound is used to demonstrate ovarian (O)
mobility along the lateral uterus (U), as well as the right pelvic
sidewall (PSW), in the transverse plane
Video 6.3 Transvaginal ultrasound is used to demonstrate fixation of the
left ovary (LO) to both the posterior uterus (U) and left pelvic
sidewall (LPSW), in the sagittal plane
Video 6.4 Transvaginal ultrasound is used to demonstrate fixation between
the left ovary (O) and the posterior uterine cervix (C), in the sag-
ittal plane
Video 7.1 (a) Transvaginal ultrasound is used to demonstrate a positive
“sliding sign” between the anterior rectum and posterior uterine
cervix/retro-cervix (C) in the sagittal plane. POD pouch of
Douglas. (b) Transvaginal ultrasound is used to demonstrate a
positive “sliding sign” between the rectosigmoid bowel and
posterior uterine fundus (U) in the sagittal plane
ix
x List of Videos
Video 7.2 (a) Transvaginal ultrasound is used to demonstrate a negative

“sliding sign” between the anterior rectum (R) and posterior
uterine cervix/retro-cervix (C) in the sagittal plane. (b)
Transvaginal ultrasound is used to demonstrate a negative “slid-
ing sign” between the rectosigmoid bowel (RS) and posterior
uterine fundus (U) in the sagittal plane
Video 7.3 (a, b) Transvaginal ultrasound is used to demonstrate a positive
“sliding sign” for a retroverted uterus, at both the posterior uter-
ine fundus and anterior lower uterine segment, respectively (sag-
ittal plane). In Video (a), the anterior rectum glides freely over
the posterior uterine fundus. In Video (b), the rectosigmoid
bowel glides freely over the anterior lower uterine segment. U
uterus
Video 8.1 Normal anterior pelvic compartment. Note the sliding of the
bladder and uterus. The bladder wall has normal shape and
morphology
Video 8.2 Normal posterior pelvic compartment. Note the sliding of the
rectum and uterus. The vaginal wall, uterosacral ligaments, and
anterior rectal wall appear normal and the sliding sign is
positive
Video 8.3 Transvaginal sagittal scan of the bladder showing a ureteral jet
Video 10.1 Tenderness-guided evaluation of a forniceal nodule
Video 10.2 Tenderness-guided evaluation of a diabolo-like nodule
Video 10.3 A forniceal nodule evaluated without sonovaginography
Video 10.4 The same nodule evaluated using sonovaginography
Video 13.1 An ultrasonographic evaluation of a scar endometriosis in a
32-year-old woman with a cesarean section 6 years before with
uncorrect focalization
Video 13.2 An ultrasonographic evaluation of a scar endometriosis in the
same patient of Video 13.1 but with a better focalization
Video 13.3 A color Doppler scan of the same nodule of Videos 13.1 and
13.2
Video 13.4 An ultrasonographic evaluation of two nodules of scar endome-
triosis in a 39-year-old woman with a previous cesarean section
6 years before
Video 13.5 An ultrasonographic evaluation of two nodules of scar endome-
triosis in a 39-year-old woman with a previous cesarean section
6 years before
Video 13.6 An ultrasonographic evaluation of Villar’s nodule in a 33-year-
old woman without previous abdominal surgery
Video 13.7 An ultrasonographic color Doppler evaluation of Villar’s nodule
in a 33-year-old woman without previous abdominal surgery
Video 13.8 An ultrasonographic evaluation of a rectus abdominis endome-
triosis in a 30-year-old woman with one previous cesarean sec-
tion 4 years before
Video 13.9 An ultrasonographic color Doppler evaluation of a rectus
abdominis endometriosis in a 30-years-old woman with one pre-
vious cesarean section 4 years before
List of Videos xi
Video 13.10 Sonographic features of right inguinal endometriosis present-

ing as a cystic mass with internal septa (few color Doppler
spots peripherally) and hypoechoic content located in inguinal
area
Video 14.1 RWC-TVS shows a mild stenosis (≥50%) of the rectal lumen
due to endometriosis. The endometriotic nodule is hypoechoic
and has blurred margins. A thinner section (“tail”) is noted at
one end. During surgery, nodule shaving was performed
Video 14.2 RWC-TVS shows a significant intestinal stenosis (≥50%) of
the rectal lumen due to endometriosis. The endometriotic
nodule, located on the anterior rectum, causes a thickening of
the hypoechoic muscularis propria. The nodule is hypoechoic
and has blurred margins. A thinner section (“tail”) is noted at
one end. The nodule infiltrates the rectal submucosa and
mucosa. The patient was treated by segmental resection
(Fig. 14.13)
Video 14.3 Sonovaginography with gel. An assistant holds the bottle of gel
with its mouth facing downward. The syringe is introduced
into the lower part of the inverted bottle. The plunger is held
steady in position, and the barrel (outer sleeve) is slowly
pushed farther up into the inverted bottle of gel to fill the
syringe with 20 mL of gel [6]
Video 17.1 Complete septate uterus, rectovaginal nodule with involvement
of vaginal posterior wall, uterosacral ligaments, and anterior
rectum wall (diabolo-like nodule)
Video 17.2 Presence of negative sliding sign in the anterior compartment
(obliteration of uterovesical region). Also can be observed a
uterovesical region nodule of 12 × 10 × 12 mm. In the posterior
compartment, it is possible to observe a nodule of
16 × 9 × 12 mm with involvement of left uterosacral ligament
insertion
Video 17.3 Presence of fixed ovaries, right atypical endometrioma with
solid component without vascularization. Corpus luteum in the
left ovary and presence of two anterior rectal wall nodules of
12 × 11 × 8 mm and 13 × 7 × 9 mm, respectively (multifocal
lesions). Also, it can be observed another lesion of
14 × 10 × 11 mm in between both rectal lesions. Negative slid-
ing sign in the posterior compartment
Video 17.4 Multifocal compromise of rectosigmoid with anterior rectal
wall nodules with complete septate uterus. In addition, you can
observe another lesion with compromise of the left uterosacral
ligament and posterior vaginal wall
Video 17.5 The measurement of anterior rectal wall nodule was
22 × 9 × 14 mm, without involvement of submucosa. Another
lesion of 14 × 9 × 10 mm, fixed to the previous one, involving
the uterosacral ligaments was found
Video 17.6 Bladder dome nodule of 10 × 7 × 10 mm. Ureteral intravesical
segment nodule (extrinsic compromise) of 18 × 9 × 10 mm
xii List of Videos
Video 17.7 Bladder base intramural nodule of 19 × 20 × 21 mm, without

compromise of intravesical ureters. Also can be observed a
right uterosacral ligament nodule of 9 × 6 × 7 mm, fixed to the
posterior vaginal wall
Video 17.8 A rectosigmoid anterior rectal wall nodule of 43 × 13 × 14 mm
with involvement of vagina and uterosacral ligament. In addi-
tion, you can observe another lesion of 16 × 16 × 11 mm
Video 17.9 At seven centimeters from the anal verge, it can be seen a rec-
tosigmoid anterior rectal wall nodule with involvement of
vagina and uterosacral ligaments of 42 × 7 × 19 mm. Also you
can observe vaginal lesion of 17 × 8 × 12 mm
Video 17.10 Retroverted uterus. A rectosigmoid anterior rectal wall nodule
with transmural compromise with involvement of submucosa
of 30 × 10 × 22 mm. It can be observed a lesion involving the
uterosacral ligaments with superficial vaginal involvement
Electronic supplementary material is available in the online version of the related chapter
on Springer Link: http://link.springer.com/
Endometriosis: Clinical
and Anatomical Considerations
1
Sukhbir S. Singh
1.1 Introduction One of the key challenges for the individual

who presents with symptoms of chronic pelvic
Endometriosis is one of the most challenging dis- pain and/or infertility due to endometriosis is
eases to diagnose and manage in gynecology accessing a timely diagnosis and management
today. It is a common condition and has been plan. Delayed diagnosis of endometriosis-
reported to have an overall prevalence of 5–10% associated pelvic pain is a recognized global
in the general population [1, 2]. In females with challenge with an average delay of 7–10 years in
pelvic pain and infertility, endometriosis is reported surveys [6]. As a result, there is a need
known to have a higher prevalence of 50% and for guidance and education to help assess and
25–40%, respectively [3, 4]. evaluate those with suspected endometriosis-
Endometriosis is defined as “endometrium-like related sequelae.
tissue that is found outside of the uterine cavity.” The diagnosis of endometriosis has tradition-
Its underlying etiology remains elusive and likely ally relied on histology from surgical specimens.
involves multiple mechanisms rather than one This “gold standard” approach, when performed
simplistic explanation [5]. Furthermore, the clini- by laparoscopy, in experienced surgical settings,
cal presentation of this complex disease can vary offers both diagnostic and therapeutic benefits
from completely asymptomatic in some to signifi- [7]. Surgical management of endometriosis-
cant pelvic pain in others. Anatomical distortion, associated pelvic pain has shown to improve pain
inflammation, and impaired endometrial receptiv- and, in cases of mild to moderate disease, may
ity may lead to infertility in some but not all. improve fertility as well. However, endometriosis
is recognized as a chronic relapsing condition,
which requires a long-term care plan.
Electronic Supplementary Material The online version
Surgical diagnosis and management has its
of this chapter (https://doi.org/10.1007/978-3-319-71138-
6_1) contains supplementary material, which is available limitations including access to experienced sur-
to authorized users. geons, inherent risks of surgery itself, and the
possibility of missing disease on laparoscopic
S. S. Singh evaluation. In addition, chronic pelvic pain is sel-
University of Ottawa, Ottawa, ON, Canada
dom due to one condition alone, and while sur-
Shirley E. Greenberg Women’s Health Centre, The gery may assist in managing the pathology
Ottawa Hospital, Ottawa, ON, Canada
(endometriosis lesions), it may not address the
Ottawa Hospital Research Institute, other comorbid pain conditions or improve
Ottawa, ON, Canada
e-mail: susingh@toh.ca
© Springer International Publishing AG, part of Springer Nature 2018 1

S. Guerriero et al. (eds.), How to Perform Ultrasonography in Endometriosis,
https://doi.org/10.1007/978-3-319-71138-6_1
2 S. S. Singh
symptoms in those who have developed central Extrapelvic endometriosis is a less common
sensitization [8]. variation of the disease but often seen in high-
Because of the identified need for an earlier volume referral centers. Endometriosis implants
diagnosis and understanding that surgery has its and invasive disease may be found throughout
limitations, there is growing support to provide the body with corresponding signs and symptoms
health-care providers with the tools necessary to as noted below:
help make a clinical diagnosis of endometriosis.
Site of disease Potential symptoms
When endometriosis is part of the differential
Lung/pleural cavity Catamenial pneumothorax
diagnosis, a thorough history, physical examina- or hemothorax
tion, and targeted imaging are key to guiding Diaphragm (Fig. 1.1a, b) Catamenial shoulder tip
management [9, 10]. Proper evaluation allows for pain
earlier targeted interventions including medical, Nerves (i.e., sciatic) Catamenial or non-
surgical, and/or fertility therapies. menstrual-related nerve
irritation (i.e., sciatica)
Past surgical incisions Catamenial swelling, pain
(i.e., Pfannenstiel for localized to incision site
1.2 How We Do It? cesarean section or
laparoscopy site)
Video 1.1: Scar
1.2.1 History Endometriosis
Bowel Intermittent obstruction,
On history, it is important to assess all aspects of hematochezia
the presenting complaint, related systemic
issues, past medical and surgical history, habits, A past surgical history confirming endometri-
and family history. A review of pain symptoms osis is helpful; however the quality of the surgical
with a focus on the four “D”s (dysmenorrhea, evaluation, documentation of the findings, and
dyspareunia, dyschezia, and dysuria) is impor- images (if available) should be reviewed.
tant. If a patient has more than one of these Misclassification of disease in inexperienced
symptoms, there is a greater likelihood of endo- hands may mislead clinicians, and as a result,
metriosis [11]. current history and examinations should help
While cyclic (catamenial) symptoms of pain guide next steps for evaluation.
prompt us to consider endometriosis, non- Family history is important as endometriosis has
menstrual pelvic pain (NMPP) should also be a genetic component as shown in twin and family
evaluated through history. A classic history of studies [12]. However, assessment for risk for ovar-
pain that began as cyclic in nature earlier in ian or breast cancer should also be considered as
reproductive life may turn into daily pelvic or treatment options may change in high-risk patients.
abdominal pain with catamenial exacerbation.
This finding may represent a shift from nocicep- 1.2.2 Key Historical Points
tive pain (pain due to inflammation and local tis-
sue damage) to centralized pain. Consider endometriosis in females with:
Systemic complaints in women with endome-
triosis are also commonly described. • Chronic pelvic pain (pain that persists for
Gastrointestinal or urinary tract symptoms greater than 3 months)
including bloating, constipation, nausea, or dys- • Catamenial (cyclic)-related pain symptoms
uria may be seen in women with endometriosis- including:
associated pain. However, systemic complaints –– Dysmenorrhea
may also require evaluation of comorbid condi- –– Dyspareunia
tions such as irritable or inflammatory bowel dis- –– Dysuria
ease and painful bladder syndrome [12]. –– Dyschezia
1 Endometriosis: Clinical and Anatomical Considerations 3
a b
Fig. 1.1 (a) Right diaphragm endometriosis lesions causing catamenial right shoulder tip pain for greater than 10
years. (b) Post resection of deep endometriosis of the diaphragm. (Courtesy of Dr. S. Singh)
• Infertility and pelvic pain nally and subsequently evaluating each aspect of
• Catamenial symptoms in other systems the patient’s experience. Pain that is elicited with
(extrapelvic) light touch only is termed allodynia, and pain
with deeper palpation but not in keeping with the
expected response is termed hyperalgesia.
1.3 Examination Allodynia and hyperalgesia are signs of central
sensitization or neuropathic pain and should be
An appropriate and targeted abdominal/pelvic documented separately.
examination will help evaluate the patient with Further evaluation of the pelvic floor and
suspected endometriosis-related pelvic pain. Many abdominal wall muscles is also extremely
with endometriosis may be asymptomatic, and important during the evaluation of the chronic
examination findings may be incidental. Females pain patient. Severe pelvic floor tension (hyper-
with infertility may or may not have pelvic pain. tonicity) is also a common finding among those
Rectal (or pelvi-rectal) examination may be who have suffered with long-standing pelvic
required in cases of suspected rectal pathology or pain, as a protective adaptive response, and
rectovaginal deep endometriosis (DE). should be documented and discussed.
Upon bimanual examination, the clinician Physiotherapy is often an important adjunct to
should attempt to distinguish the axis of the rest- treatment in these patients.
ing uterus (anteverted, retroverted), palpate for The importance of identifying allodynia,
nodularity, and map out regions of pain. hyperalgesia, and pelvic floor hypertonicity is
Figure 1.2 demonstrates a posterior vaginal for- key to effective multimodal treatment and also
nix nodule palpated and visualized on pelvic should be documented for and by the imaging
examination. expert who will be proceeding with transvaginal
An important consideration is to approach the ultrasound. Patients with extreme vulvodynia and
examination of a patient with “pain” in a step- pelvic floor hypertonicity may not tolerate or
wise manner that begins with light touch exter- may refuse transvaginal examination.
4 S. S. Singh
Fig. 1.2 Vaginal nodule (confirmed endometriosis) detected on physical examination. (Courtesy of Drs. S. Singh and
H. Stone)
1.3.1 Key Examination Tips care. Empirical medical management for

suspected or clinically diagnosed endometriosis
• An abdominal and pelvic exam should assess has been widely described in international guid-
for sites of pain and identify: ance statements [9, 10]. In individuals with pain,
–– Masses a trial of medical therapies including combined
–– Allodynia or hyperalgesia hormonal contraceptives, progestogens, gonado-
–– Muscle tone and tenderness (pelvic floor tropin analogues, or intrauterine progestins have
and abdominal wall) all been proposed as potential options. This may
–– Previous scars or injury help delay or avoid surgery in patients who
–– Nodularity along the vaginal fornices or respond.
cul-de-sac Surgery plays an important role in the diag-
–– Uterine mobility and axis nosis and treatment of endometriosis and has
–– Neurological patterns of pain or sensory shown to benefit those with pain and infertility.
deficits However, the disease has a variable anatomical
• Pelvi-rectal examination may help identify presentation with three general phenotypes
rectovaginal fullness or nodularity. described: superficial, ovarian endometrioma,
• Speculum exam may help identify vaginal and deep infiltrating disease (Figs. 1.3a, b,
lesions of endometriosis. 1.4a, b, and 1.5). The various forms have sig-
nificant implications for surgical management
and require an advanced skill set and interdis-
1.4 linical Assessment to Guide
C ciplinary care for deep disease (Video 1.2:
Diagnosis, Management, Approach to Excision of Endometriosis). As a
and Triage result, another role for appropriate diagnosis is
to help triage patients who would be better
The goal of the clinical assessment to help diag- served by referral to a center experienced in
nose endometriosis in those with chronic pelvic managing more complex cases of
pain and/or infertility is ultimately to help direct endometriosis.
a b
Fig. 1.3 (a) An example of superficial endometriosis (black deposits) along the vesicouterine peritoneum. (b) Post
excision of endometriosis and surrounding peritoneum. (Courtesy of Dr. S. Singh)
a b
Fig. 1.4 (a) Right pelvic sidewall superficial endometriosis deposits (white arrows). (b) Post peritoneum excision of
superficial disease. (Courtesy of Dr. S. Singh)
Fig. 1.5 Complex pelvis disease: Often there are multi-

ple pathologies in the same patient that require manage-
ment. In this case the patient had an “obliterated
cul-de-sac,” fibroids, right ovarian endometrioma, and
deep invasion with rectovaginal nodular disease (not seen
here). (Courtesy of Dr. S. Singh)
6 S. S. Singh
1.5 Role of Clinical Diagnosis
Positive
Response
Trial of Therapy
Change Therapy
Incomplete
or Referral
Reponse (Triage)
Clinical
Diagnosis
Chronic Pain
Management
Complex Pain or
Invasive Disease
Complex
Surgical
Managment
a b
Fig. 1.6 “Hidden disease.” While the cul-de-sac is ultrasound. (c) Illustrates the level of dissection required
reported as “open” on traditional imaging (a), there is (mid-surgery) to help excise the disease. (Courtesy of Dr.
deep invasive disease and anatomical distortion with nod- S. Singh)
ular disease (b) identified preoperatively on expert-guided
1.6 Imaging in Endometriosis Traditional imaging that is general or nonspe-

Care cific may not identify endometriosis [14]. While
superficial endometriosis is not identifiable on
The need for quality imaging for endometriosis imaging, ovarian endometriomas and DE often
care can be demonstrated by the need for a non- can be visualized. Diagnosis of endometriosis
surgical diagnosis of DE. This should be done to validates the patient experiences and also helps
help with surgical planning and in certain cir- direct therapy (Fig. 1.6a–c).
cumstances to allow for follow-up of response to Reasons for improving imaging for endome-
medical therapies [13]. triosis care include:
• Identify ovarian and deep endometriosis 1.7.1 Pelvic Spaces

• Triage care to appropriate care plan and pos-
sibly referral From a surgical perspective, there are eight
• Plan for optimal surgical intervention potential avascular pelvic spaces. A description
• Rule out concomitant or alternative conditions of these spaces is provided below:
• Retropubic/Prevesical Space
1.7 Anatomical Considerations
• The retropubic space, also known as the space
for Pelvic Endometriosis
of Retzius, is a potential space lying immedi-
ately posterior to the pubic symphysis, with
The approach to endometriosis evaluation and
the urethra and urethrovesical junction
management should consider the relevant ana-
forming the floor and the obliterated umbilical
tomical relationships of the normal pelvic struc-
arteries forming the lateral boundaries.
tures that may assist with navigating the distorted
• Paravesical Space
pelvic anatomy. The pelvis may be considered in
• The prevesical space is contiguous with the
three anatomical compartments to assist with
right and left paravesical spaces, with the
approach to endometriosis involvement: anterior,
obliterated umbilical arteries serving as the
middle, and posterior compartment.
boundaries. Each paravesical space is bounded
The anterior compartment includes the blad-
laterally by the obturator internus muscle
der and vesicouterine peritoneum. Endometriosis
of this area may be present as superficial or deep
(Figs. 1.3a and 1.7).
The middle compartment would include the
ovaries, fallopian tubes, and uterus itself.
Endometriosis of this compartment is the most
expected and described forms of the disease
including ovarian endometriomas and peritubal
adhesions.
The posterior compartment describes the pos-
terior cul-de-sac including the rectum, pararectal
spaces, and presacral anatomy. Often, the DE
lesions are found here and often involving the Fig. 1.8 A deep endometriosis nodule obliterates the rec-
rectum (Fig. 1.8). tovaginal space. (Courtesy of Drs. S. Singh & H. Stone)
a b
Fig. 1.7 A deep endometriosis nodule invading the bladder at laparoscopy. (b) Endometriosis invading the bladder
mucosa at cystoscopy. (Courtesy of Dr. S. Singh)
8 S. S. Singh
along with the obturator nerve and vessels and internal iliac vessels (laterally). Further delin-
posteriorly by the endopelvic fascial sheath eation of a lateral (Latzko’s space) and medial
that encompasses the internal iliac artery, (Okabayashi’s space) pararectal space divided
vein, and its anterior branches. by the uterosacral ligament has been described
• Vesicovaginal Space to assist with the surgical approach to the rec-
• This is an avascular potential space that exists tovaginal nodule [15].
between the bladder and the vagina. • Presacral Space/Retrorectal Space
• Rectovaginal Space (Fig. 1.8) • While not often accessed during endometrio-
• The rectovaginal space is a potential space sis surgery, this space may be entered during
between the vagina anteriorly and rectum low anterior segmental bowel resection. The
posteriorly. space is an area of areolar connective tissue
• Pararectal Space (Fig. 1.9 and Video 1.3) between the rectum anteriorly, the sacrum and
• The pararectal spaces are also avascular poten- upper coccyx posteriorly, the peritoneal reflec-
tial spaces located posterior to the crossing of tion superiorly, the levator ani and coccygeal
the ureter with the uterine artery. They are muscle inferiorly, and the ureter and iliac ves-
bounded by the rectum (medially) and the sels laterally.
1.7.2 elevant Pelvic Sidewall

R
Anatomy
In superficial, ovarian, or deep endometriosis, the

disease often involves the pelvic sidewall due to
adhesions or infiltrating nodules. As a result, if
surgery is required, the sidewall anatomy is an
important area to “navigate” to prevent complica-
tions and facilitate excision.
The “surgical layers” of the pelvic sidewall
Fig. 1.9 The posterior compartment spaces during dis-
section for excision of a rectovaginal endometriosis nod- caudal to the bifurcation of the common iliac ves-
ule. (Courtesy of Drs. S. Singh & H. Stone) sels are often taught as follows (Fig. 1.10a, b):
a b
Fig. 1.10 (a) Deposit of endometriosis along left pelvic (yellow line) with overlying peritoneum excised, avascu-
sidewall peritoneum (white arrow) with underlying ureter lar spaces (*), and the internal iliac vessels (IIA) and the
(yellow line). (b) Post excision demonstrating the “surgi- external iliac vein (EIV). (Courtesy of Dr. S. Singh)
cal” layers of the left sidewall beginning with the ureter
• 1st layer—ureter and overlying peritoneum the bowel. However, DE of the bowel is esti-
• 2nd layer—internal iliac vessels and their mated to occur in 8–12% of females with endo-
branches metriosis [17]. These complex patients require
• 3rd layer—pelvic sidewall musculature with experienced care providers and often a multidis-
overlying obturator nerve and external iliac ciplinary approach [17, 18].
vessels Any part of the bowel may be involved includ-
ing the appendix and small bowel [19] (Fig. 1.13a–
Between each surgical layer lies a potential c). However, the large bowel and especially the
avascular space to facilitate dissection.
Disease that involves the sidewall often
involves the ureter. Ureteric involvement may be
either superficial or in severe cases it can lead to
obstruction. Recent reports suggest that over half
of patients presenting with DE may have some
type of urinary tract endometriosis [16]. As a
result, in DE, urinary tract evaluation presurgery
should be performed (Figs. 1.11a, b, 1.12, and
Video 1.4: Excision of Bladder Endometriosis).
1.7.3 Bowel Endometriosis
Endometriosis may also affect the gastrointesti-

nal tract. Superficial disease may result in adhe-
sions between the bowel and pelvic structures, Fig. 1.12 Left ureterolysis required to excise endometri-
and ovarian endometriomas may be adherent to osis plaque (*). (Courtesy of Dr. S. Singh)
a b
Fig. 1.11 (a) Left ureteric nodule (arrow) that resulted in severe obstruction and left renal dysfunction. (b) Intraoperative
fluoroscopy with ureteroscopy confirming external ureteric obstruction. (Courtesy of Dr. S. Singh)
10 S. S. Singh
a b
Fig. 1.13 (a) Superficial vesicles of endometriosis over endometriosis invasion. (c) Small bowel surface endome-
the surface (arrow) of the appendix. (b) Classic “hockey triosis deposits (arrows). (Courtesy of Dr. S. Singh)
stick” sign (arrow) at tip of appendix associated with
rectosigmoid colon are most often involved. The and appropriate referral for treatment in many of
disease is seldom isolated, and hence a thorough these patients.
evaluation is required preoperatively.
One of the key considerations is that colonos- Acknowledgments Dr. S. Singh would like to acknowl-
copy may not detect disease of the colon unless it edge his local team for making it possible to provide great
multidisciplinary care that includes nursing support,
is invading through the mucosa (Fig. 1.14a–c). expert imaging, and great surgical care. Drs. Margaret
As a result, imaging is again necessary in the Fraser, Shauna Duigenan, and Vincent Della Zazzera pro-
evaluation to enhance appropriate management. vide local expert imaging for complex endometriosis
cases. Our fellows Drs. Michael Suen, Cici Zhu, and
Maris Yap-Garcia provide surgical and clinical care. Our
residents, Drs. Heather Stone and Devon Evans, worked
1.8 Summary on educational material to help advance our teaching of
surgical approaches. Shannen McDonald, Karen Deme,
Endometriosis is a common and debilitating dis- Kelly Lacombe, Monique Newman, and Ottawa Hospital
staff help support our patients through their journey. Our
ease affecting millions of women worldwide. surgical team includes Drs. Kristina Arendas, Innie Chen,
Many of those affected are often struggling with Karine Lortie, and Hassan Shenassa. Our interdisciplinary
pelvic pain and/or infertility. However, the diag- team of surgeons includes Drs. S. Gilbert (Thoracics),
nosis is often delayed likely due to the variable S. Tadros (General Surgery), and The Ottawa Hospital
Urology and Colorectal Services. Finally, our research
presentation of symptoms and disease states. team including Dr. Teresa Flaxman, Ms. Erica Nichols,
Thorough clinical evaluation, including focused Carly Cooke, Suzanah Wojcik, and Cairina Frank help
expert imaging, may help with a timely diagnosis with our endometriosis research program.
a b
Fig. 1.14 (a) Intraoperative colonoscopy is suggestive of Zazzera, Ottawa Hospital). (c) An example of pathology
a mass effect but not diagnostic of endometriosis (*). (b) specimen with an invasive intramural nodule (X) of endo-
Transvaginal expert-guided ultrasound completed preop- metriosis from a low anterior resection of the rectosig-
eratively identified a rectal nodule measuring 3 × 1.4cm to moid colon. (Courtesy of Dr. S. Singh)
aid in surgical planning (Image Courtesy of Dr. V. Della
7. Singh SS, Suen MW. Surgery for endome-

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2016;48(3):318–32. bowel endometriosis. J Minim Invasive Gynecol.
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Imaging. 2015;40(3):587–94. trating the recto-sigmoid: critical factors to con-
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Medical and Surgical Management
of Endometriosis
2
Errico Zupi, Lucia Lazzeri,
and Caterina Exacoustos
2.1 Introduction they should effectively treat pain and have an

acceptable side-effect profile. Long-term use
Endometriosis is a chronic, multifactorial dis- should be safe and affordable. Moreover, they
ease, affecting predominantly healthy young should not be contraceptive and not interfere with
women with a negative impact on quality of life spontaneous ovulation and normal implantation
[1]. It is associated mostly with pelvic pain, dys- of the endometrium. Furthermore, they should
pareunia, and intestinal disorders and can lead to have no teratogenic potential in case of inadver-
infertility. Treatment of deep endometriosis (DE) tent use during the first trimester of a pregnancy.
can be either hormonal, aiming at inducing a They should suppress the growth of already exist-
hypoestrogenic state, atrophy or quiescence of ing lesions, prevent the development of new ones
endometriotic lesions, and a reduction of the to limit the need for repeat surgery, and prevent
chronic peritoneal inflammatory status, [2] or the complications associated with advanced
surgical, aiming at restoring the normal anatomy endometriosis. Finally, they should be efficacious
by removing endometriotic lesions. In order to for all disease phenotypes, including superficial
plan an appropriate medical or surgical treatment disease, ovarian endometriomas, DE, extrapelvic
of this condition, imaging (ultrasonography and disease, and adenomyosis [6].
magnetic resonance imaging (MRI)) is useful for Currently available medical therapies for
assessing the number, size, and anatomical local- endometriosis do not meet all these aforemen-
ization of the endometriotic nodules [3, 4]. tioned requirements. For the most part, they do
Available data suggest that medical treatment not definitively cure the disease but rather are
and surgical excision are similarly effective in directed at symptomatic relief, typically utilizing
improving pain symptoms associated with DE the hormone responsiveness of endometriotic tis-
[5]. Ideally, medications for endometriosis should sue to induce lesion atrophy. Pain relapse after
be curative rather than suppressive. In addition, treatment suspension is a common event. Even
though treatment with pharmacological therapies
for endometriosis should be viewed in terms of
E. Zupi · C. Exacoustos (*)
Department of Biomedicine and Prevention years, agents that need to be withdrawn after a
Obstetrics and Gynecological Clinic, University of few months due to poor tolerability or severe
Rome “Tor Vergata”, Rome, Italy metabolic side effects do not greatly benefit
L. Lazzeri women with symptomatic endometriosis.
Department of Molecular and Developmental Laparoscopy still remains the gold standard
Medicine, Obstetrics and Gynecological Clinic, for the treatment of endometriosis especially in
University of Siena, Siena, Italy

https://doi.org/10.1007/978-3-319-71138-6_2
14 E. Zupi et al.
very young or premenopausal patients [7]. resulted in a shift of first-line treatment of endo-
Laparoscopic management of endometriosis metriosis from surgery to medical therapy.
should be individualized, maintaining an Hypoestrogenizing drugs induce atrophy of the
approach toward the disease which maximizes ectopic endometrium and possibly allow the con-
surgical cytoreduction while preserving and safe- trol of pain symptoms by reducing the intra- and
guarding function of pelvic structures [8]. peri-lesional inflammation of endometriotic nod-
Surgical excision of DE nodules is necessary ules. This diminishes the production of prosta-
when they cause bowel stenosis associated with glandins and cytokines and thus results in less
subocclusive symptoms and ureteral stenosis stimulation of pain fibers. However, since the dis-
causing hydronephrosis or in cases of symptom- continuation of hormonal medications for endo-
atic bladder DE nodules. In addition, surgery is metriosis is associated with the recovery of
necessary in approximately one in three women endometrial function under the influence of ovar-
in whom hormonal treatments fail [9]. ian steroids and thus with the recurrence of pain
The choice of medical versus surgical treat- symptoms, such medications need to be adminis-
ment of DE must be shared between the physician tered for long periods [12]. Therefore, provided
and the woman, after she has been adequately that the efficacy in the control of pain is compa-
informed of the risks and benefits associated with rable between all the available hormonal com-
both options. Each woman must have a clear pounds [13, 14], the choice of treatment is
understanding that DE lesions are benign and usu- primarily based on safety in the long term, side
ally not progressive [10], and therefore the choice effects, and costs. Based upon such principles,
of treatment should focus on her symptoms and progestins and estroprogestins in the form of oral
expectations rather than the eradication of the dis- contraceptives (OC) represent the first-line
ease. The information about the likelihood of pain choice for the medical treatment of endometrio-
relief after surgery or medical therapy should be sis [14–19]. In cases of endometrioma associated
as detailed as possible, and the rates of both inter- with pain symptoms, medical therapy should be
national and institutional surgical complications preferred to surgery when reassuring ultrasound
should be provided. Moreover, the woman’s age features are present. Surgery should be consid-
and the desire for pregnancy are two important ered only when medical treatment fails in con-
variables influencing the therapeutic plan. trolling pain symptoms, when the endometriotic
In women with endometriosis seeking preg- cyst undergoes a rapid growth, or if ultrasound
nancy, assisted reproductive technologies should features become less reassuring.
be considered because currently available hor-
monal treatments are all contraceptive. In case of
repeated IVFs, surgery is indicated [11]. The goal 2.2.1 Oral Contraceptives
of clinical management of endometriosis is to
individualize the timing of endometriosis treat- OC and progestins are considered as first-line
ment, integrating medical and surgical strategies, medical treatment for endometriosis-associated
to avoid repetitive surgery with the aim of chronic pelvic pain [20, 21]. OC inhibit the pro-
improving quality of life. duction of gonadal estrogen via a negative feed-
back mechanism. Moreover, by suppressing
ovarian activity, they also lead to a reduction in
2.2 Medical Treatment estrogen-induced production of prostaglandins,
of Endometriosis decreasing the inflammation associated with
endometriosis. The uninterrupted use of the oral
In the last decade, the substantial progress of contraceptive pill appears to be associated with a
diagnostic imaging has allowed a reliable nonin- greater pain score reduction [22]. Furthermore,
vasive diagnosis of DE, i.e., without the need for the continuous administration represents a valid,
surgical and histological confirmation. This has safe, and economical therapeutic coverage that
2 Medical and Surgical Management of Endometriosis 15
might be used in patients who have undergone nificant improvements in diarrhea, intestinal
conservative surgery for endometriosis [23, 24]. cramping, passage of mucus with stool, and cyclic
Moreover, different studies have demonstrated rectal bleeding [32]. In 2014, a 24-week open-
that women with rectovaginal endometriosis- label prospective study suggested that treatment
associated pain benefit from treatment with non- with dienogest might improve pain symptoms in
oral contraceptives such as the contraceptive women with rectovaginal endometriosis who had
vaginal ring and the contraceptive patch [25]. pain persistent after 6 months of NETA therapy
[33]. A recent study has shown that dienogest is as
effective as NETA in improving pain symptoms in
2.2.2 Progestins women with rectovaginal endometriosis. Because
the two molecules are similar and because all hor-
Progestins have been used in the treatment of monal therapies for endometriosis have been
endometriosis for over 30 years. Thanks to central proven effective without significant differences
and peripheral mechanisms, the mitogenic action among different drugs [13, 14], this outcome was
and estrogen-induced proliferation are lacking. expected. No major adverse side events were
Furthermore, the endometrium, firstly, undergoes recorded. Minor side effects were experienced by
a secretory transformation and then a decidualiza- 55% of women in the NETA group and 41% of
tion, and, finally, it becomes atrophic, thus creat- women in the dienogest group, the most frequent
ing a pseudopregnancy state [26, 27]. A recent being weight gain, vaginal spotting, and decreased
Cochrane review has shown that the use of libido. Overall tolerability was significantly better
medroxyprogesterone acetate (MPA) at a dose of in women using dienogest than in those using
100 mg/day is more effective in controlling pain if NETA. However, the overall effectiveness was
compared with placebo, but it is burdened by sev- higher with NETA, owing to limited compliance
eral side effects (menstrual irregularities, amenor- with dienogest therapy resulting from the high
rhea, weight gain, and breast tenderness) [28]. cost of this drug [34].
Norethindrone acetate (NETA) and dienogest are It has been suggested that the effectiveness of
the progestins that have been more extensively dienogest in the treatment of endometriosis
evaluated for the treatment of endometriosis. Both depends on its ability to create a hypoestrogenic
of them are 19-nortestosterone derivative proges- and hyperprogestinic endocrine environment,
tins, and the pharmacological differences between which, initially, causes the decidualization of
the two compounds are limited: NETA has ectopic endometrial tissue. Subsequently, for
“strongly effective” progestogenic activity and prolonged treatments, dienogest causes an atro-
androgenic activity, whereas dienogest has “effec- phy of the lesions. An open-label extension of
tive” progestogenic activity and antiandrogenic this study for up to 53 weeks showed that long-
activity [29, 30]. The only randomized controlled term dienogest has a favorable efficacy and safety
trial available, evaluating the medical treatment of profile, with progressive decrease in pain and
rectovaginal endometriosis, has compared oral bleeding irregularities [35]. Furthermore, the
NETA 2.5 mg daily with an oral contraceptive pill decrease of pelvic pain persisted for at least
containing ethinyl estradiol 0.01 mg and cyproter- 24 weeks after therapy discontinuation. These
one 3 mg [31]. In the NETA group, women who effects should be due to the multiple mechanisms
were free of symptom at 12-month follow-up of action of the drug that reduces the growth and
ranged between 74% for dyspareunia and 92% for the neoangiogenesis of the lesions and provides
dysmenorrhea. Comparable results were observed an anti-inflammatory activity [35].
in the estrogen-progestin combination group. In recent years, the use of the levonorgestrel-
Another study showed that after 12 months of releasing intrauterine device (LNG-IUD) has
treatment with NETA, 40 women with rectosig- aroused interest. Its use in the treatment of endo-
moid endometriosis, who were still symptomatic metriosis of the rectovaginal septum provides a
following non-radical surgery, experienced sig- significant reduction in dysmenorrhea, pelvic
16 E. Zupi et al.
pain and deep dyspareunia, as well as the size of administration after surgical treatment prolongs
the endometriotic implants, showing levels of the pain-free interval [45, 46]. The treatment for
efficacy comparable to gonadotropin-releasing 3 months with a GnRH-a may reduce the painful
hormone (GnRH) analogues [36, 37]. symptoms for about 6 months [45]. Among the
Furthermore, it appears to be effective in pre- limitations of their use, there are the high rate of
venting the recurrence of endometriosis after recurrence of pelvic pain (5 years after with-
surgical treatment [38]. Clinical trials that com- drawal of therapy is at 75%) and the side effects,
pared the use of LNG-IUD and depot medroxy- such as deterioration in the lipid profile, depres-
progesterone acetate (DMPA), administered for sion, flushes, urogenital atrophy, loss of libido,
a period of 3 years, showed better compliance in and bone mass decrease [47]. The latter may be
patients who used the IUD [39]. Moreover, bone avoided by an “add-back therapy” that involves
gain was observed with LNG-IUD, whereas the use of hormone replacement treatment (HRT)
bone loss was reported with DMPA [39]. alone or in combination with biphosphonates or
Danazol is a synthetic androgen derivative of other antiresorptive agents [48].
17α-ethinyltestosterone, commercially intro-
duced about 30 years ago with a specific indica-
tion for the treatment of endometriosis [40]. It 2.2.4 GnRH Antagonist
carries out a multifactorial biological action
inducing a hypoestrogenic-hyperandrogenic state, The use of GnRH antagonists in the treatment of
which is very hostile to the endometriotic tissue endometriosis has been recently introduced, with
growth. Several studies have demonstrated the optimistic results [49]. They reduce estrogen lev-
efficacy of danazol in reducing the pain associ- els in order to inhibit the pain symptoms but with-
ated with endometriosis [41]. However, its oral out triggering side effects as a result of estrogen
use is limited by significant side effects such as deprivation. Furthermore, in contrast to GnRH-a,
weight gain, muscle cramps, acne, seborrhea, they do not determine the initial stimulation of the
decreased breast size, hirsutism, and deepening of pituitary-ovarian axis with the resulting gonado-
the voice, all strongly related to the androgenic tropic peak [50]. A recent phase 2, randomized,
action [42]. The vaginal administration, through a double-blind, placebo-controlled study has shown
vaginal ring or gel or intrauterine device extended- that a new GnRH antagonist (elagolix) has an
release, has been tested in patients with DE with acceptable efficacy and safety profile [51]. More
encouraging results [43]. clinical trials are required before such agents
should be introduced into clinical practice.
2.2.3 Gonadotropin-Releasing
Hormone Analogues 2.2.5 Nonsteroidal Anti-
inflammatory Drugs
GnRH analogues (GnRH-a) suppress estrogen
ovarian production through a downregulation of Nonsteroidal anti-inflammatory drugs (NSAIDs)
GnRH receptors at pituitary level, causing a pro- are the most commonly used first-line treatment
found hypoestrogenism and consequently amen- for endometriosis [20, 21]. However, there is
orrhea and a hypoatrophic regression of the inconclusive evidence to show whether or not they
heterotopic endometrium. This effect is readily are effective in relieving pain associated with
reversible after stopping GnRH-a administration. endometriosis [52]. Furthermore, there is no evi-
They are considered as a second-line treatment in dence on whether any individual NSAID is more
case of failure of therapy with oral contraceptives effective than another [52]. NSAIDs interfere with
or progestins or when they are not tolerated or the function of the enzymes COX-1 and COX-2,
contraindicated. GnRH-a provide a reduction of inhibiting the production of prostaglandins, mole-
symptoms in about 50% of cases [44], and their cules involved in the genesis of endometriosis-
associated pain [53]. Specific inhibitors of COX-2, these drugs favors the onset of bone fractures,
as rofecoxib, have also the property to block the osteopenia, and osteoporosis [62]. The combina-
growth of ectopic cells and induce apoptosis, with tion of conventional therapy and aromatase
equivalent result to one achieved with GnRH-a inhibitors determines the block of the production
[54]. To date, there are no sufficient clinical data to of estrogens both in ovarian and extraovarian
prove the NSAIDs are as effective in the treatment endometriotic foci, reducing the painful symp-
of endometriosis-associated pain. toms. They have been used in a pilot study evalu-
ating 12 women with rectovaginal endometriosis,
who had pelvic pain resistant to conventional
2.2.6 elective Estrogen Receptor
S treatments: after 6 months of treatment with
Modulators letrozole (2.5 mg/day), norethisterone acetate
(2.5 mg/day), calcium citrate, and vitamin D,
Selective estrogen receptor modulators (SERMs) there have been a significant reduction in abdom-
interact with estrogen receptors as agonists or inal-pelvic pain and the disappearance of endo-
antagonists depending on the target tissue [55]. metriotic lesions at second-look surgery [63]. A
In patients with endometriosis, the rationale for subsequent study, from the same group, showed
their use is related to the estrogen-antagonistic that the association of letrozole with norethister-
activity at endometrial level and estrogen-agonis- one acetate provides pelvic pain control more
tic activity on bone and plasma lipoproteins [55]. effectively than norethisterone acetate alone [64].
Although studies on animals looked very promis-
ing [56, 57], currently available data in humans
on SERMs do not support their clinical use. In 2.2.8 Immunomodulators
fact, a double-blind prospective study comparing
raloxifene with placebo was halted early because Tumor necrosis factor-a (TNF-a), a proinflamma-
the raloxifene group had statistically significantly tory cytokine able to initiate inflammatory cas-
earlier pain and necessity of a second surgery cades, is increased in the peritoneal fluid and
[58]. serum of women with endometriosis. It has been
implicated in the pathogenesis of endometriosis
[65]. Clinically, a small randomized controlled
2.2.7 Aromatase Inhibitors trial of infliximab, another TNF-a blocker, was
shown to have no effect on endometriosis-related
An overexpression of the aromatase enzyme, the pain [66]. In a systematic review, the effective-
main responsible factor for estrogen synthesis in ness and safety of anti-TNF-a treatment in the
the ectopic endometrium, has been demonstrated management of endometriosis in premenopausal
in endometrial tissue [59]. Aromatase catalyzes women were evaluated. Only 1 trial of 21 patients
the conversion of the steroidal precursors into was included where infliximab (a monoclonal
estrogens, which stimulate the expression of the anti-TNF-a antibody) was compared with pla-
enzyme COX-2. The estrogens produced in the cebo. The reviewer concluded that there is not
endometrial tissue through aromatase promote enough evidence to support the use of anti-TNF-a
the growth and invasion of endometrial lesion drugs in the management of women with endo-
and favor the onset of pain and prostaglandin- metriosis for the relief of pelvic pain [66].
mediated inflammation [60]. The third-genera-
tion aromatase inhibitors, including letrozole,
anastrozole, and exemestane, are triazole deriva- 2.2.9 Antiangiogenic Agents
tives and have a selective, potent, and reversible
action [61]. Their side effects are represented Neoangiogenesis is essential for the initiation,
mainly by headache, stiffness or joint pains, nau- growth, invasion, and recurrence of endometrio-
sea, diarrhea, and flushing. The long-term use of sis. A wide variety of antiangiogenic agents have
18 E. Zupi et al.
been evaluated in vitro as potential treatments for “combined” technique [85, 86], have been pro-
endometriosis. Different members of the statin posed. The “three-stage” technique consists of a
family have been shown to be effective in vitro in first operative laparoscopy, where fenestration
reducing angiogenesis and endometriotic implant and drainage of the endometrioma are performed;
size in mice [67–69], rats [70], and human cells a second stage, consisting of a 3-month GnRH
in vitro [71, 72]. Multiple dopaminergic agonists analogue treatment; and a second laparoscopy,
also exhibit antiangiogenic activities. Cabergoline representing the third stage, where CO2 laser
was shown to decrease VEGF and VEGFR-2 pro- ablation of the cyst wall is performed. In a ran-
tein expression in cabergoline-treated mice [73]. domized controlled trial comparing the “three-
In addition, cabergoline and quinagolide have an stage” technique to the conventional stripping
equal effect in reducing endometriotic lesions as technique, better results in terms of ovarian
antiangiogenic agents [74]. Moreover, cabergo- reserve, evaluated both with antral follicle count
line and bromocriptine were comparable to (AFC) [83] and anti-Mullerian hormone (AMH)
GnRH agonist in reducing endometriotic lesion [84], have been reported with the “three-stage”
size in one human study [75]. technique. The small sample size (ten patients
per arm), the higher recurrence rate in the “three-
stage” arm (20 vs. 0% in the excision arm), and
2.3 Surgical Management the higher costs of a repeat surgical procedure do
of Endometriosis not sufficiently support the “three-stage” tech-
nique as a validated alternative to the stripping
2.3.1 Ovarian Endometrioma technique.
The “combined technique” has been recently
Since endometriomas often do not respond to proposed [85, 86] as an alternative to the strip-
medical therapy, surgical excision is generally ping technique, in the attempt to combine the
considered the treatment of choice in large endo- advantages of the two standard techniques (strip-
metriomas, especially when associated symp- ping and fenestration with coagulation/ablation),
toms are present [17–19, 76, 77]. Surgery may be avoiding the disadvantages of both. The excision
indicated in particular when pain persists despite technique is in fact associated with better results
medical treatment or in case of enlarging or sus- in terms of subsequent fertility and pain recur-
pect endometriotic cysts. The surgical approach rence, whereas the fenestration with coagulation/
to an ovarian endometrioma can be either com- ablation technique may be more respectful of the
plete excision of the cyst wall (the so-called strip- ovarian reserve. In the combined technique, strip-
ping technique, by which the plane of cleavage ping is performed for most of the surgical proce-
between the cyst wall and the ovarian paren- dure, whereas the coagulation/ablation technique
chyma is developed by traction and countertrac- is performed in the final part near the hilus, to
tion with two atraumatic forceps) or fenestration decrease the possible damage to the tissue.
and subsequent ablation or coagulation of the However, a recent randomized controlled trial
cyst wall. Three randomized controlled trials [87], comparing the stripping technique with the
[78–80] and a Cochrane meta-analysis [81] dem- combined technique in bilateral endometriomas,
onstrated that laparoscopic excision of the ovar- did not report significant differences between the
ian endometrioma yields better results in terms of two techniques in terms of recurrence rates and
subsequent pregnancy rates, pain control rates, ovarian reserve (evaluated with AFC). Ovarian
and cyst recurrence rates, compared with fenes- endometrioma ablation using plasma energy
tration and coagulation/ablation of the cyst wall. appears to be a valuable alternative to cystec-
Due to concerns that recently emerged on the tomy, because it could spare the underlying ovar-
possibility that surgical excision may damage the ian parenchyma. Recent studies [88, 89] reported
ovarian reserve [82], alternative surgical tech- high spontaneous conception rate after this abla-
niques, such as the “three-stage” [83, 84] and the tion technique and suggest ovarian endometri-
oma ablation using plasma energy as a valuable and size of the infiltrative lesion. Careful dissec-
alternative to cystectomy in patients presenting tion using a skinning technique removing super-
with endometriosis and pregnancy intention. ficial endometriosis of the bladder peritoneum
Other alternative techniques have been can be performed, followed by closure of the
reported [90–92], but none has been proven supe- defect with interrupted 3-0 monofilament suture.
rior to the standard excisional technique in ran- Infiltrative lesions with involvement of the blad-
domized controlled trials. Therefore, there is still der mucosa situated in the bladder dome can be
insufficient evidence to recommend any alterna- managed with partial cystectomy. Closure of the
tive technique instead of the stripping technique bladder with a single- or double-layer monofila-
as the procedure of choice for the surgical treatment is recommended, and methylene blue test
ment of endometriomas. Whichever the tech- should be performed to ensure integrity of the
nique, surgery should be performed by expert suture line. In cases of more complex lesions
operators, since it has been demonstrated that involving the posterior wall of the bladder or the
damage to the ovary is inversely correlated with trigone, cystoscopy and insertion of double J
surgeon’s experience [93]. stents may be considered. Adhesions between the
anterior uterine wall and the vesicouterine fold
should be divided prior to performing partial cys-
2.3.2 Deep Endometriosis tectomy. Removal of double J stents should be
delayed by 6–8 weeks postoperatively and a uri-
2.3.2.1 Anterior Compartment nary catheter left in situ for a minimum of 7 days.
In our practice, a urinary catheter is more often
Urinary Tract Endometriosis left in place for a minimum of 10 days. Low-
Endometriosis of the urinary tract is generally pressure cystography can also be performed prior
reported as affecting approximately 1% of to removal of the catheter to verify adequate
women with endometriosis; however, the inci- repair and healing of the bladder.
dence varies between centers and has been
reported to be as high as 20% [94, 95]. Of these Ureteral Endometriosis
cases, 85% involve the bladder, 10% ureter, 4% Ureteric involvement can be categorized into
kidney, and 2% urethra [96]. Bladder endometri- intrinsic or extrinsic and although rare can cause
osis is more commonly associated with other significant morbidity with silent loss of renal
lesions of the pelvis. function. Extrinsic disease accounts for 85% of
cases and causes infiltration of the overlying peri-
Bladder Endometriosis toneum, which can cause compression of the ure-
Bladder endometriosis is defined as the presence ter resulting in hydronephrosis and, if left
of endometrial glands infiltrating the detrusor untreated, renal impairment [96, 98]. Intrinsic dis-
muscle. It is associated with a myriad of nonspe- ease occurs in 15% of cases leading to fibrosis of
cific urinary symptoms such as urinary frequency, the muscularis and, in some instances, the mucosa.
dysuria, urgency, and, rarely, hematuria, which Ureteric endometriosis is more prevalent on the
can delay diagnosis. Cyclical pain related to left-hand side, which may be attributed to the
menses may confirm a clinical suspicion of endo- menstrual reflux theory and anatomical differ-
metriosis [94, 97]. The gold standard for diagno- ences of the right and left hemi pelvis [99]. The
sis of bladder endometriosis is direct visualization main aim of surgical treatment is to relieve
of lesions at cystoscopy or laparoscopy. obstruction, if present, while preserving renal
Transvaginal ultrasonography (see Chap. 8) and function and preventing recurrence. Surgical
MRI (see Chap. 15) may be useful in diagnosis; treatment options include ureterolysis, ureteral
however, small lesions may be missed. resection with end-to-end anastomosis, or ure-
Laparoscopic management of bladder endome- teroneocystostomy, and in cases of complete loss
triosis is dependent on the anatomical position of kidney function, ureteronephrectomy can be
20 E. Zupi et al.
considered [96, 100]. Placement of a double J result in infiltration of the cardinal ligament and
stent should be considered in cases of urinary may lead to ureteric involvement by means of
obstruction and hydronephrosis or where signifi- extrinsic compression [105]. In 16.8% of cases,
cant ureteric stenosis has been diagnosed preop- uterosacral disease was associated with additional
eratively. Due to the inflammatory nature of lesions, most commonly of the vagina, followed
endometriosis, the double J stent should be left in by intestinal and lastly bladder lesions [104].
place for approximately 6 weeks. At laparoscopy, Surgical excision of uterosacral endometriosis has
the ureter should be identified above the level of been demonstrated to be effective in the manage-
disease. This is more easily done at the level of the ment of pelvic pain symptoms with a 0.8% risk of
pelvic brim where the retroperitoneal space can major intraoperative complications [104]. Surgical
be opened and the course of the ureter followed. strategy for the management of isolated uterosac-
In ureteric endometriosis, ureterolysis should be ral lesions typically involves ureterolysis, with dis-
performed with care taken to avoid devasculariza- section medial to the ureter so it can be lateralized.
tion by preserving the adventitial layer and corre- During dissection, care should be taken to avoid
sponding vascular branches. Fibrosis secondary damage to the hypogastric nerve, which is closely
to endometriosis often leads to medial displace- related to the uterosacral ligaments as it attaches to
ment of the ureter, and care should be taken dur- the posterolateral aspect of the uterus [106].
ing its dissection. In cases of critical stenosis of
the ureter or intrinsic disease, a ureteral resection Bowel Endometriosis
with end-to-end anastomosis can be performed. Endometriosis involving the bowel occurs in
Studies have shown promising results with mini- 3–37% of cases, commonly affecting the rectum,
mal complications and recurrence rates [98, 101, rectosigmoid junction, or sigmoid colon in up to
102]. Ureteroneocystostomy is recommended 90% of cases [107]. This type of DE is complex
when a long ureteric segment requires resection with distortion of pelvic anatomy which often
or if the disease is near the level of the uretero- requires a multidisciplinary team approach with
vesical junction. Reimplantation of the ureter involvement of colorectal surgeons. Different
allows the fibrotic area of disease to be bypassed, surgical techniques exist, ranging from less radi-
minimizing the risk of recurrence [96]. A tension- cal excision by means of “shaving” or discoid
free anastomosis should always be observed, and resection to more aggressive surgical treatment,
if more length is required, a psoas hitch can be namely, bowel segmental resection with some
considered. Due to the rarity of this condition, studies reporting no relapses [98]. Shaving, or
there is limited evidence regarding treatment of mucosal skinning, involves careful dissection of
ureteral endometriosis. Most studies involve the endometriotic nodule freeing it from the
observational case series; however, the results are bowel wall without breaching the bowel lumen.
promising and in terms of patient morbidity are Areas of exposed mucosa are then sutured to
comparable to those treated by laparotomy. The maintain integrity and avoid postoperative perfo-
overall incidence of complications has been ration. This shaving technique has had promising
reported as 12% with some studies illustrating no results with low complication rates. Donnez and
long-term consequences and low recurrence rates Squifflet reported a 1.4% rate of rectal perfora-
[103]. Similarly, recurrence rates have been tion in a series of 500 patients and a recurrence
reported ranging from 5 to 15%. rate of approximately 7% [108]. The overall
pregnancy rate was 84%, with a natural concep-
2.3.2.2 Posterior Compartment tion rate of 78% [108]. Similar studies have
DE commonly affects the posterior compartment, reported low complication rates and recurrence
with involvement of the uterosacral ligaments rates of approximately 19%. This conservative
most frequently found. Isolated uterosacral lesions approach allows preservation of nerves and blood
occur in up to 83% of cases [104]. Lateral exten- supply, minimizing the risk of postoperative
sion of lesions from the uterosacral ligament can functional bowel and bladder complications.
Discoid excision involves removal of disease tion for endometriosis, postoperative digestive
with full-thickness resection of the anterior rectal symptoms may persist or de novo symptoms may
wall and subsequent laparoscopic repair in 1–2 develop. A recent systematic review of outcomes
layers or by using a transanal circular stapler associated with different surgical treatments of
[109]. An initial shaving of the nodule may be bowel endometriosis described an overall com-
necessary for debulking purposes. A guide suture plication rate of 13.9% [118] This varied from
is then placed at the level of the nodule and a cir- 2.8% in the shaving group to 29.6% in the resec-
cular stapler is inserted transanally. This tech- tion group [118].
nique is suitable for bowel lesions up to 2–3 cm in
size. For larger lesions up to 5 cm, a double dis-
coid technique can be used. Two circular stapling 2.4 Future Perspectives
lines are formed, the first above the lesion and the
second more distal including the initial suture line Endometriosis is a benign complex clinical con-
from the first firing [110]. Anterior discoid resec- dition, associated with chronic pelvic pain, which
tion has been shown as effective in reducing a can adversely affect women’s quality of life, sex-
patient’s symptoms with low complication rates ual satisfaction, and the possibility to conceive.
ranging from 0 to 12.5% [109, 111, 112]. Future improvements in imaging modalities and
Radical excision is unavoidable, specifically their interpretation in the context of endometrio-
in cases where the nodule is greater than 3 cm in sis and pelvic nerve involvement may help in
length and where there is sigmoid involvement, defining preoperative assessment and surgical
more than 50% circumferential disease or con- planning. This approach would not only aid the
current bowel stenosis, and multicentric disease surgeon but also provide more accurate informa-
[113, 114]. Studies have demonstrated that com- tion for the patient with regard to the length, type
plete excision of bowel lesions, including seg- of surgery, subsequent recovery, and risk of com-
mental resection, are associated with significant plications. Nowadays, the surgical approach is
improvement in pain symptoms and subsequent progressively changing its direction with the
quality of life [115, 116]. Surgical excision of most aggressive procedures being replaced by
bowel and rectovaginal endometriosis can be more conservative surgeries. Maintaining a bal-
associated with major complications such as ance between high success rates of treatment,
bowel perforation and peritonitis. Segmental minimal risk of recurrence, and low complication
bowel resection may be indicated where endome- rates drive the need for a more conservative sur-
triosis is found to be infiltrating both serosal and gical approach. At the same time, significant
mucosal layers. In these cases, we advocate seg- research has been focused on new drugs specifi-
mental bowel resection to be as economic as pos- cally designed for the treatment of endometriosis.
sible. The bowel is dissected at the edge of the Although current medical treatments are helpful
mesentery respecting all the vascular branches. for many women with endometriosis, these treat-
Once the diseased segment has been adequately ments have limitations that include side effects in
dissected, the bowel is divided caudal to the some women and contraceptive action for those
lesion using a linear stapler device. An endo- desiring pregnancy. Emerging medical treat-
scopic linear stapler is used to resect the bowel ments range from GnRH antagonists, aromatase
above the nodule. A minilaparotomy incision can inhibitors, and immunomodulators to antiangio-
be used to cut the rectum and place the anvil in genic drugs. More research into local neurogen-
the proximal bowel; alternatively, a transvaginal esis, central sensitization, and the genetics of
or transanal approach can be used [114]. A circu- endometriosis may provide future targets. The
lar stapler is inserted through the caudal portion role of the physician is to guide the woman
of the rectum and an end-to-end anastomosis per- through all therapeutic possibilities in order to
formed [117]. Despite a significant improvement resolve or minimize the impact of the disease
in pelvic pain following segmental bowel resec- while managing her expectations.
22 E. Zupi et al.
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Standardized Ultrasonographic
Diagnostic Protocol to Diagnose
3
Endometriosis Based on the
International Deep Endometriosis
Analysis (IDEA) Consensus
Statement
Mathew Leonardi and George Condous
3.1 Introduction participate based on their expertise in the diagno-

sis and management of endometriosis. The pri-
In April of 1978, Sandler et al. published a series mary goal of this consensus is to standardize
of ten cases entitled “The Spectrum of Ultrasonic terminology, including definitions of anatomy,
Findings in Endometriosis” [1]. The authors made measurements of sonographic findings, and
the recommendation that sonographers should nomenclature of endometriosis lesions, for uni-
consider endometriosis in the differential diagno- form use on the international scientific stage. The
sis when a pelvic mass was visualized on ultra- downstream objective is to encourage homogene-
sound. In the almost 40 years since this publication, ity in terminology to enhance comparison between
the international scientific community has con- future studies, promote multicenter studies, and
tributed to the literature on the utility of ultra- improve patient outcomes.
sound in the diagnosis and management of The purposes of ultrasound in patients with
endometriosis. The recent consensus statement on suspected endometriosis are threefold: (1) attempt
the systematic approach to sonographic evalua- to explain the patient’s symptoms, (2) map the dis-
tion of the pelvis in patients with suspected endo- ease location, and (3) assess the severity of dis-
metriosis demonstrates broad international ease. The systematic approach to this ultrasound
collaboration [2]. This landmark paper was pub- technique involves four basic steps (Table 3.1),
lished in Ultrasound in Obstetrics and Gynecology which will be outlined in the section, “How We Do
in 2016 by the International Deep Endometriosis It.” Each of the four steps will then be expanded
Analysis (IDEA) group, which was comprised of upon in greater detail in subsequent chapters.
clinicians, gynecological sonologists, advanced
laparoscopic surgeons, and radiologists. The 29
members of 15 different countries were invited to 3.2 How We Do It
Prior to beginning the ultrasound scan, one

M. Leonardi (*) · G. Condous should explain the nature of procedure to the
Acute Gynaecology, Early Pregnancy and Advanced patient and obtain consent to proceed. A trans-
Endosurgery Unit, Sydney Medical School Nepean, vaginal ultrasound (TVS) is the recommended
Nepean Hospital, University of Sydney,
imaging modality in the diagnosis of endometrio-
Sydney, NSW, Australia
e-mail: mathew.leonardi@mail.utoronto.ca; sis [3]. Patients should be instructed to empty
george.condous@omnigynaecare.com.au their bladder immediately prior to the TVS. They

https://doi.org/10.1007/978-3-319-71138-6_3
28 M. Leonardi and G. Condous
Table 3.1 Four basic sonographic steps, which can be adopted in this or any order as long as all four steps are per-
formed to confirm/exclude the different forms of endometriosis
Routine evaluation of the uterus and adnexa (+ sonographic signs of adenomyosis/presence or
First step absence of endometrioma)
Second step Evaluation of transvaginal sonographic “soft markers” (i.e., site-specific tenderness and ovarian
mobility)
Third step Assessment of status of POD using real-time ultrasound-based “sliding sign”
Fourth step Assessment for DE nodules in anterior and posterior compartments
POD pouch of Douglas, DE deep endometriosis
should then be positioned and draped Next the adnexa should be evaluated. Ovarian
appropriately. A wedged cushion or medical
size and characteristics should be documented.
couch, with stirrups or lowering bottom section, The presence or absence of endometriomas
can be used to ensure adequate mobility with the should be noted. The following three elements
transvaginal probe. After sanitary protocols have are critical when assessing endometriomas. First,
been followed for probe cleaning, ultrasound gel the size, measured in three orthogonal planes. To
should be placed on the tip of the probe. A probe achieve appropriate orthogonal plane measure-
cover can then be placed overtop, followed by ments, the length is obtained in the midsagittal
lubricating gel to ease insertion of the probe into plane, thickness in the anteroposterior plane, and
the patient’s vagina. The scan can then begin. It is transverse diameter in the transverse plane.
recommended to implement a local protocol to Second, the number of endometriomas should be
ensure all steps are completed, though they may noted. Third and lastly, the sonographic charac-
differ in order than that presented here. Most teristics should be described according to termi-
importantly, the operator needs to be experienced nology published by the International Ovarian
in the evaluation of patients with potential deep Tumor Analysis (IOTA) group [7]. When an
endometriosis (DE). endometrioma is visualized, there is significantly
higher likelihood of multiple lesions of DE [8].
Though the IDEA consensus statement recom-
3.2.1 First Step mends all four steps in all patients with suspected
endometriosis, operators performing the ultra-
The first structure often identified is the uterus. sound should be more vigilant for DE when an
The orientation (anteverted, retroverted, or axial) endometrioma is diagnosed.
should be noted. Any uterine abnormalities The Fallopian tubes, though not usually visi-
should be noted. Specifically with endometriosis ble on ultrasound in a normal state, may be dis-
in mind, one should inspect carefully for signs of torted or blocked by adhesions in patients with
adenomyosis as there is significant correlation endometriosis. If a hydrosalpinx or hematosal-
between the two processes [4]. These findings pinx is seen on ultrasound, endometriosis should
should be described using the terms and defini- be considered as an etiology.
tions published in the Morphological Uterus
Sonographic Assessment (MUSA) consensus
opinion [5]. Though not included in the MUSA 3.2.2 Second Step
group’s opinion, the “question mark sign” should
be noted when seen as this can represent adeno- The next element of the scan is a dynamic assess-
myosis and/or endometriosis [5, 6]. In the context ment of “soft markers” – site-specific tenderness
of endometriosis, this sign generally signifies a (SST) and ovarian mobility [2]. “Soft markers” are
fixed (i.e., nonmobile) anteverted/retroflexed defined as sonographic features that indirectly
uterus with the fundus adhered posteriorly to the suggest the presence of endometriosis, specifically
rectum and/or sigmoid colon. superficial endometriosis and intra-abdominal
3 Endometriosis Ultrasound Protocol based on IDEA Consensus Statement 29
adhesions, neither of which can be directly visual- may be adhered to each other, known as “kissing”
ized [9, 10]. These “soft markers” are elicited ovaries (Fig. 3.1). Not only does this particular
using the transvaginal probe [10]. ultrasound sign indirectly indicate intra-abdomi-
Firstly, before evaluating for SST, it is important nal adhesions, but it may also represent underlying
to inform the patient that he or she may experience DE of the Fallopian tubes and/or bowel [11].
discomfort or pain. Their feedback to the operator
performing the scan is essential to this step. The
key anatomic locations to assess in this component 3.2.3 Third Step
of the scan include the uterus, adnexa, uterosacral
ligaments (USL), and pouch of Douglas (POD). The third step is another dynamic, real-time
No scoring system has been validated as yet for ultrasound technique involving assessment of the
SST. Currently, the IDEA group recommends a status of the POD called the “sliding sign.” When
scoring system of 0 or 1: 0 for no pain and 1 for the uterus and cervix move independently (i.e.,
pain. It may be prudent to complete this aspect of slide) along the anterior rectum and sigmoid, the
the ultrasound at the very end to prevent interrup- test is positive and the POD is not obliterated.
tion or termination of the scan secondary to pain. When the uterus and cervix move in unison with
Secondly, ovarian mobility should be judged by the anterior rectum and sigmoid, the test is nega-
applying pressure to the ovaries using the trans- tive and the POD is thought to be obliterated [12,
vaginal probe. The ovaries may be fixed laterally 13]. Depending on the orientation of the uterus,
to the pelvic side wall, medially to the uterus, or the method to test for POD obliteration is slightly
inferiorly to the USLs. In some cases, the ovaries different (Table 3.2).
Fig. 3.1 “Kissing”

ovaries sign; indirectly
indicates intra-
abdominal adhesions,
and possibly underlying
DE of posterior
compartment. This
ultrasound image depicts
a right (Rt) ovarian
endometrioma and a left
(Lt) ovarian
hemorrhagic cyst [2]
Table 3.2 Pouch of Douglas assessment for obliteration using “sliding sign”
Anteverted Retroverted
Step 1 Place gentle pressure against the retro-cervix using Place gentle pressure against the posterior upper
the transvaginal probe. Observe whether the uterine fundus with the transvaginal probe. Observe
anterior rectum glides freely across the posterior whether the anterior rectum glides freely across the
aspect of the cervix and posterior vaginal wall posterior upper uterine fundus
Step 2 Place one hand over lower anterior abdominal wall Place one hand over lower anterior abdominal wall
and ballot the uterus between the palpating hand and ballot the uterus between the palpating hand
and the transvaginal probe. Assess whether the and transvaginal probe. Assess whether the anterior
anterior bowel glides freely over the posterior sigmoid glides freely over the anterior lower uterine
aspect of the upper uterine fundus segment
3.2.4 Fourth Step transabdominal scan of the kidney is necessary

[2]. The purpose of the ultrasound is to rule out
The fourth and last step entails searching for DE hydroureteronephrosis, which may exist in asymp-
lesions in the anterior and posterior compart- tomatic ureteral stenosis [26, 27].
ments (Fig. 3.2). The anterior compartment is
comprised of the urinary bladder, uterovesical
region, and ureters. The posterior compartment 3.2.6 Posterior Compartment
sites include USLs, posterior vaginal fornix, rec-
tovaginal septum (RVS), anterior rectum/anterior DE nodules in the posterior compartment should
rectosigmoid junction and sigmoid colon [2, 14]. be sonographically localized based on the ana-
The IDEA group has recommended that DE tomic landmarks specified in the IDEA consen-
lesions located in the bladder, RVS, vagina, sus statement. Moreover, it is critical to document
USLs, anterior rectum, and rectosigmoid should the size and characteristics of these nodules.
be measured, like endometriomas, systematically Generally, they appear as hypoechoic thickening
in three orthogonal planes (Fig. 3.3) [2]. of the bowel wall or vagina, or as hypoechoic
solid nodules with variable sizes and contours
[2]. Chapters 9–12 will focus on the various
3.2.5 Anterior Compartment aspects of the posterior compartment in greater
detail.
Ideally by the time the bladder is scanned, some In order to satisfactorily perform a TVS of the
urine has accumulated. A small amount of urine posterior compartment with the intention of diag-
reduces the frequency of false-negative findings nosing DE, one must understand the anatomy.
[2]. The anatomical landmarks of the bladder will The IDEA group has developed a schematic to
be discussed in greater detail in Chap. 8. To meet delineate the RVS and the posterior vaginal for-
diagnostic criteria for a DE lesion, the muscularis nix (Fig. 3.4). Involvement of the RVS should be
of the bladder wall must be affected. Generally, suspected when a DE nodule is seen on TVS in
this is the most common layer impacted by endo- the rectovaginal space below the line passing
metriosis. Lesions may appear as hypoechoic lin- along the lower border of the posterior lip of the
ear or spherical lesions, with or without regular cervix (under the peritoneum) [20]. Involvement
contours [15–21]. With respect to the uterovesi- of the posterior vaginal fornix and/or lateral vagi-
cal region, the most important aspect to under- nal fornix should be suspected when a DE nodule
stand is whether the posterior bladder is tethered is seen on TVS in the rectovaginal space below
to the uterus (i.e., obliteration of the space). The the line passing along the caudal end of the peri-
concept of the “sliding sign” can be applied here toneum of the lower margin of the POD and
as well, but one must interpret the results in the above the line passing along the lower border of
context of the patient’s past surgical history, the posterior lip of the cervix (under the perito-
including cesarean sections [22]. neum) (Fig. 3.4). In the same vicinity, a recto-
The ureters can also be imaged and assessed for vaginal nodule could be identified, extending
damage secondary to endometriosis. First, identify from the posterior vaginal fornix to the anterior
the urethra in the sagittal plane and move the probe rectum. These appear as hourglass-shaped or
toward the lateral pelvic wall. Along this path, and “diabolo”-like nodules (Fig. 3.5) [28]. As these
in order, is the intravesical segment of the ureter, lesions lie beneath the peritoneum of the POD,
the site of ureter exiting bladder, and finally, where they are not visible on laparoscopy. However,
it crosses the bifurcation of the common iliac ves- they are usually large at an average of 3 cm [29].
sels. The examiner should evaluate for ureteric To evaluate for endometriotic lesions of the
dilatation, and if present, the distance between the USLs, place the transvaginal probe in the poste-
dilatation and the distal ureteric orifice should be rior vaginal fornix in the midline in the sagittal
measured [23–25]. In the event of DE on TVS, a plane and then sweep the probe inferolaterally to
URETHRA
COMPARTMENT
UTERINE OVARY
ANTERIOR
ARTERY
TER
URE
BLADDER
DE
TRIGONE VESICAL DOME URETER UTERO-VESICAL OBLITERATION
2
SEPTUM VAGINAL RECTAL VAGINA
ONLY WALL WALL & RECTUM 3
COMPARTMENT
POSTERIOR
RECTOVAGINAL
SEPTUM 1- LOWER (RETROPERITONEAL)
ANTERIOR RECTUM
2- UPPER (VISIBLE)
ANTERIOR RECTUM
POSTERIOR VAGINAL FORNIX ‘DIABOLO-LIKE’ NODULE 3- RECTO-SIGMOID
UTEROSACRAL LIGAMENT TORUS UTERINUS
POUCH OF DOUGLAS OBLITERATION
RECTUM & RECTOSIGMOID cm 0
Bowel (rectum & sigmoid)
Vagina
Bladder
Peritoneal cavity
Uterus
Endometriotic nodule
Uterosacral ligaments
Anal sphincter
Adhesions
Fig. 3.2 Overview schematic demonstrating various sites of endometriotic nodules and adhesions in the anterior and
posterior compartments, with associated legend. Reprinted with permission from Wiley Publishers [2]
sagittal
transverse
Fig. 3.3 Schematic drawing demonstrating method of obtaining orthogonal measurements, i.e., midsagittal, anteropos-
terior, and transverse. Reprinted with permission from Wiley Publishers [2]
Fig. 3.4 Schematic drawing demonstrating ultrasound (space between the blue line and the red line). Reprinted
definition of the rectovaginal septum (RVS) (double- with permission from Wiley Publishers [2]
headed green arrow) and the posterior vaginal fornix
Fig. 3.5 Ultrasound

image demonstrating a
“diabolo-like” nodule of
deep endometriosis from
the posterior vaginal
fornix extending into the
anterior rectum.
Reprinted with
permission from Wiley
Publishers [2]
the cervix [2]. Normal USLs are not usually visu-

alized on TVS. If a hypoechoic thickening is seen
within the peritoneal fat surrounding the USLs, it
is felt that the USLs are harboring DE. An attempt
should be made to identify whether the lesion is
part of a larger complex, encompassing other
nearby anatomic sites.
Bowel endometriosis generally involves the
anterior rectum, rectosigmoid junction, and/or sig-
moid colon [14]. The schematic in Fig. 3.6 delin-
eates these areas but also dichotomizes the anterior
rectum into lower (retroperitoneal) and upper (vis-
ible at laparoscopy). Bowel DE usually appears on
TVS as a thickening of the hypoechoic muscularis
propria or as hypoechoic nodules, with or without
hyperechoic foci (Fig. 3.7). Any nodule recog-
nized in the bowel wall should be recorded in three Fig. 3.6 Schematic drawing identifying distinct seg-
orthogonal planes, and the distance between the ments and the rectum and sigmoid colon: lower (or retro-
peritoneal) anterior rectum (1), upper (visible at
lower margin of the most caudal lesion and the laparoscopy) anterior rectum (2), rectosigmoid junction
anal verge should be measured using TVS. Lastly, (3), and anterior sigmoid (4). Reprinted with permission
the morphological appearance should be docu- from Wiley Publishers [2]
mented based on the types of lesions described in
the IDEA consensus opinion [2].
method has been externally validated. The
consensus opinion approach is currently
3.3 Important Technical Tips undergoing a multicenter study to externally
validate its recommendations.
• Various ultrasound techniques for the diagno- • The patient should understand the nature of
sis of endometriosis have been published in the ultrasound, including the indication, ben-
the literature [30, 31] prior to the publication efits, and risks. They should provide their
of the IDEA consensus statement. No single informed consent. They should be aware that
SEROSA
a Longitudinal muscle
MUSCULARIS EXTERNA
b
Circular muscle
SUBMUCOSA
Muscularis mucosa
Lamina propria
MUCOSA
Epithelium
Lumen
Blood vessels
Gland in
submucosa
Fig. 3.7 Schematic image showing the histological layers of the rectum (a), which can be seen on the adjacent ultra-
sound image (b); a DE nodule can be seen as labeled. Reprinted with permission from Wiley Publishers [34]
this is a dynamic ultrasound involving testing 3.4 Future Perspectives

for SST, which may cause discomfort or pain.
• The operator should understand the indica- From a general perspective, there are two natural
tions for the ultrasound and ensure appropri- next steps. Presently, an observational non
ate patient selection. interventional academic multicenter study is
• A strong knowledge of pelvic anatomy and the underway. This study will evaluate the use of the
ultrasound appearance of anatomy is critical to IDEA terminology in different groups of patients
a successful scan, regardless of findings. in whom pelvic ultrasound is currently routinely
• Operators should follow a protocol that encap- performed, e.g., dysmenorrhea, dyspareunia,
sulates all four of the steps for all scans. The and/or dyschezia. The IDEA group will evaluate
protocol does not have to follow the same prospectively if the ultrasound appearances of the
order of steps outlined in the IDEA consensus. pelvis in patients with chronic pelvic pain can
Thoroughness every time is key, but when predict the different phenotypes of endometriosis
more routinely identified abnormalities such in patients scheduled for laparoscopic surgery.
as endometriomas are seen, operators should Secondly, educational studies are necessary to
be on high alert for other lesions. understand the learning curves to reach compe-
–– It may be advisable to perform aspects that tency in the techniques described above. Tammaa
are pain-evoking toward the end of the et al. have suggested that in gynecologists experi-
procedure. enced in ultrasound for general gynecologic
• When DE is visualized, it should be described problems (defined as having performed approxi-
in detail in a standardized fashion as outlined mately 2500 transvaginal scans), roughly 40
in the IDEA consensus statement. endometriosis-focused scans are required to
–– Ultrasound features reach competency in the prediction of POD oblit-
–– Location eration and DE of the rectum [33]. Lesser experi-
–– Size (three orthogonal planes) enced operators’ learning curve is still to be
–– Proximity to important structures (e.g., determined. As an advanced ultrasound approach,
anal verge, ureteric orifice) operators of diverse backgrounds may require
• When DE is diagnosed on ultrasound, a trans- different amounts of time, number of scans, or
abdominal ultrasound of the kidneys should levels of supervision before they can indepen-
be done to ensure there is no evidence of dently perform this scan. Implementation of this
hydroureteronephrosis. approach as standard of care requires a stronger
• Importantly, the absence of DE on ultrasound appreciation of this concept.
scan does not mean the patient does not have We have described the IDEA group’s system-
endometriosis [32]. atic approach, using dynamic ultrasound, to
examine the pelvis in patients with suspected 9. Guerriero S, Ajossa S, Lai MP, Mais V, Paoletti
AM, Melis GB. Transvaginal ultrasonography in
endometriosis. The published defined anatomical the diagnosis of pelvic adhesions. Hum Reprod.
terms and measurements used to describe the 1997;12(12):2649–53.
appearances of all endometriosis phenotypes 10. Okaro E, Condous G, Khalid A, Timmerman D,
should represent the benchmark standard for Ameye L, Huffel SV, et al. The use of ultrasound-based
“soft markers” for the prediction of pelvic pathology
endometriosis ultrasound henceforth. This in turn in women with chronic pelvic pain - can we reduce
will not only raise the standard of diagnostic the need for laparoscopy? BJOG. 2006;113(3):251–6.
ultrasound in this field but also ensure that expe- 11. Ghezzi F, Raio L, Cromi A, Duwe DG, Beretta P,
rienced operators, regardless of country of origin, Buttarelli M, et al. “Kissing ovaries”: a sonographic
sign of moderate to severe endometriosis. Fertil Steril.
describe the location and extent of disease in a 2005;83(1):143–7.
way which is uniform and easily interpretable. 12. 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
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Uterine Evaluation Using
a Diagnostic Protocol Based
4
on MUSA
Thierry Van den Bosch
4.1 Introduction This chapter gives an overview of how to

describe the myometrium based on the MUSA
In 2015, the MUSA group published a consensus consensus [2].
paper on how to report the myometrium and
myometrial lesion at ultrasound examination.
Myometrial lesions are mostly benign including 4.2 How We Do It
fibroids and adenomyosis, while malignant myo-
metrial lesions or sarcomas are rare. The total length of the uterus includes the thick-
Fibroids are typically well-defined round ness of the fundus, the length of the cavity, and
lesions (Fig. 4.1) with circumferential vascular- the length of the cervix.
ity. The echogenicity of fibroids varies from Myometrial walls are reported as symmetrical
hypoechogenic to highly hyperechogenic. In the or asymmetrical. It is important to realize that
latter case, this causes strong retrolesional transient focal myometrial contractions may give
shadowing. a false impression of asymmetry. Therefore, wall
Adenomyosis gives rise to ill-defined lesions asymmetry should be interpreted with caution.
of mixed echogenicity, myometrial cysts, fan- The presence of wall asymmetry should at least
shaped shadowing, hyperechogenic islands, and be confirmed at the end of the examination or,
irregular junctional zone with subendometrial preferably, during a second scan later in time.
lines and buds. At color Doppler imaging, trans- Given the possible transient nature of wall asym-
lesional vascularization is seen [1, 2] (Figs. 4.2 metry, the diagnosis of adenomyosis should
and 4.3). never be based only on myometrial asymmetry,
Sarcomas are reportedly large, oval shaped, in the absence of other adenomyosis features.
inhomogeneous, and highly vascularized lesions The overall echogenicity of the myometrium
without calcifications [3–5]. is recorded as homogeneous or heterogeneous. It
has to be taken into account that the myometrium
echogenicity depends on, e.g., focal depth, uter-
ine flection, the presence of an intrauterine
device, transient uterine contractions, or extra-
T. Van den Bosch
Department of Obstetrics and Gynecology, University uterine structures such as bladder filling or over-
Hospitals KU Leuven, Leuven, Belgium lying bowel loops. If the myometrium appears
RZ Tienen, Tienen, Belgium heterogeneous, the reason for this should be
e-mail: thierry.vandenbosch@uzleuven.be search for and reported.

https://doi.org/10.1007/978-3-319-71138-6_4
38 T. Van den Bosch
Fig. 4.1 Ultrasound images of fibroids
Asymmetrical thickening
Hyperechoic subendometrial
lines and buds
Cysts
Translesional vascularity
Irregular junctional zone

Hyperechoic islands
Interrupted or ill-defined
junctional zone
Fan shaped shadowing
Fig. 4.2 Ultrasound features of adenomyosis (From Van den Bosch et al. [2])
Myometrial lesions may be well-defined or In clinical practice, an accurate lesion map-

ill-defined. A fibroid is typically a well- ping is particularly relevant if surgical removal is
defined lesion, while adenomyosis is often planned. The surgeon will plan his/her procedure
ill-defined. according to the number, the location, the site,
4 Uterine Evaluation Using a Diagnostic Protocol Based on MUSA 39
and the size of each lesion. However, in a poly-

myomatous uterus, in which the number, the site,
and the size of the lesions preclude myomectomy,
the estimation of the total volume of the uterus
may be more relevant.
The lesion location is reported as anterior,
posterior, fundal, right lateral, left lateral, or
global. Although lesion location can be defined
during 2D scanning, the use of 3D ultrasonogra-
phy may help illustrating the findings for the sur-
geon. Tomographic ultrasound imaging (TUI) is
especially suited in the reporting to the surgeons Fig. 4.5 Outer lesion-free margin (OFM) (From Van den
who are confident with the interpretation of simi- Bosch et al. [2])
lar tomographic images from CT scan or
MRI. Uterine fibroids are further recorded
according to the FIGO classification 1–7 [6]
(Fig. 4.4).
Fig. 4.6 Inner lesion-free margin (IFM) (From Van den

Bosch et al. [2])
Well-defined lesions are measured in three

perpendicular diameters. This can be measured
on 2D or after acquisition of a 3D volume. In the
latter case, sectional planes are selected, and the
Fig. 4.3 Ultrasound image of adenomyosis (asymmetri- central dot is placed at the center of the target
cal thickening of the posterior myometrium, multiple lesion in plane A. The lesion is measured in plane
myometrial cysts, fan-shaped shadowing, echogenic A in two perpendicular diameters, and the third
islands, endometrial line, interrupted junctional zone)
diameter is measured in plane B.
In fibroids, the outer and the inner lesion-free
5 7
margin is measured. The outer lesion-free margin
6 2-5 (OFM) is the minimal distance between the sero-
sal surface and the outermost border of the lesion
4
0 (Fig. 4.5).
1 The inner lesion-free margin (IFM) is the
2 minimal distance between the endometrium and
3 the inner border of the lesion (Fig. 4.6).
In ill-defined lesions, the penetration is
reported (Fig. 4.7). The penetration is defined as
Fig. 4.4 FIGO classification of fibroids (adapted from the ratio between the thickness of the lesion
Munro [6]) (measured as the maximal lesion diameter per-
40 T. Van den Bosch
pendicular to the endometrium) and the total all myometrial echogenicity may be heteroge-
uterine wall thickness (measured perpendicular neous, making the reference echogenicity less
to the endometrium). Both should be measured reliable. The subjectivity of the scoring system
on the same image. had to be taken into account in the interpretation
The extent of an ill-defined lesion is reported of the report.
as localized, if less than 50% of the total uterine Shadowing originating from the myometrium
is involved, or as diffuse, if at least half of the may present as edge shadows, internal shadows,
uterine volume is involved. The extent may also or fan-shaped shadowing (Fig. 4.8). The degree
be recorded as the percentage of the myome- of shadowing is recorded as slight, moderate, or
trium involved. The estimation of ill-defined strong (Fig. 4.9).
lesions is a rough subjective estimation and is Myometrial cysts may be present. Cyst may
deemed difficult and probably not optimally be caused by adenomyosis, atrophy, and necrosis
reproducible. or may be drug induced (e.g., tamoxifen). The
The echogenicity of a myometrium lesion is cyst fluid may be anechogenic and have a low
reported as uniform or nonuniform. A uniform level echogenicity, a ground-glass appearance,
lesion may be hypo-, iso-, or hyperechogenic as or a mixed echogenicity. The cyst size may vary
compared with the surrounding (unaffected) considerably. At least in the presence of larger
myometrium. For research purposes, the rela- cysts, the number of cysts and the maximal
tive echogenicity can be scored as very
hypoechogenic (−−), hypoechogenic (−),
isoechogenic, hyperechogenic (+), or very
hyperechogenic (++). As stated before, the over-
Fig. 4.7 Penetration of ill-defined lesions (From Van den Fig. 4.9 Ultrasound image of a calcified fibroid causing
Bosch et al. [2]) intense internal shadows
Edge shadows Internal shadows
Present Present
Fig. 4.8 Shadowing caused by fibroids (From Van den Bosch et al. [2])
Fig. 4.11 Ultrasound image of adenomyosis: irregular

Fig. 4.10 Ultrasound image of adenomyosis: myome- junctional zone
trial cyst surrounded by an echogenic rim (yellow arrow)
and endometrial bud (red arrow)
diameter of the largest cyst are recorded. In ade-

nomyosis numerous small cysts may be present.
In this case, it is not feasible to record the exact
number nor the size of the cysts. A typical ade-
nomyosis cyst has an echogenic rim caused by
endometrial tissue surrounding the cyst cavity
(Fig. 4.10).
In adenomyosis, the presence of endometrium
tissue within the myometrium may be seen as
hyperechogenic islands. The outline of these
hyperechogenic islands is often ill-defined or
Fig. 4.12 Ultrasound image of adenomyosis: interrup-
irregular but may also be quite regular. For tion of the junctional zone caused by and echogenic bud
research purposes, the maximum diameter and
the number may be recorded.
Early myometrial invasion by endometrial tis- percentage of the JZ not visualized may be
sue may be apparent at ultrasound examination as recorded. If possible, the reason for the irregular-
subendometrial echogenic lines and buds. For ity/interruption may be specified (e.g., cystic
research purposes, their number and location areas, hyperechogenic dots, hyperechogenic buds
may be recorded. and lines, fibroid) (Fig. 4.12). The vascularity of
The junctional zone (JZ) or inner myometrium the myometrium using color or power Doppler
is the hypoechogenic rim surrounding the endo- imaging starts with the assessment of the overall
metrium. The junctional zone may appear regu- vessel pattern within the uterine walls, reported
lar, irregular, or interrupted or may not be visible as uniform or nonuniform.
(Fig. 4.11). The clinical relevance of the mea- The vascularization of the myometrial lesion
surement of the minimal and maximal JZ thick- may be clinically relevant in the diagnosis, the
ness remains to be proven and is restricted to management choice, and the follow-up. The
research protocols. In case of irregular or inter- amount of color in a lesion is reported as a color
rupted JZ, the location of the irregularity/inter- score. Both the percentage of the lesion being
ruption may be specified as anterior, posterior, vascularized and the color hue are taken into
fundal, lateral right, lateral left, or global. The account. The color score ranges from 1 to 4:
extent of the irregular JZ may also be estimated score 1 meaning no color, score 2 minimal color,
and recorded as the percentage of the JZ being score 3 moderate color, and score 4 abundant
irregular. In case of interruption of the JZ, the flow. In case of uneven spread of vascularization,
42 T. Van den Bosch
the color score of the most vascularized part may The vessel morphology can further be
be reported using the same color score ranging described as to vessel number, size, branching,
from 1 to 4, and the percentage of solid tissue and direction. The number of vessels is recorded
with color signal can be specified (0–100%). The as single or multiple. The vessel size may be
vascularity within the lesion may be compared to large and equal, small and equal, or unequal.
the adjacent myometrium and reported as iso-, Vessels may exhibit regular or irregular branch-
hypo-, or hyper-vascularization. ing, or no branching. The direction of the vessels
The location of vessels is reported as circum- is recorded as perpendicular or not perpendicu-
ferential, intralesional, or translesional lar to the uterine cavity.
(Fig. 4.13). Circumferential flow is typical for
fibroids, whereas translesional vascularity is
characteristic for adenomyosis (Fig. 4.14). The 4.3 Technical Tips
vessel spread within a lesion may be uniform or
not uniform. In the latter case, there are areas Using 2D, the uterus is scanned in sagittal and
with increased or decreased vascularity within transverse plane to assess its position, shape, and
the lesion. volume. In transverse plane, a section high in the
a b
Fig. 4.13 Color imaging: circumferential (a), intralesional (b), and translesional (c) vascularization (adapted from Van
den Bosch et al. [2])
a b
Fig. 4.14 Ultrasound image of a fibroid with circumferential flow (a) and adenomyosis with translesional flow (b)
hard to distinguish. Using color Doppler and

scanning the lateral border of the cervix and
a
lower corpus, the visualization of the uterine
b c arteries may be helpful to define the level of the
isthmus.
Some uteri are rotated around the craniocau-
dal axis. This may render it more difficult to
obtain a midsagittal section. Moreover, if the sag-
ittal section is not perpendicular to the frontal
plane of the uterus, the measurement of the endo-
Fig. 4.15 Measurement of the length of the uterus (From metrial thickness and of the anteroposterior
Van den Bosch et al. [2])
diameter of the uterus may be significantly
overestimated.
cavity, at the level of both tubal ostia, is impor- A 3D acquisition enables to visualize all three
tant to exclude congenital uterine anomalies section planes: the sagittal, transverse, and coro-
(e.g., unicornuate uterus, bicornuate uterus). nal planes. The frontal or coronal section is
Measuring the total length of the uterus is not essential in the diagnosis of congenital uterine
always easy due to the flexion of the uterus. anomalies as well as in the assessment of the
Unless the uterus is outstretched, the true size of junctional zone [7, 8].
the uterine length will be underestimated using a The outer border of the myometrium is the
straight line. Therefore the use of a curved mea- uterine serosa, the inner border the endometrium.
sure line will be more accurate. Often an approxi- The serosa is usually seen as a regular white line.
mated measurement is made using three straight It is of clinical importance to assess the mobility
measure lines: [total length] = [fundus] + [cav- of the uterus against the surrounding organs
ity] + [cervix] (Fig. 4.15). (bowel, bladder). This has been referred to as the
Clinician should be aware of these limita- sliding sign [9], being a marker for the presence
tions. In clinical follow-up, it is important to use of adhesions caused by endometriosis, infection,
the same methodology. For myometrial lesions, or cancer. For the assessment of the sliding sign,
the measurement of the uterine corpus is the the examiner applies some gentle pressure on the
most relevant. The topographic zone between the uterus with the vaginal probe and uses his/her
corpus and the cervix is the isthmus and is often freehand push on the patient’s lower abdomen
44 T. Van den Bosch
(Fig. 4.16). It is important to ask the patient if she ultrasound images of the JZ [11] (Fig. 4.17). If
experiences some discomfort or pain during the the endometrium is not clearly visible, the junc-
scanning. Site-specific tenderness [10] when tional zone cannot be evaluated neither. In those
applying some pressure on the uterus may be cases, fluid instillation may be helpful.
caused by, e.g., adenomyosis or infection. To detect vessels of lower velocity, the pulse
It is not always easy to identify the JZ on rate frequency (PRF) should be set low enough
ultrasound examination. The use of volume con- (e.g., 0.3). In most cases, the arcuate and the radial
trast imaging (VCI) set at 2 mm after 3D volume vessels are visible, providing an appropriate set-
acquisition has been reported to yield the best ting (Fig. 4.18). However, the vessels in the myo-
metrial wall nearest to the ultrasound probe are
more readily detectable than in the opposite wall.
An apparent asymmetrical vascularity between
anterior and posterior myometrium is mostly due
to a difference in focal depth and acoustic attenua-
tion. Transient myometrial contractions may cause
a temporary disappearance of the blood flow [12].
Arcuate artery
Radial arteries
Fig. 4.16 Examining the sliding sign (From Guerriero
et al. [9]) Fig. 4.18 Vascularization of the uterus
Fig. 4.17 Ultrasound image of adenomyosis using VCI and TUI: irregular junctional zone
4.4 Future Perspectives on fibroid morcellation: a literature review. Gynecol

Surg. 2015;12:3–15.
5. Exacoustos C, Romanini ME, Amadio A, Amoroso
Future studies will address the value of ultraso- C, Szabolcs B, Zupi E, Arduini D. Can gray-scale
nography and color Doppler imaging in the pre- and color Doppler sonography differentiate between
diction of fibroid growth. Ultrasonography may uterine leiomyosarcoma and leiomyoma? J Clin
Ultrasound. 2007;35:449–57.
prove to be a key examination in the management 6. Munro MG, Critchley HO, Broder MS, Fraser
of fibroids and in the choice between expectant IS. FIGO classification system (PALM-COEIN) for
management, medical therapy, ablation, and causes of abnormal uterine bleeding in nongravid
selective embolization. women of reproductive age. Int J Gynaecol Obstet.
2011;113:3–13.
A better understanding of the association 7. Naftalin J, Hoo W, Nunes N, Mavrelos D, Nicks
between adenomyosis and pain or bleeding H, Jurkovic D. Inter- and intraobserver variability
symptoms as well as the role of adenomyosis in in three-dimensional ultrasound assessment of the
infertility and adverse obstetrical outcome should endometrial-myometrial junction and factors affect-
ing its visualization. Ultrasound Obstet Gynecol.
be addressed in future research. The exact corre- 2012;39:587–91.
lation between ultrasonographic features and his- 8. Naftalin J, Jurkovic D. The endometrial-myometrial
tological findings [13] also deserves more junction: a fresh look at a busy crossing. Ultrasound
attention. These issues should be solved before Obstet Gynecol. 2009;34:1–11.
9. Guerriero S, Condous G, van den Bosch T, Valentin L,
deciding on the place—if any—of surgery in the Leone FP, Van Schoubroeck D, Exacoustos C, Installé
management of adenomyosis [14]. AJ, Martins WP, Abrao MS, Hudelist G, Bazot M,
Finally, a better understanding of ultrasonog- Alcazar JL, Gonçalves MO, Pascual MA, Ajossa S,
raphy in the detection and—more importantly— Savelli L, Dunham R, Reid S, Menakaya U, Bourne
T, Ferrero S, Leon M, Bignardi T, Holland T, Jurkovic
in the exclusion of sarcomas is a crucial challenge. D, Benacerraf B, Osuga Y, Somigliana E, Timmerman
To date, there is no evidence whatsoever for any D. Systematic approach to sonographic evaluation
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lence and the absence of pathognomonic features sis, including terms, definitions and measurements:
a consensus opinion from the International Deep
(Van den [15]). Endometriosis Analysis (IDEA) group. Ultrasound
Obstet Gynecol. 2016;48:318–32.
10. Okaro E, Condous G, Khalid A, Timmerman D, Ameye
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Ovarian Endometriosis
5
Juan Luis Alcázar
5.1 Introduction Ovarian endometrioma usually appears in

women during the third and fourth decade of life.
Ovarian endometriosis is a common form of endo- Many of them are asymptomatic. When symp-
metriosis. Typically, on ultrasound, it appears as a toms occur, the most frequent are pelvic pain,
cystic lesion with “ground-glass” echogenicity with dysmenorrhea, and dyspareunia. It should be
no papillary projection or solid areas. This cystic noted that the finding an ovarian endometrioma
lesion is also known as an ovarian endometrioma or is associated to deep endometriosis (DE) in up
“chocolate cyst” due to the cyst’s content. to 23% of the cases [6]. Therefore, all patients
Ovarian endometriosis occurs in about with ovarian endometrioma should be thoroughly
17–44% of women affected by endometriosis scanned searching other lesions of DE.
[1]. In a large series of surgically removed ovar- The risk of malignant transformation of an
ian lesions, endometrioma constituted 21–33% ovarian endometrioma has been estimated as
of all benign masses [2, 3]. The left ovary is more 0.6–0.8% of the cases [7].
frequently affected than the right one but bilater- Asymptomatic ovarian endometrioma may
ally is found in 30–50% of the cases [4]. be managed expectantly with serial ultrasound
The pathogenesis of ovarian endometrioma is a scans [8]. However, symptomatic endometrioma
source of controversy. Three different theories have should be treated. Laparoscopic cystectomy is
been proposed for explaining the formation of ovar- considered as the first-line treatment [9]. Fine-
ian endometrioma: (1) the invagination of the ovar- needle aspiration and sclerotherapy may be
ian cortex affected by active superficial implants an option [9]. More radical treatment such as
on the ovarian surface, (2) the endometriotic trans- oophorectomy or adnexectomy may be consid-
formation of ovarian functional cysts, and (3) the ered for women with completed families [9].
metaplastic potential of pelvic mesotelium [5]. Medical treatment is not an effective cure for
ovarian endometriosis but might be used to relief
Electronic Supplementary Material The online version symptoms [9].
of this chapter (https://doi.org/10.1007/978-3-319-71138- In this overview, we shall review the sono-
6_5) contains supplementary material, which is available graphic spectrum of ovarian endometriomas. We
to authorized users.
also shall discuss the diagnostic performance of
J. L. Alcázar ultrasound for the specific diagnosis of this kind
Department of Obstetrics and Gynecology, Clinica of ovarian lesion, as well as the role of adjuvant
Universidad de Navarra, University of Navarra,
Pamplona, Spain ultrasound techniques such as Doppler and three-
e-mail: jlalcazar@unav.es dimensional ultrasound.

https://doi.org/10.1007/978-3-319-71138-6_5
48 J. L. Alcázar
5.2 How We Do It homogeneous echogenic content, representing the

blood within the cystic cavity, and is commonly
5.2.1 Technique termed “ground-glass” echogenicity [10, 11]. The
cyst is clearly demarcated from the surrounding
Transvaginal ultrasound (TVS) is the optimal ovarian parenchyma and usually does not exhibit
approach for assessing the ovary and the endo- any papillary projection or solid area (Fig. 5.1).
metrium. In cases where TVS cannot be per- Mean lesion size is about 5 cm, but it may vary
formed, transrectal ultrasound is a very good from 0.5 cm up to 15 cm (Figs. 5.2 and 5.3).
alternative as it provides quite similar images to Although this typical appearance has been
TVS. Transabdominal ultrasound may be also an reported in 73–82% of endometriomas, the sono-
option; however, the resolution of the ultrasound graphic spectrum is wide [12, 13]. Ovarian endo-
image is worse. metrioma may appear as unilocular anechoic cyst
TVS does not require any specific prepara- (5% of the cases) (Fig. 5.4), as a cyst with hemor-
tion by the patient before the procedure is done. rhagic content (2% of the cases) (Fig. 5.5) or as
Mandatory cleaning of the transvaginal probe by an unilocular cyst with homogeneous low-level
an acceptable disinfectant technique prior to its echoes, but not “ground glass” (6% of the cases)
use in a new patient and placement of a condom (Fig. 5.6). Thus, the main differential diagnoses
or ultrasound sheath for covering the ultrasound are simple or serous cyst, hemorrhagic cyst, or
probe is essential. unilocular mucinous cyst.
For transrectal ultrasound, rectal cleansing is Multilocularity has been reported in 18–24%
recommended before ultrasound is performed, of endometriomas [13, 14] (Fig. 5.7). However,
and the same measures for probe covering than very probably endometriomas are not septate
TVS are mandatory. lesions but single lesions one adjacent to other.
For transabdominal ultrasound, full bladder is A clue for this is what I call the “lambda sing” in
required. reportedly multilocular cystic lesions; a similar
After inserting the endovaginal probe into finding to that observed in dichorionic-diamni-
the vagina, a thorough scanning of the pelvis is otic twin pregnancies (Alcazar, personal com-
always advised including the uterus and ovaries munication) (Fig. 5.8). As a matter of fact in
(see Chap. 3), for ruling out the presence of any some women, multiple endometriomas can be
uterine or adnexal pathology, such as congenital observed in the same ovary (Fig. 5.9).
uterine anomalies, fibroids, adenomyosis (see
Chap. 4), or adnexal masses. For assessing ovar-
ian endometrioma, special attention must be paid
to the adnexal regions in order to identify any
cystic lesion.
If a cystic lesion is found, then we must try
to identify whether the lesion is derived from
the ovary itself or from other areas (uterus,
para-ovarian or paratubal regions, or even from
another pelvic organ such as the bladder, rectum,
or sigmoid).
5.2.2 Spectrum of Sonographic

Findings
Fig. 5.1 Typical appearance of an ovarian endometri-
The typical ultrasound appearance of an ovarian oma: unilocular cyst with ground-glass echogenicity and
endometrioma is a cystic lesion with low-level no papillary projections
5 Ovarian Endometriosis 49
Fig. 5.5 An ovarian endometrioma showing some echo-

Fig. 5.2 Typical endometrioma with a clear demarcation genic bands within the cyst cavity mimicking hemor-
of ovarian parenchyma (echogenic capsule surrounding rhagic echogenicity
the cyst)
Fig. 5.3 Small ovarian endometrioma with hyperecho- Fig. 5.6 Two ovarian endometriomas with low-level
genic foci located close to ovarian surface echogenicity, but not a ground-glass appearance
Fig. 5.7 Transvaginal ultrasound showing a “multilocu-

lar” endometrioma. Actually, this finding used to be sev-
Fig. 5.4 Transvaginal ultrasound depicting an ovarian
eral endometriomas one adjacent to each other
endometrioma as an anechoic cyst, some debris can be
seen in the bottom of the cyst cavity
50 J. L. Alcázar
Fig. 5.8 Transvaginal ultrasound showing a “septate” Fig. 5.10 Transvaginal ultrasound showing an atypical
endometrioma. In fact, this is two different endometrio- endometrioma containing a solid area (S) arising from
mas (E) separated by ovarian parenchyma (S). Arrows internal surface of cyst’s wall
show the so-called “lambda sign”
Fig. 5.9 Transvaginal ultrasound showing an ovary con-

taining multiple small endometriomas (E)
Fig. 5.11 Transvaginal ultrasound showing an ovarian

In some cases, endometriomas may show endometrioma with apparent solid echogenicity
atypical features, the so-called atypical endo-
metriomas. Usually, this term is used in endo-
metriomas that exhibit solid areas or papillary
projections [10, 11] (Fig. 5.10). In one of the
largest series of sonographic findings in ovarian
endometriomas, this feature has been reported in
15% of all ovarian endometriomas [13]. A purely
solid appearance of ovarian endometriomas is a
rare finding (<1% of the cases) (Fig. 5.11).
The presence of small hyperechoic foci in the
cyst wall has been reported as a very specific sign
for ovarian endometrioma (Fig. 5.12). They may
appear in about one third of these lesions [15].
However, some authors have challenged this idea
and consider that small hyperechoic foci are not a Fig. 5.12 Ovarian endometrioma showing hyperecho-
reliable indicator of endometrioma [16]. genic foci (arrows)
Another very specific feature proposed for A recent study has shown that ultrasound fea-
ovarian endometrioma is the so-called acoustic tures of ovarian endometriomas change with the
streaming. Acoustic streaming is defined as the patient’s age [21]. For example, ground-glass
bulk movement of fluid due to the effect of a echogenicity appears in 75% of endometriomas
sound field caused by energy transfer from an in premenopausal women but only in 62% of
ultrasound beam to the fluid. In other words, endometriomas in peri-/postmenopausal women.
the energy of the ultrasound beam “pushes” the Anechoic cysts are uncommon in premenopausal
particles of the fluid away from the transducer women (3%) but may appear in up to 11% of
(Video 5.1). Clarke et al. supported the concept peri-/postmenopausal women.
that ovarian endometrioma never show acous- There are two clinical entities that deserve partic-
tic streaming [17]. However, a subsequent ular mention: decidualization of an e ndometrioma
study in a much large series demonstrated that and ovarian cancer arising from an endometrioma.
acoustic streaming occurs in 9% of endome- Endometrioma decidualization is a phenomenon
triomas, and, therefore, this feature cannot be characterized by the thickening of the ectopic endo-
considered as 100% specific for ovarian endometrium due to the effect of progesterone during
metrioma [18]. pregnancy. When decidualization occurs, endome-
The inherent dynamic nature of ultrasound triomas may mimic an ovarian cancer during ultra-
evaluation allows the evaluation of two additional sound evaluation. Typical findings are the presence
signs [1]. The assessment of ovarian cyst mobil- of one to several vascularized solid papillary projec-
ity is important. The lack of mobility is due to tions arising from the internal surface of the cyst’s
the formation of adhesions to the uterus, to the wall [22, 23] (Video 5.4). The knowledge of past
pelvic wall, or to the contralateral ovary, the so- history of endometriosis observing the “suspicious”
called kissing ovaries (Fig. 5.13). The presence lesion in the same ovary where endometrioma had
of ovarian adhesion to the uterus, pelvic wall, or been diagnosed prior to pregnancy may give clues
contralateral ovary is highly predictive of ovar- for considering decidualization. Another important
ian endometrioma [19] (Video 5.2), but it is not tip is paying attention to the surface of the papillary
always present (Video 5.3) [2]. The presence of projection. In decidualized endometriomas surface
site-specific tenderness (see Chap. 3) when mov- uses to be smooth [22], whereas in malignancy
ing the ultrasound probe against particular struc- surface uses to be irregular. Serial evaluation dur-
tures is also very suggestive of endometriosis [20]. ing pregnancy can be advised in cases of suspected
decidualized endometriomas [24].
Although there is a clear association between
endometriosis and ovarian cancer [25], the risk of
developing a malignancy from ovarian endome-
trioma is low [7]. Testa et al. reported a retrospec-
tive study comprising 15 malignancies arising
from ovarian endometrioma [26]. They found
that all malignancies were characterized by the
presence of solid tissue, as compared to 16% of
benign endometriomas. Blood flow within the
solid component was observed in 92% of malig-
nancies and only in 8% of benign endometriomas
with solid areas. Both mean size of the lesion and
mean size of the solid areas were significantly
Fig. 5.13 Transvaginal ultrasound showing the two ova-
larger in malignancies. Figure 5.14 shows a case
ries containing several ovarian endometriomas (E) and
adhered one to each other (A), the so-called kissing of ovarian malignancy arising from an ovarian
ovaries endometrioma.
52 J. L. Alcázar
One study has evaluated the agreement among

expert examiners for the diagnosis of ovarian endo-
metrioma [28]. This study showed that intra-observer
and interobserver reproducibility were high.
5.2.4 Role of Doppler Ultrasound
The use of pulsed Doppler ultrasound was advo-

cated in the 1990s for discriminating ovarian
endometriomas from other benign ovarian
lesions. However, the results of those studies
were controversial [14, 29]. Guerriero and col-
Fig. 5.14 Transvaginal sonography depicting a unilocu- leagues found that the addition of power Doppler
lar cyst with irregular walls. Histopathology revealed an
endometrioid carcinoma arising from an endometrioma mapping to conventional grayscale findings
would increase the diagnostic performance of
ultrasound [30]. However, these findings have not
5.2.3 Diagnostic Performance been confirmed in other studies.
of Ultrasound for the Specific Alcazar and co-workers found in a retrospec-
Diagnosis of Ovarian tive study that endometrioma vascularization
Endometriosis was related to the presence of pain the women
with ovarian endometrioma [31], supporting the
Several studies have evaluated the diagnostic per- concept that neoangiogenesis is related to pain
formance of TVS for the specific diagnosis of symptoms in women with endometriosis. This
ovarian endometrioma. Moore et al. performed a was confirmed in a subsequent prospective study
systematic review in which sensitivity ranged by the same group [32]. In this study, the authors
from 64 to 89%, whereas specificity ranged from found that there was a significant correlation
89 to 100% [27]. However, most of studies between microvascular density in endometriomas’
included in this review were small series. capsule and the amount of power Doppler signals
Sokalska et al. reported results of a prospec- surrounding the endometriomas. Additionally,
tive study assessing the diagnostic performance both power Doppler and microvascular density
of TVS for the specific diagnosis of different were correlated to the severity of pain symptoms
types of ovarian lesions in 1066 women (199 complained by the patients. However, Seckin
endometriomas) [2]. They reported a sensitivity et al. did not find a relationship of color Doppler
and specificity of 77% and 98%, respectively, for mapping and pain symptoms [33]. These con-
ovarian endometrioma. troversial results could be explained by different
Alcazar et al. performed a similar study com- patient selection and because of different Doppler
prising 2148 women (558 endometriomas) and settings used. Because of these controversial
reported a sensitivity and specificity of 88% and results, the use of Doppler ultrasound should not
97%, respectively [3]. However, these authors be recommended as routine in clinical practice for
analyzed the diagnostic performance in pre- assessing ovarian endometrioma.
menopausal and postmenopausal women. They
found that specificity was similar (96% and 99%,
respectively), but sensitivity was lower in post- 5.2.5 he Role of Three-
T
menopausal women as compared with premeno- Dimensional (3D) Ultrasound
pausal women (68% and 89%, respectively). This
could be explained by the findings of Guerriero’s Few studies have assessed the role of 3D ultra-
study above cited [21]. sound in the evaluation of ovarian endometrioma.
Alcazar et al. evaluated the use of the so-called 5.3 Important Technical Tips
mean gray value (MGV) of the cyst’s content for
discriminating endometrioma from other benign There are several important technical tips to be
unilocular cysts [34]. MGV represents the mean considered when evaluating the ovary and ovarian
intensity of grayscale voxels contained in a given endometriomas. These technical tips are basically
3D region of interest and can be calculated using related to the ultrasound machine settings and
the virtual organ computer-aided analysis depth. The objective of the examination from the
(VOCAL™) software (Fig. 5.15); the more technical point of view is trying to get the maxi-
anechoic the content, the lower MGV, and the mum possible resolution. This is the main reason
more echogenic content, the higher MGV. They why TVS should be performed whenever possi-
found that MGV in endometriomas was signifi- ble, and the use of transrectal ultrasound is the
cantly higher as compared with other cysts (sim- best alternative when TVS cannot be performed.
ple cysts, hemorrhagic cysts, and mucinous cysts).
However, Huang et al. found the opposite
findings; MGV was significantly lower in ovarian 5.3.1 Depth
endometrioma [35]. These controversial results
can be explained by two facts: first, Huang’s The distance between the transducer and any
study included dermoid cysts, which tend to structure under examination is a very relevant
show highly echogenic areas. Second, MGV is issue, especially if Doppler is used, since Doppler
highly affected by some machine settings (espe- signal is heavily affected by attenuation. If the
cially gain), so different machine settings used ovary and/or uterus are far from the transducer
render different MGV values. Due to the paucity (>5 cm), gentle pressure with the hand over the
of studies and their controversial results, it could abdomen while performing the ultrasound exam-
be stated that the role of 3D ultrasound still needs ination may get these structures closer to the
to be determined. transducer favoring image resolution.
Fig. 5.15 Three-dimensional ultrasound showing mean gray value calculation from the cyst content in a case of ovar-
ian endometrioma
54 J. L. Alcázar
5.3.2 Machine Settings 5.4 Future Perspectives
Ultrasound machine settings are also important Several areas in the ultrasound evaluation and
for achieving a good resolution image. The trans- follow-up of endometriomas should be evaluated
ducer’s frequency is the most important machine in the future research studies. These include:
setting. It should not be less than 5 MHz and even
higher frequency (8–9 MHz) is advisable. If 1. Assessment of diagnostic performance of
Doppler is used, 5 MHz is an optimal frequency. ultrasound in hands of non-expert examiners.
Gain is another important ultrasound machine 2. Assessment of reproducibility on ultrasound
setting to be considered, especially for grayscale diagnosis of ovarian endometrioma among
ultrasound. Gain significantly affects the echo- non-expert examiners.
genicity of the structures. Thus, using adequate 3. Define the role of 3D ultrasound.
gain is essential for avoiding confusion between 4. Long-term prospective studies based on
different cyst’s content echogenicity. For gray- expectant management for determining the
scale evaluation, mid gain is initially advisable, risk of developing ovarian cancer from ovar-
increasing or lowering it until good quality image ian endometrioma.
is obtained. Very low gain may render an endo- 5. Prospective studies to determine if expectant
metrioma as an anechoic cyst, whereas high gain management of decidualized endometriomas
may render it as an echogenic cyst, both resulting during pregnancy is safe and what criteria
in potential to miss ground-glass echogenicity. should be used for advising expectant
For color/power Doppler assessment, it is rec- management.
ommended to increase gain until saturation and
then reduce gain reaching sub-noise gain level.
Harmonics increases image resolution, but References
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Melis GB. Diagnosis of pelvic adhesions in patients 33. Seckin B, Oruc AS, Turkcapar F, Ugur M. The rela-
with endometrioma: the role of transvaginal ultraso- tion of pelvic pain and dense adhesions to Doppler
nography. Fertil Steril. 2010;94:742–6. ultrasound findings in patients with ovarian endome-
20. Guerriero S, Ajossa S, Gerada M, Virgilio B, Angioni triomas. Arch Gynecol Obstet. 2013;287:723–8.
S, Melis GB. Diagnostic value of transvaginal ‘ten- 34. Alcázar JL, León M, Galván R, Guerriero
derness-guided’ ultrasonography for the prediction S. Assessment of cyst content using mean gray value
of location of deep endometriosis. Hum Reprod. for discriminating endometrioma from other unilocu-
2008;23:2452–7. lar cysts in premenopausal women. Ultrasound Obstet
21. Guerriero S, Van Calster B, Somigliana E, Ajossa S, Gynecol. 2010;35:228–32.
Froyman W, De Cock B, Coosemans A, Fischerová 35. Huang CY, Wang HI, Wang PH, Wu YC, Yang MJ, Chen
D, Van Holsbeke C, Alcazar JL, Testa AC, Valentin LH, Chao KC, Chen CY. Mean grey value is lower in
L, Bourne T, Timmerman D. Age-related differences endometriomas: differentiating a hypoechogenic adnexal
in the sonographic characteristics of endometriomas. cyst by 3-dimensional power Doppler ultrasound--a pre-
Hum Reprod. 2016;31:1723–31. liminary study. J Chin Med Assoc. 2011;74:75–80.
Soft Marker Evaluation
6
Shannon Reid
6.1 Update on Soft Markers [2, 3]. The most common sites for ovarian adhe-
sions to form are with the neighbouring uterus
Transvaginal sonography (TVS) soft markers for (Fig. 6.1) or pelvic sidewall; however, the
endometriosis include ovarian immobility and bowel and uterosacral ligaments (USL) can
site-specific tenderness (SST). In the recently also be involved. Okaro et al. found that preop-
published consensus statement entitled erative TVS ‘soft markers’ (i.e. site-specific
‘Systematic approach to sonographic evaluation tenderness, reduced ovarian mobility) and ‘hard
of the pelvis in women with suspected endome- markers’ (i.e. endometrioma, hydrosalpinx) in
triosis, including terms, definitions and measure- women with a history of CPP correlated with
ments: a consensus opinion from the International the presence or absence of disease at laparos-
Deep Endometriosis Analysis (IDEA)’, the eval- copy [4]. Pre-operative TVS and transrectal
uation of soft markers is recommended as a com- ultrasound have also been used to predict endo-
ponent of the ultrasound evaluation of women metriosis stage (including pelvic adhesions) at
with suspected pelvic deep endometriosis (DE)
[1].
6.2 Ovarian Mobility
The relationship between ovarian immobility at

TVS and the presence of peri-ovarian adhesions
at laparoscopy has been demonstrated in women
investigated for symptoms such as chronic pel-
vic pain (CPP), infertility, and/or endometriosis

6_6) contains supplementary material, which is available
Fig. 6.1 Transvaginal sonography (TVS) image in the
sagittal plane, displaying the left ovary fixed to the poste-
rior uterine fundus; the white arrows indicate the adhesion
S. Reid site. The ovarian sliding sign was negative in this region
Department of Obstetrics and Gynaecology, during the TVS assessment, i.e. the left ovary did not glide
Liverpool Hospital, Sydney, NSW, Australia smoothly across the posterior uterine fundus

https://doi.org/10.1007/978-3-319-71138-6_6
58 S. Reid
laparoscopy, with a sensitivity and specificity of indicating a high false-positive rate [9]. This
86% and 82%, respectively, for Stage III and 76% study did not find SST was predictive of superfi-
and 91%, respectively, for Stage IV disease [5]. cial endometriosis location.
In a recent study by Marasinghe et al., the With regard to posterior compartment DE,
combination of ovarian immobility and clinical some studies have found that tenderness-guided
findings (i.e. dyspareunia, dysmenorrhea and vag- TVS may aid in the prediction of specific locations
inal examination) was able to demonstrate a sen- of posterior compartment DE [10, 11]. A recent
sitivity/specificity of 92%/61% for the detection study from our group showed that TV probe ten-
of endometriosis at laparoscopy [6]. More specifi- derness in the posterior pelvic compartment (left
cally, ovarian immobility at TVS is strongly asso- USL, POD and right USL) was significantly asso-
ciated with the presence of endometrioma [2, 7] ciated with both deep and superficial endometrio-
and POD obliteration [8]. The identification of ses in the posterior pelvic compartment (p < 0.05)
ovarian immobility at TVS may improve our abil- [12]. SST appears to be a useful soft marker for the
ity to stage endometriosis severity preoperatively, prediction of the presence/absence of endometrio-
allowing for improved surgical planning. sis at laparoscopy [4, 9] and should be included in
The diagnostic accuracy of ovarian immobility the sonographic evaluation of the pelvis in women
at TVS has been reported in previous studies, usu- with suspected endometriosis [1].
ally in the presence of endometriomas. In a study
by Guerriero et al., women undergoing surgery for
endometrioma were assessed for ovarian mobility 6.4 How We Do It
in relation to the uterus. The sensitivity and speci-
ficity of the fixation to the uterus of at least one 6.4.1 Assessment of Ovarian
ovary were, respectively, 89% and 90% [2]. Mobility
Holland et al. also evaluated TVS accuracy for
ovarian adhesions in women with proven/sus- In order to assess for ovarian mobility, the exam-
pected endometriosis by classifying adhesions as iner places gentle pressure with TV probe toward
minimal, moderate or severe in accordance with the ovary of interest in order to mobilize the
the rASRM classification. For severe ovarian ovary. The examiner assesses whether the ovary
adhesions, the sensitivity and specificity of TVS glides freely along (1) the corresponding pelvic
was 83.5% and 93.5%, respectively. In another sidewall and (2) the neighbouring uterine sur-
study by our group, ovarian immobility was face. This is the same concept that is applied to
assessed as a sonographic ‘soft marker’ of DE and the assessment of the POD for obliteration using
was found to perform better in the presence of the uterine sliding sign, where a negative sliding
endometriomas compared with normal ovaries [7]. sign indicates adhesions are present causing lim-
ited mobility [13, 14]. Ovarian mobility is
assessed in both the sagittal and transverse planes
6.3 Site-Specific Tenderness for each location (i.e. pelvic sidewall and uterine
(SST) surface). If the ovary glides smoothly along the
surface of the uterus and pelvic sidewall, the
A relationship between SST at TVS and endome- ovarian sliding sign is considered positive and the
triosis at laparoscopy has also been demonstrated ovary is recorded as mobile in these regions.
in previous studies. In a study that evaluated ten- Video 6.1 displays a mobile right ovary (positive
derness during a combination of vaginal and TVS ovarian sliding sign) along the right pelvic side-
examination, Yong et al. found that SST may be wall, in the transverse plane. Video 6.2 displays
helpful in predicting abnormal laparoscopy and ovarian mobility along the lateral uterus (positive
the presence of superficial endometriosis; how- ovarian sliding sign), as well as the pelvic side-
ever, the specificity of this study was low (22%), wall, in the transverse plane.
6 Soft Marker Evaluation 59
Fig. 6.2 A transvaginal sonography image in the sagittal

plane demonstrating the location of the right ovary in rela-
tion to the right external iliac vein
Fig. 6.3 A transvaginal sonography (TVS) image (in the
sagittal plane) demonstrating an anteverted, retroflexed
uterus (U). The rectosigmoid bowel (RS) is adherent pos-
When assessing ovarian mobility along the teriorly to the uterine fundus (indicated by <), causing
pelvic sidewall, colour Doppler may be used to POD obliteration. The ovary (O) is adherent posteriorly to
the uterine fundus and to the rectosigmoid bowel (indi-
visualize the external iliac vessels and to con- cated by asterisk)
firm the location of the pelvic sidewall in rela-
tion to the corresponding ovary (Fig. 6.2). By
directing pressure in the region of the ovary Figure 6.3 demonstrates adhesions between the
with the TV probe, a mobile ovary will glide ovary and posterior uterus, as well as the rectosig-
freely along the external iliac vessels. If the moid bowel.
ovary is not well mobilized with the pressure
from the TV probe alone, the examiner can
place gentle downward pressure with the left 6.4.2 Assessment of SST
hand (if the TV probe is being held in the right
hand) over the iliac fossa region of the lower The assessment of SST during the TVS examina-
anterior abdominal wall to mobilize the ovary. If tion involves the examiner placing gentle pres-
the ovary does not glide freely against the pelvic sure with the TV probe against each of the
sidewall, this indicates a negative ovarian slid- following six pelvic locations: anterior fornix,
ing sign, and the ovary is recorded as immobile right adnexa, left adnexa, right USL, left USL
or fixed in this region. Video 6.3 demonstrates and posterior vaginal fornix. A verbal numerical
ovarian fixation (negative sliding sign) at both rating scale (NRS) is often used to assess for
the posterior uterus and left pelvic sidewall, in SST. Women rate their pain score on a scale from
the sagittal plane. Video 6.4 demonstrates a neg- 0 (no pain) to 10 (worst pain imaginable) for each
ative ovarian sliding sign between the left ovary of the six locations.
and the posterior uterine cervix, in the sagittal
plane.
Whenever the ovarian sliding sign is negative, 6.4.3 Important Technical Tips
the examiner should then assess for the nature of
the adhesion limiting ovarian mobility. In addition 1. If the examiner is not able to mobilize the
to adhesions between the ovary and pelvic side- ovary with the TV probe alone, the left hand
wall/uterus, ovarian mobility can be limited by can be used to place downward pressure over
adhesions between the ovary and the contralateral the iliac fossa region to mobilize the ovary of
ovary, fallopian tube, USL, POD and/or bowel. interest.
60 S. Reid
2. The external iliac vessels can be used to help In a recent study by our group, ovarian mobility
orientate the examiner to the pelvic sidewall and SST were included in the evaluation of an
when assessing ovarian mobility in this region. ultrasound-based endometriosis staging system
The colour Doppler function is used to confirm (UBESS) for the prediction of level of complexity
the location of the external iliac vessels. of laparoscopic surgery for endometriosis. The
3. The ovaries can be difficult to locate in the accuracy, sensitivity, specificity and positive and
presence of complex endometriotic disease, as negative predictive values of UBESS I for predict-
the anatomy can be severely distorted. Try to ing a requirement for Level 1 laparoscopic surgery
be systematic in the assessment of each ovary, were 87.5%, 83.3%, 91.7%, 90.9% and 84.6%;
carefully identifying each structure that is those of UBESS II for predicting Level 2 surgery
adherent to the ovary. These difficult scans were 87.0%, 73.7%, 90.3%, 65.1% and 93.3%;
take more time to perform as several struc- and those of UBESS III for predicting Level 3 sur-
tures may be involved, particularly in the pres- gery were 95.3%, 94.8%, 95.5%, 90.2% and
ence of endometriomas. 97.7%, respectively. This study demonstrated that
4. The addition of ultrasound gel (15–20 ml) in UBESS has the potential to facilitate the triage of
the posterior vaginal fornix (i.e. sonovaginog- women with suspected endometriosis to the most
raphy) may improve the view of the structures appropriate surgical expertise required for laparo-
in the posterior pelvic compartment, thereby scopic endometriosis surgery [12]. External vali-
helping the examiner to identify structures dation of UBESS is currently being performed to
that are associated with ovarian adhesions. determine the applicability of this system for plan-
ning laparoscopic endometriosis surgery.
6.4.4 Future Directions

References
The incorporation of soft markers such as ovarian
mobility and SST into a standardized TVS assess- 1. Guerriero S, Condous G, Van den Bosch T, Valentin L,
ment for women with pelvic pain may allow for Leone F, Van Schoubroeck D, Exacoustos C, Installé
improved surgical planning and counselling for AJF, Martins WP, Abrao MS, Hudelist G, Bazot M,
Alcazar J, Gonçalves MO, Pascual MA, Ajossa S,
these women. Further studies are required to Savelli L, Dunham R, Reid S, Menakaya U, Bourne T,
evaluate the usefulness of soft markers for the Ferrero S, Leon M, Bignardi T, Holland T, Jurkovic D,
prediction of endometriosis type and location. In Benacerraf B, Osuga Y, Somigliana E, Timmerman D.
particular, the use of soft markers to predict Systematic approach to evaluate the pelvis in women
with suspected endometriosis including terms, defini-
superficial endometriosis location could allow tions and measurements to describe the sonographic
for improved surgical planning for women under- features of deep infiltrating endometriosis: a consen-
going laparoscopy. This is particularly relevant sus opinion from the International Deep Endometriosis
for women with superficial pelvic sidewall dis- Analysis (IDEA) group. Ultrasound Obstet Gynecol.
2016;48(3):318–32. Epub 2016/06/28.
ease overlying the ureter, as ureterolysis is an 2. Guerriero S, Ajossa S, Garau N, Alcazar JL, Mais V,
advanced laparoscopic skill that is not typically Melis GB. Diagnosis of pelvic adhesions in patients
performed by general gynaecologists. If the pre- with endometrioma: the role of transvaginal ultra-
diction of pelvic sidewall disease at laparoscopy sonography. Fertil Steril. 2010;94(2):742–6. Epub
2009/04/17
could be improved using preoperative TVS soft 3. Guerriero S, Ajossa S, Lai MP, Mais V, Paoletti
markers, then these women could be referred to AM, Melis GB. Transvaginal ultrasonography in
an advanced laparoscopic surgeon from the out- the diagnosis of pelvic adhesions. Hum Reprod.
set. This may negate the need for two laparosco- 1997;12(12):2649–53. Epub 1998/02/10
4. Okaro E, Condous G, Khalid A, Timmerman D,
pies, one by a generalist who is unable to excise Ameye L, Huffel SV, et al. The use of ultrasound-based
the disease and followed by a second laparoscopy ‘soft markers’ for the prediction of pelvic pathology
by an advanced laparoscopic surgeon who is able in women with chronic pelvic pain--can we reduce the
to excise the disease. need for laparoscopy? BJOG. 2006;113(3):251–6.
6 Soft Marker Evaluation 61
5. Exacoustos C, Zupi E, Carusotti C, Rinaldo D, 10. Guerriero S, Ajossa S, Gerada M, D'Aquila M, Piras
Marconi D, Lanzi G, et al. Staging of pelvic endo- B, Melis GB. “Tenderness-guided” transvaginal ultra-
metriosis: role of sonographic appearance in sonography: a new method for the detection of deep
determining extension of disease and modulating endometriosis in patients with chronic pelvic pain.
surgical approach. J Am Assoc Gynecol Laparosc. Fertil Steril. 2007;88(5):1293–7.
2003;10(3):378–82. Epub 2003/10/22 11. Saba L, Guerriero S, Sulcis R, Pilloni M, Ajossa S,
6. Marasinghe JP, Senanayake H, Saravanabhava N, Melis G, et al. MRI and “tenderness guided” trans-
Arambepola C, Condous G, Greenwood P. History, vaginal ultrasonography in the diagnosis of recto-
pelvic examination findings and mobility of ova- sigmoid endometriosis. J Magn Reson Imaging.
ries as a sonographic marker to detect pelvic adhe- 2012;35(2):352–60. Epub 2011/10/29
sions with fixed ovaries. J Obstet Gynaecol Res. 12. Menakaya U, Reid S, Lu C, Gerges B, Infante F,
2014;40(3):785–90. Epub 2014/04/17 Condous G. Performance of an Ultrasound Based
7. Gerges BLC, Reid S, Menakaya U, Nadim B, Condous Endometriosis Staging System (UBESS) for pre-
G. “Soft marker” evaluation of ovarian mobility in the dicting the level of complexity of laparoscopic sur-
normal and endometriotic ovary. Ultrasound Obstet gery for endometriosis. Ultrasound Obstet Gynecol.
Gynecol. 2015. https://doi.org/10.1002/uog.15990. 2016;48(6):786–95. Epub 2016/01/15
8. Reid S, Lu C, Condous G. Can we improve the predic- 13. Holland TK, Yazbek J, Cutner A, Saridogan E, Hoo
tion of pouch of Douglas obliteration in women with WL, Jurkovic D. Value of transvaginal ultrasound in
suspected endometriosis using ultrasound-based mod- assessing severity of pelvic endometriosis. Ultrasound
els? A multicenter prospective observational study. Obstet Gynecol. 2010;36(2):241–8.
Acta Obstet Gynecol Scand. 2015;94(12):1297–306. 14. Reid S, Winder S, Reid G, Condous G. Can we pre-
Epub 2015/09/25 dict pouch of Douglas (POD) obliteration using a new
9. Yong PJ, Sutton C, Suen M, Williams C. Endovaginal real-time ultrasound technique: the “sliding sign”.
ultrasound-assisted pain mapping in endometrio- 21st World Congress on Ultrasound in Obstetrics and
sis and chronic pelvic pain. J Obstet Gynaecol. Gynecology. Los Angeles: Wiley-Blackwell; 2011.
2013;33(7):715–9. Epub 2013/10/17 p. 1–55.
Ultrasound in the Evaluation
of Pouch of Douglas Obliteration
7
Shannon Reid
7.1 Introduction rectum). In this case, a portion of the POD may

remain visible (i.e., contain normal peritoneum),
The pouch of Douglas (POD) is described as the and this situation is known as partial or unilateral
region of peritoneum which occupies the deepest POD obliteration.
part of the female pelvis and is located between Women with POD obliteration at laparoscopy
the lower posterior cervix and the anterior rec- have a threefold increased risk of rectal DE (and
tum. Complete POD obliteration is described the need for rectal surgery) compared to women
when this area of peritoneum between the poste- without POD obliteration at laparoscopy [1]. As
rior cervix and anterior rectum is no longer visi- with bowel DE, the surgical treatment of POD
ble due to adhesions or scarring in the POD. POD obliteration requires the skill of an advanced lap-
obliteration is most commonly associated with aroscopic surgeon and potential colorectal input
adhesions between the anterior rectum and poste- at the time of surgery. In addition to posterior
rior cervix and/or between the rectosigmoid compartment DE, ovarian endometrioma and
bowel and posterior uterine fundus. Figure 7.1 ovarian immobility at TVS are also significantly
displays examples of POD obliteration due to associated POD obliteration at laparoscopy [2].
rectal/rectosigmoid deep endometriosis (DE) Studies have demonstrated that POD oblitera-
adhesions to the posterior cervix/uterine fundus. tion can be detected preoperatively with a sev-
These adhesions in the POD are often caused by eral imaging techniques, including transvaginal
an underlying DE nodule, but may also be caused sonography (TVS), computed tomography, and
by scarring in the POD from pelvic inflammatory magnetic resonance imaging (MRI). A recent
disease, previous surgery, or extensive ovarian/ systematic review and meta-analysis assessed
peritoneal endometriosis. Adhesions may also the accuracy of various imaging techniques for
form unilaterally in the POD, between a structure POD obliteration and found the sensitivity/spec-
containing a DE nodule and adjacent structure(s) ificity for TVS and MRI to be 87%/96% and
(i.e., uterosacral ligament (USL) and anterior 84%/93%, respectively [3]. During TVS, the
POD is assessed for obliteration/utero-rectal
Electronic Supplementary Material The online version adhesions using the uterine “sliding sign” tech-
of this chapter (https://doi.org/10.1007/978-3-319-71138- nique [4]. TVS is recommended as the first-line
imaging technique for POD obliteration due to
its high accuracy, low cost, and minimal patient
S. Reid discomfort.
Department of Obstetrics and Gynaecology,
Liverpool Hospital, Sydney, NSW, Australia

https://doi.org/10.1007/978-3-319-71138-6_7
64 S. Reid
a b
c d
Fig. 7.1 Examples of complete POD obliteration at trans- level of the posterior cervix to the posterior uterine fundus.
vaginal ultrasound (sagittal plane). (a) The anterior rectum (c) The anterior rectum contains a DE nodule (N) that infil-
contains a DE nodule (N) and is adherent posteriorly to the trates the posterior cervix (C) and rectovaginal septum
uterine cervix. (b) The anterior rectum/rectosigmoid bowel posteriorly. (d) The rectosigmoid bowel contains a DE
contains a DE nodule (N) that forms an adhesion from the nodule (N) that is adherent to the posterior uterine fundus
Given the strong relationship between POD The “sliding sign” has also been demon-
obliteration and ovarian endometrioma/posterior strated to have substantial to almost perfect
compartment DE, our group developed and vali- inter- and intra-observer agreement among
dated two mathematical TVS models to deter- sonologists/sonographers experienced in gyne-
mine whether a combination of TVS markers cological ultrasound [5] and is an easily learned
could improve the prediction of POD obliteration technique for those with previous experience in
as compared with the uterine “sliding sign” alone. gynecological ultrasound. Tammaa et al. deter-
These models included TVS findings such as mined the learning curve to be ~40 scans in
posterior compartment DE, ovarian fixation, and order to achieve competency in predicting POD
ovarian endometrioma, in addition to a negative obliteration using the uterine “sliding sign” [6].
uterine “sliding sign.” This study found that the Another study found similar results, with 38
incorporation of additional TVS markers did not scans required to reach competency for predic-
improve the prediction of POD obliteration as tion of POD obliteration using the “sliding
compared to the “sliding sign” alone [2]. sign” [7].
7 Ultrasound in the Evaluation of Pouch of Douglas Obliteration 65
7.2 How We Do It rectosigmoid bowel glides smoothly over the

anterior lower uterus, the “sliding sign” is con-
7.2.1 The Uterine “Sliding Sign” sidered positive in this region (Video 7.3b). If the
bowel does not glide smoothly in one or both of
In order to perform the uterine “sliding sign,” the these locations (i.e., negative “sliding sign”), the
transvaginal (TV) probe (held in the right hand) POD is deemed obliterated.
is inserted into the posterior vaginal fornix, and
gentle pressure is placed against the posterior
cervix with the probe. In a normal pelvis (i.e., no 7.2.2 Important Technical Tips
POD obliteration), this maneuver mobilizes the
posterior cervix, causing the anterior rectum to 1. Prior to performing the uterine “sliding sign”
glide smoothly along the posterior vaginal wall/ procedure, it is important to ascertain whether
posterior cervix; this is termed a positive “sliding the woman has a history of painful intercourse
sign” (Video 7.1a). Next, the examiner places the (dyspareunia). The “sliding sign” can be pain-
other hand (left hand) over the lower anterior ful for women with dyspareunia, and women
abdominal wall and gently places downward should be informed of the possibility of pain
pressure to ballot the uterine fundus. If the recto- from this procedure.
sigmoid bowel glides smoothly along the poste- 2. Before performing the “sliding sign,” ensure
rior uterine fundus, the “sliding sign” is that the anterior rectum/rectosigmoid bowel
considered positive for this region (Video 7.1b). are well visualized within the frame, as you
If the “sliding sign” is positive in both locations will need to assess their mobility in real time,
(i.e., posterior cervix and posterior uterine fun- in relation to the posterior cervix and uterine
dus), the POD is considered not obliterated. If the fundus.
“sliding sign” is negative in either location (i.e., 3. Partial (or unilateral) POD obliteration may
the anterior rectum does not glide smoothly occur. This is demonstrated at TVS when the
against the posterior cervix or the rectosigmoid anterior rectum/rectosigmoid glides smoothly
does not glide smoothly across the posterior uter- along the posterior cervix/uterus on one side
ine fundus), the POD is deemed obliterated. of the pelvis, but not the other. This finding
Video 7.2a demonstrates POD obliteration at the suggests adhesions exist between the bowel
level of the cervix, and Video 7.2b demonstrates and the corresponding uterosacral ligament,
POD obliteration at the level of the posterior uter- pararectal space, and/or lateral posterior
ine fundus. cervix.
The anatomical relationships are somewhat 4. A negative “sliding sign” carries a high risk
different for a retroverted uterus, and as such, the for associated posterior compartment DE. A
“sliding sign” technique is slightly modified. The thorough ultrasound assessment for DE
TV probe (held in the right hand) is inserted into lesions, especially for DE involving the rec-
the posterior vaginal fornix, and gentle pressure tum/rectosigmoid, should be performed if the
is placed against the posterior uterine fundus. If POD is obliterated at TVS.
the anterior rectum glides smoothly along the
posterior uterine fundus, the “sliding sign” is
considered positive (Video 7.3a). The examiner 7.3 Future Perspectives
then places their left hand on the lower anterior
abdominal wall to ballot the uterus to determine POD obliteration is associated with complex sur-
whether the rectosigmoid bowel glides smoothly gery that requires advanced laparoscopic skills,
along the anterior lower uterine segment. If the longer operating times, and the possible need for
66 S. Reid
colorectal input. Given the significant relation- niques to assess POD obliteration: a systematic
review and meta-analysis. In: Gynecol UO, editor.
ship between rectal DE and POD obliteration, a 26th World Congress on Ultrasound in Obstetrics
negative uterine “sliding sign” is an important and Gynaecology; September 2016; Rome. 2016.
red flag for the increased risk of bowel DE [8]. p. 165.
The ability to predict POD obliteration preopera- 4. Reid S, Lu C, Casikar I, Reid G, Abbott J, Cario G,
et al. Prediction of pouch of Douglas obliteration in
tively is therefore essential for appropriate women with suspected endometriosis using a new
specialist referral, surgical planning, and coun- real-time dynamic transvaginal ultrasound tech-
seling for these high-risk women. nique: the sliding sign. Ultrasound Obstet Gynecol.
As recommended in the recent consensus 2013;41(6):685–91. Epub 2012/09/25
5. Reid S, Lu C, Casikar I, Mein B, Magotti R, Ludlow
statement by the International Deep Endometriosis J, et al. The prediction of pouch of Douglas oblit-
Analysis group [9], women with pelvic pain/sus- eration using offline analysis of the transvaginal
pected endometriosis, should ideally undergo a ultrasound ‘sliding sign’ technique: inter- and intra-
standardized TVS examination for pelvic DE, observer reproducibility. Hum Reprod. 2013.; Epub
2013/03/14
including assessment for POD obliteration with 6. Tammaa A, Fritzer N, Strunk G, Krell A, Salzer H,
the uterine “sliding sign.” Although the “sliding Hudelist G. Learning curve for the detection of pouch
sign” has a high accuracy for the prediction of of Douglas obliteration and deep infiltrating endome-
POD obliteration and is an easily learned tech- triosis of the rectum. Hum Reprod. 2014;29(6):1199–
204. Epub 2014/04/30
nique, very few ultrasound centers currently per- 7. Piessens S, Healey M, Maher P, Tsaltas J, Rombauts
form an assessment for POD obliteration. Future L. Can anyone screen for deep infiltrating endometri-
gynecological ultrasound training programs will osis with transvaginal ultrasound? Aust N Z J Obstet
benefit from the integration of this important Gynaecol. 2014;54(5):462–8. Epub 2014/10/08
8. Hudelist G, Fritzer N, Staettner S, Tammaa A, Tinelli
technique into their curriculum for the ultrasound A, Sparic R, et al. Uterine sliding sign: a simple
assessment of women with suspected sonographic predictor for presence of deep infiltrat-
endometriosis. ing endometriosis of the rectum. Ultrasound Obstet
Gynecol. 2013;41(6):692–5. Epub 2013/02/13
9. Guerriero SCG, Van den Bosch T, Valentin L, Leone
F, Van Schoubroeck D, Exacoustos C, AJF I, Martins
References WP, Abrao MS, Hudelist G, Bazot M, Alcazar J,
Gonçalves MO, Pascual MA, Ajossa S, Savelli L,
1. Khong SY, Bignardi T, Luscombe G, Lam A. Is pouch Dunham R, Reid S, Menakaya U, Bourne T, Ferrero
of Douglas obliteration a marker of bowel endome- S, Leon M, Bignardi T, Holland T, Jurkovic D,
triosis? J Minim Invasive Gynecol. 2011;18(3):333–7. Benacerraf B, Osuga Y, Somigliana E, Timmerman
2. Reid S, Lu C, Condous G. Can we improve the predic- D. Systematic approach to evaluate the pelvis in
tion of pouch of Douglas obliteration in women with women with suspected endometriosis including
suspected endometriosis using ultrasound based mod- terms, definitions and measurements to describe the
els? A multicenter prospective observational study. sonographic features of deep infiltrating endometrio-
Acta Obstet Gynecol Scand. 2015;94(12):1297–306. sis: a consensus opinion from the International Deep
3. Shakeri B, Nadim B, Reid S, Martins WP Condous Endometriosis Analysis (IDEA) group. Ultrasound
G OP34.04: Accuracy of different imaging tech- Obstet Gynecol. 2016;48(3):318–32.
Anterior Compartment Including
Ureter
8
Luca Savelli and Maria Cristina Scifo
8.1 Introduction colon) or both [7]. The expression of urinary tract

endometriosis (UTE) is used to indicate anterior
Endometriosis is usually classified into three compartment endometriosis, but it comprises
main forms: ovarian, superficial, and deep endo- even the presence of endometriosis of the retro-
metriosis (DE). The latter is the most severe uterine portion of the ureter and the subsequent
type of endometriosis and is defined as the pres- involvement of the kidneys, organs which lie pos-
ence of endometrial glands and stroma infiltrat- terior (dorsal) to the level of the uterine corpus.
ing a depth of >5 mm beneath the peritoneum Notably, true bladder endometriosis is defined as
[1, 2]. Implants of endometriosis may be sup- the infiltration of the bladder muscularis propria
plied by the nerves and lymphatic and blood [8] by endometrial glands and stroma, which can
vessels and are surrounded by a variable amount reach even the bladder mucosa, thus excluding
of collagen fibers and elastin. Infiltration of the the superficial endometriosis of the peritoneal
urinary tract occurs in approximately 1–2% of layer covering the bladder dome. Overall, blad-
patients with endometriosis [3], but its preva- der involvement occurs in 70–85% of cases of
lence increases to 19–53% among patients with UTE, while ureteral involvement is found in
severe endometriosis, as for those with DE 25–30% of UTE cases [9].
[4–6]. The pathogenesis of UTE has not been clearly
DE can involve the anterior pelvic compart- explained; several proposed hypotheses include
ment (anatomical region anterior to the uterine migration, transplantation of endometrial glands
corpus) including bladder and ureters or the pos- and stroma, and the iatrogenic theory. It has been
terior pelvic compartment (uterosacral ligaments, even proposed that UTE can develop from the
torus uterinus, rectum, pouch of Douglas, sigmoid presence of remnants of the Mullerian ducts,
located in the vesicouterine space and vesico-
Electronic supplementary material The online version vaginal septum.
of this chapter (https://doi.org/10.1007/978-3-319-71138- Once considered a rare pathological condi-
6_8) contains supplementary material, which is available tion, bladder endometriosis is actually underdi-
to authorized users. agnosed due to nonspecific symptoms, often
mimicking recurrent cystitis such as dysuria,
L. Savelli (*) · M. C. Scifo
Gynecology and Early Pregnancy Ultrasound Unit, urgency, frequency, suprapubic pain, vesical
Department of Obstetrics and Gynecology, tenesmus, incontinence, and hematuria [2, 7].
S.Orsola-Malpighi Hospital, University of Bologna, These symptoms may worsen during menstrua-
Bologna, Italy tion, or may have a noncyclical presentation.
e-mail: luca.savelli@aosp.bo.it

https://doi.org/10.1007/978-3-319-71138-6_8
68 L. Savelli and M. C. Scifo
Moreover, a variable percentage of patients with

UTE are asymptomatic until a severe grade of
anatomical distortion of affected organs is
reached.
In particular ureteral endometriosis is more
often asymptomatic and can lead to loss of renal
function due top urinary flow obstruction [10]. In
most of the cases, the disease affects the pelvic
portion of the ureter [9], at the level of the cross
with the uterine artery. Commonly, two different
Fig. 8.2 Transabdominal scan of the cranial portion of
types of ureteral involvement are distinguished: the right ureter (same patient as in Fig. 8.1). Note the
extrinsic and intrinsic. The first is by far the most enlarged ureter (calipers) arising from the renal pelvis
common (80% of the patients) and is due to the
extension of a fibrotic reaction around a pelvic thorough evaluation of the kidneys anatomy in
DE nodule which narrows the ureter causing a patients with DE mandatory (Fig. 8.2). A high
variable degree of stricture, thus limiting the pas- index of suspicion and an accurate assessment of
sage of urine and eventually causing a dilated dis- the urinary tract are thus needed in patients with
tal ureteric segment. The intrinsic form represents known or suspected pelvic endometriosis in order
20% of the cases and is defined as the presence of to avoid the progression of the disease, planning
glands and endometrial stroma directly infiltrat- proper treatment, and eventually a complete sur-
ing the wall of the ureter: adventitia, muscularis gical excision [11]; delayed or incomplete diag-
propria, and intima may be infiltrated with subse- nosis can lead to increased morbidity and
quent anatomical and functional impairment. incorrect and inefficient treatment [7].
As stated, a common feature in anterior com-
partment endometriosis is the nonspecific symp-
toms often leading to an insidious onset and 8.2 How We Do It
progressive anatomical distortion of the affected
structures which can lead to severe hydronephro- 8.2.1 Urinary Bladder
sis (Fig. 8.1). Endometriosis
The percentage of patients with endometriosis
and a hydronephrosis is actually not known, but Endometrial lesions may involve every part of
its silent progression up to severe cases renders a the bladder; the most commonly affected por-
tions are the bladder base and the dome, while the
extra-abdominal bladder is rarely involved [12].
It has been proposed to divide the bladder into
four zones: (a) the trigone, a smooth triangular
region lying within 3 cm of the urethral opening
and laterally delimited by the two ureteral ori-
fices; (b) the bladder base, adjacent to the vagina
and the supravaginal cervix; (c) the bladder
dome, lying superior to the base; and (d) the
extra-abdominal bladder (Fig. 8.3).
Symptoms of bladder endometriosis depend
on the size and location of the nodule, the endo-
Fig. 8.1 Transabdominal scan of the right kidney stage II crine condition of the patient, and the effect of
hydronephrosis. Both renal pelvis and calices appear
anechoic. Sagittal scan shows obvious expansion of the
drugs assumed (such as contraceptive pills, pro-
renal pelvis (calipers) with no thinning of the renal gestins). As stated, one-third of patients remain
cortex asymptomatic or complain only minor complaints
8 Anterior Compartment Including Ureter 69
but its diagnostic accuracy does not outperform

that of TVS [17].
With any imaging modality, it is crucial to
determine the size of the nodule involving the
balder wall, the location, and the exact distance
between the nodule and the internal ureteral ori-
fices. In fact, the need for preoperative ureteral
stent positioning, the surgical skills, and the tech-
nique needed (e.g., ureteral reimplantation
requirement) depend on the sum of such informa-
tion, together with the degree of symptoms.
Fig. 8.3 Transvaginal longitudinal sonogram. By posi-
tioning the probe at the level of the anterior fornix, it is Bladder endometriotic nodules can be seen at
possible to visualize the entire bladder, moderately filled TVS as discrete solid hypoechoic lesions embed-
by urine. The urethra is easily identified, as a tubular sag- ded in the bladder wall, altering the profile of the
ittal structure directed downward. The trigonal zone starts muscle layer. The most frequent sites involved
at the level of the urethra up to 3 cm upward and is later-
ally delimited by the ureteral orifices. The bladder base are the posterior wall of the bladder, close to the
faces backward and downward lies adjacent the supra- vesicouterine pouch (Fig. 8.4), or the dome of the
vaginal cervix. The bladder dome lies superior to the base bladder (Fig. 8.5). This space is easily investi-
and is intra-abdominal. The remaining portion is named gated if the bladder is distended by a small
“extra-abdominal bladder”
amount of urine; we therefore recommend asking
patients not to empty their bladder before the
[13]. Symptomatic women refer a variable amount sonographic examination. In fact, a moderate
of symptoms including chronic pelvic pain, dys- amount of urine, creating an anechoic acoustic
uria, urinary urgency and/or frequency, painful window, facilitates the detection of nodules along
micturition, and discomfort in the retropubic area. the bladder wall.
Usually symptoms are recurrent and worsen in the The morphology of bladder endometriotic nod-
peri-menstruation days. Hematuria is rare (20% ules is rather constant, either spherical or comma-
of patients) because in a minor proportion of shaped [14]; their borders are regular and can
patients, the bladder mucosa is involved and pen- show a bright rim due to the presence of congested
etrated by endometrial glands. Differential diag- adipose tissue. At color/power Doppler, few blood
noses should include overactive bladder, acute/ vessels are seen within or around the nodule [14].
chronic cystitis, and bladder cancer.
Diagnosis can be made incidentally at a pelvic
examination performed due to infertility or pain
symptoms or at a diagnostic imaging modality,
but usually only large foci of DE are seen with
any imaging technique but transvaginal ultra-
sound (TVS).
The accuracy of TVS performed by expert
hands is high, but the sensitivity of the method is
related to the size of the nodule, besides the expe-
rience of the operator [14]. Cystoscopy has been
advocated as mandatory by some Authors [13]
but may reveal only lesions protruding toward the Fig. 8.4 Transvaginal scan of the bladder base (sagittal
lumen and infiltrating the bladder mucosa (which section) showing the presence of an endometriotic nodule
at the level of the bladder base close to the trigonus (cali-
are a minority) or those producing hyperemia and pers). The nodule has blurred margins and continues with
distortion of the mucosa. Magnetic resonance the muscle layer of the bladder (detrusor). Note the pres-
imaging (MRI) has been proposed [11, 15, 16], ence of a small anechoic area inside the nodule
Fig. 8.6 Transvaginal scan of a patient with a bladder

cancer. The neoplasm has filled the lumen of the bladder
Fig. 8.5 Transvaginal scan of the bladder dome (sagittal and appears as a bulky inhomogeneous mass with indis-
section) showing the presence of an endometriotic nodule tinct borders
at this level (calipers). The nodule has a comma shape and
is covered by a normal layer of bladder mucosa
space, as well as the fixity of bladder and uterus,
The mean lesion diameter at TVS is usually can be considered as a “soft markers” for bladder
lower than the diameter of the nodule measured endometriosis.
at histologic examination [14] because the sur- Differential diagnosis with bladder cancer is
geon when removing the nodule must reach mandatory: at TVS a neoplasm appears as a dif-
healthy margins of the bladder incised in order to fuse lesion invading the wall of the bladder and
obtain a good reconstruction (suture) of the blad- eventually leading to complete distortion of its
der. In a series we recently reported, TVS showed anatomy (Fig. 8.6, AVI bladder cancer). Its outer
a high overall accuracy of 95% in diagnosing border is ill-defined, and power Doppler may
bladder endometriosis, but the sensitivity is low reveal an enhanced vascularization of the tumor
for small nodules (<2 cm mean diameter). This is compared to that of DE.
in agreement with a previous study by Bazot
et al. [18] on a smaller number of cases. It is rea-
sonable to think that the bigger the nodule, the 8.3 Ureteral Endometriosis
easier the diagnosis; thus, both the physician per-
forming the preoperative ultrasound and the sur- Endometriosis may affect one (80% of the cases)
geon managing the patient should be aware that or both (20%) the ureters, being either intrinsic or
small endometriotic nodules can be missed at extrinsic. The first type is the rarest (20% of the
TVS. We have the strong impression that implants cases) and is due to the presence of glands and
forming a bulky nodule (either comma-shaped or stroma directly infiltrating the ureteral wall.
spherical) are clearly detectable at TVS, while Extrinsic ureteral endometriosis is more common
those forming a fibrous plaque along the bladder and is due to the distortion, narrowing of the ure-
wall can be missed if the sliding of the cervix teral lumen by the fibrotic retraction caused by a
along the bladder is not systematically sought. In distant nodule, which may originate from the pos-
fact, as most nodules obliterate the vesicouterine terior pelvic compartment and extend laterally
space, and extend toward the anterior wall of the toward the parametrium, thus reaching the ureter
uterus, we suggest evaluating the sliding of the (most frequently at the level of the uterine artery).
cervix along the bladder by gently pushing the These two pathological forms may coexist; more-
vaginal probe while looking for the eventual over it is often impossible preoperatively to state
presence of an endometriotic implant. The pain which form of ureteral damage is present.
produced by pressing with the probe, due to the TVS coupled with transabdominal ultra-
fibrosis and obliteration of the vesicouterine sound (TAS) is accurate in diagnosing urinary
tract involvement, and examination of the com-

plete urinary tract should be considered an inte-
gral part of US assessment of women with
suspected endometriosis. Unfortunately, ultra-
sound and every other imaging modality
(Uro-CT, MRI, urography) have limited value in
providing accurate information about the exact
degree of ureteral wall infiltration [13] which
might be evaluated only at surgery or at histo-
pathologic examination. The ureters are tubular
hypoechoic structures (Fig. 8.7) measuring
Fig. 8.8 Transvaginal scan of a filled bladder showing a
22–30 cm in length approximately divided in a ureteral jet. This appears as a colored flame pointing
pelvic and abdominal parts. The lumen is virtual toward the ureteral orifice and lasting 1–3 s
and surrounded by transitional epithelium
(mucosa), longitudinal and circular muscle lay- power Doppler can help in visualizing the small
ers, and outer fibrous tissue. Their course starts amount of urine injected in the bladder lumen
from the kidneys, dorsal to the renal artery, and for a 1–4 s interval (AVI ureteral jet).
continues caudally on the anterior edge of the The pelvic segment of normal ureters can be
psoas muscle until crossing the iliac vessels visualized, and their size can be measured at
anteriorly. They are covered by the peritoneum TVS. Starting from a longitudinal section of the
of the pelvic side wall, behind the lateral attach- urethra, the probe should be moved toward the
ment of the broad ligaments [19]. At this level pelvic side walls without tilting in order to visu-
they curve medially and forwards, crossing cau- alize the distal portion of the ureter adjacent to
dally the uterine arteries approximately 2 cm the trigone (Fig. 8.7). Ureters can be visualized
lateral and above the lateral fornices of the as hypoechoic tubular structures surrounded by a
vagina. Then they reach the bladder base at the hyperechoic mantle running from the bladder
level of the upper angles of the trigone passing wall toward the common iliac vessels [19].
medially in front of the upper vagina with an Visualization of the ureters is possible in 96% of
oblique course. At ultrasound their function can the patients after a handful of seconds and seems
be evaluated by visualizing the “ureteric jets,” more difficult only in obese women and those
indicating normal patency (Fig. 8.8): color/ with absent uteri most probably due to anatomi-
cal changes in their position. The mean diameter
of the ureter is 1.7 mm at rest and 2.9 mm during
peristalsis. A dilated ureter appears as a tubular
structure with anechoic content and thick walls
measuring >6 mm in diameter (Fig. 8.9). At TVS
it is possible to visualize even the presence of a
catheter, which is correctly positioned in the
lumen of the ureter, as often is done before
extensive laparoscopic ureterolysis (Fig. 8.10).
One of the most common sites where the ureters
are narrowed by DE is at the level of the cross
with the uterine artery, lateral to the cervix. In
Fig. 8.7 Transvaginal scan of a left ureter (normal size) fact a bulky endometriotic nodule, often origi-
appearing as a tubular structure located besides the blad-
nating from the pouch of Douglas, involving the
der wall. After waiting a sufficient length of time, it is
possible to visualize normal peristaltic movements of the uterosacral l igaments and the anterior wall of the
ureter rectum can extend laterally toward the parame-
Fig. 8.9 Transvaginal scan of left pelvic sidewall show-

ing a dilated ureter as a straight tubular structure with
anechoic content. The ureter is delimited by a thick mus- Fig. 8.12 Transvaginal scan (transverse section) of the
cular wall, and this helps in differentiating with an iliac left parametrium showing the presence of a diffuse DE
vessel. It is generally possible to visualize the peristalsis involving the retroperitoneal space and narrowing the
in the ureter by waiting for a few seconds. Moreover, colon (arrow). The left ureter is included in the vast
Doppler helps in the differential diagnosis as the dilated fibrotic retraction caused by the nodule
ureter shows no blood flow inside
Fig. 8.13 Transvaginal scan (longitudinal section) of the

Fig. 8.10 Transvaginal scan of the bladder (parasagittal posterior fornix showing an endometriotic nodule involv-
section) showing the first part of the ureter containing a ing a uterosacral ligament, the vaginal wall, and the para-
catheter (arrow) metrium (star)
tria (Figs. 8.11 and 8.12). The ureter can disap-

pear embedded in the nodule; a dilated ureter is
seen cranial to the stricture as a straight tubular
structure located beneath the peritoneum, devoid
of blood flow, not movable by the pressure
exerted with the probe, and surrounded by a
thick wall (Fig. 8.9). Peristalsis is often seen
even in dilated ureters after waiting a sufficient
amount of seconds. Involvement of the ureter
should be suspected even in case of bulky nod-
ules extending laterally from the uterosacral lig-
aments to the parametrium because of the close
Fig. 8.11 Transvaginal scan (transverse section) of the
cervix (arrow). Besides the cervix a bulky endometriotic proximity of the ureter to this anatomic structure
nodule is seen at the level of the right parametrium (Fig. 8.13).
8.4 Important Technical Tips (or the three orthogonal diameters), mobility with
regard to the anterior uterine wall, and pain at
All scans should be performed both via transab- pressure with the probe should be recorded.
dominal (TAS) and transvaginal ultrasound Moreover, the relationship of the DE with the tri-
(TVS). The investigator must be aware of the gonus and the internal ureteral orifices should be
patients’ clinical and surgical history, symptoms evaluated, eventually waiting for the ureteral jet
(dysmenorrhea, dyspareunia, chronic pelvic to appear (Video 8.3). Assessment of vasculariza-
pain, dysuria, urgency, frequency, suprapubic tion of the nodule by means of color/power
pain, vesical tenesmus, infertility), and the Doppler does not seem to be crucial, but it might
results of a physical bimanual examination of be of help in the differential diagnosis with a
the patient. The optimal situation would be the bladder neoplasm (which is usually more vascu-
case in which the same physician performing larized than DE).
TAS and TVS is expert in bimanual exploration Pelvic sections of the ureter should be rou-
of the female pelvis (gynecologic examination) tinely evaluated at TVS [19] both at rest and
in order to obtain the best from both exams. The during peristalsing to identify any evidence of
ultrasound examinations must be performed in a ureteric dilatation, abnormal bending, or dif-
standardized manner using ultrasound machine ferences in peristalsis frequency between the
equipped with broadband abdominal and vagi- ureters [19]. In women with evidence of ure-
nal probes. teric obstruction, the distance between the nod-
At first, an accurate examination of the pelvis ule and the ureteric orifice should be measured.
should be undertaken to evaluate the anatomy of As already discussed, the operator must be
the uterus and the ovaries. The transvaginal trans- aware of the fact that nodules involving the
ducer should then be positioned in the anterior ureter are most often large nodules of the pos-
vaginal fornix and tilted upward to visualize the terior pelvic compartment extending laterally
vesicouterine space and the bladder, on a longitu- toward the parametrium (Figs. 8.11 and 8.12),
dinal and on a transverse section. In these planes, at the level of the uterine cervix, thus reaching
the bladder wall can easily be visualized if a the ureter either directly or as an involvement
moderate amount of urine is present. The sliding caused by the fibrotic reaction (collagen fibers,
of the normal bladder wall toward the anterior smooth muscle cells) surrounding the
wall of the uterus should be evaluated by gently DE. Thus, it is mandatory to perform a com-
pushing with the transvaginal probe (Video 8.1). plete evaluation of the posterior pelvic com-
The physician must be familiar with the normal partment. As previously recommended, TVS
anatomy of the bladder, in order to recognize the should be performed in a dynamic and interac-
peritoneum covering the intra-abdominal portion tive manner, while asking the patient about
(dome) of the bladder, the muscle layer, and the possible complaints and looking for painful
mucosa. site (pain mapping). A normal pelvis will show
Diagnostic criteria indicative of a bladder the sliding of the rectum toward the posterior
endometriotic nodule are the following [14, 18]: uterine wall (Video 8.2).
The examination is completed only after a
1. The presence of a hypo- or isoechogenic nod- TAS is done (which can be even done before
ule in the bladder wall TVS) by means of a 3.5–5.0 MHz curvilinear
2. The presence of a nodule with a heteroge- probe. Kidneys are easy to be evaluated by posi-
neous echostructure containing numerous tioning the woman on a lateral decubitus position
anechoic (“bubble-like”) areas (Fig. 8.14). with the probe in the lower intercostal space at
the level of the midaxillary line. Kidneys are
Whenever a bladder endometriotic nodule is scanned on a longitudinal (long axis) and trans-
seen at TVS, its location, shape, mean diameter verse (short axis) views.
Fig. 8.14 Transvaginal scan of a bladder endometriotic tom right) shows the distortion of bladder anatomy and
nodule (multiplanar image plus 3D reconstruction). The indenting of the bladder lumen. The nodule does not infil-
nodule appears as hypoechoic mass containing small cys- trate the mucosal layer which is smooth and has a normal
tic spaces (bubble-like). Three-dimensional image (bot- appearance
Hydronephrosis is diagnosed and graded junction with the hyperechoic fibrous layer sur-
using commonly accepted ultrasound criteria rounding the ureter [19].
[20]. When the cranial portion of the ureter
appears dilated (Figs. 8.1 and 8.2), it should be
followed on its abdominal and pelvic portions to References
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Uterosacral Ligament
Endometriosis
9
Francesco Paolo Giuseppe Leone
9.1 Introduction 9.2 How We Do It
Endometriosis occurs in 15–30% of patients with 9.2.1 Clinical History

endometriosis and may involve, in descending
order of frequency, the uterosacral ligaments A detailed clinical history is always a manda-
(USLs), the pouch of Douglas, the rectosigmoid tory preliminary step. USL deep endometrio-
colon, the rectovaginal septum, the vagina, and sis (DE) can be associated with dysmenorrhea,
the bladder [1, 2]. Considerable diagnostic delay deep dyspareunia (or even apareunia), and
of up to 8 years from presenting symptoms often dyschezia [7].
confers a heavy economic and social price [3–5].
Preoperative diagnosis of USL endometriosis
is extremely relevant for the surgeon, as removal 9.2.2 Clinical Pelvic Examination
of these lesions is associated with a high risk of
bladder dysfunction. Nerve-sparing surgery of The physical pelvic examination is based on digi-
the inferior hypogastric plexus is recommended tal vaginal and/or rectal examinations, which is
to avoid this complication; it is especially feasi- considered suggestive of USL DE when an area
ble in women with isolated USL endometriosis, of thickening or a nodule in the uterosacral liga-
whereas more extensive endometriotic lesions ments, often painful, is found [8].
are not always compatible with this conservative
surgery [6].
This overview will focus on the sonographic 9.2.3 2D-Transvaginal Sonography
diagnosis of USL endometriosis, by transvaginal
sonography (TVS) with color and power Doppler TVS can be performed throughout the menstrual
(CD and PD) assessment, combined with sono- cycle, without bowel preparation (i.e., without
vaginography (SVG) (using either saline contrast use of laxatives or enema).
or gel infusion) or with three-dimensional trans- Conventional 2D-TVS is performed, using a
vaginal sonography (3D-TVS). wide-band 3–9-MHz vaginal high-resolution
microconvex probe, to obtain an overview of the
whole pelvis by a tenderness-guided and dynamic
F. P. G. Leone
methodology according to IDEA consensus’
Department of Obstetrics and Gynaecology, Clinical
Sciences Institute L. Sacco, University of Milan, sonographic steps (see Chap. 3). The tenderness-
Milan, Italy guided exam is performed with or without an

https://doi.org/10.1007/978-3-319-71138-6_9
78 F. P. G. Leone
acoustic window between the transvaginal probe The probe can be positioned either in the anterior
and the surrounding vaginal structures, combined or in the posterior vaginal fornix.
with an active role of the patient, who indicates The color and power Doppler box should
the site of any tenderness experienced during the include the nodule with the surrounding fat and
pelvic scan [9, 10]. Then, the image is magnified structures. Magnification and settings should be
to contain only the upper vagina, cervix, and adjusted to ensure maximal sensitivity for blood
lower uterus, to be assessed in the sagittal plane flow:
of the cervix from uterine artery to uterine artery
and in the transverse plane from the external to (a) Ultrasound frequency “normal” (at least
the internal cervical os. The magnification should 5.0 MHz)
be as large as possible, focusing on the area of (b) Pulse repetition frequency 0.6 kHz
interest. Furthermore, in order to obtain a high- (0.3–0.9 kHz)
quality image, a proper setting of the following is (c) Wall filter “low” 40 Hz (30–50 Hz)
of paramount importance: (d) Color and power Doppler gain (reduced until
all color artifacts disappear)
(a) Depth (the complete cervix on the screen
after whole pelvic assessment) The color content in the DE nodule may be
(b) Gain (setting also overall time gain scored using the standardized color score (CS), a
compensation) subjective semiquantitative assessment of the
(c) Dynamic range (less relevant for cervical amount of blood flow present: CS 1, no color
assessment) flow; CS 2, only minimal color; CS 3, moderate
(d) Focus (single enough, below the cervix) color; and CS 4, abundant color.
(e) Zoom (better high definition (HD) zoom) Normal USLs are usually not visible on ultra-
sound. USL DE lesions appear as hypoechoic
However, difficulties may arise from varia- thickening with regular, smooth outline, or irreg-
tions in uterine position (particularly when axial) ular, stellate margins, within the hyperechoic
or with uterine rotation (endometriosis or previ- peritoneal fat surrounding the USLs, with homo-
ous surgery-related adhesions). This problem geneous or heterogeneous echogenicity
may be overcome in some cases by pressing (Fig. 9.1) [2]. USL DE nodule can be seen in the
on the abdomen with the non-scanning hand. parasagittal view of the cervix (Fig. 9.2):
Fig. 9.1 USL DE lesion may appear as an hypoechoic, homogeneous thickened nodule with regular, smooth outline
(left) or as an hypoechoic, heterogeneous thickened nodule with irregular, stellate margins (right)
9 Uterosacral Ligament Endometriosis 79
a b
Fig. 9.2 (a) Sagittal image of the cervix with an imagi- the cervix, medial to the uterine artery, with an imaginary
nary line passing through the cervical internal os. (b) line passing at the level of the hypoechoic USL DE
Lateral sagittal image of the cervix with an imaginary line nodule
passing at the level of uterine artery. (c) Sagittal image of
(a) Place the transvaginal probe in the anterior or (b) Obtain the transverse plane of the cervix.
in the posterior vaginal fornix. (c) Sweep the probe cranially up to the internal
(b) Obtain the sagittal plane of the cervix and cervical os, and the USL DE nodule appears
select the midline (passing through the cervi- as a hypoechoic lesion.
cal canal).
(c) Trace an imaginary line passing through the The USL lesion may be isolated or may be
internal cervical os. part of a larger nodule extending into the vagina
(d) Sweep the probe laterally up to the uterine or into other surrounding structures (rectosig-
artery. moid, ovary) (Fig. 9.4). If the nodule is seen as a
(e) Sweeping back medially to the uterine artery, central block of hypoechoic tissue of the retrocer-
the USL DE nodule appears as a hypoechoic vical area (arciform abnormality), it should be
lesion. considered a DE lesion of the torus uterinus [2].
In the presence of an extended nodule, a posterior
Similarly, USL DE nodule can be seen in the negative “sliding sign” (i.e., pouch of Douglas
transverse view of the cervix (Fig. 9.3): obliteration) is usually observed [11, 12].
The thickness of the USL nodule should be
(a) Place the transvaginal probe in the anterior or measured systematically in three orthogonal
in the posterior vaginal fornix. planes by sagittal and transverse scans, to obtain
80 F. P. G. Leone
a b
Fig. 9.3 (a) Transverse image of the cervix with the vagi- Cranial transverse image of the uterine isthmus with the
nal bright edge. (b) Cranial transverse image of the upper hypoechoic left USL DE nodule adherent to a rectosig-
cervix with the hypoechoic left USL DE nodule. (c) moid bowel DE nodule
The whole procedure should be digitally

recorded for second opinion (videoclips) and the
selected diagnostic images stored and/or printed.
The former option is particularly relevant when
discussing with surgeons the surgical strategy.
9.2.4 Sonovaginography
with Saline or Gel
Sonovaginography combines TVS with injection

of saline or gel into the vagina. Up to 50 mL of
these contrast agents, injected into the vagina
Fig. 9.4 Extended USL DE lesion, hypoechoic with
irregular outline, adherent to an ovarian endometrioma using a plastic syringe and a Foley catheter or a
and to a retrocervical DE nodule condom, create an acoustic window between the
transvaginal probe and the structures surrounding
the length (midsagittal measurement), thickness the vagina, thus permitting more complete visu-
(anteroposterior measurement), and transverse alization of the vaginal walls and anterior/poste-
diameter in millimeters. rior vaginal fornices [13, 14]. The great advantage
of the condom fulfilled with gel is that it lasts selected cases or if TVS is impossible or inap-
longer, with no backflow and no need of a spe- propriate (virgo intacta) [15].
cific set (catheter, syringe). SVG should be
always performed when the clinical interview
and the preliminary pelvic exam suggest the pres- 9.2.6 3D-Transvaginal Sonography
ence of posterior DE nodules, permitting to iden-
tify isolated (Fig. 9.5) or extended lesions In the last decades, a large number of papers
(Fig. 9.6). As well as above, the whole procedure referred the usefulness of 3D-TVS in gynecolog-
should be digitally recorded for second opinion ical investigations, mainly focused on uterine
(videoclips) and the selected diagnostic images congenital anomalies and adenomyosis but
stored and/or printed. poorly on DE [16].
3D-TVS should always be performed after a
detailed tenderness-guided and dynamic trans-
9.2.5 Transrectal Sonography vaginal exam, useful to adequately report the
USL DE lesion on the three orthogonal planes
Transrectal sonography using transvaginal probe and its relationship with surrounding structures,
should be used if necessary to support TVS in thus easily permitting to distinguish isolated and
extended lesions (Fig. 9.7).
In order to obtain a high-quality 3D image, it is
of paramount importance to acquire an excellent
volume by a high-quality 2D image. Therefore:
(a) Obtain a good 2D image of the upper cervix

and of the USL DE lesion.
(b) Select 3D/4D static mode.
(c) Select quality option (slower the speed of
acquisition, longer the duration of the sweep,
thus higher the quality).
(d) Select sweep angle (range of volume sweep
85°–120°; the smaller the range, the higher
Fig. 9.5 Isolated USL DE lesion, hypoechoic with the quality; thus select the smallest angle fit-
smooth outline, at gel sonovaginography ting the target).
a b
Fig. 9.6 Extended USL DE lesion, hypoechoic with smooth outline (a) and CS1 (b), at gel sonovaginography, strictly
adherent to a retrocervical DE hypoechoic lesion
82 F. P. G. Leone
(e) Choose the sagittal and/or transverse plane, In particular, the following steps after volume
being sure to include the whole nodule and acquisition of the USL DE lesion at 3D-TVS
surrounding structures. should be performed:
(f) Hold still, avoid pressure with the probe, ask
the patient to remain still during the acquisi- (a) Identify and magnify the selected image of
tion, acquire the volume, and store it elec- the USL DE lesion, in the multiplanar dis-
tronically for later analysis. play mode and add VCI.
(g) Magnification over 70% of the screen and (b) Shift the selected plane forward and back-
virtual navigation on the multiplanar display, ward to identify the plane containing the
referring to the fulcrum (dot of interest) and largest diameter of the DE lesion and evalu-
by rotating the three orthogonal planes on the ate involvement of surrounding structures.
rotational axis X, Y, and Z. (c) Rotate the DE lesion on its ideal center (“ful-
(h) Assessment and measurements of the USL crum”) on the Z-axis until the line passes
DE findings, by adding post-processing tools through the center of the nodule and assess
(volume contrast imaging (VCI), rendering extension to surrounding structures
mode, tomographic ultrasound imaging (Fig. 9.10).
(TUI)). (d) Report images adding TUI or rendering
mode if potentially useful to discuss in a clin-
Volume contrast imaging (VCI) is a technol- ical multidisciplinary setting.
ogy based on a volume acquisition technique that
leads to contrast enhancement and speckle sup- 3D volumes can be stored and analyzed later
pression in the two-dimensional ultrasound as many times as needed, permitting a second
image, by offering to increase resolution and to opinion by sending volumes by internet, offer-
reduce noise and artifacts. Hence, the result of ing the possibility of studying an infinite num-
VCI is a thin surface-rendered image of the DE ber of sections through the lesions. This latter
nodule, which thickness usually set at 2 mm by feature is particularly relevant when discussing
the sonographer (Fig. 9.7). with surgeons the surgical strategy (Figs. 9.11
Volume rendering analysis is based on the and 9.12).
selection of the region of interest (ROI) and of
the observation plane of the acquired volume of
the nodule, thus obtaining a thick slice of the 9.3 Future Perspectives
lesion (Fig. 9.8).
Tomographic ultrasound imaging (TUI) is a TVS should remain the first-line method in the
technology which leads to multiple planes dis- evaluation of patients with suspicion of DE. The
played at the same time, with the option of con- future uptake of the recent IDEA consensus on
comitant use of VCI. Similarly, the number of terms, definitions, and measurements of DE
images and the thickness might be selected by the lesions may improve standardization of scanning
sonographer, with differences depending on the and reporting and in turn potentially reduce the
plane used for analysis. I would suggest the operator dependency. This may optimize the pre-
option with three or nine images with distances operative triage and potentially improve surgical
of 0.5–3.5 mm depending on USL lesion (iso- outcomes. Furthermore, it may lead to large mul-
lated or extended) and involved surrounding ticentric studies and proper meta-analyses on
structures (Fig. 9.9). ultrasound diagnosis of endometriosis.
Fig. 9.7 Multiplanar images with VCI analysis (2 mm) of an isolated (a) and an extended nodule (b) infiltrating the
rectosigmoid
84 F. P. G. Leone
Fig. 9.8 Multiplanar images with VCI (a) and Volume neous USL DE nodule, compared to the macroscopic sur-
Rendering Analysis (b), with the selection of the curved gical specimen (c)
render ROI, of an isolated hypoechoic smooth homoge-
Fig. 9.9 TUI images (nine images with distance of 3.5 mm) with VCI analysis (2 mm) of an isolated hypoechoic
smooth homogeneous isolated USL DE nodule
Fig. 9.10 Multiplanar images with VCI analysis (2 mm) of an extended irregular hypoechoic homogeneous USL DE
nodule adherent to an ovarian endometrioma and to the sigmoid serosa
86 F. P. G. Leone
a b
Fig. 9.11 Extended hypoechoic homogeneous USL DE sigmoid nodule at 2D-TVS (a), with CS1 (b), and at
lesion with irregular outline, strictly adherent to a retro- 3D-TVS with multiplanar images and VCI analysis
cervical DE hypoechoic lesion and to an infiltrating recto- (2 mm) (c)
a b
Fig. 9.12 Bilateral extended hypoechoic heterogeneous 2D-TVS on a transverse plane (a) and at 3D-TVS with
USL DE lesions with irregular outline, strictly adherent to multiplanar images and VCI analysis (2 mm) (b, c)
an arciform retrocervical DE hypoechoic lesion at
sive tests for the diagnosis of endometriosis. Cochrane

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Forniceal-Vaginal Deep
Endometriosis
10
Stefano Guerriero, Gil Cohen, Silvia Ajossa,
Ornella Comparetto, Camilla Ronchetti,
Bruno Piras, Alba Piras, and Valerio Mais
10.1 Introduction rounds foci of endometriosis, and the foci

sometimes contain small cavities. The endome-
The forniceal-vaginal anatomical area is located trial glands and stroma infiltrate the adjacent
in the recess at the vault of the vagina. Forniceal fibromuscular tissue and elicit smooth muscle
deep endometriosis (DE) is mainly located in the proliferation and fibrous reaction, resulting in
posterior part of the vaginal fornix but might solid nodule formation [6–8]. Endometriotic
involve also the lateral parts of the fornix [1]. The glands are found to be very near to the vaginal
mean prevalence of vaginal DE is 17% [2], rang- mucosal epithelium [9].
ing from 4 to 39% [3, 4]. This wide range is prob- Donnez et al. [10] proposed a classification to
ably due to the different classification systems forniceal-vaginal endometriotic lesions, previ-
used before the International Deep Endometriosis ously called “retroperitoneal” or “retrocervical”
Analysis (IDEA) consensus [5]. lesion. This classification is based on their theory
The histologic findings of infiltrative lesions of disease pathogenesis which states that adeno-
of deep pelvic endometriosis are mainly charac- myosis originates in the retrocervical area and
terized by fibromuscular hyperplasia that sur- involves the retroperitoneal space. These authors
proposed a classification that takes into account
the location of the retroperitoneal lesion
Electronic Supplementary Material The online version (Fig. 10.1) [11]. This classification has been
described also by Del Frate et al. [12]:
Type I: rectovaginal septum DE nodules (10% of
cases). These lesions are situated within the
S. Guerriero (*) · S. Ajossa · O. Comparetto rectovaginal septum between the posterior
C. Ronchetti · B. Piras · A. Piras · V. Mais
wall of the vaginal mucosa and the anterior
Department of Obstetrics and Gynecology, University
of Cagliari, Policlinico Universitario Duilio Casula, wall of the rectal muscularis [10].
Cagliari, Italy Type II: posterior vaginal fornix DE nodules
e-mail: gineca.sguerriero@tiscali.it; (65% of cases). These lesions develop from
gineca.sajossa@tiscali.it;
the posterior fornix toward the rectovaginal
camilla.ronchetti@fastwebnet.it; valerio.mais@alice.it
septum. The posterior fornix is retrocervical
G. Cohen
and corresponds, in the attachment of the vag-
Department of Obstetrics and Gynecology,
Ultrasound Unit, Bnai-Zion Medical Center, inal mucosa, to the posterior face of the poste-
Haifa, Israel rior lip of the cervix [10].

https://doi.org/10.1007/978-3-319-71138-6_10
90 S. Guerriero et al.
Fig. 10.1 A drawing of the three different localizations of forniceal-vaginal endometriotic lesions, previously called
“retroperitoneal or retrocervical lesion” proposed by Donnez et al. [10]
Type III: hourglass-shaped or diabolo-like DE that the presence of vaginal infiltration by the
nodules (25% of cases). These lesions occur posterior DE was related to the severity of dys-
when posterior fornix lesions extend cranially menorrhea, while this correlation was not
to the anterior rectal wall. The part of the observed by Vercellini et al. study [15].
adenomyotic lesion situated in the anterior
Several studies evaluated the sensitivity and
rectal wall is in the same size as the part situ- specificity of transvaginal ultrasound (TVS) for
ated near the posterior fornix. A small but vaginal DE lesions. Guerriero et al. [2] in their
well-observed continuum exists between these meta-analysis found a sensitivity of 58% and a
two parts of the lesion. These lesions always specificity of 96%. Nisenblat et al. [16] in a
occur under the peritoneal fold of the recto- Cochrane review found a mean sensitivity of
uterine pouch or pouch of Douglas and were 57% and a mean specificity of 99%. Noventa
found to be large (their average size estimated et al. [17] in their meta-analysis found a sensitiv-
to be 3 cm by clinical examination) [10]. ity of 50% with a specificity of 88.7%.
The present chapter is focused on types II and
III. Type I or rectovaginal septum DE is
described in Chap. 11. 10.2 How We Do It
Fauconnier et al. [13] found an association As suggested by IDEA consensus [5], an optimal
between the presence of vaginal DE and painful sonographic evaluation starts with a detailed clin-
defecation during menstruation and other gastro- ical history evaluation [5, 18–20]. It is mandatory
intestinal symptoms. Chapron et al. [14] found to do a vaginal examination in women with a
10 Forniceal-Vaginal Deep Endometriosis 91
Posterior UTERUS Anterior
CERVIX
Fig. 10.3 A solid forniceal nodule as visualized using

transvaginal ultrasonography
Posterior Anterior
Fig. 10.2 A forniceal nodule as visualized using

speculum CERVIX
vaginal DE nodule. Indeed, some forniceal DE

lesions can be visualized directly by a speculum Fig. 10.4 A solid forniceal nodule as visualized using
examination (Fig. 10.2).
On TVS, the posterior fornix refers to the
sonographic area between the lower border of the
posterior lip of the cervix and the caudal end of
the peritoneum of the lower margin of the recto-
uterine peritoneal pouch (pouch of Douglas) (see
Chap. 11). At TVS a forniceal DE lesion appears Posterior Anterior
as a thickened posterior vaginal fornix or as a dis-

crete nodule in the hypoechoic layer of the vagi- UTERUS
nal wall. The hypoechoic nodule may be

homogeneous or inhomogeneous with or without CERVIX
large cystic areas with or without cystic areas sur-
rounding the nodule [5] (Figs. 10.3, 10.4, 10.5,
10.6, 10.7, 10.8 and 10.9). Fig. 10.5 A solid forniceal nodule as visualized using
The sonographic assessment of the posterior transvaginal ultrasonography
fornix should aim to identify not only the pres-
ence of DE but also the size (in three orthogonal
planes), the anatomical relationship with contig- to rule out other possible diagnoses (Figs. 10.10,
uous structures, and eventually the possible 10.11 and 10.12). After a careful ultrasound eval-
mobility or fixation of the surrounding organs uation of the posterior vaginal fornix, the observer
with or without tenderness. We suggest to use the has to proceed with exploring the relationship
color Doppler modality for every lesion in order with the rectal wall by sliding the transvaginal
Posterior Anterior
Posterior Anterior
CERVIX CERVIX

transvaginal ultrasonography Fig. 10.9 A cystic forniceal nodule as visualized using
Posterior Anterior Posterior Anterior
UTERUS
UTERUS
CERVIX
Fig. 10.7 A solid forniceal nodule as visualized using Fig. 10.10 A solid forniceal nodule as visualized using
transvaginal ultrasonography transvaginal ultrasonography and power Doppler
CERVIX
Posterior Anterior
UTERUS
Anterior Posterior
UTERUS
CERVIX
Fig. 10.8 A solid forniceal nodule as visualized using Fig. 10.11 A solid forniceal nodule as visualized using
transvaginal ultrasonography transvaginal ultrasonography and power Doppler
probe back and forth from the vaginal introitus wall where a nodule is present at the level of
along the rectovaginal septum. muscularis mucosa (further details in Chap.
In vaginal DE cases which are hourglass- 12) (Figs. 10.13 and 10.14). In such cases,
shaped or diabolo-like in appearance, the both DE nodules should be measured in the
lesions extend cranially to the anterior rectal three planes.
Posterior Anterior
CERVIX
b
transvaginal ultrasonography and power Doppler
Posterior Anterior
Fig. 10.15 A forniceal nodule as visualized using plain

transvaginal ultrasonography (a) and using tenderness
technique (b)
probe cover (but using only a finger glove). This

“standoff” technique creates a gap between the
Fig. 10.13 A diabolo-like nodule as visualized using tip of the transvaginal probe and surrounding
transvaginal ultrasonography. In the white circle, the rec-
tosigmoid nodule; in the red one, the forniceal nodule vaginal fornices. The transvaginal probe is gently
inserted into the vagina to avoid obliteration of
the gel. The gradual introduction of the probe to
the level of the posterior fornix may assist to
visualize lesions previously not detected. During
Posterior Anterior this initial ultrasound evaluation, the patient
should be asked to inform the operator about the
onset and the site of any tenderness experienced
UTERUS during the probe’s placement in the posterior
vaginal fornix. Particular attention must be noted
to the indicated painful site which may reveal
adjacent endometriosis lesions [21] (Fig. 10.15).
Using this modality, a better visualization of the
lesion has been demonstrated [21] (Videos 10.1
Fig. 10.14 A diabolo-like nodule as visualized using
transvaginal ultrasonography. In the white circle, the rec- and 10.2). Further details are present in Chap. 14.
tosigmoid nodule; in the red one, the forniceal nodule The use of a three-dimensional (3D) TVS is
also a suggested modality. After acquiring the 3D
volume, the observer can perform a virtual navi-
For vaginally located DE, the use of tender- gation and a 3D evaluation using the B plane with
ness-guided ultrasound examination is recom- the ROI line on the left side of the 3D box and the
mended [4]. In this modality, an increased amount green line curved into the center of lesion (using
of ultrasound gel is inserted into the transvaginal
Fig. 10.16 A three-dimensional visualization of a diabolo-like nodule. The straight arrow indicates the rectosigmoid
lesion and the curved arrow the forniceal nodule
a sagittal plane). Typically these lesions appear as fornix. In the assessment for DE lesions in the
small irregular nodules [22] (Fig. 10.16). posterior compartment, our advice is to include
In the presence of suspected vaginal DE, the the following information:
final recommended step for forniceal-vaginal
evaluation is to perform a TVS combined with 1. The size of DE lesion (measured in three
the use of either saline [23, 24] or gel [25–27] orthogonal planes)
sonovaginography (see Chap. 14). Using gel son- 2. The anatomical relationship with contiguous
ovaginography, before the insertion of the trans- structures
vaginal probe, approximately 20–50 mL of 3. The possible mobility or fixation of the sur-
ultrasound gel is inserted into the posterior vagi- rounding organs
nal fornix by using a 20 mL plastic syringe [25– 4. The presence or absence of flow using color
27]. The gel creates an acoustic window that Doppler
allows a “standoff” view of the structures of the
posterior compartment. It has been reported that The following recommendations might also
using this modality gives better visualization of be useful:
the lesion [25–27] (see Videos 10.3 and 10.4).
1. Perform a gradual introduction of the trans-
vaginal probe using gentle movements and the
10.3 Important Technical Tip possible addition of gel with lidocaine on the
cover probe.
Our advice is to use the four basic sonographic 2. Remember the synergy between the operator
steps proposed by the IDEA consensus [5], tak- and the patient especially when assessing ten-
ing note of site-specific tenderness and the derness-guided ultrasound.
dynamic evaluation of the relationship between 3. Explore suspected vaginal DE by using gel
the anterior rectal wall and the posterior vaginal sonovaginography. When compared to saline
sonovaginography, gel sonovaginography is Until now, there are no studies on rectosonog-

less complicated to perform, requires less raphy or 3D rectosonography in evaluating forni-
preparation, and produces less discomfort. ceal-vaginal DE (see Chap. 14). Transvaginal
Before performing gel sonovaginography, we elastography may be a future tool in exploring
recommend that the gel must be carefully forniceal-vaginal DE. Fusion imaging, also
drawn up into the syringe, ensuring there are known as real-time virtual sonography, is a new
no or only minimal air bubbles in the gel; and technique that uses magnetic navigation and
the syringe is filled completely, so that the computer software for the synchronized display
plunger comes in direct contact with the gel, of real-time ultrasound and multiplanar recon-
reducing the possibility of air pockets when structed magnetic resonance imaging (MRI)
instilling the gel into the vagina. images. This technique combines the advantages
4. Report the absence of the normal sonographic of both MRI and ultrasound. Fusion imaging
anatomy. allows better identification of the main anatomi-
5. Emphasize the presence of hourglass-shaped cal sites of DE and has the potential to improve
or diabolo-like nodules in the written report. the performance of ultrasound and MRI exami-
This might influence the surgical planning (to nation [30].
proceed or not) as well as increase the surgical
risks due to the associated invasiveness with
such lesions. References
6. Use offline 3D volumes for a virtual naviga-
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of location of deep endometriosis. Hum Reprod.
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a specificity of 94% [22]. However, the mobility T, Jurkovic D, Benacerraf B, Osuga Y, Somigliana
of the pelvic organs cannot be evaluated using E, Timmerman D. Systematic approach to sono-
graphic evaluation of the pelvis in women with sus-
this modality. Three-dimensional introital sonog- pected endometriosis, including terms, definitions
raphy might be an additional option, but this and measurements: a consensus opinion from the
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Rectovaginal Septum
Endometriosis
11
Gernot Hudelist and Kristine Aas-Eng
11.1 Introduction SVSe
The rectovaginal septum (RVS) is located in the

posterior compartment of the pelvis situated ret-
VCS
roperitoneally between the posterior wall of the
vagina and the anterior part of the rectum [1]. It is
a specific anatomical structure consisting of
strong connective tissue between the rectum and RVS
the vagina. Histopathological studies have dem-
VVS
onstrated that it is formed of a network of colla-
gen and elastic fibres, small vessels, smooth
muscle cells and nerve fibres predominantly
deriving from the autonomic inferior hypogastric
plexus [2]. It thereby connects the perineal body
and endopelvic fascia (Fig. 11.1). Anatomically Fig. 11.1 Median sagittal section through the female pel-
the RVS is described to extend from the base of vis showing the midline connective tissue spaces between
the rectovaginal pouch of Douglas to the urogeni- the bladder, vagina and rectum. The vesicocervical space
(VCS) is separated from the vesicovaginal space (VVS) by
tal diaphragm at the top of the perineal body the supravaginal septum (SVSe). The rectovaginal space
(Fig. 11.2) [3]. (RVS) is located between the rectum and the vagina,
In rectovaginal endometriosis, which per defi- extending from the perineal body to the bottom of the cul-
de-sac of Douglas (from The Global Library of Women’s
nition infiltrates the RVS, the rectal wall is usu-
Medicine, free resource)
ally affected unlike in retrocervical endometriosis
where the bowel wall is not affected by deep
infiltrating disease [3]. The distinction between Bazot et al. defined that the RVS was affected on
rectovaginal and retrocervical endometriosis is transvaginal ultrasound (TVS) when “a nodule or
important in the surgical management since the mass was found below the horizontal plane pass-
former is often treated with bowel resection and ing through the lower border of the posterior lip
the latter with local excision or ablation [4]. of the cervix (under the peritoneum)” [5]. Others
similarly have defined the RVS on TVS as “the
area between the rectum and the posterior vaginal
G. Hudelist (*) · K. Aas-Eng
Department of Gynecology, Hospital St. John of God, wall from the level of the introitus up to a level
Vienna, Austria defined by the lower border of the posterior lip of

https://doi.org/10.1007/978-3-319-71138-6_11
98 G. Hudelist and K. Aas-Eng
Pouch of
Douglas
Blad.
Vagina
Posterior Recto-
vaginal vaginal
wall septum
Ant. rectal Rectum

wall
Fig. 11.2 Partly dissected rectovaginal septum extending from the pouch of Douglas to the perineal body (from The
Global Library of Women’s Medicine, free resource)
the cervix” [6]. The prevalence of endometriosis sensitivities of 18% compared with TVS (9%)
involving the RVS has been found to range and MRI (55%).
between 6 and 52% [7, 8] in patients with sus- Additional methods have been proposed to
pected deep endometriosis (DE). The varying improve sensitivity rates of TVS detecting rec-
prevalence rates may be attributable to differ- tovaginal DE. For example, the use of 3-D TVS
ences in sonographic definition of DE affecting for RVS DE appears to reach a sensitivity of
the RVS but also patient populations and the 76% and a specificity of 100% [14]. Ros et al.
sonographer’s experience in TVS. RVS endome- [15] looked at improving sensitivity of TVS in
triosis does not occur solely in this anatomical detection of rectal disease with bowel prepara-
compartment, i.e. the RVS, and is usually associ- tion from 73% without bowel preparation.
ated with endometriotic infiltration of the vagina Saccardi et al. [16] found saline contrast
and anterior rectal wall [9, 10], based on the pre- sonography, i.e. TVS with introduction of
sumption that it originates from these neighbour- saline solution in the vagina, had better sensi-
ing structures [9]. tivity comparable to MRI for diagnosing endo-
TVS is regarded as the first-line tool in diag- metriosis of the RVS of 81% and 83%,
nosing DE affecting the rectum and associated respectively, whereas TVS without contrast
structures [11, 12]. However, diagnosis of RVS had a sensitivity of 58%.
nodules may be difficult which is reflected by High sensitivity rates of 78% have been
sensitivity rates of TVS ranging between 9 and reported for detection of RVS endometriosis
78% [5, 6, 10]. Bazot et al. [13] compared TVS using simple vaginal examination and TVS when
with rectal endoscopic sonography (RES) and the two methods were used isolated or in a com-
found an improved sensitivity from 11 to 22% bined setting [6, 17]. However, the sensitivity for
using RES, although the patient number was the detection of rectosigmoid lesions that often
small (n = 9). These findings have been supported occur with RVS was higher with TVS of 90%
by a study comparing physical examination, compared to 39% vaginal examination alone.
TVS, RES and MRI in detecting DE [10]. Within Furthermore, a modified TVS method with trans-
this, physical examination and RES had similar vaginal “tenderness-guided” ultrasonography,
11 Rectovaginal Septum Endometriosis 99
which entails an acoustic window created by 11.2 How We Do It

increasing the amount of gel to 12 mL and paying
particular attention to areas that provokes pain, The International Deep Endometriosis Analysis
reached similar sensitivity for RVS nodules of (IDEA) group proposes a four-step systematic
74%, specificity 88%, LR+ 6.21 and LR− 0.30 approach to assess women with suspected endo-
[7]. Compared to the previous studies mentioned, metriosis. The fourth step consists of evaluating
sensitivity rates were found to be much higher in the anterior and posterior compartment [18]. The
these two studies, which may be explained by most common sites of DE affecting the posterior
differences in patient populations and possibly compartment are the uterosacral ligaments, pos-
the sonographers’ experience. However, TVS terior vaginal fornix, anterior rectum/anterior
remains the most accessible, cost-effective and rectosigmoid junction and sigmoid colon.
well-tolerated tool in the diagnosis of RVS endo- According to the IDEA group definition, infiltra-
metriosis with or without rectal/vaginal involve- tion of the RVS is suspected on TVS in cases
ment. Ideally, a combination of clinical/visual where nodular deep infiltrating disease can be
inspection, vaginal examination and TVS may be visualized below the line passing along the lower
the method of choice for accurately diagnosing border of the posterior lip of the cervix (under the
RVS involvement. peritoneum) [18] (Fig. 11.3).
a b
c d
Fig. 11.3 (a) Schematic drawing of the RVS (double- (from Guerriero et al. [18] with permission). (b–d)
headed green arrow) below (anatomically) the blue line Schematic drawing demonstrating DE of the RVS with
passing along the lower border of the posterior lip of the predominantly vaginal involvement (b), rectal involve-
cervix with the posterior vaginal fornix between the blue ment (c) or both structures (d) (from Guerriero et al. [18]
line and the red line according to the IDEA consensus with permission)
On TVS, RVS endometriotic lesions can be the anterior rectal wall, which is followed by the
described to appear isolated which is very uncom- RVS, is visualized as an anechogenic line due to
mon and extremely rare. Usually, DE of the RVS its three layers of muscle fibres and the covering
involve the vaginal wall, the rectal wall or both mucosa which appears hyperechogenic
(Fig. 11.3b, c, d). The IDEA group emphasizes (Fig. 11.4). In patients with DE of the posterior
the importance of locating the number, size and compartment, the endometriotic tissue infiltrating
anatomical distribution of DE nodules in the rec- the RVS and adjacent structures such as the vagina
tovaginal septum, vaginal wall, rectovaginal nod- and/or rectum usually appears as hypoechoic
ules, rectum, rectosigmoid junction, sigmoid and thickening of the posterior part of the vagina and/
uterosacral ligaments. We believe this is funda- or anterior wall of the bowel (Fig. 11.5a–c).
mental in planning medical and/or surgical treat- Rarely, cystic components of vaginal DE can be
ment and in the follow-up of patients with visualized as hypo- or a nechogenic cystic struc-
DE. The RVS DE nodules should be measured in tures which may vary in size and have smooth or
three orthogonal planes, i.e. midsagittal, antero- irregular contours [6, 20]. Full visualization of the
posterior and transverse [18]. Additionally, the RVS can only be achieved by lifting the probe at
estimated distance between the lower margin of the level of the vaginal introitus. The visualization
the lesion and the anal verge should also be mea- of the RVS should include concomitant visualiza-
sured in the opinion of the authors due to its rel- tion of the rectum and vagina since these struc-
evance for possible surgery. tures will most likely be affected at the same time
In the author’s practice, TVS and possible which therefore allows better orientation and
detection of RVS nodules in patients with DE are localization of disease infiltrating the RVS. DE of
done without bowel preparation or other enhance- the RVS predominantly starts from the level of the
ment techniques. This is predominantly explained upper third of the RVS and will extend down-
by the fact that most patients will not undergo wards into the middle third of the vagina. As a
cleansing of the bowel for personal and infra- consequence, special attention should be given to
structural reasons of our referral setting. Using this area. In cases where bowel contents may cre-
the IDEA algorithm, the transvaginal probe is ate acoustic artefacts or may appear as possible
held in the midsagittal plane of the pelvis visual- thickening of the rectal wall suggesting rectal DE,
izing the uterus and cervix. Then the handle of we suggest to repeat the examination following a
the probe is gradually moved upwards, and at the brief pause of 10–15 min and to possibly use
same time, the tip of the probe is moved down- bowel preparation in selected cases to increase the
wards to visualize the rectovaginal septum
including neighbouring structures such as the
posterior cervix and vaginal wall beginning from
the introitus. Concurrently the rectal wall is thor-
oughly assessed for endometriotic lesions involv-
ing or separated from the RVS.
11.3 Important Technical Tips
In healthy women, the RVS appears as a thin,

hyperechogenic layer between the vagina and
anterior rectum, parity being associated with
increasing length [19]. In the midsagittal section, Fig. 11.4 TVS image (midsagittal section) depicting the
the vaginal wall appears thicker compared to the normal sonoanatomy of the vagina appearing as moder-
ately hypoechogenic line (+), the posterior cervical lip
RVS and usually can be visualized as iso-, partly (**), and RVS appearing as thin and moderately hyper-
moderate hypoechogenic layer which is in direct echogenic line (*) adjacent to the clearly hypoechogenic
contact with the sonographic probe. In contrast, anterior rectal wall (#)
11 Rectovaginal Septum Endometriosis 101
a b
Fig. 11.5 (a) TVS image (midsagittal section) depicting wall (+) with focal infiltration of the upper vaginal fornix
DE of the RVS predominantly infiltrating the vagina and (*) next to the cervix (**). (c) TVS image (midsagittal
RVS (+) and focally the anterior rectal wall (++) which is section) depicting DE of the RVS predominantly infiltrat-
involved above the RVS. Normal RVS (*); cervix (**). (b) ing the vagina (+), RVS and the anterior rectal wall (++)
TVS image (midsagittal section) depicting DE of the RVS which is involved below the level of the posterior cervical
predominantly infiltrating the RVS and anterior rectal lip (*)
sonographic contrast of the vagina, RVS and rec- RVS. Lateral spread will often involve the auton-
tal wall combined with a gel tip in a glove or con- omous nerve fibres and thereby increase morbid-
dom covering the vaginal probe. ity in cases where DE is fully resected, especially
in cases of bilateral inferior hypogastric nerve
involvement.
11.4 Future Perspectives DE extending deep into the RVS usually
involves both the rectum and vagina. In women
Over the past decade, TVS has become a stan- where surgery is considered, TVS may allow to
dard for pre-surgical evaluation of patients with assess the risk of rectovaginal surgery as low
DE. In how far results of TVS influence surgical anterior resections with lesions with a distance
planning and practice is dependent on the grade less than 5–8 cm from the anal verge carry higher
of collaboration between the sonographer and the risks of anastomotic leaks and rectovaginal fistu-
surgeon. In the author’s practice, the ideal sce- las [3, 21]. The decision whether to perform pro-
nario is to perform both TVS and possible conse- tective ileostomies usually depends on the
quent surgery. TVS allows the surgeon to gain a distance between the anastomosis and the anal
non-invasive, in vivo image of the extent of DE verge, concomitant vaginal involvement and
prior to surgery. From the surgical point of view, resection of vaginal DE as well as possible
it is pivotal to estimate the extent of disease later- comorbidities of the patient. The accurate pre-
ally to pelvic sidewalls and caudally into the surgical use of TVS to measure the distance from
the anal verge to the lowermost part of the endo- 10. Bazot M, Lafont C, Rouzier R, Roseau G, Thomassin-
Naggara I, Darai E. Diagnostic accuracy of physical
metriotic nodule may provide this information examination, transvaginal sonography, rectal endo-
prior to surgery and will thereby influence the scopic sonography, and magnetic resonance imag-
surgical strategy. In addition, counselling of ing to diagnose deep infiltrating endometriosis. Fertil
women with DE considering surgery may gain Steril. 2009;92(6):1825–33.
11. Hudelist G, English J, Thomas AE, Tinelli A, Singer
increasing accuracy and quality by adequate CF, Keckstein J. Diagnostic accuracy of transvagi-
information of the extent of disease, possible sur- nal ultrasound for non-invasive diagnosis of bowel
gical complications such as fistula formation and endometriosis: systematic review and meta-analysis.
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12. Guerriero S, Ajossa S, Orozco R, Perniciano M,
the RVS. Future studies on the accuracy of TVS Jurado M, Melis GB, et al. Accuracy of transvaginal
regarding the extent of RVS DE and prediction of ultrasound for diagnosis of deep endometriosis in the
the level of bowel anastomosis in cases where rectosigmoid: systematic review and meta-analysis.
rectal surgery and/or vaginal resections are per- Ultrasound Obstet Gynecol. 2016;47(3):281–9.
13. Bazot M, Malzy P, Cortez A, Roseau G, Amouyal P,
formed are under way. Darai E. Accuracy of transvaginal sonography and
rectal endoscopic sonography in the diagnosis of
deep infiltrating endometriosis. Ultrasound Obstet
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and Sigmoid Endometriosis
12
Manoel Orlando Goncalves, Leandro Accardo de
Mattos, and Mauricio S. Abrao
12.1 Introduction and small intestine, cecum, and/or appendix).

Multifocality is one of the main characteristics of
Deep intestinal endometriosis (DE) is defined as deep endometriosis, mainly when the intestinal
nodules infiltrating at least the muscularis propria tract is involved. Multifocal bowel lesions are
layer [1]. Lesions with dense adhesions and/or observed in up to 30% of the patients with recto-
endometriotic infiltration up to the bowel serosa are sigmoid involvement [2, 4, 5]. Likewise, resec-
not considered DE. Statistical analysis of groups tion of more than one nodule from the bowel wall
considered as reference in highly complex surger- is known to be more complex than resecting just
ies demonstrates that up to 50% of endometriotic one localized nodule [1, 6].
patients may have intestinal involvement [2, 3]. Intestinal endometriosis may cause several
Around 64% of the lesions are located in the symptoms depending on the location, inflamma-
rectum, 21% in the sigmoid, and 15% in the right tory activity, size, and related adherence process.
iliac fossa (appendix, ileum, and/or cecum). The main complaints are cyclic:
The disease may be multifocal (more than one
lesion in the same segment) or multicentric (mul- –– Painful evacuation
tiple lesions affecting different segments—large –– Rectal bleeding
–– Changes in evacuation frequency (more or
less frequent)
M. O. Goncalves
Female Pelvis Diagnosis Section, Alta Laboratory,
Sao Paulo, Brazil In extreme cases, when there is significant
L. A. de Mattos lumen reduction, there may be subocclusive or
Female Pelvis Diagnosis Section, DASA Laboratory, occlusive conditions.
Sao Paulo, Brazil When the bowel is compromised in the right
Department of Diagnostic Imaging, Escola Paulista iliac fossa, there may be cyclic epigastric pain [7].
de Medicina, Universidade Federal de Sao Paulo In some patients, there is a discrepancy
(EPM-Unifesp), Sao Paulo, SP, Brazil between the intestinal and clinical involvement,
M. S. Abrao (*) such as:
Endometriosis Section, Gynecologic Division,
Hospital das Clinicas HCFMUSP, Faculdade de
Medicina, Universidade de Sao Paulo, (a) There is intestinal endometriosis without
Sao Paulo, Brazil specific symptoms.
Ginecologic Division, BP—Beneficiencia Portuguesa (b) There is no intestinal endometriosis, but the
de Sao Paulo, Sao Paulo, Brazil patient presents suggestive symptoms due to

https://doi.org/10.1007/978-3-319-71138-6_12
104 M. O. Goncalves et al.
adjacent endometriotic lesions (mainly retro- and that in special groups, its efficacy might even
and paracervical) with or without adherence be superior to that of the MRI in helping define
to the rectum or sigmoid. the therapeutic planning.
However, one must bear in mind that intestinal

pains or evacuation changes may also be caused 12.2 TVUS Examination
by other diseases (e.g., neoplasias, colitis, and
food intolerance). Some basic concepts must be known in order to
Clinical treatments are palliative and may perform the examination:
reduce or eliminate the symptoms without sig-
nificantly reducing the size of the lesions. Surgery • Terminology and anatomy:
is the therapy of choice for symptomatic patients The distal segment of the colon is divided as
with deep lesions who do not improve with clini- follows:
cal treatment [8]. –– Lower rectum: from the rectal introitus until
The noninvasive DE diagnosis method began approximately 6 cm of the anal verge (AV).
approximately 20 years ago. In 1998 some –– Middle rectum: between 6 and 12 cm of the
authors started publishing articles using the tran- AV.
srectal ultrasound or rectal endoscopic sonogra- –– Upper rectum: between 12 and 18 cm of
phy with good results in detecting and staging the AV.
rectum and sigmoid lesions, but there are certain –– Sigmoid: more than 18 cm of the AV.
disadvantages: it requires the use of specific –– Rectosigmoid transition: this is the transi-
transducers, dedicated equipment, and anesthe- tion region between the rectum and the sig-
sia, and it is ineffective in other sites, mainly the moid, which is anatomically characterized
anterior compartment and ovaries [9–11]. as the ending point of the distal segment of
Magnetic resonance imaging was initially the “taenia coli.” Due to the impossibility
used to detect ovarian endometriosis; however, as of visualizing the “taenia” via imaging
of 2005 [12], specific protocols were developed techniques, the distance of the anal verge
to diagnose deep endometriosis. Continuous (approximately 18 cm above the rectal
learning and further improvement of the equip- introitus) is used as a criterion to locate this
ment led to greater accuracy of the technique [3, region (Fig. 12.1).
13, 14]. Specialized ultrasound examination and –– Peritoneal reflection: the rectouterine
MRI (1.5 and 3.0 T MRI) with dedicated proto- pouch’s most caudal segment where the
cols today share the leadership in diagnosing peritoneum makes a curve separating the
endometriosis. intraperitoneal rectum from the retroperito-
Other techniques, such as barium enema [15] neal rectum. This point is approximately
and computerized tomography [16], may also be 7 cm above the anal verge. The reflection is
used to diagnose DE, but with significant disad- visible when there is fluid in the rectouter-
vantages in terms of accuracy in detecting DE ine pouch, most often in the post-ovulation
and lack of efficiency in evaluating other sites. period. When the peritoneum line is not
Transabdominal and transvaginal ultrasound visible, the following method can be used
(TVUS) were initially only used to examine to define the topography of the reflection:
ovarian endometrioma. However, as of 2003 with a sagittal distal image of the colon and
[11], some researchers started publishing studies the transducer positioned on the anterior
that used TVUS to diagnose deep endometriosis vaginal fornix, trace a line on the coronal
[14, 17, 18, 19]. Despite the variances in proto- axis of the inferior edge of the cervical lips
cols and results among the studies, current meta- [23]. Nevertheless the ideal is direct visual-
analyses demonstrate almost a consensus [20–22] ization of the peritoneal reflection, because
that TVUS is the first-line technique to examine the indirect method may not be precise
deep endometriosis, especially the intestinal one, (Fig. 12.2).
12 Rectum, Rectosigmoid, and Sigmoid Endometriosis 105
Fig. 12.1 Segments of

the rectum and sigmoid. 18 cm
Rectosigmoid transition Sigmoid
(curved arrow) at the
end of “taenia coli”
(blue lines). Peritoneal
reflection (asterisk) 12-18 cm
Upper rectum
6-12 cm
Middle rectum
0-6 cm
Lower rectum
• Bowel layers (Fig. 12.3)

Beginning at the outer layer and continuing
toward the inner layers:
–– Serosa: thin hyperechoic line.
–– Muscularis propria: longitudinal (external)
and circular (internal). Two hypoechoic
strips are separated by a fine hyperechoic
line that corresponds to connective tissue.
–– Submucosa: hyperechoic strip.
–– Muscularis mucosa: hypoechoic line.
–– Mucosa: hyperechoic line.
• Aspect of the deep lesions:
DE lesions are predominantly hypoechogenic;
Fig. 12.2 TVUS-BP: there is approximately a 2.0 cm dif- in addition to the glandular, stromal, and fibro-
ference (white line) between the correct peritoneal reflec-
tion (asterisk) and the estimated one (curved arrow) by a sis component, the intestine’s muscularis pro-
line traced on the lower edge of the cervical lips (yellow pria layer is significantly hypertrophic. When
line) there is simultaneous thickening of the adja-
cent connecting tissue due to retrouterine
As to the compromised intestinal segment, the endometriosis and/or significant adherences,
most important thing is to report whether the an irregular peripheral hyperechogenic com-
lesions are intra- or retroperitoneal, due to greater ponent is observed. Hyperechogenic spots and
surgical difficulty if foci are located under the cysts are rarely seen in intestinal lesions, unlike
reflection and greater risk of postoperative fistu- what is observed in retrocervical and deep vag-
las, especially when a simultaneous opening of inal endometriosis.
the rectum and the posterior vaginal fornix is They tend to be nodular and fusiform in shape
necessary due to deep endometriotic infiltration. with somewhat irregular borders, depending
Iumen
mucosa
mucosa muscularis
submucosa
circular muscularis propria
connective tissue
longitudinal muscularis propria
Fig. 12.3 TVUS-BP: longitudinal view of the intestine with the layers
no study has ever described any characteristic

on color Doppler that may help diagnose or
determine the activity level of the disease, but,
in our experience, the intestinal polyps and neo-
plasias are more hypervascular (Fig. 12.6).
• Information about the lesions:
Once a DE focus is detected, the following
information must be given:
–– Size
The lesions must be measured in the longi-
tudinal, anteroposterior, and transverse
axes. When the compromised segment is
Fig. 12.4 TVUS-BP: DE in the rectum (R) and sigmoid rectilinear, the tool to measure between
(S) adhered to each other and forming a loop in the bowel two points is used; when the loop is curved
(yellow lines)
(“u” shape), the trace is made manually,
following the curve of the intestinal mucosa
on the size and degree of wall infiltration. (Figs. 12.7 and 12.8). When the adjacent
When the lesions affect contiguous segments, connecting tissue is thickened, a peripheral
the aspect may be even more bizarre (Fig. 12.4). hyperechogenic component is observed,
When the intestinal endometriosis is superfi- and when it is well defined, it must be
cial, there is only a slightly irregular thicken- excluded from the anteroposterior mea-
ing adhered to the loop, without alterations in surement of the intestinal lesion.
the muscularis propria layer. Exclusive –– Number of lesions
involvement of the serous membrane is more The number of lesions and the distance
frequently caused by retrocervical or paracer- between them are important to define the
vical endometriosis that adheres to the intes- strategy to be used in surgical cases (Fig. 12.9).
tine (Fig. 12.5) Teams that receive highly complex patients
DE is somewhat hypovascular on Doppler, and have an incidence of approximately 1.5 nod-
its distribution is disorderly or perpendicular to ules per patient with DE [24, 25].
the greater axis of the loop. To our knowledge, –– Compromised circumference of the bowel
a b
Fig. 12.5 TVUS-BP: paracervical endometriosis (a) adhered to and thickening the sigmoid serosa (arrows). With the
use of sepia (b), it is easier to see that the muscular propria layer is normal
a b
c d
Fig. 12.6 TVUS-BP: well-delimited polyp in the intesti- not curve the loop’s external form (arrow). Both protrude
nal lumen (a, b) completely surrounded by the wall into the lumen and are more vascularized (b, d) and well
(arrows). Gastrointestinal stromal tumor (c, d) that does delimited than endometriosis
The significance of the assessment of this of the circumference. In order to estimate

parameter depends on the circumstance, the percentage of the compromised cir-
for its usefulness resides in deciding on the cumference, the best method is to calculate
surgical technique (nodulectomy or seg- the total circumference of the loop (TC)
mental resection). Most patients (approxi- and the transverse diameter of the lesion
mately 80%) present lesions on the anterior (TD) and make the following relationship:
wall of the rectum (up to 12 cm of the anal TD/TC × 100 = % compromised
verge) which compromise less than 40% (Fig. 12.8b).
Fig. 12.7 TVUS-BP: extensive DE infiltrating the submucosa (arrows). Longitudinal (white line) and anteroposterior
(yellow line) measurements
a b
Fig. 12.8 TVUS-BP: (a) DE infiltrating the circular circle (green line) measurements. In (a) we can see an
muscular layer, with normal hyperechogenic strip of the underestimated measurement of the transverse axis using
submucosa (arrow). (b) Calculation of the compromised a straight line in a curved lesion
circumference using the transverse (white line) and full
Fig. 12.9 TVUS-BP: two endometriosis lesions (arrows) in the same segment, separated by normal wall (curved arrow)
a b
Fig. 12.10 Types of lesions that can cause stenosis. (a) Large lesion involving more than 50% of the circumference.
(b) Endometriosis curving the intestine (>90°)
Abrão et al. demonstrated that when the sub- irregular thickening of this layer in the seg-
mucosa is compromised, more than 40% of the ment, irrespective of whether the hyperechoic
circumference is infiltrated at the histological strip that separates the external from the inter-
examination [26]. It is important to mention that nal muscularis propria was interrupted
this parameter is not a criterion for lumen stenosis. (Fig. 12.8a). The criteria used to evaluate the
Significant stenosis is suggested when (Fig. 12.10): infiltration of the submucosal layer are the
existence of hypoechoic tissue originating in
a) The lesions compromise more than 50% of the the serous layer and the muscularis propria
circumference and have an anteroposterior causing partial or total interruption of the
diameter of more than 1.0 cm. hyperechoic line corresponding to the submu-
b) The DE significantly curving the compro- cosal layer (Fig. 12.11).
mised segment—angle greater than 90°. When there is infiltration of several contigu-
To summarize, there are morphological and ous spots, the submucosal layer has a serrated
measurement criteria to diagnose stenosis via aspect (Fig. 12.7). In terms of diagnosis, the
TVUS; however, the subjective impression submucosal and mucosal layers can be con-
that there is little passageway for fecal content sidered a single layer, since this would not
(assessed by the transversal axis of the loop) is impact the decision on which therapy or surgi-
also important. If there is doubt, other tech- cal procedure to adopt [11, 21, 25]. Hudelist
niques may be used, such as colonoscopy, and Goncalves without and with intestinal
opaque enema, or CT with rectal contrast to preparation, respectively, evaluated the effi-
obtain more direct and accurate information ciency of TVUS to determine the depth of the
about the degree of the stenosis. intestinal lesion by endometriosis (Table 12.1).
–– Infiltrated intestinal layers –– Distance of the anal verge
There is DE when the lesion affects at least This is an important data and should be
the muscularis propria layer. The criterion evaluated preoperatively. The surgical treat-
used to predict whether the lesion has infil- ment of lower rectal lesions (defined as
trated up to at least the muscularis propria is beginning less than 8 cm from the anal
the existence of a nodule or hypoechoic, verge) is associated with a higher risk of
a b
Fig. 12.11 TVUS-BP: (a) DE infiltrating the submucosa fornix (arrow) in the same patient, reinforcing the idea
(arrow), characterized by interruption of the white strip of that endometriosis is almost always a multifocal disease
the wall. (b) Deep endometriosis in the posterior vaginal
Table 12.1 TVUS in the evaluation of the layer infil- shaving, circular/linear stapler, or segmental
trated by intestinal endometriosis resection technique.
SM/M To determine the best therapeutic options for
At least MP (Sens/Spec) patients with DE that compromises the sig-
(Sens/Spec) (%) (%)
moid and/or rectum, it is important to under-
Goncalves 2010 with 100/100 83/94
bowel preparation stand the roles of clinical factors,
Hudelist 2009 without 98/99 62/96 preoperative morphologic characteristics
bowel preparation obtained from images, surgical consider-
MP muscularis propria, SM/M submucosa/mucosa, Sens ations, recurrence rate, and impact on qual-
sensibility, Spec specificity ity of life. The analysis of all these parameters
may contribute to restrain the current trend
postoperative anastomotic leaks [27] and tran- toward excessive use of laparoscopic
sient neurogenic bladder dysfunction [28]. colorectal resections [30].
It is difficult to objectively measure the dis-
tance of the anal verge via TVUS mostly
because of the axis of the segment between 3 12.3 Examination Technique
and 8 cm from the anal verge whose angle is
of approximately 90° in relation to the proxi- We always suggest the following bowel prepara-
mal and distal segments of the rectum. This tion prior to the ultrasound examination to detect
assessment is made using two parameters: the endometriosis:
first and the second rectal curves—which are
approximately 3.0 and 8.0 cm distant from the –– Day before: sodium picosulfate 10 mg—oral
anal verge, respectively. Thus, we can esti- simeticone 75 mg, oral—every 8 h
mate the distance of the lesions from the anal –– Day of the exam: rectal enema with 120 mL of
verge (Fig. 12.12). Obtaining this information sodium diphosphate 1 h before the exam
prior to surgery also allows the surgeon to take –– Two-hour fasting before the exam to reduce
a better strategic decision [29]. the possibility of intestinal peristalsis bringing
–– The suprapubic and transvaginal ultrasound feces or air from proximal intestinal segments
allows examination of at least 30–40 cm of the to the rectum or sigmoid
intestine above the anal verge.
The size, number of the lesions (if multiple - This preparation facilitates identification of
distance between them) and the compromised the different intestinal segments, the anal verge,
circumference are important information for and the degree of infiltration of the wall and the
the surgeon to determine whether to adopt the lesions, even when these are small or multiple.
Fig. 12.12 Drawing and TVUS showing the first (at 3 cm AV) and second curves (at 8 cm AV) of the rectum. The
peritoneal reflection (asterisk) is about 7 cm above the AV
Should there still be significant residue despite It is possible to obtain good results in identify-
this preparation, the patient receives another unit ing single lesions in the rectum or sigmoid with-
of phosphoenema and is reevaluated after 15 or out bowel preparation. However, to our
30 min. We have performed the exam with this knowledge, no study has been able to identify
preparation for over 15 years and have not had multiple foci without bowel preparation to date.
any problem regarding acceptance by the patient, In 2010, via TVUS with prior bowel preparation,
as long as she is previously informed about the our group assessed the multiplicity of lesions in
diagnostic advantages. the rectum and sigmoid [25] (Table 12.2).
Table 12.2 TVUS-BP’s ability to detect rectosigmoid 12.4 he Intestinal Tract Exam:
T
endometriosis and estimate the existence of multifocality
Step by Step
Sensitivity Specificity Accuracy
(%) (%) (%)
Initiate evaluation with a suprapubic examination
Lesion 97 100 99
detection of the left iliac fossa [29, 33] using a high-resolu-
Presence of at 81 99 96 tion linear transducer (8–14 MHZ), the same
least 2 lesions used for breast ultrasound. We begin with trans-
versal and longitudinal cuts of the distal descend-
Table 12.3 Comparison between the TVUS with and ing colon and sigmoid, following them up to
without bowel preparation in the diagnosis of rectosig- where possible inside the pelvis. It is usually
moid endometriosis easier to locate the sigmoid by beginning the
Sensitivity Specificity search with transversal cuts on the lateral region
(%) (%) LR+ of the left paracolic gutter and further comple-
TVUS without prior 73 88 6.08 ment these cuts with sagittal images.
bowel preparation
TVUS with prior 100 99 25
With the same transducer, we always examine
bowel preparation the right iliac fossa to detect lesions in the appen-
LR+ likelihood ratio dix, ileum, and cecum. The screening of this area
begins with transversal cuts on the right paracolic
gutter to identify the cecum, which is the larger
Another point worth mentioning is that recent loop with residue observed in this region. After
studies employing transvaginal ultrasound with locating the end of the cecum, we try to find the
prior bowel preparation have also demonstrated exit of the appendix in this region. Its emergence
less learning curve time with this technique [31]. is often medial or central at the end of the cecum
In 2017 Cristina Ros et al. [32] improved sig- and follows inferiorly, at times “diving” into the
nificantly the ability to detect intestinal lesions pelvis beside the iliac vessels. When the tip or the
using prior bowel preparation (Table 12.3). entire appendix is in the pelvis, we must continue
Several authors have proposed different proto- the evaluation while performing the transvaginal
cols, such as water enema, tridimensional ultra- exam. The majority of the lesions are at the tip of
sound, exam guided by the patient’s pain, and the appendix, causing it to curve (shape of a
others. walking cane with a curved handle). Subsequently,
We believe that the main factors that lead to an with transversal cuts, we move 2 or 3 cm upward
accurate diagnosis of deep endometriosis, espe- to locate and follow the terminal ileum that
cially the intestinal one, are: emerges medially from the cecum (ileocecal
valve). We follow the ileum until it is inferiorly
–– Examiner’s specific experience in TVUS for possible with the linear transducer and later com-
identification of endometriosis plement this exam by analyzing the pelvic ileal
–– Facilitating protocols loops with the transvaginal transducer. The aspect
–– Examination of all sites in all patients, of the lesions is similar to that observed in the
whether or not there are specific symptoms rectosigmoid, and these may be single or multifo-
and even if the gynecological examination is cal/multicentric. When observing the lesions in
within normality the ileum and appendix, the differential diagnosis
for neoplasias (mainly neuroendocrine tumors)
Our team has always opted for the pelvic and must be borne in mind, for the aspect can be very
transvaginal ultrasound with prior intestinal prep- similar to that of DE (Fig. 12.13). A safe way to
aration in view of our belief that this is the most differentiate them has not yet been described;
effective and practical method to obtain a high however, when other foci of endometriosis are
level of accuracy. However, each group must test observed in the pelvis, there is very little possibil-
the protocols proposed and found in literature and ity of neoplasia. In case the lesions are located
determine which has the best outcomes for them. only on the right iliac fossa or if in doubt, the
a b
Fig. 12.13 Suprapubic ultrasound with high-resolution linear transducer: nodular thickening at the tip of the appendix
(arrows), being endometriosis in (a) and carcinoid tumor in (b)
patient must be submitted to surgery for excision lesions are located in the anterior wall, some are
and anatomic pathological analysis. more laterally located and can only be clearly
The suprapubic examination of the loops with seen with a transversal view. It is important to
a high-resolution transducer is more limited remember that endometriosis foci are seldom
when there is some content on the loops or in seen in the posterior wall of the rectum, for
obese patients. Nonetheless, employment of lesions that occupy the totality of the circumfer-
dosed compression with the transducer and the ence are rare, and there are no isolated lesions on
prior bowel preparation minimize these issues. the posterior wall. We recommend at least two
Subsequently, the transvaginal transducer is complete evaluations from the rectal sphincter to
introduced (transvaginal ultrasound with bowel the proximal sigmoid. In the first evaluation, the
preparation—TVUS-BP) and guided to the loop is examined mainly in its longitudinal axis
patient’s sagittal axis with the beam angled and, in the second, in its transversal axis. Three-
downward (30–60°) to locate the rectum dimensional transducers that allow the examiner
(Fig. 12.12). to manually angle the beam reduce the patient’s
We follow the intestine along the several seg- discomfort because it is thus not necessary to
ments: rectum, rectosigmoid transition, and sig- angle the transducer as much during transversal
moid, along the curves. Most patients have a evaluation of the lower and middle rectum.
curve to the right and another one immediately to A normal rectosigmoid wall is 1–2 mm thick.
the left after the rectum, leading to the left Diffuse circumferential thickenings are related to
adnexal region and passing beside the ipsilateral inflammatory processes (colitis) or diverticular
ovary (Fig. 12.14). However, there are many vari- disease. DE is characterized by focal thickenings
ations in the extension and topography of the sig- that begin in the most external layers (serosa and
moid. This also justifies the prior bowel muscularis propria) and may infiltrate even the
preparation, for it makes it easier to follow the mucosae. In most cases, if we make a transversal
loop. cut, the thickened areas will be located in the rec-
The examiner must evaluate the largest possi- tum between 9 and 3 o’clock. The sigmoid pres-
ble rectum and sigmoid segment (usually up to ents greater variability of foci location, but the
30–40 cm of the anal verge) in the longitudinal other characteristics (texture and morphology)
and axial axes of the bowel. Although most of the are similar to those of the rectum.
ment—including the foci and the areas that are

free of endometriosis. Therefore, if a rectosig-
moidectomy is indicated, the surgeon has an idea
of the total segment to be excised.
The techniques adopted to resect DE vary
according to each surgeon’s experience and pref-
erence [34, 35]; however, generally speaking,
shaving is performed when there is superficial
infiltration of the bowel loop (serosa and external
muscularis propria). In such cases, total thick-
ness of the wall does not usually exceed 7 mm
and compromises up to 30% of the circumfer-
ence. For nodules less than 3 cm in length and
without stenosis, a discoid resection can be per-
Fig. 12.14 Drawing showing one of the most frequent formed, despite the depth of the lesion [5, 36].
trajectories of the rectum and sigmoid Double discoid resection in the same nodule (of
up to 4.0 cm) or in distinct nodules has been
described [37, 38]. For nodules exceeding 3 cm
When the examiner suspects there is focal in length, for multiple nodules, for compromise
thickening of the wall, he must compress the of more than 40% of the circumference [6], or for
transducer lightly to rectify the loop and perform significant stenosis, the tendency is to perform a
visualization in several axes (transversal and lon- rectosigmoidectomy. However, more extensive
gitudinal) to verify if it is not an artifact or super- and deep shavings have been described in these
position of images. False positives are more cases, and the surgical conduct to resect the intes-
common on intestinal curves. tinal endometriosis remains controversial and
Once the lesion is found, all information varied and depends on the experience of the sur-
described above must be obtained. The following geons and their teams.
is a chart with data that we attach to the report: As in other endometriotic sites, there are asso-
ciated adherences. The same criteria used for
Distance from the ____ cm
other sites are adopted to evaluate the presence of
anal verge
Dimensions Longitudinal × anteroposterior adherences to the intestine, i.e., if the bowel is too
× transversal close to another organ or if there are thickenings
% circumference ___ % connecting it to other structures, the transducer is
compromised moved frontward and backward, pushing the
Compromised layers Serosa/muscularis propria/
organs and certifying in real time whether there is
submucosae
Significant stenosis Yes/no/doubtful or not sliding among them.
In case of adherences in the lower posterior
When there is doubt whether the patient has compartment, there may be cul-de-sac block
significant stenosis and she will not undergo sur- (CSB), which is surgically defined as an adher-
gery, we indicate further assessments with spe- ence process that inhibits visual access of the
cific exams (colonoscopy, CT with rectal contrast, peritoneum under the insertion of the uterosacral
or opaque enema). ligaments [39]. CSB may be partial (unilateral)
If there are several lesions, each of them must or total (bilateral). CSB’s most common cause is
be described with all the information necessary rectum adherence to the vagina and/or cervix
listed on a separate chart, as above. The distance (Fig. 12.15). It may occasionally have other
between the lesions must also be measured as causes, especially when the two ovaries are fixed
well as the total size of the compromised seg- retrouterine and both are adhered to the rectum or
Fig. 12.15 TVUS-BP: deep endometriosis of the rectum (curve arrow) adherence to the posterior vaginal fornix lesion
(arrow), causing complete Douglas cul-de-sac blockage
sigmoid. In terms of TVUS, it may be said that 12.5 Controlling Development

there is CSB when we identify a significant
adherence process, usually involving the rectum As in other forms of deep endometriosis, DE has
and/or ovaries at the level of insertion of the a rather slow development curve. Therefore, if
uterosacral ligaments. there is no risk of stenosis or increased symp-
Some authors [23, 40] use the term sliding toms, controls may be made in 6–12 months.
sign positive or negative to define if there is any In case of surgeries with resection of intestinal
sliding between the cervix and the intestine (ante- nodules and as long as the postoperative period
verted uterus) or between the cul-de-sac and the presents no complications, we suggest the first
rectosigmoid (retroverted uterus). To obtain control be made after 3 months. This is so because
greater exam sensitivity (as is done in the ova- practically the entire postoperative reaction
ries), the examiner moves the transvaginal trans- process should have already regressed during this
ducer to push the uterus while pressing the period, and it is possible to evaluate the condition
anterior wall of the lower abdomen with his free of the bowel and the related adherences/collec-
hand. If there is sliding, the sign is positive and tions. Ideally, there should be no residual thicken-
there should not be CSB. If there is no sliding, the ing or fluid collected in the manipulated region.
sign is negative and suggestive of CSB [41]. Should there be parietal thickening, measure-
Hudelist also suggest that the negative sliding ments should be made in the longitudinal, antero-
sign indicates deep intestinal (rectal) endometrio- posterior, and transversal axes for further control
sis; however, certain factors, such as large uterus in 6–12 months. When staples are used to close
and large ovarian cysts located posteriorly, in the loop, it is possible to visualize them at trans-
addition to chronic inflammatory or adherence vaginal ultrasound and to determine if it was dis-
processes that are not related to endometriosis, coid or a segmental resection (anastomosis) and if
may also lead to a false negative result. False the staples occupy only one quadrant or the total
positives may also occur in this maneuver since circumference of the loop in the transversal axis.
many rectal lesions do not cause a significant In more extensive intestinal surgeries, mainly
adherence process. Therefore, we recommend of the rectum, it is very common to observe
that the sliding of the structures be used as a fac- adherences and small quantity of fluid collected
tor solely to assess the adherence process and that and/or septated anechoic around the loop. In gen-
diagnosis of deep endometriosis be based on the eral, these findings do not cause significant
direct visualization of the lesions. symptoms.
12.6 False Positives base or sessile with a wide base. Texture and vas-
cularization vary, but, in general, they are more
The main causes leading to false positives in vascularized than DE (Fig. 12.6a, b).
intestinal endometriosis are: Gastrointestinal stromal tumor (GIST): This is
the most difficult differential diagnosis, for its
–– Accentuated curves with fan-folded loops. nodules are hypoechogenic and quite homoge-
Solution: compression maneuver with the neous. However, unlike DE, they are usually
transducer, repairing the loop. round and have well-defined limits and do not
–– The sigmoid crosses the left round ligament curve the loop’s external form. Vascularization
(Fig. 12.16). Solution: rotate the transducer, varies but is generally more accentuated than in
and observe if the thickening extends out of DE (Fig. 12.6c, d).
the loop and heads toward the uterine horn. Adenocarcinomas: Primary neoplasias of the
Unless it is compromised by endometriosis, intestine, when observable at ultrasound, are
the ligament’s texture is similar to that of the more hyperechogenic than DE, with poorly
uterus, unlike the DE, which, in general, is defined limits, and they grow from the mucosae.
hypoechogenic. At color Doppler, they are hypervascular and are
–– The tube is adjacent or adhered to the intes- disorderly distributed.
tine. Solution: rotate the transducer, and Should there be doubts concerning differential
observe if the thickening extends outside the diagnosis, the colonoscopy is the standard exam.
loop. In addition, a Doppler allows detection
of the typical vascularization of the tube,
which is characterized by thin vessels that are 12.8 Exam Time
parallel to the greater axis and at time have a
spiral aspect. DE is quite hypovascular at Following the protocol we have developed, with
Doppler; when it is present, it has a disordered the suprapubic evaluation of the right iliac fossa
aspect or is perpendicular to the greater axis of and the proximal sigmoid (linear transducer) and
the loop. transvaginal, it takes us around 15–25 min to
examine the intestinal sites. Some factors impact
the exam time: inadequate preparation, number
12.7 Differential Diagnoses of detected lesions, and related adherence pro-
cess. Large uteri, retroverted uterus, or ovarian
Polyps: These are easily differentiated from DE cysts larger than 5 cm may also make the exami-
due to their location in the loop’s lumen and well- nation more difficult, mainly of the sigmoid, thus
defined limited. They may be long with a narrow increasing exam time.
a b
Fig. 12.16 TVUS-BP: (a) transversal view—apparent endometriosis (arrow) in the sigmoid (S) wall. (b) Turning the
transducer, it is possible to see that it is a false lesion caused by the normal left round the ligament (arrows)
12.9 Important Technical Tips sufficient resolution to identify small

intestinal endometriosis lesions. This
–– All patients with suspected endometriosis, examination is more difficult to perform
even if they do not have intestinal symptoms, in obese women. However, employment
must perform bowel preparation. As in other of dosed compression with the transducer
types of deep endometriosis, the symptoms on the abdominal wall minimizes the
are not always exactly related to the compro- problem.
mised region or to the severity of the process. –– Initiate the transvaginal examination by
–– If there is fecal residue after the oral prepara- evaluating the intestine and performing a
tion and the phosphoenema, we ask the patient first quick screening up to the sigmoid,
to be submitted to another rectal phosphoen- even if the examiner promptly identifies a
ema. If, even so, the preparation is still inade- focus in the rectum. In view of the light
quate, we ask the patient to return the following prior bowel preparation which eliminates
day after a more rigorous preparation. We basically the residue in the rectosigmoid,
have had extremely rare instances in which we if the examiner takes too long to examine
ask the patient to return the following day. the sigmoid, content from the left colon
–– Examine all possible endometriosis sites in all might flow down and impair the examina-
patients, regardless of the medical center or tion. Always examine all segments in the
physical examination. longitudinal and transversal axes. The
–– Inform the patient about the procedure and transversal screening must be done at the
that the discomfort is similar to that of a rou- end of the examination for it causes a
tine transvaginal examination. The exam does stronger discomfort to most of the patients.
not cause significant pain, but there are factors –– It is easier to follow along the intestine if
that may increase pain, such as vaginismus, the transducer is positioned in the poste-
anxiety, and very large or retroverted uteri, in rior vaginal fornix. If the uterus is large or
addition to endometriosis itself. if there are large ovarian cysts, at times it
is not possible to position the tip of the
Factors that may reduce pain: transducer closer to the wall of the loop.
In such cases, follow the loop using the
(a) Slowly introduce the vaginal transducer uterus or ovary as a “window” (Fig. 12.17).
lubricated with gel. –– Postoperative control in up to 3 months.
(b) If it is a 3D transducer with manual move- Bowel preparation is usually not necessary
ment of the crystal, rotate the ultrasound in this postoperative control unless the sur-
directing it to the pouch when examining the geon did not locate the intestinal lesion
rectum in the transversal axis. described prior to the surgery or supposes
(c) Let the patient stretch her legs. This enables a significant residual focus still remains. It
a better angle of the uterus and reduces the should be borne in mind that, in addition to
transducer inclination as well as allows the the possibility of false positives and nega-
patient to be more relaxed. tives at ultrasound, the surgeon not always
(d) Sedation: in general, sedation is never neces- manages to locate small and isolated sig-
sary. However, if the patient wishes, she may moid lesions, especially when there is not
take a tranquilizer. Extreme cases may related adherence process.
require sedation such as in endoscopies. –– The initial learning curve in diagnosing DE
–– Use high-resolution linear transducers via ultrasound is quicker than one sup-
(10–15 MHZ) for the suprapubic intesti- poses, even when we are referring to ultra-
nal examination. The conventional sonographers that only perform pelvic
abdominal transducers (3–5 MHZ) or examination. However, ultrasonographers
micro-convex (6–9 MHZ) does not have experienced in abdominal ultrasonography
Table 12.4 Results of TVUS intestinal endometriosis

detection obtained by trainees against the results obtained
by their expert trainer (approximately 95% sensitivity and
specificity in this diagnosis)
Sensitivity (%) Specificity (%) LR+ LR−
Trainee 1 72 96 16.6 0.29
Trainee 2 89 95 19.6 0.12
Only 50% of the patients underwent surgery. LR likeli-
hood ratio
12.10 Future Perspectives
There are currently few medical centers dedi-

cated to the diagnosis of deep endometriosis with
high levels of accuracy; thus, the first short- and
medium-term perspective is that more special-
ized centers be created and the protocols be more
Fig. 12.17 TVUS-BP: uterus increased in volume, with homogeneous.
fibroids (N), preventing the placement of the transducer in The greater development and spread of 3D
contact with the bowel. The sigmoid seen through the equipment will make it possible for experts to
uterus, with endometriosis (arrow). The other wall is nor-
assess this technology in advanced centers of pri-
mal (curved arrow)
mary health services.
Initial study on the use of fusion imaging
have an initial advantage, especially those (real-time ultrasound and multiplanar recon-
who perform US of the hollow viscus. In structed MR images) for endometriosis was pub-
any case, the basic prerequisite for quicker lished [43]. However, these programs have still to
progress is vast experience in diagnosing be further developed in order to prove they can
gynecological pathologies. actually significantly enrich the diagnosis.
As to the ultrasound detection of deep intesti-
The table below shows the results obtained by nal endometriosis, the more experienced centers
Tammaa et al. [42] in connection with the learn- are close to 100% sensitivity and specificity;
ing process to perform transvaginal ultrasound thus, there is little space for further progress.
for diagnosis of rectum or sigmoid endometrio- However, knowledge dissemination and develop-
sis. Summarizing: ment of new technologies are challenges still to
be overcome.
–– Approximately 40 expert-supervised exami-
nations are necessary for the trainee to reach
60–80% of the effectiveness and efficiency of 12.11 Final Comments
an experienced examiner.
–– The learning process varies significantly Integration of highly trained professionals in the
among the trainees (Table 12.4). fields of diagnosis and treatment of endometrio-
sis is essential for adequate therapeutic planning.
Surgeons and imaging examiners must pro- In cases of surgery, this integration allows the
vide ongoing feedback in order to achieve diag- patient to be informed on the procedure and
nostic progress. Completed reports with the helps build a multidisciplinary team when neces-
main findings of both groups and regular com- sary. It is thus possible to diagnose, treat, and
parison of results are preferable, and an anatomic monitor patients in a more accurate manner
pathologist will have the final say in cases of while reducing costs and, most importantly,
discrepancy. improving the patients’ quality of life, not to
mention increasing pregnancy possibility and 11. Bazot M, et al. Transvaginal sonography and rectal
endoscopic sonography for the assessment of pel-
reducing psychological and physical troubles vic endometriosis: a preliminary comparison. Hum
caused by endometriosis.Compliance with Reprod. 2003;18:1686–92.
Ethical Standards 12. Takeuchi H, et al. A novel technique using magnetic
resonance imaging jelly for evaluation of rectovaginal
endometriosis. Fertil Steril. 2005;83:442–7.
Funding This chapter did not receive external 13. Hottat N, et al. Endometriosis: contribution of 3.0-T
funds. pelvic MR imaging in preoperative assessment—ini-
tial results. Radiology. 2009;253:126–34.
Conflict of interest The authors certify that they 14. Abrao MS, et al. Comparison between clinical
examination, transvaginal sonography and magnetic
have no affiliations with or involvement in any resonance imaging for the diagnosis of deep endome-
organization or entity with any financial interest. triosis. Hum Reprod. 2007;22:3092–7.
15. Ribeiro HS, et al. [Double-contrast barium enema in
Ethical approval This chapter is a review which the diagnosis of intestinal deeply infiltrating endome-
triosis]. Rev Bras Ginecol Obstet. 2008;30:400–5.
does not contain any studies with human partici- 16. Biscaldi E, Ferrero S, Remorgida V, Rollandi
pants or animals performed by any of the authors GA. Bowel endometriosis: CT-enteroclysis. Abdom
Imaging. 2007;32:441–50.
17. Hudelist G, et al. Combination of transvaginal
sonography and clinical examination for preopera-
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Other Locations of Deep
Endometriosis
13
Stefano Guerriero, Silvia Ajossa,
Ornella Comparetto, Camilla Ronchetti,
Virginia Zanda, Bruno Piras, Alba Piras,
and Valerio Mais
13.1 Introduction tion systems for extrapelvic endometriosis, although

in 1989, Markham et al. [3] proposed a classifica-
While pelvic endometriosis is defined as lesions of tion system that divided extragenital endometriosis
the fallopian tubes, ovaries, and local peritoneum, into four different classes including a class “I”
extrapelvic endometriosis refers to endometriotic involving the intestinal tract, a class “U” involving
implants found elsewhere in the body [1]. The the urinary system, a class “L” involving the lung
extrapelvic implantation of endometrial tissue has and thoracic cavity, and a class “O” involving “all
been described in virtually every organ, system, and other sites.” However, this classification remains
tissue in the body [2]. The true prevalence of extra- underused in the literature. In the present chapter,
pelvic endometriosis is unknown because of a lack we will describe only the localizations in which the
of well-defined epidemiological studies; in fact, use of ultrasound has been reported, in particular:
only surgical and gynecological case reports are
reported. Many diagnostic methods have been pro- (a) Abdominal wall endometriosis
posed, but none of them represents the gold stan- –– Laparotomy scar endometriosis (most
dard. The role of ultrasonography has been proposed frequent)
and recognized only in some locations [1]. –– Umbilical (0.5–1% of all cases of extra-
The multiple localization of endometriosis in genital endometriosis)
combination with the wide range of its clinical –– Inguinal canal or canal of Nuck
expressions should raise the clinical suspicion in endometriosis
every woman with cyclical symptoms in extrapelvic –– Rectus abdominis muscles
organs. There are currently no accepted classifica- (b) Abdominal organs
–– Lower abdomen (endometriosis of the
Electronic Supplementary Material The online version appendix)
of this chapter (https://doi.org/10.1007/978-3-319-71138- –– Upper abdomen (hepatic and diaphrag-
to authorized users. matic endometriosis)
S. Guerriero (*) · S. Ajossa · O. Comparetto

C. Ronchetti · V. Zanda · B. Piras · A. Piras · V. Mais
Department of Obstetrics and Gynecology, University 13.2 Abdominal Wall
of Cagliari, Policlinico Universitario Duilio Casula, Endometriosis
Monserrato, Cagliari, Italy
e-mail: gineca.sguerriero@tiscali.it; gineca.sajossa@
Abdominal wall endometriosis is defined as the
tiscali.it; camilla.ronchetti@fastwebnet.it; zavirgi@
tiscali.it; valerio.mais@alice.it presence of ectopic endometrium located at the

https://doi.org/10.1007/978-3-319-71138-6_13
abdominal wall structures. It is a predominantly Unfortunately this condition is often misdiag-

iatrogenic condition. Many cases of abdominal nosed since endometriosis may occur from
wall endometriosis occur after laparoscopy or 6 months to several years after surgery, the pain is
laparotomy involving the uterine cavity. Most often not cyclic, and not always there is a palpa-
cases of abdominal wall endometriosis occur as a ble mass. The sonographic finding of a solid mass
result of closure to cesarean-section scars, but in the abdominal wall is not pathognomonic for
some lesions are not a consequence of the previ- endometriosis, but if located close to a cesarean
ous surgery. The extremely high incidence of a section scar, it should be considered in the dif-
history of previous cesarean section in the abdom- ferential diagnosis (Figs. 13.1, 13.2, and 13.3)
inal wall endometriosis group suggests that the (Videos 13.1, 13.2, 13.3, 13.4, and 13.5) [4].
endometrium during pregnancy may have certain
characteristics that make transplantation and
implantation particularly successful [1]. 13.2.2 Villar’s Nodule
Symptoms of abdominal wall endometriosis
include a growing, painful, tender mass that may Umbilical endometriosis, also known as Villar’s
increase in size and become more painful during nodule, is a rare occurrence and is often a result
menses. Cyclical bleeding can occur at the site of of iatrogenic seeding in surgical scars (Fig. 13.4).
the lesion [4]. The success rate of medical therapy Umbilical endometriosis in the absence of any
has been reported to be low, offering only tempo- prior abdominal or uterine surgery is an even
rary relief of symptoms often followed by recur- rarer clinical entity [6]. Umbilical endometriosis
rence after cessation of the drug. Wide surgical has been reported in more than 100 cases and was
excision therefore is the treatment of choice [4]. first described by Villar in 1886. The umbilicus
represents the location of 0.5–1% of extrapelvic
endometrioses [7].
13.2.1 Scar Endometriosis It may appear during active menstrual life as a
small, firm, bluish-pink mass in the umbilical
This condition is caused by the dissemination of area, with a diameter varying from a few milli-
endometrial tissue into a wound at the time of meters to 6 cm. It may cause pain, swelling, or
surgery. The deposits can involve uterine scar, tenderness mainly in the premenstrual period.
abdominal musculature, or subcutaneous tissue. Sometimes secretion or some bleeding may occur
Endometriosis has been reported in scars origi- through the umbilical skin, concomitant with
nated after cesarean section, in episiotomy scar menses; for this reason, it is often called the
after delivery, and in consequence of procedures “menstruating tumor.” Umbilical endometriosis
involving contact with endometrial tissue, such frequently exists as a solitary lesion without
as hysterectomy, ectopic pregnancies, salpingos- accompanying pelvic disease [7] (Figs. 13.5,
tomies, and those performed during the first half 13.6, and 13.7) (Videos 13.6 and 13.7).
of pregnancy [5].
Reported incidences vary around 3.5% of
women who had a gynecological intervention [5] 13.2.3 I nguinal Endometriosis or
and could be present in approximately 0.8% of Canal of Nuck Endometriosis
all women who had cesarean deliveries. The
occurrence of endometriosis in the episiotomy The canal of Nuck is an evagination of the parietal
scar is less frequent than in scars of the abdomi- peritoneum that accompanies the round ligament
nal wall [4]. Cesarean section might be the first through the inguinal ring into the inguinal canal.
risk factor for the development of scar endome- Endometriosis in the inguinal region was first
triosis. This high risk can be explained by the reported by Cullen in 1896, and the incidence of this
higher exposure of endometrial cells to the sub- localization of endometriosis in women was found
cutaneous tissue during the procedure [5]. to be 0.6% [8]. Direct extension of endometrial
13 Other Locations of Deep Endometriosis 123
a b
c d
Fig. 13.1 Some ultrasonographic images of scar endo- tures (c) and (d), using linear probe. The resolution is bet-
metriosis (straight arrows) in a 32-year-old woman with a ter in (c) and (d) due to higher frequencies with a more
cesarean section 6 years before. In the pictures (a) and (b), detailed and sensitive color Doppler evaluation (d)
the nodule visualized using convex probe and, in the pic-
Fig. 13.2 Ultrasonographic images of two nodules of scar endometriosis (straight arrows) in a 39-year-old woman
with a previous cesarean section 6 years before
Fig. 13.3 Color Doppler ultrasonographic images

(straight arrows) of a scar endometriosis in a 39-year-old
woman with one previous cesarean section 6 years before Fig. 13.4 The typical appearance of Villar’s nodule
Fig. 13.5 The ultrasonographic appearance of Villar’s Fig. 13.6 A more detailed visualization (due to a better
nodule (straight arrows) in a 33-year-old woman without focalization) of Villar’s nodule (straight arrows) of
previous abdominal surgery Fig. 13.5. The solid appearance is more evident
a b
Fig. 13.7 The ultrasonographic appearance of Villar’s abdominal surgery. In this case, the ultrasonographic
nodule (straight arrows) using B-mode (a) and color appearance was more cystic than solid
Doppler (b) in a 20-year-old woman without previous
Fig. 13.8 Sonographic features of right inguinal endo-

metriosis presenting as a cystic mass with internal septa,
hypoechoic content, and few peripheral color spots
located in inguinal area
tissue along the round ligament is a possible patho-

genesis of inguinal endometriosis because, occa-
sionally, it will remain patent, creating a link between
the peritoneal cavity and the inguinal canal [9]
(Fig. 13.8) (Video 13.10). More than 90% of ingui-
nal endometriosis cases are right sided and often
associated with an inguinal hernia. Common symp- Fig. 13.9 The ultrasonographic appearance of a rectus
toms associated with inguinal endometriosis are abdominis endometriosis (straight arrows) in a 30-year-
inguinal pain and the presence of an inguinal mass, old woman with one previous cesarean section 4 years
which sometimes becomes enlarged during the before. The muscular layer (star)
menstrual period [8].
13.2.4 Rectus Abdominis

Endometriosis
Endometriosis involving the rectus abdominis

muscle is a very rare occurrence. Up to the pres-
ent, only 18 cases with lesions contained entirely
within the rectus abdominis muscle were clearly
documented in medical literature with only four Fig. 13.10 The power Doppler ultrasonographic appear-
cases as a primary location [10] (Figs. 13.9, ance of a rectus abdominis endometriosis (straight
arrows) in a 30-year-old woman with one previous cesar-
13.10, and 13.11) (Videos 13.8 and 13.9). ean section 4 years before. The muscular layer (star)
13.2.5 Intra-abdominal immunologic functions, has not been a site of

Endometriosis reported endometriosis [1].
Endometriosis can be located in every organ of

the abdomen. Case reports include findings of 13.2.6 Endometriosis of the Appendix
extrapelvic endometriosis in the appendix, inside
liver parenchyma, and diaphragm muscle. Endometriosis of the appendix is a rare condi-
Interestingly, the spleen, with its important tion. It may be asymptomatic or present as acute
sis can be difficult with the differential diagnosis

including both benign conditions, such as echi-
nococcal cyst, abscess, hematoma, cystadenoma,
and malignant cystic neoplasms, such as cystad-
enocarcinoma or metastatic disease [12]. The dif-
ferential diagnosis of appendicular endometriosis
should include diverticular disease, colorectal
carcinoma, inflammatory bowel disease, carci-
noid tumors, benign intramural neoplasm, occult
intra-abdominal metastases, mesenteric neo-
plasm, and pelvic abscess [13].
Fig. 13.11 The sonoelastographic appearance of a rectus Malignant transformation has been reported in
abdominis endometriosis (straight arrows) in a 30-year- approximately 1% of endometriosis cases, and
old woman with one previous cesarean section 4 years
most frequently this transformation takes place at
before
the ovary, accounting for about 80% of the
endometriosis- associated malignancies [14].
appendicitis, lower gastrointestinal bleeding, Malignant transformation of endometriosis occur-
intestinal perforation, or intestinal obstruction ring in surgical abdominal scar is very rare: clear
from intussusception. Appendiceal endometrio- cell histology accounts for only 4.5% of extrago-
sis can be diagnosed histopathologically. The nadal endometriosis-associated malignancies
mucosa of the appendix is never affected, and while representing the most common histotype in
usually glandular tissue, endometrial stroma, and case of parietal localization [15]. A series of 23
hemorrhage are observed in the muscular and cases of endometriosis associated with clear cell
seromuscular layers [11]. carcinoma (CCC) arising within cesarean section
scar are reported in the literature [16]. Despite the
rarity of this condition, the number of reported
13.2.7 Hepatic Endometriosis cases has increased over time likely due to a
higher attention focused on this disease but also to
Hepatic endometriosis is one of the rarest local- the increased rate of cesarean sections and uterine
izations of extrapelvic endometriosis; only 22 surgeries documented over time. Careful collec-
cases have been reported so far in the literature. tion and evaluation of patient history would be
The pathogenesis of hepatic endometriosis is important to have a high index of suspicion for
unclear with vascular-lymphatic dissemination endometriosis-associated malignancy. These
having a potential role. Although ultrasound, masses usually reach very large dimensions
computerized tomography (CT), and magnetic before the diagnosis is made [16].
resonance imaging (MRI) are helpful, no typical
image of endometriosis cyst has been described,
so the final diagnosis can be made only by histo- 13.3 How We Do It
logical evaluation [12].
1. Importance of history and concomitant
13.2.7.1 Differential Diagnosis assumption of oral contraceptives
and Transformation A detailed clinical history should be taken for
Endometriosis of the abdominal wall may be dif- all women with suspected endometriosis, with
ficult to diagnose; it is often mistaken both clini- particular emphasis on symptoms. The follow-
cally and by diagnostic imaging for other ing should be noted specifically: previous myo-
abnormal conditions such as a suture granuloma, mectomy or cesarean delivery (the main cause
an incisional hernia, or primary or metastatic of this extrapelvic endometriosis lesions), pre-
cancer [4]. The diagnosis of hepatic endometrio- vious surgery for endometriosis, family history
of endometriosis, previous nonsurgical treat- appear hypoechoic or hyperechoic [7].

ment for endometriosis (type, duration, effect), Usually few peripheral color Doppler spots
the kind of pain (chronic and acute pelvic pain are present (Fig. 13.8) (Video 13.10).
more or less related with the menstruation), and 4. Modality of evaluation of localization
concomitant use of oral contraceptives because The operator should note not only the presence of
there can be a delay in diagnosis due to partial the lesion but also the number of lesions, the
resolution of symptoms. The onset and dura- localization (right, left, and median, at the
tion of symptoms should be noted and, if pos- level of the umbilicus, or at the right/left
sible, the intensity of the pain recorded by inguinal canal), the depth (superficial, in the
asking the patient to use a visual analog scale subcutaneous fat tissue or involving the mus-
or investigating it with a 0–10 narrative numeric cle layer or between these two layers also
rating scale [17]. evaluating the relationship with the fascia),
2. Kind of probe to be used in case of suspicion and the relationship with the scar of a previous
of extrapelvic deep endometriosis cesarean section. In addition, the operator
Transabdominal sonography using a linear should evaluate the dimensions of the lesions
transducer (5.0–13.0 MHz) is mandatory in recording the three orthogonal diameters.
detecting, locating, and characterizing abdom- Power Doppler sonography, with a pulse rep-
inal wall endometriosis [18]. If possible, etition frequency of 500–750 Hz, is useful to
depending of the deepness of lesion, linear assess the vascularity of all lesions (Figs. 13.1,
superficial probe should be useful to guide the 13.3, and 13.7) (Videos 13.3, 13.7, and 13.9).
surgical removal and repair. Excessive vascularization is related to the neo-
3. Typical ultrasonographic findings plastic transformation and is mandatory for
At ultrasound examination, abdominal the differential diagnosis.
wall endometriosis shows features similar to
those of deep infiltrating pelvic endometriosis
but different from those of ovarian endome- 13.4 Important Technical Tips
trioma. The nodules appear solid with ill-
defined outer borders (Figs. 13.1, 13.2, 13.3, 1. Use of the highest possible frequency to better
13.4, 13.5, 13.6, 13.7, 13.9, 13.10, and 13.11). define the border of the lesion and the vascu-
It is necessary to evaluate the appearance of larization (Fig. 13.1).
the margins (smooth, irregular, or frankly 2. Suggest to the women to move her legs alter-
spiculated) [18]. A cystic lesion is present in natively during the scan to better identify the
few cases (Villar and Nuck nodules) muscular layer (Videos 13.8 and 13.9).
(Fig. 13.7). The echotexture should be evalu- 3. Evaluate multifocality because multiple
ated and compared with that of adjacent nor- lesions are possible.
mal subcutaneous tissue. On ultrasound, scar 4. Perform a concomitant TV evaluation using
endometriosis usually appears as an inhomo- the International Deep Endometriosis Analysis
geneous hypoechoic roundish nodule with (IDEA) protocols [17] to exclude other asso-
fibrotic changes (in the form of hyperechoic ciated endometriotic lesions. As a matter of
spots or strands), a peripheral hyperechoic fact, the purpose of performing an ultrasound
ring, spiculated margins, and a single vascular examination in a woman with diagnosis of
pedicle entering the mass at the periphery extrapelvic endometriosis and with suspected
(Figs. 13.1, 13.2, and 13.3) [19]. pelvic endometriosis is to try to explain under-
Sonographic features of inguinal endome- lying symptoms, map the disease location,
triosis are variable. It could present as a solid and assess the severity of disease prior to
mass, a cystic mass (Fig. 13.8) (Video 13.10), medical therapy or surgical intervention. This
or a combined cystic and solid mass. Some examination should be carried out in every
cystic masses have internal septa and could woman with extrapelvic endometriosis, even
if there are no symptoms of pelvic endome- ultrasound (HIFU) ablation. This technique
triosis, and according to the IDEA consensus appears to be safe and effective for the treatment
that proposes four basic sonographic steps of abdominal wall endometriosis in 21 cases
when examining women with suspected or reported in the literature [22].
known endometriosis [17]. Three-dimensional (3D) sonography appears
to be a quick, easy, specific, and noninvasive tool
in the diagnosis and presurgical approach of
13.5 Future Perspectives extrapelvic endometriosis. The 3D reconstruc-
tion clearly showed the irregular shapes and bor-
Although hormonal therapy may be a useful ini- ders of the endometriotic nodule and gave a more
tial approach for reducing symptoms and for exact analysis of the surrounding tissue
decreasing the size of larger cutaneous lesions (Figs. 13.12, 13.13, 13.14, and 13.15). Moreover,
prior to planned surgical excision [20], surgery the depth of infiltration through the facial plane
for extragenital endometriosis clearly improves can easily be shown. Preoperative evaluation of
outcome through relief of symptoms, improved the dimension, volume, and infiltration of the
quality of life, increased fertility rates, and abdominal wall endometriotic mass could be
reduced recurrences [21]. Recently a new thera- very useful to estimate how large the excision
peutic method has been proposed for the treat- will be in order to use a mesh prosthesis [23].
ment of abdominal wall endometriosis: MRI may be an addition technique for the eval-
ultrasound (US)-guided high-intensity-focused uation of endometriosis before surgery especially
Fig. 13.12 Three-dimensional ultrasonographic appearance of a scar endometriosis (straight arrows) in a 39-year-old
woman with one previous cesarean section 6 years before
Fig. 13.13 Three-dimensional ultrasonographic appearance of a scar endometriosis (straight arrows) in a 32-year-old
woman with a cesarean section 6 years before
Fig. 13.14 Three-dimensional ultrasonographic appearance of Villar’s nodule (straight arrows) in a 20-year-old
woman without previous abdominal surgery
Fig. 13.15 Three-dimensional ultrasonographic appearance of a rectus abdominis endometriosis (straight arrows) in
a 30-year-old woman with one previous cesarean section 4 years before
3. Markham SM, Carpenter SE, Rock JA. Extrapelvic

in controversial cases as it can confirm the diagno- endometriosis. Obstet Gynecol Clin North Am.
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JB. Abdominal wall endometriosis: clinical presenta-
greater than 90% in the detection of endometrio- tion and imaging features with emphasis on sonogra-
mas, with its main limitation being the detection of phy. AJR Am J Roentgenol. 2006;186(3):616–20.
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Modified Ultrasonographic
Techniques
14
Simone Ferrero,
Umberto Leone Roberti Maggiore, Fabio Barra,
and Carolina Scala
14.1 Introduction the experience of the sonographer. Improvement

in the diagnostic accuracy of TVS may be
Over the last 10 years, transvaginal ultrasonogra- obtained using a series of modified sonographic
phy (TVS) has become the first-line investigation techniques based on the introduction of saline
in women with suspicion of deep endometriosis solution or gel in the vagina and/or rectum. These
(DE) [1]. In fact, TVS has good diagnostic per- techniques, named “enhanced” or “modified”
formance, and it has several advantages com- TVS, may be useful when the findings of TVS
pared with other imaging techniques due to its are inconclusive or when the sonographers have
high diffusion among gynecologists, the rela- limited experience in the diagnosis of DE. In fact,
tively low cost, the low discomfort for the the distention of the vagina and/or rectum may
patients, and the fact that it does not require the enhance the visualization of DE lesions.
use of radiation. Based on this background, the The most common modified TVS techniques
International Deep Endometriosis Analysis will be described in this chapter.
(IDEA) group recently described a systematic
approach to the examination of patients with sus-
picion of DE [2]. 14.2 Tenderness-Guided
A frequent criticism to TVS is that its diagnos- Transvaginal
tic accuracy in patients with DE is dependent on Ultrasonography
Electronic Supplementary Material The online version Tenderness-guided transvaginal ultrasonogra-

of this chapter (https://doi.org/10.1007/978-3-319-71138- phy (tg-TVS) is based on the principle of creat-
6_14) contains supplementary material, which is available ing an acoustic window between the transvaginal
to authorized users. probe and the surrounding vaginal structures by
S. Ferrero (*) · U. L. R. Maggiore · F. Barra increasing the amount of gel introduced inside
C. Scala the probe cover [3]. In addition, during the
Academic Unit of Obstetrics and Gynecology, exam, the patients are asked to indicate which
Ospedale Policlinico San Martino, Genoa, Italy
points felt tender under gentle pressure of the
Department of Neurosciences, Rehabilitation, probe, and particular attention is paid by the
Ophthalmology, Genetics, Maternal and Child Health
(DiNOGMI), University of Genoa, Genoa, Italy sonographer to identify endometriotic nodules
e-mail: simone.ferrero@unige.it in these areas [3].

https://doi.org/10.1007/978-3-319-71138-6_14
134 S. Ferrero et al.
14.2.1 Technique (95% CI, 64–80%), the specificity 88% (95% CI,
4–8%), the LR+ 6.2, and the LR− 0.3. For other
Twelve milliliter of ultrasound gel are introduced locations (uterosacral ligaments, rectosigmoid,
into the probe cover (usually a finger from a latex anterior pouch, and bladder), the sensitivity was
glove) instead of the usual 3–4 mL. The probe is lower (ranging from 67 to 33%) with a compara-
gently inserted in the vagina in order to minimize ble specificity. More recently, a prospective study
the risk of squeezing out the gel. The exam starts including 59 patients with clinical suspicion of
with the evaluation of the vaginal wall at the level DE (30 patients with surgical diagnosis of recto-
of the posterior vaginal fornix that can be exam- sigmoid endometriosis) compared the diagnostic
ined with a sliding up-and-down movement of the accuracy of magnetic resonance imaging (MRI)
probe. The patient is requested to inform the oper- and tg-TVS in diagnosing rectosigmoid endome-
ator about the onset and site of any tenderness triosis [4]. There was no significant difference in
experienced during the probe’s pressure in the the sensitivity and specificity of MRI and tg-TVS
posterior fornix. When tenderness is evoked, the in identifying rectosigmoid involvement. In par-
sliding movement is stopped, and particular atten- ticular, the specificity, sensitivity, and LR+ and
tion is paid to the painful site via gentle pressure LR− of tg-TVS were 86%, 73%, 5.317, and
with the probe’s tip for the detection of endome- 0.309, respectively.
triotic nodules [3]. Deep endometriotic nodules
appear as hypoechoic linear thickening or nod-
ules/masses with or without regular contours [4]. 14.3 Sonovaginography
The usual time required to perform tg-TVS in
patients with suspected DE is about 15–20 min; Sonovaginography (SVG) consists of TVS com-
however, less time is required when the exam is bined with the introduction of saline solution or
negative [3, 5]. gel into the posterior vaginal fornix to improve
the visualization of vaginal and rectovaginal sep-
tum DE. On regular TVS, these nodules may
14.2.2 Diagnostic Performance escape detection primarily because of the close
proximity of these structures to the transvaginal
A prospective study including 50 women with transducer [6]. The increased clarity on gel sono-
suspected rectovaginal endometriosis (31 with vaginography is achieved because the instilled
DE at surgery) investigated the accuracy of tg- gel causes standoff and partial distension of vagi-
TVS in the diagnosis of DE [3]. The study nal walls.
showed that this technique has a good to excel-
lent diagnostic performance with specificity of
95% (95% CI, 78–100%) and sensitivity of 90% 14.3.1 Technique
(95% CI, 80–93%); the positive predictive value
was 97% (95% CI, 85–100%), the negative pre- SVG was first described by Dessole et al. in 2003
dictive value was 86% (95% CI, 70–90%), the [7]. Immediately before the exam, the patients are
positive likelihood ratio (LR+) was 17.2, the neg- asked to partially empty the bladder in order to
ative likelihood ratio (LR−) was 0.1, and the leave a small amount of urine within to enhance
kappa value was 0.86 (95% CI, 0.56–0.91). This the examination of the anterior vaginal wall and of
diagnostic performance was subsequently con- the vesicovaginal septum [7]. After the patient seat
firmed in another prospective study including 88 in the gynecological position, the gynecological
women (72 with DE) [5]. With respect to the bed is slightly tilted in anti-Trendelenburg position
vaginal walls, the sensitivity was 91% (95% CI, to avoid saline solution reflux from the vagina dur-
79–97%), the specificity 89% (95% CI, 81–93%), ing the exam. A 24-mm Foley catheter is intro-
the LR+ 8.2, and an LR− 0.09. For endometriosis duced into the vagina, and its balloon is inflated
of rectovaginal septum, the sensitivity was 74% using 5–6 mL of saline solution. A limitation of
14 Modified Ultrasonographic Techniques 135
this technique is that an operator and an assistant anesthesia just prior to laparoscopy [9]; the blad-
are required to perform each exam [7]. The opera- der was emptied by using a urinary catheter, and
tor uses the right hand to handle the transvaginal the patient was slightly tilted in anti-Trendelen-
probe and the left hand to close the vaginal chan- burg position.
nel, narrowing the minor labia with the dorsal sur- A modified SVG technique consists in the
face of the forefinger and the middle finger. This simple introduction of 20 mL [6, 10, 11] or
maneuver is necessary to avoid the reflux of saline 50 mL [12] of ultrasound gel into the posterior
solution from the vagina during the exam. The vaginal fornix using a syringe prior to performing
assistant injects 200–400 mL of saline solution TVS in the office setting. The gel should be
through a Foley catheter [7]. loaded carefully into the syringe to decrease the
Other authors described the use of a purpose- presence of air bubbles/pockets within the gel.
designed hydraulic ring (Colpo-Pneumo Occluder, Recently, Sibal described in details a technique to
CooperSurgical, Berlin, Germany) that is placed minimize the presence of air bubbles within the
at the base of the transvaginal probe and is inflated filled syringe [6]. An assistant should hold the
with approximately 40 mL of saline solution in bottle of gel with its mouth facing downward.
order to prevent the escape of the 60–120 mL of The syringe is introduced into the lower part of
saline that is subsequently injected into the vagina the inverted bottle. Then, instead of pulling the
using a Foley catheter [8]. The saline solution in plunger out to fill the syringe, as is the usual prac-
the vagina creates an acoustic window between tice, the plunger is held steady in position, and
the transvaginal probe and the surrounding struc- the barrel (outer sleeve) is slowly pushed farther
tures; furthermore, it distends the vaginal walls [7, up into the inverted bottle of gel to fill the syringe
8]. This technique improves the visualization of with 20 mL of gel. The syringe must be filled
the vaginal walls, vaginal fornix, uterosacral liga- completely, so that the plunger comes in direct
ments, pouch of Douglas, rectovaginal septum, contact with the gel, thus further decreasing the
and vesicovaginal septum. During the exam, the possibility of air pockets when instilling the gel
transvaginal probe is not in contact with the uter- into the vagina. Some gel is usually sticking onto
ine cervix; the scan is performed by sliding the the external surface of the syringe, and it can be
probe back and forward, longitudinally and trans- used as a lubricant when the syringe is introduced
versally, with up, down, and angled movements into the vagina. Subsequently, the gel-lubricated
around the cervix, which was used as a reference tips of index and middle fingers of the gloved
point. The endometriotic lesions appear as right hand are introduced into the vagina. The
hypoechoic, irregular structures. syringe, held in the gloved left hand, is held such
SVG is well tolerated, and the intensity of that its tip lies in the groove above and between
pain perceived by the patients is similar to that the index and middle fingers. The syringe is
reported during TVS [7]. introduced into the vagina, directed by the fingers
Other techniques to perform SVG have been of the right hand in the vagina (Fig. 14.1). The
described. SVG can be performed by inserting fingers of the right hand are then removed, and
into the posterior vaginal fornix a condom the syringe is gently pushed farther inside along
attached to a saline giving set. The transvaginal the posterior vaginal wall such that there is
probe is then introduced into the vagina superior enough of it outside to grip and push the plunger
to the condom which is resting against the poste- to introduce the gel into the vagina. The syringe
rior vaginal wall. Once the transvaginal probe is must be inserted far enough into the vaginal canal
in situ, the condom is filled with 200–400 mL of such that the gel fills the posterior fornix com-
normal saline to enhance the visualization of the pletely [11]. The syringe is then withdrawn. A
retrocervical area, the posterior fornix, the poste- 20-mL volume of gel is thus placed in the upper
rior vaginal wall, and the rectovaginal septum vagina mainly in the posterior fornix. The
[9]. In the original study describing this tech- transvaginal transducer is gently introduced into
nique, the SVG was performed during general the vagina, carefully observing the vaginal side
walls for any abnormalities as the probe is gradu- ducer is pushed up, the gel gets displaced, and
ally advanced upward. It is important to assess withdrawing and reinserting the transducer result
the lower vagina initially before assessing the in air bubbles getting into the vaginal gel, causing
upper vagina and cervix because once the trans- suboptimal imaging, in addition to loss of gel
volume in the upper vagina.
The ultrasound gel distends the vagina and
allows the anatomical contours of the inner
vagina to be clearly visualized (Figs. 14.2 and
14.3). The main advantage of using gel instead of
saline as a distention medium during SVG is that
gel SVG requires only one operator to insert the
gel and perform the examination [10, 11].
Some authors reported the use of bowel
preparation prior to SVG: an oral laxative
(sodium picosulfate, ten drops by mouth) the
night before the examination and a rectal enema
Fig. 14.1 Sonovaginography with gel. The syringe com-

pletely filled with gel is held in the left hand. It is intro- Fig. 14.2 Sonovaginography with gel. The ultrasound
duced into the vagina such that its tip lies in the groove gel distends the vagina and facilitates the visualization of
above and between the index and middle fingers the anatomical contours of the inner vagina
Fig. 14.3 Sonovaginography with gel. On the left, a vag- ule is enhanced by sonovaginography with gel. TV probe
inal nodule (asterisk) can be observed by transvaginal transvaginal probe
ultrasonography; on the right, the visualization of the nod-
(120 mL of sodium diphosphate) 1–2 h before ity of 93%, and LR+ of 14.0 for rectosigmoid
the examination [12]. involvement. The sensitivity, specificity, LR+,
and LR– for vaginal involvement were 60%,
98%, 30.0, and 0.41. The sensitivity, specificity,
14.3.2 Diagnostic Performance LR+, and LR– for retrocervical involvement
were 84%, 96%, 19.4, and 0.16 [12].
A preliminary prospective study including 46 A prospective study including 54 women
women scheduled for surgery because of recto- compared clinical evaluation, TVS, SVG (60–
vaginal endometriosis showed that SVG (200– 120 mL of saline solution), and MRI in the diag-
400 mL of saline solution in the vagina) diagnoses nosis of posterior DE [8]. SVG correctly
rectovaginal endometriosis more accurately than identified 43 (93.5%) cases of posterior DE, pre-
TVS. The diagnostic performance of SVG in senting higher accuracy than the other tech-
detecting rectovaginal endometriosis was sensi- niques. SVG had a sensitivity of 93.5%, a
tivity 90.6%, specificity 85.7%, PPV 93.5%, and specificity of 87.5%, a PPV of 97.7%, a NPV of
NPV 80.0% [7]. In a prospective pilot study 70.0%, a LR+ of 7.47, and a LR− of 0.07 in diag-
including 33 women with suspected endometrio- nosing posterior DE. There was no significant
sis, SVG (a condom attached to a saline giving difference in the pain perceived by the patients
set inserted in the posterior vaginal fornix) was during TVS and SVG.
performed immediately before laparoscopy
under general anesthesia [9]. The sensitivity,
specificity, positive predictive value, and negative 14.4 ectal Water Contrast
R
predictive value for SVG in the prediction of rec- Transvaginal Ultrasonography
tovaginal endometriotic nodules were 75%,
94.7%, 75%, and 94.7%. Another study per- Rectal water contrast transvaginal ultrasonogra-
formed by the same authors showed that SVG phy (RWC-TVS) is based on the concept of dis-
(10–20 mL of ultrasound gel into the vagina) has tending the rectosigmoid colon by using saline
sensitivity of 100%, specificity of 91.7%, NPV of solution while performing ultrasonography [13].
70%, and PPV of 100% in diagnosing DE of the The aim of this exam is to facilitate the identifica-
posterior compartment [10]. A multicenter pro- tion of rectosigmoid endometriotic nodules and
spective study including 189 women with clinical the assessment of their characteristics during TVS.
suspicion of endometriosis investigated the accu-
racy of SVG (20 mL of ultrasound gel into the
vagina) in diagnosing posterior DE [11]. For the 14.4.1 Technique
prediction of posterior compartment DE overall
(anterior rectum, rectosigmoid, uterosacral liga- A bowel preparation is advisable before the
ments, rectovaginal septum, and/or vagina), the exam. In some studies, patients were asked to
sensitivity was 86%, specificity was 93%, PPV drink four doses of a granular powder dissolved
was 83%, and NPV was 94%. For the prediction in 1000 mL of water per dose on the day before
of bowel endometriosis, the sensitivity was the exam [14]. However, in common clinical
88.4%, specificity was 93.2%, PPV was 79.2%, practice, bowel preparation consists of a rectal
and NPV was 96.5%. Specificity was high for all enema performed within few hours before the
locations, but sensitivity varied depending on ultrasonography to eliminate the feces present in
location (being as high as 88% for bowel nod- the rectosigmoid colon [15–17].
ules, but as low as 18% in the posterior vaginal A 6-mm (18 Ch) flexible catheter is inserted
wall and rectovaginal septum). A prospective through the anal os into the rectal lumen up to a
study including 51 patients with DE (50 mL of 15–20-cm distance from the anus (Fig. 14.4). A
ultrasound gel into the vagina after bowel prepa- gel infused with lidocaine may be used to mini-
ration) reported a sensitivity of 100%, a specific- mize the discomfort due to the passage of the
catheter. After the connection of a 50-mL syringe there is no significant leakage of saline solution into
to the catheter, warm sterile saline solution is the space between the catheter and the anus. The
slowly injected inside the rectosigmoid under exam is performed both during and following saline
ultrasonographic control. Hundred milliliter of injection. The use of the water contrast allows to
saline solution are infused continuously at the dynamically evaluate the endometriotic lesions.
beginning of the procedure; subsequently, addi- After a sagittal scan of the uterine cervix is
tional saline solution (up to 350 mL) is injected obtained with the transvaginal probe, the sonog-
as requested by the ultrasonographer depending rapher focuses on the anterior and lateral sides of
on the distensibility of the intestinal wall the rectosigmoid, where deep endometriotic nod-
(Fig. 14.5). During the examination, a Klemmer ules are usually located. As in traditional TVS, at
forceps may be placed on the catheter to prevent RWC-TVS the normal layers of the rectosigmoid
backflow of the saline solution through the catheter can be evaluated. The serosa appears as thin
when the solution was not being injected. Usually, hyperechoic line, the muscularis propria is
hypoechoic with the longitudinal smooth muscle
(outer) and circular smooth muscle (inner) sepa-
rated by a faint thin hyperechoic line, the submu-
cosa is hyperechoic, and the mucosa is
hypoechoic. In RWC-TVS, the interface between
the lumen and the mucosal layer is hyperechoic
(Fig. 14.6) [16]. Rectosigmoid endometriotic
nodules appear as a thickening of the hypoechoic
muscularis propria or as rounded or triangular
Fig. 14.6 Rectal water contrast transvaginal ultrasono-

graphic image showing normal rectal wall. The various
layers can be recognized: muscularis propria (MP), sub-
mucosa (SM), and mucosa (MU). The interface (IF)
Fig. 14.4. A 6-mm (18 Ch) catheter is inserted through between the lumen and the mucosal layer is hyperechoic.
the anal os into the rectal lumen The rectum is dilated by saline solution (WC)
Fig. 14.5 Progressive distention of the rectosigmoid colon during rectal water contrast transvaginal ultrasonography
Fig. 14.8 Rectal water contrast transvaginal ultrasonog-

Fig. 14.7 Rectal water contrast transvaginal ultrasonog-
raphy shows a rectal endometriotic nodule. The nodule
raphy shows a rectal endometriotic nodule (asterisk). The
has prominent spikes toward the bowel lumen that are
hyperechoic submucosa is not infiltrated (arrowheads).
enhanced by the distention of the rectum (“Indian head-
The rectum is dilated by saline solution (WC)
dress” or “moose antler” sign)
hypoechoic nodules, with or without hyperechoic

foci with blurred margins. The endometriotic
nodule replaces the normal appearance of the
muscularis propria; retraction and adhesions are
often present (Figs. 14.7, 14.8, and 14.9).
The time required to perform RWC-TVS is
about 15–20 min [16]. RWC-TVS is usually well
tolerated [14–16, 18], and it is always carried out
without the need of local or general anesthesia.
14.4.2 Diagnostic Performance
Several studies investigated the diagnostic per- Fig. 14.9 Rectal water contrast transvaginal ultrasonog-
formance of RWC-TVS in diagnosing rectosig- raphy shows a retrocervical endometriotic nodule (largest
moid endometriosis and compared RWC-TVS diameter 15.5 mm) infiltrating the muscular layer of the
with other imaging techniques used for the diag- rectum. The rectum is dilated by saline solution (WC);
feces (F) can be observed in the rectum. U uterus
nosis of colorectal endometriosis.
The use of RWC-TVS for the diagnosis of
rectosigmoid endometriosis was originally reported more pain with this technique than
described in a prospective study including 35 TVS (Figs. 14.10 and 14.11, and Video 14.1).
patients with rectovaginal endometriosis [19]. A prospective study including 61 patients with
The exam showed good diagnostic performance suspected rectosigmoid endometriosis demon-
(Table 14.1), but it underestimated the depth of strated that RWC-TVS and transrectal sonogra-
infiltration in nodules reaching the submucosa. phy (TRS) have the same accuracy in the diagnosis
Subsequently, the same authors compared the of rectosigmoid endometriosis [17]. Furthermore,
performance of TVS and RWC-TVS in in the same study, the authors showed that RWC-
diagnosing intestinal infiltration in women with TVS and barium enema are equally effective in
suspicion of rectovaginal endometriosis [14]. the detection of a significant intestinal stenosis
RWC-TVS was more accurate than TVS in (≥50% of the lumen) due to endometriosis [17]
diagnosing intestinal infiltration, but patients (Videos 14.1 and 14.2, Fig. 14.12).
140
Table 14.1 Performance of RWC-TVS in diagnosing rectosigmoid endometriosis

Patients with
rectosigmoid
Study endometriosis at
Authors population surgery/histology Accuracy Sensitivity Specificity PPV NPV LR+ LR−
Valenzano Menada 35 21 94.3% 100% 85.7% 91.3% 100% 7.00 –a
et al., 2008 [19] (80.8–99.3) (83.9–100.0) (57.2–98.2) (74.4–97.4) (1.94–25.26)
Valenzano Menada 90 29 98.9% 95.7% 100.0% 100.0% 98.5% –b 0.04
et al. [14] (94.0–100.0) (78.1–99.9) (94.6–100.0) (90.8–99.8) (0.01–0.30)
Bergamini et al. [17] 61 51 95.1% 96.1% 90.0% 98.0% 81.8 9.61 0.04
(86.3–99.0) (86.5–99.5) (55.5–99.8) (88.4–99.7) (53.2–94.7) (1.50–61.73) (0.01–0.17)
Ferrero et al. [18] 96 48 95.8% 93.8% 97.9% 97.8% 94% 45.00 0.06
(89.7–98.9) (82.8–98.7) (88.9–100.0) (86.6–99.7) (84.0–97.9) (6.46–313.41) (0.02–0.19)
Leone Roberti 286 151 94.8% 92.7% 97.0% 97.2% 92.3% 31.29 0.08
Maggiore et al. [16] (92.2–97.4) (87.3–96.3) (93.0–99.2) (93.0–99.2) (86.6–96.1) (11.90–82.25) (0.04–0.13)
Ferrero et al. [15] 70 40 94.3% 92.5% 96.7% 97.4% 90.6% 27.8 0.08
(88.9–99.7) (78.6–98.4) (82.9–99.9) (86.2–99.9) (75.0–98.0) (4.03–191.01) (0.03–0.23)
PPV positive predictive value, NPV negative predictive value, LR+ positive likelihood ratio, LR− negative likelihood ratio
a
LR− could not be calculated because of the absence of false-negative cases
b
LR+ could not be calculated because of the absence of false-positive cases
S. Ferrero et al.
Fig. 14.10 Rectal hypoechoic endometriotic nodule with heads indicate the submucosa that is not infiltrated by the
blurred margins and hyperechoic foci on transvaginal endometriotic nodule. C uterine cervix, N nodule, WC
ultrasonography (on the left) and rectal water contrast water contrast. The same nodule is shown in Video 14.1
transvaginal ultrasonography (on the right). The arrow-
Fig. 14.12 The resected rectal specimen shown in

Video 14.2
diagnosing multifocal rectosigmoid endometrio-

sis. RWC-TVS was better tolerated by the
Fig. 14.11 Laparoscopic image of the rectal nodule (N) patients compared with MDCT-e.
shown in Fig. 14.10 and Video 14.1 A large prospective study including 286
patients of reproductive age with clinical suspi-
cion of rectosigmoid endometriosis compared the
Another prospective study demonstrated that accuracy of RWC-TVS and magnetic resonance
RWC-TVS and multidetector computerized enema (MR-e) in the diagnosis of rectosigmoid
tomography enema (MDCT-e) have similar accu- endometriosis [16]. The two techniques had simi-
racy in diagnosing rectosigmoid endometriosis lar accuracy in the diagnosis of rectosigmoid
[18]. Both exams underestimated the size of the endometriosis, but the accuracy of RWC-TVS
endometriotic nodules compared to histology; was superior to that of MR-e in the detection of
however, the underestimation was greater for infiltration of the mucosal layer. A similar inten-
RWC-TVS than for MDCT-e. In addition, in both sity of pain was perceived by the patients during
imaging techniques, the underestimation was RWC-TVS and MR-e.
greater for nodules with diameter ≥ 30 mm. A recent prospective study compared the per-
RWC-TVS and MDCT-e had similar accuracy in formance of RWC-TVS and computed tomo-
graphic colonography (CTC) in diagnosing acquisitions are obtained by using a 3D transvag-

rectosigmoid endometriosis [15]. The results of inal transducer. The structures of interest visual-
imaging techniques were compared with surgical ized during the 3D acquisition are the uterosacral
and pathologic findings. Out of 70 patients with ligaments, vaginal apex, rectovaginal septum,
clinical suspicion of rectosigmoid endometriosis, rectosigmoid colon, and rectum. These images
40 patients (57.1%) had surgical diagnosis of rec- allow to provide a better characterization of the
tosigmoid endometriosis. There was no signifi- nodules, including measurement of the diameters
cant difference in the accuracy of RWC-TVS and in three planes, determination of the volume, the
CTC in the diagnosis of rectosigmoid endome- anatomic extension, and whether the nodules
triosis. Both techniques similarly estimated the cause bowel stenosis [21]. Each time, several 3D
length (midsagittal diameter) of the endometri- TVUS acquisitions of the posterior compartment
otic nodules independently from their location in are performed, especially when intestinal infiltra-
the low rectum, upper rectum, or rectosigmoid. tion is suspected. After acquisition, the multipla-
CTC was significantly more precise than RWC- nar display shows a sagittal view, an axial plane,
TVS in estimating the distance between the lower and a coronal plane. The coronal plane could not
margin of the rectosigmoid nodule and the anal have been obtained with conventional 2D sonog-
verge. RWC-TVS was significantly more accu- raphy. Several 3D image programs are used for
rate than CTC in in diagnosing multifocal recto- offline analysis. The virtual organ computer-
sigmoid endometriosis. Patients perceived less aided analysis (VOCAL) mode is used to assess
pain during RWC-TVS than during CTC. the volume of the DE, and the tomographic ultra-
The major limitation of RWC-TVS is that it sound imaging (TUI) mode provides series of
allows diagnosing only rectosigmoid nodules slices through any one of these planes (Fig. 14.13).
because lesions located above the sigmoid are The TUI display is modified to provide the maxi-
beyond the field that can be explored by mum of number of slices in the region of interest
TVS. CTC has the advantage of investigating the (ROI) and allows to obtain a better appreciation
whole bowel allowing diagnosing multicentric of intestinal wall infiltration. At the end of the
lesions (i.e., right colon, ileon, ileocecal junction, procedure, the surface mode is used to recon-
or appendix), and, thus, these two techniques struct the endometriotic nodule entirely, in a kind
may be combined to obtain a preoperative assess- of virtual colonoscopy that allows to assess the
ment of the whole colon. intestinal stenosis caused by the nodule.
A colorectal preparation is used before the
procedure, a rectal enema is administered twice
14.5 Three-Dimensional (at 2 h and 1 h) before the procedure [21]. In case
Rectosonography of inadequate bowel preparation, the procedure
may require to be postponed [21].
Three-dimensional rectosonography (3D-RSG)
is a modification of the RWC-TVS technique that
is mainly based on the acquisition of 3D images 14.5.2 Diagnostic Performance
when a rectosigmoid nodule is identified at TVS.
So far, 3D-RSG was used to investigate posterior
DE in only one series of 50 patients [20, 21].
14.5.1 Technique Eighteen of the 20 intestinal nodules (90%) were
identified among 19 patients by 3D-RSG. No
In the original description of the 3D-RSG tech- intestinal lesions were observed by 3D-RSG in
nique, the patients slowly inject themselves with 31 patients. When MRI was used as reference
120 mL of warm water into the rectum using a technique, the diagnostic performance of
60-mL syringe with conical tip [20]. Several 3D 3D-RSG was sensitivity 95%, specificity 97%,
Fig. 14.13 Tomographic ultrasound images obtained during rectal water contrast transvaginal ultrasound. This series
of slices can provide information regarding the extent of infiltration of intestinal wall by endometriotic nodule
PPV 95%, NPV 97%, positive likelihood ratio techniques could be an option for those operators
30.3, and negative likelihood ratio 0.05. who do not achieve good results with TVS. The
selection of a particular modified ultrasono-
graphic technique depends on the skill and expe-
14.6 Future Perspective rience of the sonographer as well as the TVS
findings [24]. For example, SVG significantly
In patients with suspicion of DE, if the initial improves the visualization of the anterior and
scan reveals lesions in a determined area, it is posterior vaginal fornices. Similarly, RWC-TVS
unlikely that additional testing is required may improve the visualization of rectosigmoid
because of the high specificity of TVS [22]. In a nodules when the sonographers are learning to
meta-analysis, Guerriero et al. found that image the posterior compartment.
enhanced approaches are not more accurate than An advantage of modified ultrasonographic
plain TVS for this diagnosis of rectosigmoid techniques compared with other imaging
endometriosis [23]. Modified ultrasonographic modalities (such as MRI) is that they cause low
techniques should be used when the result of pain or discomfort for the patient and they can
TVS are inconclusive or if it is felt additional be performed directly by the gynecologists at
information on the features of DE should be low cost. Furthermore, these techniques can
obtained [24]. However, a limitation of TVS is also be performed as a dynamic test because
that it depends on the examiner’s ability and the operator can assess the changes in the posi-
experience; therefore, modified ultrasonographic tion of endometriotic nodules compared to the
position of the pelvic organs (such as the bowel the rectovaginal septum in women with suspected
rectovaginal endometriosis: a pilot study. Australas J
and bladder) and assess their infiltration. Ultrasound Med. 2011;14(3):4–9.
Nowadays, the major challenge in the imaging 10. Reid S, Winder S, Condous G. Sonovaginography:
diagnosis of endometriosis remains the detec- redefining the concept of a “normal pelvis” on trans-
tion of superficial lesions. Future studies vaginal ultrasound pre-laparoscopic intervention for
suspected endometriosis. Australas J Ultrasound Med.
should assess whether modified ultrasono- 2011;14(2):21–4.
graphic techniques can allow the detection of 11. Reid S, Lu C, Hardy N, Casikar I, Reid G, Cario G,
superficial endometriotic lesions. et al. Office gel sonovaginography for the prediction
of posterior deep infiltrating endometriosis: a multi-
center prospective observational study. Ultrasound
Obstet Gynecol. 2014;44(6):710–8.
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Melis G, et al. MRI and “tenderness guided” trans- Venturini PL, Ferrero S. Magnetic resonance enema
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Additional Radiological
Techniques (MRI)
15
Federica Schirru, Stefano Guerriero,
and Luca Saba
15.1 Introduction 15.2 How We Do It
Endometriosis is a chronic, oestrogen-dependent 15.2.1 Imaging of Endometriosis:

inflammatory disease affecting approximately General Concepts
5–10% of women of reproductive age [1–12].
Radiology plays a key role in the diagnostic process An early diagnosis of endometriosis is necessary
in evaluating staging of the disease and in the accu- for a proper management of the disease and an
rate preoperative planning [13–19]. Sonography adequate planning of the surgical treatment
(two-dimensional and three-dimensional US) is the which should be as conservative as possible in
first-line approach for the evaluation of endometrio- order to preserve the reproductive capacity of
sis but has suboptimal results in detecting extrapel- patients [20]. There are several imaging tech-
vic implants and has a reduced sensitivity for niques that allow to identify and characterize
endometrial plaques. On the other hand, MRI [21–27] with high sensitivity and specificity the
allows for highly accurate assessment of pelvic and disease, in particular ultrasonography and mag-
extrapelvic lesions, deep endometriosis and adhe- netic resonance imaging. However, in many
sions, thus taking a central role in diagnosis and cases, imaging diagnosis remains challenging.
staging, suggesting a proper surgical treatment [7]. As already described in the previous chapters,
Taking into account the wide variety of clinical ultrasonography (US) undoubtedly represents
manifestations, the multifocal distribution of lesions, the first-line approach in the study of endometri-
the involvement of gynaecological and non-gynaeco- osis by means of its high sensitivity and specific-
logical sites and the difficulties in diagnosis as well in ity as well as its low cost. However, it has
the planning of surgical treatment, endometriosis is limitations regarding the field of view, which is
considered an extremely complex pathology. inadequate to evaluate any extrapelvic endome-
trial implant and the dependence by operator
F. Schirru · L. Saba (*) ability [22]. Therefore, when US is not sufficient
Department of Radiology, University of Cagliari, to make a conclusive diagnosis or to banish any
Policlinico Universitario Duilio Casula, Monserrato, doubt, other imaging methods are performed.
Cagliari, Italy
e-mail: lucasaba@tiscali.it
MRI is usually performed in the most difficult
cases and for an optimal presurgery planning. It
S. Guerriero
Department of Obstetrics and Gynecology,
is considered an excellent technique for diagnos-
University of Cagliari, Policlinico Universitario ing and assessing endometriosis according to its
Duilio Casula, Monserrato, Cagliari, Italy high spatial resolution, high space/contrast
e-mail: gineca.sguerriero@tiscali.it

https://doi.org/10.1007/978-3-319-71138-6_15
148 F. Schirru et al.
r esolution, a wide field of view and an excellent Pelvic Imaging working group of the European
tissue characterization. Moreover, it allows both Society of Urogenital Radiology (EPI-ESUR).
to detect endometrial implants hidden by adhe- Recommendations have been proposed in guide-
sions and to recognize lesions located in an extra- lines for indication for MRI, technical require-
pelvic site. In addition, MRI, also with the use of ments, patient preparation and MRI acquisition
contrast material, permits to distinguish deep pel- protocols [22].
vic endometriosis from other pelvic inflamma-
tory conditions or to solve differential diagnosis 15.2.2.1 Indications for MRI
problems, for instance, between benign and in Endometriosis
malignant ovarian masses or with other malig- In the literature, there is no common agreement
nancies of the pelvic organs [7, 8, 23–25]. In lit- on the use of US rather than MRI, and there are
erature, there is no general agreement on the use no publications for executing MRI in pelvic
of US rather than MRI. In general, papers pub- endometriosis. Common indications for pelvic
lished by gynaecologists support US diagnostic MRI are evaluation of pelvic pain and infertility
superiority, while those published by radiologists or assessment of adnexal mass; however, in
emphasize the value of MRI [22]. However, the many ESUR centres, the most frequent reason
most recent meta-analyses have shown that addi- that leads to MRI is the staging of deep pelvic
tional examinations, especially MRI, are recom- endometriosis (90% of cases). Therefore, con-
mended in symptomatic patients with negative sidering the most recent meta-analyses (as men-
US findings [22, 26]. Moreover, MRI is also sug- tioned in the previous paragraph), guidelines
gested as a second-line approach in preoperative suggest that [22]:
workup of deep pelvic endometriosis in patients
with unclear US [22]. The value of MRI can fur- –– MRI should be considered the second-line
ther grow and improve by means of an intense approach in evaluation of pelvic endometrio-
collaboration between radiologists and sis, especially in symptomatic patients with
gynaecologists. negative US findings.
The Computed Tomography (CT) has a mar- –– MRI is recommended before surgery for pre-
ginal role in the assessment of endometriosis operative workup of pelvic endometriosis.
because it lacks both sensitivity and specificity,
and often findings are nonspecific and non-diag- 15.2.2.2 Technical Requirements
nostic. However, CT might be useful in evaluat-
ing any complications of endometriosis, such as 1.5-T or 3.0-T System and Array Type
intestinal obstruction, hydronephrosis conse- Guidelines do not provide any recommendations
quent to ureteral compression, hemoperitoneum regarding the use of 1.5-T magnet rather than
and acute abdomen secondary to the rupture of an 3.0-T magnet; both are considered valid for
endometrioma [27]. studying endometriosis, but there are no suffi-
cient comparing studies in literature [22]. The
increased spatial resolution, due to the improved
15.2.2 M
agnetic Resonance Imaging signal-to-noise ratio of 3.0-T MRI versus 1.5-T,
Technique allows to identify smaller lesions of DPE and sur-
face implants by showing adhesions and perito-
Recently (in December 2016), the European neal irregularities [28–30]. However, due to the
Society of Urogenital Radiology (ESUR) has increased image heterogeneity at 3.0-T system,
published guidelines for optimal MRI protocols negative effects on fat-saturation techniques
and imaging interpretation in endometriosis. (which are very useful in the imaging study of the
These are based on a careful and detailed review disease) may occur [29, 31]. Therefore, more
of the most recent literature and on the consen- comparative studies are needed for a more accu-
sus opinion between experts from the Female rate evaluation of the two systems and for
15 Additional Radiological Techniques (MRI) 149
c hoosing what is the better one in the assessment Fasting before the onset of MRI is recom-
of endometriosis. mended by guidelines, but its length is variable
Both with 1.5-T magnet and with 3.0-T, pelvic (3, 4 or 6 h) [22]. It is useful in order to reduce
phased-array coils are recommended by guide- intestinal peristalsis.
lines for DPE evaluation [22]. These assure a Bowel preparation is advocated as “best prac-
high signal-to-noise ratio, high spatial resolution tice” for the detection of DPE. Several studies
with anatomical detail accuracy and improved suggest an intestinal preparation that involves the
tissue characterization. For such reasons, pelvic use of oral laxatives on the day before the exami-
phased-array coils should be used for the study of nation or a bowel enema with water. In addition,
pelvis. Although some authors have described a it is recommended that patients undergo a dietary
higher diagnostic accuracy of endoluminal coils preparation with a low-residue regimen on the
in evaluating the invasion and the infiltration day before and the day of examination [22, 33].
depth within the rectal wall or bladder, their use There is a common agreement on the impor-
seems limited by the small field of view and the tance of an adequate bladder distension in order
pain related to their positioning. Moreover, the to achieve a precise detection of endometrial
use of the endovaginal coil prevents endoluminal implants. A moderately filled or full bladder
filling with ultrasound gel, which is a useful tool allows to modify the angle of uterine antever-
for improving the visualization of the vagina and sion; in this manner, the visualization of pelvic
rectal wall [32]. anatomical structures is improved with a conse-
quent better detection of small endometrial
Timing of MRI Examination implants sited in the vesicouterine pouch or
The timing of MRI examination is controversial anterior to it. Another advantage of having a
and, in fact, there is not a common agreement. moderately full bladder is the reduction of
Some authors have argued that there is no greater motion artefacts (due to the intestinal peristalsis)
diagnostic accuracy of MRI performed during the because the sigma and the adjacent small intes-
menstrual cycle since the signal or the size of tine loops are displaced superiorly. For all these
endometriosis nodules do not significantly change reasons, a moderately full bladder is recom-
with menses [27]. In a recent paper, Menni et al. mended in the evaluation of DPE, and, in gen-
have suggested that MRI should be performed in eral, patients are instructed to not empty the
the first 12 days after the beginning of patient’s bladder 1 h before the examination [22]. In con-
last menstrual period. In fact, during this phase, trast, an empty or overfilled bladder might com-
endometrial haemorrhagic foci are best detected promise the evaluation of anatomic structures,
because of the maximum hyperintense signal of resulting in a worst detection of lesions. In addi-
blood products in the T1-weighted images [7]. In tion, the overfilled bladder may be the cause of
conclusion, guidelines do not recommend a spe- motion artefacts due to the activity of the detru-
cific timing, related to the menstrual cycle, of sor muscle [8, 24, 34].
MRI examination in the evaluation of DPE [22].
Patient Position
Patient Preparation: Fasting, Bowel MRI should be performed with the patient in the
Preparation, and Bladder Emptying supine position; however, the prone position may
Adequate patient preparation is necessary to be considered an option in claustrophobic patients
obtain high-quality images, and, despite this, no in order to reduce stress, anxiety and distress [22].
general consensus is found on patient preparation
before MRI examination. The MRI protocol Antiperistaltic Agent
should be chosen and tailored according to the Antispasmodic agents (e.g. hyoscine-N-butylbro-
principal indication, and it will be different mide, glucagon) are recommended in the evalua-
depending on whether endometriosis or an ante- tion of DPE, as they reduce motion artefacts
rior mass have to be evaluated. caused by bowel and uterine peristalsis [22, 32].
Vaginal and Rectal Opacification sequences in diagnosis of endometrioma, allow-

There is some discrepancy in the literature ing to differentiate it from haemorrhagic cysts or
regarding the improvement of diagnostic accu- fatty content cysts [39, 40]. They are useful for
racy and image interpretation obtained through the evaluation of the signal of normal anatomical
the vaginal or rectal opacification. Filling the structures and the characterization of uterine and
vaginal or the rectum cavity with sterile ultra- ovary lesions. In particular, the suppression of fat
sound gel or with water has the aim to distend signal permits to better highlight the hyperin-
these cavities; this improves the visualization and tense signal of haemorrhagic foci of endometrial
differentiation of the various anatomical struc- lesions, even if small [7].
tures that are close to each other [32]. Besides, Half-Fourier acquisition single shot turbo-spin-
the patient’s discomfort and the onset of motion echo acquisition (HASTE; also known as single-
artefacts for rectosigmoid colon spasm limit the shot fast-spin echo (SSFSE)) is recommended for
clinical practice of rectal opacification [35]. So, the evaluation of uterine peristalsis; in fact, it has
both vaginal and rectal opacification are consid- been observed that in patients with endometrio-
ered an option in the evaluation of deep endome- sis, uterine peristalsis is reduced during the peri-
triosis [22]. ovulatory phase, thus favouring infertility
[39–41]. Moreover, these sequences provide
15.2.2.3 MRI Protocol kinematic images that also allow to detect pelvic
There is a large variability concerning the proto- adhesions [42].
cols used for the study of endometriosis. Due to its ability to characterize tissues and
However, guidelines recommend the use of cellularity, diffusion-weighted imaging (DWI)
2D-T2-weighted sequences in three planes (axial, with quantitative assessment of the diffusion
sagittal and oblique), T1-weighted sequences coefficient (ADC) plays an important role in MR
with and without fat suppression and half-Fourier imaging, especially in the field of pelvic oncol-
single shot turbo-spin-echo acquisition. No rec- ogy [43]. However, there are no sufficient studies
ommendations are provided regarding the use of to determine the diagnostic accuracy of DWI in
diffusion-weighted imaging and susceptibility- evaluating endometriosis and its utility in differ-
weighted imaging [22]. entiating benign lesions from malignant ones.
T2-weighted sequences are considered the Balaban et al. has demonstrated that endometri-
best sequences for detecting pelvic endometriosis oma has lower ADC values, at all b values, com-
as they are able to provide accurate assessment of pared with those of haemorrhagic ovarian cysts
both localization and extension of the implants, [44]. Diffusion tensor imaging (DTI) is a particu-
as well as their relationships with the surround- lar application of DWI which could be useful in
ing structures. Sequences should be acquired on evaluating patients with endometriosis and sus-
the axial (from Renal hila to the pubic bone), pected involvement of the sacral nerve roots [45].
coronal and oblique planes [32, 36]. The coronal Susceptibility-weighted imaging (SWI) are
oblique images (perpendicular to the long axis of able to detect small amounts of haemorrhage and
the uterine corpus) improve the evaluation of blood products which distort the local magnetic
possible adenomiosis, implants within the lower field and may be less visible on other MRI
sigma or the upper third rectal wall and adhesions sequences. According to this, SWI is sensitive in
between all these structures and the uterus. the diagnosis of extraovarian endometriosis, in
Instead, the axial oblique images (perpendicular particular abdominal wall endometriosis [46, 47].
to the long axis of the cervical canal or along the
uterosacral ligaments) improve the evaluation of The Use of Intravenous Contrast-Enhanced
uterosacral ligament implants and the parametric MRI
involvement [32, 37, 38]. In general, the use of contrast medium is often
T1-weighted sequences with and without fat reserved for specific cases and therefore depends
suppression are considered the “gold standard” on the indication to MRI examination. The pres-
ence of mural nodules in an endometrioma is the images (“lightbulb-like” brightness), which is due
main indication because of the strong suspect of to the high concentrations of paramagnetic hae-
malignant transformation. It can also be useful to moglobin in blood degradation products. On
distinguish an endometrioma from a lutean ovar- T2-weighted images, the lesion is characterized
ian cyst or a tubo-ovarian abscess or to distin- by intermediate-to-low signal. A typical feature of
guish endometriosis from pelvic inflammatory endometrioma is the “T2-shading” sign, which
disease [23, 48]. consists of a low signal (T2 shortening) affecting
variable portions of the cyst (small portions or the
entire cyst). In particular, the phenomenon ranges
15.2.3 M
R Imaging Features from a homogeneous complete absence of signal
of Endometriosis to different gradations of decreased signal inten-
sity on T2-weighted sequences [53–55]. The
Endometriosis has three different clinical pat- dependence of signal intensity to the high concen-
terns of manifestation, which can occur alone or tration of protein and iron within the cyst, due to
coexist: recurrent haemorrhages, reflects the chronic
nature of endometrioma. It is important to high-
–– Ovarian endometrioma
light that any signal loss on T2-weighted images
–– Peritoneal endometriosis (with or without
is highly specific for endometrioma, regardless of
adhesions)
the degree of signal loss [21].
–– Deep endometriosis
Recently, Corwin et al. have describe an MRI
finding called “T2 dark spots”, found in some
15.2.4 Ovarian Endometrioma cases of haemorrhagic cystic ovarian lesions. “T2
dark spots” are defined as markedly hypointense
Endometrioma is described as an ovarian pecu- foci within the cyst on T2-weighted images with
liar pseudocyst lined by functioning endometrial- or without T2 shading. They may be located
like tissue composed of a highly vascularized within the cyst, often against the cyst wall, but
stroma and a surface epithelium. Its content is a not within the cyst wall itself [56].
dense dark fluid, consisting of high concentra- Another important feature is the presence of
tions of degenerated blood products accumulated multiple endometriotic cysts. This seems related
over successive menstrual cycles. Because of this to the fact that cysts undergo repeated rupture
aspect, endometrioma is also called “chocolate because of the hormonal stimulation resulting in
cysts”. In case of larger endometriomas, it could internal bleeding. The bilateralism and multiplic-
be possible to observe clots, thin septa, “haema- ity of hyperintense on T1-weighted adnexal cysts
tocrit effect”, fluid levels or peripheral nodules can be considered a valid diagnostic criterion to
(due to clots) [27, 33, 49]. distinguish the endometrioma from other haem-
Endometriomas can be either single or multi- orrhagic lesions, even greater specificity than the
ple, bilateral (in more than 50% of cases), uni- T1 signal hyperintensity alone [49, 57].
locular or multilocular. In case of inter-ovarian Chemical-selective T1-weighted fat-saturated
adhesions, a particular condition called “kissing sequences are very useful for the diagnosis of
ovaries” can be observed [50, 51]. endometriosis. In fact, the saturation of the fat
improves the contrast resolution among non-fat-
15.2.4.1 MRI Findings containing T1-hyperintense structures, making
Since endometrioma may contain variable possible to detect even very small endometriomas.
amounts of blood breakdown products, proteins Moreover, the loss of fat signal is advantageous in
and fluids, its appearance on MR imaging can be characterization of T1-hyperintense adnexal
variable [52]. lesions, allowing, for instance, the differentiation
Usually, it appears as a cystic mass with a between endometrioma and mature cystic teratoma
homogeneous hyperintense signal on T1-weighted [53, 55]. It should also be emphasized that chemi-
cal-selective T1-weighted fat-saturated sequences transformation of endometrioma. In general, on

are preferred to short-tau inversion recovery (STIR) post-contrast sequences, the peripheral low signal
sequences because, in the latter, signal loss is not a intensity rim (the thick fibrous wall of the cyst)
finding specific for fat. Indeed, both haemorrhagic may show intense contrast enhancement [49].
cysts and endometriomas may have a relaxation On DWI imaging, most part of endometrioma
time similar to those of fat, thus mimicking a shows restricted diffusion and low ADC values,
mature cystic teratoma [20, 57] (Fig. 15.1). but this finding is not specific. In fact, both benign
The use of contrast medium is reserved for spe- endometrioma and haemorrhagic ovarian cysts,
cific cases, firstly in the suspicious of malignant as well as endometrial implants or benign mature
a b
c d
Fig. 15.1 Endometriomas in a 44-year-old woman with and without fat suppression, and T2-shading sign. Some
chronic pelvic pain and infertility. Axial T1-weighted (a), low signal spot (arrowheads) are visible inside the cysts
axial T2-weighted (b), axial T1-weighted with fat sup- that correspond to chronic retracted blood clots containing
pression (c) and sagittal T2-weighted MR images show in a high concentration of protein and/or hemosiderin (“dark
the right adnexa the presence endometriomas character- spot sign”)
ized by high signal in both T1-weighted sequences, with
cystic teratomas, showed restricted diffusion size, could lead to a hemoperitoneum with acute
[56]. However, as already mentioned in the previ- abdomen [27, 61].
ous paragraphs, Balaban et al. has demonstrated Ovarian Torsion: uncommon. It represents a
that endometrioma has lower ADC values, at all b gynaecological emergency requiring urgent sur-
values, compared with those of haemorrhagic gical treatment to prevent ovarian necrosis. In
ovarian cysts. Therefore, further studies are general, findings include an endometrioma within
needed to clarify the role of DWI in evaluating an enlarged oedematous ovary with multiple fol-
these lesions. licles located peripherally [14]. Twisting of the
In conclusion, the MR imaging criteria for the ovarian pedicle is the most specific feature of
diagnosis of endometrioma are [20]: ovarian torsion, but it can be very difficult to
detect.
–– Multiple adnexal cysts with hyperintense sig- Malignant Transformation: it represents a very
nal on T1-weighted images rare complication, occurring in less than 1% of
–– One or more adnexal cysts with hyperintense patients with the disease [62, 63]. MRI findings
signal on T1-weighted images and “shading suspecting malignant degeneration include [49]:
sign” on T2-weighted images
–– Presence of enhanced mural nodules (well
Using these criteria, it has been demonstrated detected on contrast-enhanced subtracted
that MR imaging reaches a diagnostic accuracy images)
of 91–96%, a sensitivity of 90–92% and a speci- –– Loss of typical “T2-shading” sign on
ficity of 91–98% in the diagnosis of endometri- T2-weighted images
oma [53, 54, 57–59]. –– Presence of mural nodule of more than 30 mm
Routine follow-up is very important for endo- in size
metriomas because of risk for many complica- –– An interval increase in the size of the cyst
tions, in particular rupture.
Enhanced mural nodules are the most sensi-
15.2.4.2 Complications tive feature on MR imaging of malignancies; oth-
of Endometrioma ers, however, are useful in suspecting neoplastic
Usually, complications may occur in about 50% transformation but less reliable. It is important to
of patients with one or more endometriomas. The evaluate the enhanced mural nodules with con-
most frequent are: trast-enhanced dynamic subtraction images since
Reduced Fertility: this complication involves the haemorrhagic content of cysts (which is also
about 30–50% of women affected by endometri- hyperintense on T1-weighted images) may mask
osis. Many studies have reported a poorer preg- the enhancement of small nodules. Therefore, to
nancy outcome in affected women probably due better visualize areas of enhancement, it is man-
to the presence of adhesions involving the ovaries datory to use contrast-enhanced subtracted
and the fallopian tubes, as well as anomalies of images [20]. However, enhanced mural nodules
the endocrine and immune systems [27, 60]. represent a sensitive (97%) but not a specific
Adhesions: extremely frequent. Adhesions (56%) feature for the diagnosis of endometrioma-
appear as low signal stranding on both associated cancer. In fact, a whole range of
T1-weighted and T2-weighted images that mask benign conditions (such as polypoid endometrio-
organ interfaces; they could cause distortion of sis, intracystic blood clots or decidualized endo-
the normal pelvic anatomy. A characteristic diag- metriosis of pregnancy) should be considered in
nostic sign is the “kissing ovaries” characterized the differential diagnosis [27].
by the closing up of ovaries resulting in inter- The loss of “T2-shading” sign seems to be due
ovarian adhesions [20, 50, 51]. to tumour secretions that dilute blood degrada-
Acute Abdomen: this medical emergency is an tion products [63, 64]. Cystic components appear
uncommon complication of endometrioma. The hyperintense on both T1-weighted and
rupture of endometriotic cyst, even very small in T2-weighted images.
15.2.4.3 Differential Diagnosis these cases, each corpus luteum cyst appears
Typically, endometrioma appears as a cystic similar to endometrioma, but the patient’s medi-
adnexal mass with hyperintensity signal on cal history of a recent oocyte retrieval helps in the
T1-weighted images with and without fat sup- diagnosis [33].
pression, T2-shading sign, restricted diffusion Tubo-ovarian abscess: it represents one of the
(the most part of cases) and, on post-contrast late complications of pelvic inflammatory dis-
sequences, an intense enhanced wall. However, ease (PID). It consists of a pelvic inflammatory
some of these aspects may occur in other different mass within both the ovary and the fallopian tube
adnexal cystic masses, with a consequent overlap- are not separately distinguished. Typically, the
ping appearance. For instance, endometriomas pelvic mass shows a thin wall and a fluid content
are most commonly misdiagnosed as dermoid or that shows hypointense signal on T1-weighted
haemorrhagic cysts. Hence, a whole range of dif- images and heterogeneous or hyperintense signal
ferential diagnosis should be considered in order on T2-weighted images.
to make a correct evaluation. Mucinous lesions and ovarian carcinoma: the
General imaging differential considerations most important ovarian mucinous masses to be
include: considered in differential diagnosis are ovarian
Haemorrhagic cyst: it represents the most fre- mucinous cystadenoma, ovarian borderline muci-
quent and complex differential diagnosis of nous tumour and ovarian mucinous cystadeno-
endometrioma. MRI findings depend on the age carcinoma. In general, the degree of hyperintensity
of haemorrhage. The haemorrhagic cyst is usu- on T1-weighted images varies depending on the
ally a solitary unilocular adnexal mass, lined by a concentration of mucin; however, the signal
thin wall. Like endometrioma, it appears hyperintensity is still lower than that of fat or blood. In
intense on T1-weighted sequences with and with- general, endometrioma has to be differentiated
out fat suppression or shows a peripheral halo of from almost all ovarian neoplasms.
signal hyperintensity on T1-weighted images. Decidualized endometriosis in pregnant
More frequently, it does not show the characteris- woman: it is a benign condition associated with
tic T2-shading sign, because there are not recur- ectopic endometrial tissue that undergone a decid-
rent bleedings so that the viscosity and ual reaction during pregnancy. It may mimic an
concentration of contents remain low; however ovarian cancer in pregnancy. These benign nod-
sometimes the T2-shading sign can be present. ules show the same signal intensity of the normal
The walls of the cyst do not show enhancement decidualized endometrium on T2-weighted
on post-contrast images. images. In addition, in the postpartum or at the
Dermoid cysts and mature cystic ovarian tera- termination of a pregnancy, decidualized endome-
tomas: together with the haemorrhagic cysts, triosis resolve or regress to uncomplicated endo-
these lesions are one of the most frequent differ- metriomas [56].
ential diagnoses of endometrioma. As fat-con-
taining lesions, they appear hyperintense on
T1-weighted images mimicking an endometri- 15.2.5 Peritoneal Endometriosis
oma. They can be differentiated by chemical- (with or Without Adhesions)
selective T1-weighted fat-saturated sequences in
which the loss of signal occurs only in these Peritoneal endometriosis is characterized by the
lesions and not in the endometrioma, because of presence of endometrial implants on the surface
the chemical shift artefact [49]. of the pelvic peritoneum.
Multiple corpora lutea: this differential diag- Small implants develop on the peritoneal sur-
nosis must be considered in women who have face and on the serosa of any abdominal and
been subjected to assisted conception treatments. pelvic organ. In general, on MR imaging they
After hormonal stimulation that induces ovula- appear as small solid masses or soft tissue thick-
tion, multiple corpora lutea frequently occur. In ening with irregular or stellate margins. Lesions
show a low-to-intermediate signal on both nized with menses) diarrhoea, constipation,

T1-weighted and T2-weighted images; some- abdominal bloating and even ascites; if the
times, they may have punctate areas of high sig- lesion infiltrates through the mucosa, rectal
nal on T1-weighted images with fat suppression bleeding may also occur. In case of urinary tract
which represent haemorrhagic foci [7]. A low involvement, DE can present with haematuria,
signal stranding on both T1-weighted and dysuria, urgency or stress urinary incontinence
T2-weighted images is the typical appearance of and urinary tract infections [65, 66]. Often,
adhesions on MR imaging. Adhesions can occur however, symptoms are nonspecific, and this
between different pelvic structures, masking results in a delay in diagnosis, which obviously
interfaces among them and causing, in the most involves the need for more invasive surgical
advanced cases, distortion of the normal pelvic treatment.
anatomy. When implants are composed of only endome-
Unfortunately, the identification of these small trial stroma (without glands), the disease is known
peritoneal endometriosis lesions is very complex as “stromal endometriosis” [8, 14, 67]. The
for both MRI and US. However, the presence of knowledge of histological aspects of endometri-
adhesions can be suspected in MRI by using half- otic implants in DE is crucial, because it allows to
Fourier single shot turbo-spin-echo acquisition better understand their appearance on MR imag-
(HASTE) sequences. As already mentioned, these ing. In addition, as currently the standard treat-
sequences allow to evaluate the uterine peristalsis ment of DE is a complete excision of endometriotic
and the limited or absent motility between the pel- implants, a proper MR imaging evaluation is
vic organs. needed to accurately understand the sites affected
by the disease, the extent of implants and their
degree of infiltration.
15.2.6 Deep endometriosis
15.2.6.1 MRI Findings
Deep endometriosis (DE), also known as deep Deep endometriotic implants have a characteristic
pelvic endometriosis, is defined by the presence infiltrative pattern of organ involvement on cross-
of endometrial implants infiltrating deeper at sectional imaging. According to the presence of
least 5 mm into the peritoneal surface, into the fibrotic tissue and hypertrophied smooth muscu-
retroperitoneum or into the wall of other pelvic lar cells, DE lesions appear as soft tissue thicken-
organs. It may occur in different fibromuscular ing or solid irregular masses with low signal on
pelvic structures, such as [8]: T2-weighted sequences and intermediate signal
on T1-weighted sequences. Nodules might have
–– Rectovaginal septum and uterosacral liga- variable size and regular, irregular or indistinct
ments (69.2%) margins; more often they show stellated margins
–– Vagina (14.5%) due to the abundant fibrosis. Because of their typi-
–– Gastrointestinal tract (9.9%): usually rectosig- cal low signal on T2 images, these solid masses
moid, small bowel, colon and appendix are very difficult to detect and can be overlooked,
–– Urinary tract (6.4%): bladder and ureters, as they are sited in close proximity to other pelvic
rarely urethra structures that are normally hypointense on
T2-weighted sequence. Unlike ovarian endome-
DE is strongly associated with severe and trioma, haemorrhagic foci within these lesions are
debilitating symptoms, such as chronic pelvic rarely visible; if present, they appear as small
pain, dyspareunia, dysmenorrhea and infertility. areas of high signal on T1-weighted sequences
Of course, symptoms depend on the anatomical (with and without fat suppression) within the nod-
site affected by the disease. In case of rectosig- ules. Obviously, their signal intensity depends on
moid involvement, the symptomatology may the age of haematic content [34, 56]. Another
consist of chronic deep pelvic pain (synchro- uncommon feature is the presence of focal areas
of increased T2 signal within the solid masses, Deep endometriosis that involves the vesico-
which represent dilated endometrial glands [34, vaginal septum appears as a cystic lesion, with
56]. The appearance of lesions after administra- the same characteristics of an endometrioma
tion of the contrast material, on enhanced [34].
sequences, is very variable; enhancement depends MRI is considered the reference standard in
on how much inflammatory reaction and glandu- urinary tract endometriosis diagnosis. According
lar and fibrous tissue there is in the lesion. So, the to some papers, if examination is performed on
post-contrast appearance is neither specific nor 3-T MRI system, the sensitivity reaches 88%,
sensitive for the diagnosis of DE [34, 56]. and specificity is higher than 98% [29, 33, 69,
72]. Recently, authors have compared three-
15.2.6.2 Anatomical Locations dimensional colour Doppler US with MRI and
of Deep endometriosis cystoscopy in the diagnosis of bladder endome-
Many authors have subdivided the pelvis into triosis; they have showed that US seems to be
three different compartments depending on the superior to cystoscopy and is at least as effective
clinical and functional requirements: anterior, as MRI in diagnosing and planning the surgery
middle and posterior [68]. In the next paragraphs, for bladder endometriosis [73].
we will analyse the common anatomical locations The urinary bladder is involved in about
of solid nodules, considering the pelvic compart- 0.3–12% of women with pelvic endometriosis,
ments classification used by Coutinho et al. and the bladder is the most common affected
site of the urinary system (80%) [74]. Bladder
15.2.6.3 Anterior Compartment involvement may be extrinsic or intrinsic.
The anterior compartment contains the urinary Extrinsic involvement is more common and
bladder and urethra. Furthermore, the terminal often asymptomatic; lesions are sited on the
part of ureters is considered in this site. The serosal surface. Usually lesions involve the
bladder is separated from the vagina and the posterior wall [34]. On MR examination, nod-
uterus through fat planes known as vesicovagi- ules appear as localized or diffuse thickening
nal septum and prevesical space. The vesico- of the wall bladder, with low signal on
uterine pouch, or anterior cul-de-sac, is a T2-weighted sequences, which replace the nor-
peritoneum fold that lies between the bladder mal signal of detrusor muscle. Sometimes it is
(anterior) and the uterus (posterior). The vesico- possible to identify small foci with variable
uterine pouch is the most frequently affected signal on T1 and high signal on T2-weighted
site by endometriosis [68]. Implants into the sequences representing dilated endometrial
vesicovaginal septum, bladder and ureters are glands. On contrast-enhanced sequences, there
less common. is a greater enhancement of lesions than nor-
An involvement of other pelvic structures has mal detrusor muscle [75] (Fig. 15.2 c, d).
been reported in 50–75% of cases of urinary tract Endometriosis of the ureter is the second most
endometriosis involvement. Moreover, these common manifestation of urinary tract endome-
patients have also a more advanced stage of dis- triosis. In extrinsic form, endometrial tissue
ease than women without urinary tract involve- invades only the outer layer of the ureter (the
ment [69–71]. adventitia) and surrounding connective tissue,
Lesions of the anterior cul-de-sac appear as sometimes leading to obstruction of the ureter;
nodules that adhere to the anterior uterine sur- lesions originate from adjacent disease of the
face, with low signal intensity on T2-weighted ovary, broad ligaments or other uterosacral liga-
sequences. Because of the tight adherence to the ments. Both forms may manifest with obstructive
peritoneum of the bladder fold and the uterus, symptoms; cyclic haematuria is typical of the lat-
these lesions are associated to obliteration of the ter form [74]. On MRI examination, lesions
vesicouterine pouch and to anteflexion of the appear as irregular nodules with low signal on
uterus [34] (Fig. 15.2 a, b). T2-weighted sequences. Loss of the fat plane
a b
c d
Fig. 15.2 Anterior compartment. (a, b) Endometriosis of Endometriosis of the bladder in a 30-year-old woman with
the vesicouterine pouch in a 34-year-old woman with pel- haematuria. Sagittal T2-weighted (c) and axial T2-weighted
vic pain. Sagittal T2-weighted (a) and coronal T2-weighted (d) MR images depict irregular focal thickening of the
(b) MR images show irregular hypointense nodular lesion bladder wall, which contains small intermingled hyperin-
that adheres to the anterior uterine surface and to the upper tense foci that correspond to the dilated endometrial
bladder wall surface. The lesion obliterates the vesicouter- glands. The deep infiltrating endometriotic lesion does not
ine recess. Anteflexion of the uterus is associated. (c, d) adhere to the anterior uterine surface
between the ureter and nodule is highly suspi- intravenous pyelogram, urography) have limited
cious of extrinsic involvement. Retractile adhe- value in providing accurate information about the
sions may be present and appear as periureteral extent of the disease and the degree of tissue infil-
hypointense lines arranged in confluent angles tration. Recently Sillou et al. demonstrated that
[76]. If the nodule is obstructive, dilatation of the MRI is more sensitive than surgery (91% vs.
ureteral portion cranial to the lesion can be stud- 82%) but less specific (59% vs. 67%) in diagnos-
ied with MRI urography. Unfortunately, both ing intrinsic involvement of ureteral endometrio-
MRI and other imaging techniques (US, Uro-CT, sis sites [74, 77].
15.2.6.4 Middle Compartment tion are rarer. Endometriosis of round ligaments

The middle compartment of the pelvis includes might manifest as thickening (usually more than
the vagina, uterus, ovaries, fallopian tubes and 10 mm) or nodularity of these structures; RLUs
uterine ligaments (broad ligaments and round may be shortened or irregular. Implant signal
ligaments). The broad ligaments are folds of peri- depends on the presence of stromal tissue, glands,
toneum which reflect over the upper genital tract haemorrhage or fibrosis. If lesions are made of
and connect the uterus and the lateral walls of the fibrous tissue only, they show low signal on both
pelvis; they are part of the rectouterine and vesi- T1- and T2-weighted images, while haemor-
couterine folds [68]. Every organ of this compart- rhagic foci are characterized by high signal on
ment may be involved by endometriosis. T1-weighted sequences with and without fat sup-
Ovaries are the most frequently involved sites pression. Moreover, if inflammatory reaction
of the middle compartment. Endometriosis may occurs, contrast enhancement is observed.
manifest with one or more endometriotic cysts According to Gui et al., the detection of free fluid
(endometrioma) or small implants which lead to around the RLUs on “anti-declive position”
scarring and adhesions with adjacent paraovarian might be an indirect sign of endometriosis of the
structures [34] (Fig. 15.3 a, b). intrapelvic portion of the RLUs [79].
Deep endometriosis of the uterus may appear
as endometrial implants on the serosal surface, 15.2.6.5 Posterior Compartment
along with diffuse peritoneal enhancement on The posterior compartments may be highly
post-contrast T1-weighted sequence with fat sup- involved by deep endometriosis. It includes the
pression. Women with a retroflexed uterus are rectovaginal septum, retrocervical area, posterior
more likely to develop DE in the posterior com- vaginal fornix, uterosacral ligaments, rectovagi-
partment (while those with an anteflexed uterus nal pouch (or posterior cul-de-sac or pouch of
are more likely to develop anterior compartment Douglas), the rectum and connective tissue that
endometriosis) [34]. surrounds it. All these structures may be site of
Concerning the fallopian tube, endometriosis deep pelvic endometriosis. The rectal fascia rep-
is the main cause of peritubal adhesions in resents the morphologic demarcation of this
women of reproductive age. On MRI, it appears compartment; it appears as a thin structure with
as a tortuous distension of the fallopian tube, low signal that borders the perirectal compart-
filled with haemorrhagic fluid, with hyperintense ment [34] (Fig. 15.4).
signal in both T1- and T2-weighted sequences. The rectovaginal is filled of fat and is visible
Furthermore, it should be considered specific for on MRI; however, when interstitial fat is absent,
pelvic endometriosis, and also it may be the only the rectal and vaginal walls are not easily distin-
finding of the disease at MR imaging in some guishable. The use of rectal opacification with gel
women [56, 78] (Fig. 15.3 c, d). improves the visualization of this structure [54,
The involvement of uterine ligaments has a 68]. Rectovaginal septum is rarely affected by
viable frequency, ranging from 0.3 to 14% for DE. These lesions account only for 10% of retro-
round ligaments. Round ligaments of the uterus peritoneal endometriotic lesions; they may
(RLUs) course laterally from the uterus through involve the rectovaginal septum alone but fre-
the broad ligament, running along the pelvic quently represent an extension from retrocervical
sidewall and leaving the abdomen through the or posterior vaginal implants. Nodules may be
internal ring. They are divided into two portions: palpated at vaginal examination. On MR imaging,
an intrapelvic and an extrapelvic (in the canal of usually they appear as irregular hypointense solid
Nuck). On MR images, normal RLUs appear as masses, with low signal on T2-weighted sequences
thin structures with low signal on both T1- and that fill the space between the walls of the two
T2-weighted sequences. Several cases of endo- organs, retracting them. The most important thing
metriosis sited in the extrapelvic portion of RLUs to evaluate is whether the lesions have infiltrated
are reported, while cases of intrapelvic localiza- the anterior rectal wall. The presence of a small
a b
c d
Fig. 15.3 Adhesions. (a, b) Endometriosis in a 37-year- Axial T1-weighted (c) and sagittal T2-weighted (d) MR
old woman; axial T-weighted (a) and coronal T2-weighted images depict a tortuous distension of the left fallopian
(b) MR images show low signal stranding between the tube (white arrow) filled with haemorrhagic fluid, with
ovaries and between ovaries and uterus. The inter-ovarian high signal on T1-W sequences and low signal on
adhesions cause the closing up of right adnexa (white T2-W. An implant is visible on the serosal surface of the
arrow) and left adnexa (yellow arrow) with tethering to fallopian tube (yellow arrow)
the uterus. (c, d) Haematosalpinx in a 36 year-old woman.
account of fluid in the rectovaginal pouch may Implants often extent to the rectal wall posteri-
facilitate the detection of peritoneal reaction. MR orly or to vaginal cuff inferiorly, in particular to
examination has an important role in the evalua- vaginal fornices. The vaginal fornices are
tion of these lesions because they are not readily recesses into which the upper vagina is divided.
accessible at endoscopic viewing [33]. These vault-like recesses (anterior, posterior and
The retrocervical area is a virtual region lateral fornices) are formed by the protrusion of
behind the cervix, above the rectovaginal sep- the cervix into the vagina. The posterior fornix is
tum, and it is commonly affected by DE. the larger recess behind the cervix, close to the
a b
c d
Fig. 15.4 Posterior compartment endometriosis in T2-weighted images show low signal fibrotic thickening
45-year-old woman with a history of chronic pelvic pain from the torus uterinus and lower uterine segment to the
and dyspareunia. Sagittal T1-weighted (a), sagittal rectum (yellow arrow) associated to a solid nodular lesion
T2-weighted (b) and axial T2-weighted MR images show sited in the anterior sigmoid wall. Involvement of the
a large solid nodular implant in the rectovaginal septum torus uterinus and of the USL is visible on axial T2-w
and retrocervical area (white arrow) with intermingled images as a diffuse and irregular thickening within the
high signal foci due to bloody content. Sagittal ligaments (yellow arrowheads)
rectouterine pouch, more frequently involved by defined as a transverse thickening that binds the
endometriosis [8, 33]. insertion of USLs on the posterior wall of the cer-
The rectouterine folds contain a considerable vix; usually it is visible only if it is thickened.
amount of nonstriated muscular fibres and fibrous When the torus uterinus is involved by endometri-
tissue attached to the anterior surface of the otic implants, they appear as a mass or thickening
sacrum; they form the uterosacral ligaments. in the upper middle portion of the posterior cer-
Therefore, the uterosacral ligaments (USLs) are vix. Nodules may have regular or irregular mar-
fibrous fascial band on each side of the uterus that gins. In many cases, the involvement may be
passes along the lateral wall of the pelvis from the unilateral. Often, associated findings might be
uterine cervix and the vaginal vault to the sacrum uterine retroversion or angular rectal attraction,
[54, 73]. The torus uterinus is anatomically reflecting the fibrotic components [73].
USLs are considered the sites most fre- Finally, the rectosigmoid is the most common
quently involved in deep endometriosis. Lesions segment of bowel involved in endometriosis. It
may affect one or both of USLs; their proximal occurs in 12–37% of patients and is associated
medial portion is the most commonly affected. with severe DE in other pelvic structures (such as
On MR imaging, normal USLs appear as thin USLs, ovaries, vagina, bladder and pelvic side-
regular semi-circular structures with low sig- wall) [81, 82]. Chapron et al. reported a high inci-
nal. On the contrary, if they are involved by dence of associated involvement of the ileocecal
endometriosis, morphologic abnormalities may region: 12% of the lesions involve the ileum, 8%
occur; they include diffuse or localized thicken- of the lesions involve the appendix and 6% of the
ing and nodules with regular or irregular mar- lesion involves the cecum. Considering that the
gin within the ligaments. Usually endometriotic success of surgical treatment is related to the com-
implants show low signal on T2-weighted plete excision of endometriotic implants, MRI
sequences; however, nodules can show cystic examination is fundamental to precisely assess the
cavities with high signal on T2- and low signal intestinal DE, in order to plan a proper surgical
on T1-weighted images or may have very small strategy [83]. DE intestinal implants have different
hyperintense foci on T1-weighted sequences, morphological characteristics. They appear as
with and without fat suppression, due to haem- nodular or plaque-like lesions. Plaque-like lesions
orrhagic content. Considering their position have ill-defined margins and rectrative or infiltra-
and proximity to the rectum and vaginal walls, tive behaviour. Nodules are generally attached to
USLs lesions may extend to infiltrate these the intestinal wall between the 10-o’clock and
structures [33, 34]. Even in this case, rectal or 2-o’clock position. They usually have a triangular
vaginal opacification with sterile gel should shape with the base attached to the intestinal wall
allow a better detection of implants occurring and the apex oriented towards the retrocervical
in these structures. region. Implants might be located on the serosal
The rectouterine pouch (called also posterior layer or infiltrate the deeper layers, causing thick-
cul-de-sac or pouch of Douglas) represents the ening of the rectosigmoid colon wall with fibrosis.
deepest point of the peritoneal cavity, sited Nodules may be rectractile or nonretractile and
between the bilateral rectouterine folds, behind may show regular or irregular margins with low
the uterus and in front of the rectum. It extends signal on T2-weighted images [33, 83]. A specific
till the middle third of the vagina in 93% of finding of solid invasive endometriosis of the
women [68]. The pouch of Douglas is another intestinal wall is the “mushroom cap” sign on
commonly involved site in DE. Sometimes solid T2-weighted images. The low- signal-intensity
infiltrative lesions of this region may be over- base of the mushroom represents the hypertrophy
looked because of their extent and invasion of the and fibrosis of the muscularis propria, while the
posterior myometrium, mimicking adenomyosis high-signal-intensity cap is attributed to the
[20]. Adenomyosis is a condition different, but mucosa and submucosa, displaced into the lumen
closely related, to endometriosis. It represents a [56] (Fig. 15.5). Further suspicious signs of DE
deep benign myometrial invasion of area of endo- intestinal involvement are the disappearance of the
metrial glands and stroma, with associated hyper- fat tissue plane between the uterus and the anterior
plasia and hypertrophy of surrounding rectosigmoid wall, the loss of the hypointense sig-
myometrium, that leads to uterine enlargement; it nal of the anterior intestinal wall on the
may form nodular lesions or be diffusely distrib- T2-weighted images and the presence of a tissue
uted [80]. DE implants appear as solid nodules of mass extending on the anterior rectosigmoid colon
different size, with irregular margins that lead to wall showing contrast enhancement on
a partial or complete obliteration of the rectouter- T1-weighted images. Contrast enhancement is
ine pouch, because of the strict adhesions. It is variable and depends on the degree of inflamma-
also possible to detect a lateralized fluid tion; moreover, inflammatory reaction causes dis-
collection. tortions of the pelvic anatomy and leads to
adhesion formation [33, 83]. Many authors report tification of the rectosigmoid endometriosis
that both MRI and TVUS are limited in their abil- (respectively, 73% and 90% for MRI and 73% and
ity to detect superficial endometriosis. According 86% for tenderness-guided TVUS) [84, 85]. In
to Abrao et al., TVUS had a sensitivity and speci- addition, MRI examination allows to evaluate the
ficity of 98% and 100% while MRI of 83% and distance between the lesion and the anal junction,
98%, respectively, for detecting rectosigmoid which is fundamental in presurgical planning, as
endometriosis. More recently, Saba et al. has dem- well as the size and number of lesions, and also the
onstrated that MRI and tenderness-guided TVUS depth of intestinal wall infiltration. All these infor-
have similar sensitivity and specificity in the iden- mation is essential for surgical planning.
a b
c d
Fig. 15.5 Rectosigmoid endometriosis in a 34-year-old cap” sign is well visible on sagittal T2-w image (the low
woman with pain during defecation and haematochezia signal-intensity base of the mushroom represents the mus-
synchronized with menses. Sagittal T1-weighted (a), cularis propria while the high-signal-intensity cap is
axial T1-weighted with fat suppression (b), sagittal (c), attributed to the mucosa and submucosa, displaced into
and coronal (d) T2-weighted MR images show hypoin- the lumen). Small intermingled hyperintense foci (arrow-
tense nodular thickening of the rectosigmoid wall that head), due to bloody content, are detected on T1-weighted
adheres to the posterior uterine surface. The “mushroom images with fat suppression
15.2.6.6 Atypical Sites of Implants synchronized with the menses, endometriosis

Terminal ileum and Appendix: Infiltrating endo- must be suspected [91, 92].
metriosis of the terminal ileum is infrequent, Other: Even more rare is the involvement of
accounting for 4.1% of all intestinal endometrio- the liver, the gall bladder, the pancreas and the
sis. More frequently, in two-third of cases, endo- breasts.
metrial lesions (gland, stroma and haemorrhagic
foci) involve the muscular and the seromuscolar 15.2.6.7 Complications
layers, whereas in one-third of cases, they are Adhesions represent the most common complica-
sited solely on the serosal surface of the appen- tion of extraovarian endometriosis. On MR imag-
dix. US is effective especially in the diagnosis of ing, they may appear as spiculated stranding with
paediatric case; CT and less MRI are used in case low signal intensity that obscure interfaces
of acute abdomen and appendix invagination. between the organs. Adhesions must be suspected
Preoperative diagnosis is a real challenge; how- in case of fixed pelvic organs (such as a fixed
ever, this condition should be considered in the retroflexed uterus), posterior displacement of the
differential diagnosis of acute abdominal pain, uterus and ovaries, angulation of bowel loops,
especially in women with a medical history of elevation of the posterior vaginal fornix, locu-
endometriosis [86, 87]. lated fluid collections, hydrosalpinx and haema-
Abdominal Wall: Endometriosis may occur in tosalpinx [7]. Often laparoscopy is needed for
abdominal and pelvic wall scars, laparoscopy inci- definitive diagnosis because the evaluation of
sion or caesarean delivery scars. The reported inci- extent and severity of adhesions can be difficult
dence of abdominal scar endometriosis following to determine with imaging.
caesarean section is 0.03–0.6%. Nodules appear Unlike adhesions, malignant transformation
similar to solid endometriosis located in other pel- of extraovarian endometriosis is a rare complica-
vic sites; so, they demonstrate high signal both on tion. While malignant transformation of endome-
T1-weighted and on T2-weighted images second- trioma has been widely documented and
ary to subacute haemorrhage [88, 89]. explained, in the case of extraovarian endometri-
Chest: Endometriotic involvement of the chest osis, it is still unclear. Approximately 25% of
was first described by Rokitansky in 1956, and cases of the endometriosis-associated malignan-
many cases are reported in the literature. This cies involve an endometriotic lesion located in an
condition is known as thoracic endometriosis extraovarian site. Several histopathological types
syndrome (TES). It is always associated with have been described, but endometrioid carcinoma
coexistent pelvic endometriosis, but it manifests and sarcomas are the most common. Rectovaginal
later (usually after 5 years after the diagnosis). and colorectal sites are the most frequently
Radiographic findings include pneumothorax, involved; the urinary bladder, vagina, ligaments,
haemothorax, and lung nodules. CT or MR umbilicus, cervix and fallopian tube are less
examination of the lung may show the endome- involved [62, 93–95]. On MR images neoplastic
trial lesions, but in many cases, they are not lesions appear as solid masses with intermediate
detectable with the exception of the occurrence signal both on T1- and T2-weighted sequences.
of pneumothorax [12, 90]. Typically, they show contrast enhancement after
Cutaneous Tissues: Cutaneous variant of administration of contrast material, and, more-
endometriosis accounts for approximately 1% of over, they have restricted diffusion. The suspi-
all cases and is commonly associated with surgi- cion of malignant transformation should arise
cal scar. On MR imaging, the lesions showed het- when a lesion with this MRI appearance is
erogeneous mixed signal intensity on T1-weighted detected in a woman with a previous diagnosis of
images, with several high signal foci presumed to endometriosis or when a lesion with such MRI
be due to haemorrhage. For this reason, in case of characteristics is seen along with other endome-
detection of an infiltrative soft tissue mass in trial lesions [43, 96]. However, the definitive
reproductive-age women, associated with pain diagnosis is histologic. Obviously, these malig-
nancies may spread by haematogenous and lym- –– Multiple adnexal cysts with hyperintense
phatic routes or perineural spread. Differential signal on T1-weighted images
diagnosis should consider primitive neoplasms –– One or more adnexal cysts with hyperin-
that originate in different organs (such as colon tense signal on T1-weighted images and
cancer or vaginal squamous cell cancer) or, if the “shading sign” on T2-weighted images
lesion occurs on a scar, with granuloma or der- • “T2 dark spots” finding seems to be highly
moid tumours [49]. specific for chronically haemorrhagic lesions;
it could be considered a useful tool to
differentiate ovarian endometriomas from

15.3 Technical Tips functional haemorrhagic cysts.
• MRI findings suspecting malignant degenera-
For the assessment and evaluation of tion of endometrioma:
endometriosis: –– Enhanced mural nodules (well detected on
contrast-enhanced subtracted images)
• Use MRI as second-line approach, especially –– Loss of “T2-shading” sign on T2-weighted
in symptomatic patients with negative US images
findings, and before surgery for preoperative –– Mural nodule of more than 30 mm in size
workup. –– Interval increase in the size of the cyst
• Fasting (3, 4 or 6 h), dietary preparation (low- • Deep endometriosis should be suspected in
residue regimen on the day before and the day case of:
of examination) and a moderately full urinary –– Haematosalpinx, as it may be the only find-
bladder are recommended; bowel preparation ing in some women
should be considered “best practice”. –– Partial or complete obliteration of the
• Use antispasmodic agents in order to reduce rectouterine pouch with a lateralized fluid
motion artefacts caused by bowel and uterine collection
peristalsis. –– Fixed pelvic organs (such as a fixed retro-
• Vaginal and rectal opacification may be used flexed uterus), posterior displacement of the
for a better visualization of anatomical struc- uterus and ovaries, angulation of bowel loops
tures that are close to each other; however, be and elevation of the posterior vaginal fornix
aware to avoid the presence of small air bub-
bles that could be mistaken for nodular wall
thickening. 15.4 Future Perspectives
• MRI protocol should be composed of:
–– 2D-T2-weighted sequences in the axial, In the future, MRI will have a more important
sagittal and oblique plane role in the assessment of endometriosis due to
–– T1-weighted sequences with and without technical advances and improvement of software.
fat suppression With its great capacity to detect and characterize
–– Half-Fourier single-shot turbo-spin-echo lesions, MRI has to be considered an important
acquisition tool in staging endometriosis and planning ade-
Diffusion-weighted imaging and susceptibility- quate presurgical counselling and treatment. We
weighted imaging may lead to additional postulate that it should reduce the need for diag-
information. nostic laparoscopy, even because the latter cannot
• The use of contrast material is reserved for detect lesions hidden by adhesions (and so not
specific cases (especially in the suspicious of easily accessible at endoscopic viewing) or can-
endometriosis-associated cancer) and there- not even assess the depth of infiltration of perito-
fore depends on the indication to MRI neal lesions. Diffusion weighted imaging (DWI)
examination. has greatly improved the diagnostic value of
• MRI criteria for endometrioma: MR imaging, giving information that allow to
differentiate between benign or malignant lesions. 10. Bulun SE. Endometriosis. N Engl J Med.
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Biomarkers in Endometriosis
16
Vicki Nisenblat and M. Louise Hull
16.1 Introduction this method is limited by the experience of the

surgeon and histological confirmation by the
Although there are no data to show that early expertise of the pathologist. A systematic review
treatment of endometriosis prevents progression of four studies of the diagnostic test accuracy of
of the disease, untreated endometriosis is linked laparoscopic visualization showed it had 94%
with reduced quality of life and outcomes such as sensitivity and 79% specificity when compared
depression, inability to work, sexual dysfunction, to histological confirmation of endometriosis in
and missed opportunity for motherhood [1, 2]. excised lesions [6]. Surgery also confers a risk of
The accuracy of diagnosing endometriosis infection, bleeding, and damage to other struc-
based on symptoms alone is low due to the varied tures in the pelvis, anesthetic risks, and a small
and nonspecific nature of the clinical presenta- risk of mortality. Even though the major compli-
tion of disease. Furthermore, there is a poor asso- cations of laparoscopy are rare, it is difficult to
ciation between the presenting symptoms and determine the exact incidence of complications
severity of the disease [3]. A recent multicenter associated with long-term morbidity.
study, which included 1396 women in 19 hospi- The high cost of surgery restricts access to
tals in 13 countries, assessed the accuracy of a diagnosis particularly for women in developing
variety of features in a woman’s history that best countries, in low socioeconomic groups, and in
predicted endometriosis and revealed that a rural and remote locations. Additionally, some
symptom-based model had insufficient diagnos- women with pelvic pain prefer to avoid surgery
tic accuracy to be relied on in a clinical setting opting for empirical medical treatment which is
[4]. While examination findings can help to an approach that has widespread acceptance [7].
improve the accuracy of diagnosis, the majority An accurate noninvasive diagnostic test for endo-
of women with laparoscopically proven endome- metriosis would afford these groups of women an
triosis have a normal pelvic examination [5]. opportunity to validate their symptoms and to
Laparoscopic visualization of lesions in the reduce anxiety related to diagnostic uncertainty
peritoneal cavity is the only test sufficiently accu- regardless of their reasons for not undertaking
rate to be accepted as the diagnostic “gold stan- surgery.
dard” in clinical care. However, diagnosis using Consensus groups are increasingly recogniz-
ing the need for more accurate noninvasive diag-
V. Nisenblat (*) · M. L. Hull nostics and recommending that nonsurgical
Discipline of Obstetrics and Gynaecology, School of diagnosis should be considered before embarking
Medicine, Robinson Research Institute, The
on an operative procedure [8, 9]. A simple and
University of Adelaide, Adelaide, SA, Australia

https://doi.org/10.1007/978-3-319-71138-6_16
170 V. Nisenblat and M. L. Hull
reliable low-invasive test for endometriosis is as either diseased or non-diseased 100% of the
expected to minimize surgical risks, reduce diag- time. In practice, false-positive and false-nega-
nostic delay, and provide an opportunity for ear- tive tests create a misclassification of some indi-
lier interventions with potential to improve viduals in the non-diseased and diseased groups.
patient outcomes and to decrease healthcare- The basic measures of how well a test discrimi-
related costs. Furthermore, the ability to assess nates between disease and non-disease states
the progression of endometriosis in a noninvasive include sensitivity, defined as the proportion of
way would advance clinical research in endome- all patients with the disease who indeed have a
triosis, including development of new effective positive test result, and specificity, defined as the
therapeutic and preventive strategies. proportion of all patients without the disease who
The literature on low-invasive peripheral have a negative test result. Sensitivity and speci-
and endometrial biomarkers and on imaging ficity are independent of the prevalence of the
diagnostic tests for endometriosis is growing, disease and are commonly used in the diagnostic
with a steady stream of new reports on accurate studies to evaluate and compare the performance
diagnostic tests. Although none of the pro- of different tests. A trade-off exists between the
posed tests have been considered sufficiently sensitivity and specificity of index test as their
accurate to legitimately replace laparoscopy in values vary inversely in relation to the cutoff
everyday practice, imaging tests are being point chosen to define a positive or negative
increasingly employed as a diagnostic adjunct result.
to surgery, and their use is being progressively The purpose of the test and the clinical conse-
explored. quences of under- and overdiagnosis of the con-
This chapter provides a synthesis of the up-to- dition determines the level of diagnostic
date research evidence on diagnostic accuracy of performance required for a clinically useful test.
low-invasive tests for endometriosis. It aims to In endometriosis, a noninvasive test could be
answer the question whether any low-invasive used as (1) a replacement test which replaces
diagnostic tests, either individually or in combi- diagnostic laparoscopy as it has similar or better
nation, may be considered sufficiently accurate to accuracy and (2) a triage test, used to identify the
either replace laparoscopy as a diagnostic test for individuals who likely to benefit from laparos-
endometriosis or be used as a triage test to copy, which may alter the number of those who
improve selection of women for a diagnostic sur- are offered a surgical intervention [10]. A replace-
gery. In addition, this chapter evaluates the appli- ment test is expected to have high sensitivity and
cability of the presented findings to clinical specificity, while triage tests could be highly sen-
practice and provides insight regarding future sitive but less specific or vice versa. A high sensi-
research in the field. tivity triage test rules out the condition if the test
is negative, but a positive result has little diagnos-
tic value (SnOUT test). Alternatively, a high
16.2 Quantifying Performance specificity triage test rules conditions “in” if the
of the Diagnostic Tests test is positive but is less informative if the result
for Endometriosis is negative (SpIN test). Both types of triage test
are clinically useful and can be implemented in
To discuss diagnostic test accuracy studies in a sequential manner to optimize a diagnostic algo-
meaningful way, the tests need to be interpreted rithm (Fig. 16.1).
in an appropriate clinical and methodological To assist with the interpretation of the diag-
framework. Diagnostic test accuracy refers to the nostic estimates and to put the results into clini-
degree of agreement between the diagnostic per- cal context, a series of Cochrane Library
formance of the test under study (index test) and diagnostic test reviews proposed the cutoff val-
that of a clinical gold standard (reference test). ues for the potentially clinically significant diag-
The ideal diagnostic test classifies all individuals nostic estimates. The diagnostic threshold for a
16 Biomarkers in Endometriosis 171
replacement test for endometriosis was deter- Highly diagnostic accuracy on its own is not
mined as a sensitivity ≥0.94 and a specificity sufficient to determine that a test is clinically use-
≥0.79, which is the same diagnostic accuracy ful, and the value of diagnostic tests ultimately
conferred by a diagnostic laparoscopy [6]. It was lies in their effect on patient outcomes. Evaluation
assumed that a 5% error in the correct diagnosis of the diagnostic test to advance the markers from
was statistically and clinically acceptable for a benchtop to clinically relevant products usually
triage test, whereas diagnostic uncertainty comprises a series of sequential steps to assess
should be limited to less than 50% of individu- clinical, financial, psychological, and societal
als. Therefore, the criteria for triage tests were consequences of the test [11]. Diagnostic perfor-
set as a sensitivity ≥0.95 and a specificity ≥0.50 mance of the test is an important initial step in the
for a SnOUT test and a sensitivity ≥0.50 and a pipeline of test evaluation and thus has to rely on
specificity ≥0.95 for a SpIN test [10]. high-quality reproducible evidence.
Fig. 16.1 Sequential approach to non-invasive testing of endometriosis

16.3 Biomarkers [16]. Over the years, considerable number of

for Endometriosis studies demonstrated high specificity but low
sensitivity of the test but explored different cutoff
16.3.1 Peripheral Biomarkers levels and showed substantial heterogeneity in
the obtained diagnostic estimates. Two recent
Hormonal dysregulation, immune dysfunction, systematic reviews reached different conclusions
and inflammation are features of endometriosis, regarding the optimal diagnostic cutoff level of
which is increasingly recognized as a systemic CA-125. The Cochrane Database systematic
condition rather than localized pelvic disease [12, review that included 45 studies with a total of
13]. Identification of the cellular and molecular 5534 women demonstrated that although none of
systemic hallmarks of endometriosis has the evaluated cutoffs showed adequate diagnostic
prompted the evaluation of their potential as performance, CA-125 > 16.0–17.6 U/ml was the
diagnostic tools. Peripheral biomarkers for endo- best performing test for pelvic endometriosis,
metriosis have been extensively explored in the with a mean sensitivity of 0.56 (95% CI 0.24,
blood and urine and were appraised in several 0.88) and mean specificity of 0.91 (95% CI 0.75,
recent systematic reviews [10, 14, 15]. 1.00) [10]. The test approached the criteria for a
The diagnostic test accuracy of 122 biomark- SpIN triage test, being able to confirm the diag-
ers measured in serum, plasma, or whole blood nosis if positive result, but remained nonconclu-
was evaluated in a Cochrane Library systematic sive for the levels below the cutoff point. CA-125
review [10]. Diagnostic estimates (sensitivity and seemed to perform better for ovarian endometrio-
specificity) were reported for 47 biomarker-based sis compared with the other forms of the disease,
tests, which included angiogenesis/growth fac- but there were no sufficient data for formal com-
tors, apoptosis markers, cell adhesion molecules, parison, and valid conclusions could not be made.
high-throughput markers, hormonal markers, A systematic review of 14 studies, with a total of
immune system/inflammatory markers, oxidative 2920 participants, solely focused on
stress markers, microRNAs, tumor markers, and CA-125 > 30 U/ml and demonstrated higher
other proteins. The majority of index tests were diagnostic estimates for this threshold than those
assessed in small individual studies, often using presented in the Cochrane review [17]. The
different cutoff thresholds and diverse laboratory authors suggested using a cutoff >30 U/ml to rule
methods. Meta-analysis was only possible for the disease in, and this was supported by more
four tests (anti-endometrial antibodies, interleu- recent well-designed prospective study in 58 con-
kin-6 (IL-6), cancer antigen-19.9 (CA-19.9), and secutive women, which demonstrated a sensitiv-
CA-125), and there was substantial heterogeneity ity of 0.57 (95% CI 0.37, 0.75) and a specificity
in diagnostic estimates between the studies in of 0.96 (95% CI 0.82, 1.00%) for detecting endo-
every meta-analysis. None of the meta-analyses metriosis using CA-125 at a cutoff of ≥30 U/ml
revealed a test which met the criteria for consid- [18]. Earlier studies have also suggested a role of
eration as a replacement or triage test for pelvic CA-125 as a marker for the recurrence of endo-
endometriosis. metriosis and for monitoring the response medi-
CA-125 is the most studied biomarker in cal therapy but did not reach firm conclusions.
endometriosis. Its diagnostic role has been While some showed progressive reduction in
explored for several decades since its first publi- CA-125 levels in women treated with postopera-
cations in the early 1980s. The first systematic tive danazol of GnRH agonists with posttreat-
review that assessed the performance of ment rebound [19, 20], others revealed that 50%
CA-125 in endometriosis in 22 studies with a of patients with clinical improvement showed no
total of 2866 women revealed that while CA-125 change in serum CA-125 levels [21]. Moreover,
has limited performance in endometriosis, it per- second-look laparoscopy in small subset of
forms better in advanced disease and hence may treated patients demonstrated persistent endome-
be of clinical value in selected subsets of patients triosis despite normal CA-125 levels [19].
Furthermore, there is no consensus on optimal endometriosis and identified miRNA panels with
timing of the test in relation to phase of the men- high diagnostic estimates [30–33]. Each study,
strual cycle. Koninckx was the first to show that however, reported different set of miRNA bio-
plasma concentrations of CA-125 were higher markers, and the results could not be replicated
during menses than during follicular or mid- by others (personal communication). It becomes
luteal phase in both control and endometriosis increasingly evident that emerging advances in
groups and observed more pronounced differ- technology and bioinformatics provide a unique
ences in mild forms of the disease [22]. Since opportunity for elucidating biological pathways
then, the literature on inter-cycle differences of and discovering clinical biomarkers. Optimization
CA-125 remains inconsistent, and there is sub- and standardization of the laboratory and analyti-
stantial variation between the studies with regard cal methods with a focus on reproducible research
to timing of the test in menstrual cycle. Overall, are important to advance the preliminary discov-
biases in study design and limitations in report- eries into clinical applications.
ing in most studies contributed to low quality of A limited number of urinary tests have been
current evidence. The diagnostic role of CA- assessed for their potential to diagnose endome-
125 in endometriosis, either as a single test or triosis. A Cochrane Library diagnostic test accu-
when integrated in more complex diagnostic racy review of 8 studies with a total of 646
algorithms, remains elusive and needs to be participants evaluated 6 tests: enolase 1 (NNE),
established in patients with different clinical vitamin D binding protein (VDBP), cytokeratin
phenotypes. 19 (CK 19 or CYFRA 21-1), vascular endothelial
A number of biomarkers demonstrated high growth factor (VEGF), tumor necrosis factor-
diagnostic estimates for pelvic endometriosis or alpha (TNF-α), and urinary proteome [15]. Most
endometrioma in individual studies (Table 16.1). were evaluated in small individual studies and
Future research needs to confirm their diagnostic meta-analyses could not be performed. Of these,
value and in endometriosis using high-quality NNE, VDBP, and cytoskeleton molecule CK-19
diagnostic test accuracy methodologies in large showed low diagnostic estimates, whereas VEGF
cohorts of well-characterized patients. The list of and TNF-α did not distinguish women with and
blood-derived biomarkers continues to expand as without endometriosis and their diagnostic accu-
high-throughput profiling of the metabolome racy was not assessed.
[23–25], proteome [26–29], and miRNAs, the Matrix-enhanced laser desorption/ionization
posttranscriptional regulators of gene expression time-of-flight mass spectrometry (MALDI-
[30–33], becomes increasingly accessible. TOF-MS) was used to identify the urinary pro-
The high-throughput platforms carry great teome in two studies with some variation in
potential, since they enable comprehensive cov- methodology between studies and some inconsis-
erage of molecules of interest in small amount of tencies with regard to the identified peptide mark-
biological material. However, the identification ers. In one study, a test that included five urinary
and characterization of metabolic and proteomic peptides of 1433.9 Da, 1599.4 Da, 2085.6 Da,
fingerprint molecules is a challenging task, and 6798.0 Da, and 3217.2 Da had a sensitivity of
methodology is still under development. 0.91 [95%CI 0.59, 1.00] and a specificity of 0.93
Unstandardized approach to sample processing [95%CI 0.66, 1.00] [34]. Although clinically
and data handling and variation in analytical attractive, these findings require replication using
techniques across studies invariably limit transla- similar technical and analytical approaches
tional application of the “omics” science. High- before their value in clinical practice can be
throughput experiments have limited established. Recent reports indicated that nuclear
reproducibility and are rarely validated in large magnetic resonance (NMR) spectroscopy can be
independent cohorts. For example, several used to reveal the metabolome of women with
research groups have examined potential use of endometriosis in urine samples, but the diagnos-
circulating miRNA as diagnostic marker for tic validity of the test is yet to be established [35].
Table 16.1 Peripheral and endometrial biomarkers of endometriosis that require further validation [14, 17, 44]
Blood Angiogenesis and growth • Vascular endothelial growth factor (VEGF) >680 pg/ml and
biomarkers markers >236 pg/ml
• Brain-derived neurotrophic factor (BDNF)
High-throughput markers • Metabolome signatures
• Proteome signatures
Immune system and • Interleukin-6 (IL-6) >12.2 pg/ml
inflammatory markers
Oxidative stress markers • Paraoxonase-1 (PON-1) <141.5 U/l
• Carbonyls <14.9 μM
Post-transcriptional • miR-9*
regulators of gene expression • miR-141*
(miRNAs) • miR-145*
• miR-20a
• miR-22
• miR-532-3p
Tumor markers • CA-125 (cut-off value > 43 U/ml)
Combination of several • Interleukin-6 (IL-6) >12.2 pg/ml + Tumor necrosis factor-α
blood tests (TNF-α) > 12.45 pg/ml
• IL-6 > 12.2 pg/ml + C-reactive protein (CRP) >438 μg/ml
• TNF-α > 12.45 pg/ml + CRP > 438 μg/ml
• CA-125 + Syntaxin-5 (STX-5) + Laminin-1 (LN-1)
• IL-6 > 12.2 pg/ml + TNF-α > 12.45 pg/ml + CRP > 438 μg/ml
• CA-125 > 17.6 IU/ml + VEGF > 236 pg/ml
• CA-125 + CA-19-9 + Survivin
• CA-125 > 50 IU/ml + C-C motif receptor-
1(CCR1) > 1.16 + Monocyte chemotactic protein-1 (MCP-
1) > 140 pg/ml
• CA-125 > 20 IU/ml + MCP-1 > 152.744 pg/ml + leptin > 3.14 ng/
ml
• CA-125 + IL-8 + TNF-α
• CA-125 + CA-19.9 + IL-6 + IL-8 + TNF-α + CRP
• miR-199a + miR-542-3p
• miR-199a + miR-122 + miR-145* + miR-542-3p
Tests that differentiate • Urocortin > 29 pg/ml
endometrioma from other • Urocortin > 33 pg/ml
benign ovarian cysts • Follistatin > 1433 pg/ml
• CA-125 > 30 U/ml and >36 U/ml
• CA-125 ≥ 25 U/ml + CA-19.9 ≥ 22 U/ml
Urinary High-throughput markers • Proteome signatures
biomarkers
Endometrial High-throughput markers • Proteome signatures
biomarkers Hormonal markers • 17-β hydroxysteroid dehydrogenase type 2 gene (17βHSD2)
Immune system and • Interleukin-1 receptor type II gene (IL-1R2)
inflammatory markers
Myogenic markers • Caldesmon
Neural and nerve sheath • Protein gene product 9.5 (PGP 9.5)
markers • Vasoactive intestinal polypeptide (VIP)
• Calcitonin gene-related protein (CGRP)
• Substance P (SP)
• Neuropeptide Y (NPY)
• Combined test (VIP + PGP 9.5 + SP)
16.3.2 Endometrial Biomarkers women. The eutopic endometrium from women

with endometriosis had an aberrant responsive-
Many studies have demonstrated biological dif- ness to ovarian hormones characterized by pro-
ferences when endometrium from endometriosis gesterone resistance and incomplete transition
patients is compared to that from disease-free from proliferative to luteal phase of menstrual
cycle, which was associated with decreased other biomarkers were assessed in single studies
endometrial receptivity [36–38]. Dysregulated and could not be statistically evaluated in any
gene expression profiles and changes in hor- meaningful way. CYP19 (8 studies, 444 women)
mone-responsive, gene regulatory pathways were had a mean sensitivity of 0.77 (95% CI 0.70,
also identified in eutopic endometrium from 0.85) and a specificity of 0.74 (95% CI 0.65, 84).
endometriosis [39]. An analysis of the DNA PGP 9.5 (7 studies, 361 women) showed a mean
methylome in endometrium from women with sensitivity of 0.96 (95% CI 0.91, 1.00) and a
endometriosis and disease-free individuals specificity of 0.86 (95% CI 0.70, 1.00). While the
revealed different methylation patterns that fluc- pooled estimates for PGP 9.5 suggest it could
tuated across the phases of the menstrual cycle replace surgical diagnosis, there was significant
indicative of aberrant epigenetic regulation of the diversity in the diagnostic estimates between the
endometrium in endometriosis [40]. studies. It has been noted that PGP 9.5 expression
The inflammatory and hypoxic peritoneal is highly sensitive to variation in endometrial
environment identified in endometriosis was sampling and a narrow full-thickness biopsy with
linked to an aberrant expression of chemokines, an adequate amount of stroma is critical to its
cytokines, growth factors, and immune cells in detection. PGP 9.5 expression is also influenced
eutopic endometrium that are involved in immune by the microscopy method used and optimization
response, proliferation, cell migration, and neo- of the assay as studies that utilized conventional
vascularization [10]. Secretomic approaches light microscopy showed lower diagnostic esti-
have characterized protein composition of the mates [43] and some immunohistochemical
endometrial secretions and revealed the presence assays did not demonstrate a difference in PGP
of cytokines, growth factors, ions, carbohydrates, 9.5 staining between groups [44]. Thus, while the
and steroids, in human uterine fluid [41]. Taken data for PGP 9.5 are encouraging, this biomarker
together, these observations support the premise needs further validation in large independent
that eutopic endometrium and aspirated uterine high-quality studies using standardized endome-
fluid could contain diagnostic biomarkers rele- trial sampling and laboratory methods.
vant to endometriosis. Several additional biomarkers assessed in
A Cochrane Library diagnostic test accuracy individual studies displayed high diagnostic
review explored 95 endometriosis-associated bio- potential (Table 16.1). Additional work to com-
markers in eutopic endometrium and menstrual prehensively assess these biomarkers would be
fluid [42]. Included were angiogenesis factor pro- important to confirm their diagnostic role.
kineticin 1 (PROK-1), cell adhesion molecules Overall, most studies had major methodological
(integrins α3β1, α4β1, β1, and α6), DNA repair flaws, and the data should be interpreted with
molecule human telomerase reverse transcriptase caution.
(hTERT), endometrial and mitochondrial pro- Nonstandard methods of sample collection
teome, tumor marker (CA-125), inflammatory and processing, sampling at different phases of
marker interleukin-1 receptor type II (IL-1R2), the menstrual cycle, and inconsistency in pheno-
and myogenic marker caldesmon (CALD-1). typing the samples across studies lead to hetero-
Other hormonal markers (aromatase cytochrome geneity in papers that report the diagnostic
P450 (CYP19), 17β-hydroxysteroid dehydroge- accuracy of endometrial biomarkers. The method
nase type 2 (17βHSD2), and estrogen receptors of obtaining endometrial sample appeared to
(ER-α, ER-β)) and neural markers (protein gene influence the results of PGP 9.5, and this may be
product 9.5 (PGP 9.5), vasoactive intestinal poly- an issue for other biomarkers. Furthermore,
peptide (VIP), calcitonin gene-related protein different uterine or pelvic pathologies such as
(CGRP), substance P (SP), neuropeptide Y (NPY), such as leiomyoma or adenomyosis could engen-
and neurofilament (NF)) were also assessed. der overlapping endometrial aberrations.
The only markers with sufficient data for a Uterine fluid has been increasingly explored
meta-analysis were PGP 9.5 and CYP19 as the using proteomic and metabolomics methods to
try and identify biomarkers of endometriosis. To decreased pelvic organ mobility indicate the
date there are no identified biomarkers in men- presence of endometriosis in specific clinical
strual fluid that distinguish women with and context.
without endometriosis with an acceptable sensi- In addition to their ability to identify endome-
tivity and specificity. triosis lesions in a noninvasive way, imaging tests
carry substantial advantages in preoperative
assessment of women with clinically suspected
16.3.3 Concluding Remarks deep endometriosis. In severe forms of the dis-
on Biomarkers ease, proper pelvic visualization at laparoscopy
for Endometriosis can be obscured by adhesions, while preoperative
lesion mapping can assist with completeness of
In summary, none of the peripheral or endome- surgical treatment. Furthermore, identifying deep
trial biomarkers can be used in clinical practice infiltrating lesions of the bowel, bladder, or ureter
outside a research setting. CA-125, the most can improve preoperative planning and patient
studied biomarker, could serve as a rule in triage counseling, which allows to establish appropriate
test (SpIN) , but the quality of CA-125 literature referral pathways and to utilize multidisciplinary
had not sufficiently improved in over several team approach in more effective way.
decades. The questions regarding its adequate Over the years, large number of studies
cutoff levels and optimal test timing and contri- attempted to define diagnostic performance of
bution to clinical decision-making remain unan- different imaging tests in endometriosis, integrat-
swered. While the majority of the investigated ing emerging technologies and modifications to
biomarkers were not diagnostically useful for more traditional methods. In ultrasound field,
endometriosis, for those markers that showed modified methods include transvaginal ultra-
adequate diagnostic estimates, the evidence sound with bowel preparation (TVUS-BP), instil-
remains either conflicting or insufficient for lation of contrast medium transrectally
meaningful recommendations. Low-quality het- (RWC-TVUS) or transvaginally (sonovaginogra-
erogeneous studies and unstandardized research phy), and “tenderness-guided” approach with
methods undermine the reliability of the pre- particular attention to the tender points evoked
sented results. There were no diagnostic studies during examination and 3-D technology. In MRI,
that focused on the downstream value of the test 3.0Tesla Magnetom system (3.0 T MRI); intro-
in terms of health or behavioral consequences. duction of ultrasonographic gel into the vagina,
Likewise, except for early low-quality reports on rectum, or rectosigmoid (MRI jelly method); or
CA-125, no studies specifically assessed the role utilization of three-dimensional coronal single-
of the biomarkers in monitoring disease progres- slab MRI (3D Cube) have been used in addition
sion or recurrence. to more traditional systems.
The Cochrane Library systematic review
assessed all the available imaging methods in one
16.4 Imaging Tests coherent document and demonstrated that trans-
as a Diagnostic Tool vaginal ultrasound (TVUS) and magnetic reso-
for Endometriosis nance imaging (MRI) were the most studied
modalities [45]. In studies that did not specify
While clinical presentations of endometriosis type of endometriosis and presumably looked at
vary, morphological characteristics of endometri- the overall pelvic endometriosis, no imaging
otic lesions appear to be consistent across differ- method met the diagnostic criteria for a replace-
ent patient phenotypes and, if visualized with ment test or a triage test (Table 16.2). TVUS was
imaging methods, serve as basis for radiological the best performing method and had sensitivity of
markers of the disease. In addition, distorted pel- 0.79 (95% CI 0.36, 1.00) and specificity of 0.91
vic anatomies such as retroverted uterus and (95% CI 0.74, 1.00), although there was
Table 16.2 Diagnostic performance of different imaging methods for the diagnosis of endometriosis: a meta-analysis
[47]
No. of studies; Pooled Pooled
No. of sensitivity specificity
Test participants (95% CI) (95% CI) Comments
Pelvic TVUS 5; 1222 0.79 (0.36, 0.91 (0.74, 1 outlier study was excludeda
endometriosis 1.00) 1.00)
MRI 7; 303 0.79 (0.70, 0.72 (0.51, 3.0T MRI (2 studies) showed the
0.88) 0.92) highest diagnostic accuracy
Ovarian TVUS 8; 765 0.93 (0.87, 0.96 (0.92, Studies published after 2006 (4
endometriosis 0.99) 0.99) studies) showed the highest
diagnostic accuracy
TRUS 1; 92 0.89 (0.74, 0.77 (0.64, Meta-analysis was not possible
0.97) 0.87)
MRI 3; 179 0.95 (0.90, 0.91 (0.86, 3.0T MRI (2 studies) showed the
1.00) 0.97 highest diagnostic accuracy
Deep endometriosis TVUS 9; 934 0.79 (0.69, 0.94 (0.88, TVUS-BP (1 study) showed the
(DE) 0.89) 1.00) highest diagnostic accuracy
MRI 6; 266 0.94 (0.90, 0.77 (0.44, 3.0T MRI (2 studies) and MRI
0.97) 1.00) jelly method (1 study) showed
the highest diagnostic accuracy
DCBE 1; 69 0.36 (0.24, 1.00 (0.16, Meta-analysis was not possible
0.48) 1.00)
DCBE double-contrast barium enema, MRI magnetic resonance imaging, TRUS transrectal ultrasound, TVUS transvagi-
nal ultrasound, TVUS-BP transvaginal ultrasound with bowel preparation
a
The excluded study utilized a sole single marker of endometriosis (kissing ovaries), in contrast to the other four studies
that surveyed pelvic anatomy
substantial diversity in diagnostic estimates TVUS, and transrectal ultrasound (TRUS) showed
between the studies. Integration of TVUS with that both MRI and TVUS provided comparable
history of dysmenorrhea or dyspareunia and vagi- estimates in diagnosing ovarian endometriosis,
nal examination for the presence of pelvic tender- while TRUS had lower diagnostic values [48].
ness, fixed retroverted uterus, or deeply infiltrating For DE, MRI approached the criteria for a
nodules resulted in improved sensitivity of 0.92 replacement test, and TVUS approached the cri-
(95% CI 0.78, 0.98) but lower specificity of 0.61 teria for a rule in (SpIN) triage test (Table 16.2).
(95% CI 0.48, 0.72) in a single study that included The direct comparison performed in one small
106 women and did not present direct compara- study demonstrated that MRI performed better
tive data with TVUS alone [46]. than 3D-TVUS in the diagnosis of DE, and there
For ovarian endometriosis, MRI met the crite- were no comparisons between MRI and other
ria for a replacement test and TVUS approached ultrasound methods [49]. Double-contrast b arium
these criteria and could qualify as a rule in (SpIN) enema (DCBE) was inferior to the other diagnos-
triage test (Table 16.2). Overall, the studies pub- tic methods for detecting DE.
lished after 2006 demonstrated higher sensitivity Notably, tenderness-guided TVUS and
for diagnosing endometrioma with ultrasound. TVUS-BP seemed to be the most accurate in
Combination with CA-125 and CA-19.9 at differ- detecting ovarian and deep endometriosis.
ent cutoff levels did not improve diagnostic per- Tenderness-guided TVUS (one study in 50
formance of TVUS for detecting endometrioma, women) showed sensitivity of 1.00 (95% CI 0.66,
as demonstrated in one study in a total of 118 1.00) and specificity of 1.00 (95% CI 0.91, 1.00)
women [47], and there were no studies on other in detecting ovarian endometrioma and sensitiv-
diagnostic combinations of imaging tests for ity of 0.90 (95% CI 0.74, 0.98) with specificity of
endometrioma. One small study that performed 0.95 (95% CI 0.74, 1.00) in detecting DE [50].
direct head-to-head comparison between MRI, TVUS-BP (one study in 57 women) demon-
strated sensitivity of 0.97 (95% CI 0.83, 1.00) Cochrane review), both TVUS and MRI could
with specificity of 1.00 (95% CI 0.87, 1.00) for qualify as a SpIN triage test [54, 57]. Formal
endometrioma and sensitivity of 0.94 (95% CI comparative analyses between TVUS and MRI
0.81, 0.99) with specificity of 1.00 (95% CI 0.85, methods were not possible due to paucity of the
1.00) for DE [51], and the findings were repli- data.
cated by another group in 85 women with endo- Collectively, the meta-analysis revealed that
metrioma [52]. 3.0 T MRI showed higher although MRI was superior to TVUS in detecting
sensitivity and specificity for diagnosing pelvic, endometrioma and DE, both methods showed
ovarian, or deep endometriosis compared to other comparable high diagnostic estimates when mod-
conventional MRI methods. However, there were ified techniques were applied. Recently, MRI
no sufficient data for formal comparative analysis was promoted as the noninvasive imaging tech-
between different modified methods. nique of choice for the detection and classifica-
Substantial number of studies focused on tion of endometriosis [58], although major
mapping deep endometriotic lesions at specific advantages of MRI over TVUS were not consis-
anatomical sites, the approach which does not tently demonstrated. Both TVUS and MRI could
have primary diagnostic role but is important for accurately detect ovarian and deep endometrio-
planning surgical strategy (Table 16.3). For rec- sis, which is consistently reported by most sys-
tosigmoid endometriosis, which was evaluated in tematic reviews on the topic [53–57, 59]. TRUS
the largest number of studies, TVUS, TRUS, and does not appear to be superior to TVUS for any
MRI reached the criteria for a SpIN triage, indi- type or site of endometriosis, which questions
cating that positive findings could confirm recto- clinical application of this method considering
sigmoid involvement, whereas negative imaging the discomfort experienced by women during
result was nonconclusive. Multi-detector com- transrectal examination. That said, TRUS remains
puterized tomography enema (MDCT-e) a valid alternative for the subgroup of patients for
appeared to be the best performing modality for whom transvaginal examination is not possible or
rectosigmoid and other bowel endometriosis, not applicable.
showing sensitivity of 0.98 (95% CI 0.94, 1.00) Several factors limit translation of the above
with specificity of 0.99 (95% CI 0.97, 1.00) and findings into clinical practice. Firstly, diagnostic
sensitivity of 0.98 (95% CI 0.92, 1.00) with spec- efficacy was largely reported by small, uncon-
ificity of 1.00 (95% CI 1.00, 1.00), respectively. trolled studies lacking comparative data. Most
For other anatomical locations, TVUS met the tests showed considerable heterogeneity of the
criteria for a rule in SpIN triage test in mapping diagnostic estimates, which could be explained
DE to USL, rectovaginal septum (RVS), vaginal by variation in study design, populations studied,
wall, and POD, which is consistent with the pre- and surgical criteria applied. It is also possible
vious reports [53–55]. Combination of vaginal that advances in technology make it difficult to
examination with TVUS much improved diag- compare earlier studies with more recent ones.
nostic accuracy for detecting DE in RVS, vaginal Importantly, there is no consistency between the
wall, POD, and rectum, but this was demon- testing protocols and radiological diagnostic cri-
strated in only one well-designed study in 200 teria across the studies, particularly for the ultra-
women [56]. Modified ultrasound methods such sound methods. Finally, most studies were
as TVUS-BP and RWC-TVS showed the highest conducted at the specialized centers for endome-
diagnostic accuracy for the evaluated anatomical triosis with a high level of expertise in gyneco-
locations of endometriosis. MRI could qualify as logical imaging, which is likely to result in higher
a SpIN triage test only for POD and vaginal wall diagnostic accuracy, and the method may not per-
endometriosis with overall better performance of form that well in more general setting. It has been
3.0 T MRI and MRI jelly methods. TRUS could reported that competency in performing ultra-
not be adequately assessed for any of these sites sound for DE can be achieved within 40 proce-
due to paucity of the data. For the detection of dures [52, 60]. Thus, wide implementation of
bladder endometriosis (not evaluated in the training programs by the centers of excellence in
Table 16.3 Imaging methods for surgical mapping of endometriosis to specific anatomical sites: a meta-analysis [47]
No. of studies; Pooled Pooled
No. of sensitivity specificity
Test participants (95% CI) (95% CI) Comments
USL endometriosis TVUS 7; 751 0.64 (0.50, 0.97 (0.93, TVUS-BP (1 study) showed the
TRUS 2; 232 0.52 (0.29, 0.94 (0.86,
0.74) 1.00)
MRI 4; 199 0.86 (0.80, 0.84 (0.68, 3.0T MRI (1 study) showed the
RVS endometriosis TVUS 10; 983 0.88 (0.82, 1.00 (0.98, TVUS-BP (3 studies) and
0.94) 1.00) RWC-TVS (1 study) showed
TRUS 2; 232 0.78 (0.51, 0.96 (0.89,
1.00) 1.00)
MRI 3; 288 0.81 (0.70, 0.86 (0.78,
0.93) 0.95)
Vaginal wall TVUS 6; 679 0.57 (0.21, 0.99 (0.96, tg-TVUS (1 study) showed the
endometriosis 0.94) 1.00) highest diagnostic accuracy
TRUS 2; 232 0.39 (0.08, 1.00 (1.00, 3.0T MRI (1 study) showed the
MRI 4; 248 0.77 (0.67, 0.97 (0.92, 3.0T MRI (1 study) showed the
POD obliteration TVUS 6; 755 0.83 (0.77, 0.97 (0.95, TVUS-BP (2 studies) showed
0.88) 0.99) the highest diagnostic accuracy
MRI 5; 154 0.90 (0.76, 0.98 (0.89, 3.0T MRI (3 studies) showed
1.00) 1.00) the highest diagnostic accuracy
Rectosigmoid TVUS 14; 1616 0.90 (0.82, 0.96 (0.94, TVUS-BP (2 studies) and
endometriosis 0.97) 0.99) RWC-TVS (2 studies) showed
TRUS 4; 330 0.91 (0.85, 0.96 (0.91,
0.98) 1.00)
MRI 6; 612 0.92 (0.86, 0.96 (0.93, MRI jelly method (1 study) and
0.99) 0.98) 3.0T MRI (1 study) showed the
highest diagnostic accuracy
MDCT-e 3; 389 0.98 (0.94, 0.98 (0.94,
1.00) 1.00)
DCBE 2; 106 0.56 (0.32, 0.77 (0.41,
0.80) 1.00)
Bowel (ileum- TVUS 3; 314 0.89 (0.81, 0.96 (0.91,
rectum) 0.97) 1.00)
endometriosis TRUS 1; 134 0.96 (0.89, 1.00 (0.94, Meta-analysis was not possible
0.99) 1.00)
MDCT-e 2; 194 0.98 (0.92, 1.00 (1.00,
1.00) 1.00)
DCBE double-contrast barium enema, MDCT-e multi-detector computerized tomography enema, MRI magnetic reso-
nance imaging, RWC-TVS rectal water contrast transvaginal ultrasonography, TRUS transrectal ultrasound, TVUS trans-
vaginal ultrasound, TVUS-BP transvaginal ultrasound with bowel preparation, tg-TVUS tenderness-guided TVUS, USL
utero-sacral ligament, RVS recto-vaginal septum, POD pouch of Douglas
endometriosis ultrasound is an important prereq- validation. Little data is available on combination

uisite for successful implementation of the of imaging tests with biomarkers and on incorpo-
method in general practice. ration of such tests in clinical decision pathways.
History and vaginal examination seem to There is an ongoing debate regarding the sig-
improve the detection of overall pelvic and deep nificance of detecting superficial peritoneal
endometriosis, but these findings require further implants, and some investigators suggest
c onsidering only the ovarian and deep forms as capture complex underlying mechanisms of
“definite disease” [8]. To resolve the controversy, endometriosis and may improve diagnostic per-
noninvasive classification of different types of formance [68, 69].
endometriosis would enable large population Reproducible research involves replication of
studies on natural history and clinical outcomes of the results by independent groups to improve
surgical versus medical treatment in women with validation of promising discoveries and relies on
superficial peritoneal disease. As there are no refined radiological protocols and standardized
diagnostic studies that applied modified, presum- laboratory methods. Moreover, publishing nega-
ably more sensitive, techniques to detect superfi- tive findings, although less scientifically attrac-
cial peritoneal lesions, the role of imaging in tive, is important to guide clinically relevant
detecting this form of endometriosis remains experimental work [70].
unclear. Until new data emerge, the statement that The value of diagnostic test expands beyond
superficial endometriosis cannot be readily seen its diagnostic accuracy, and there is a growing
with imaging methods continues to hold true. awareness that test should show clear evidence
that it improves patient’s health. Patient outcome
studies that correlate test result with clinical out-
16.5 Future Perspectives comes [71] and test-treatment trials that inform
on patient outcomes following treatment based
The search for a noninvasive test for endome- on test results are essential within test evaluation
triosis has been an ongoing and challenging framework [11]. Meaningful economic evalua-
issue. Despite substantial research efforts, there tions require high-quality data to rely on and
is no rigorous scientific evidence to support the should be carried out once the clinical perfor-
use of any of the evaluated biomarkers in every- mance of the test is demonstrated [71].
day practice. Imaging tests are being increas- Finally, the authors of the original and review
ingly employed as a diagnostic adjunct to papers should shift from the standard “more stud-
surgery, but the evidence on their clinical effi- ies needed” to more constructive topic-specific
cacy and contribution to patient management suggestions for future work. This will contribute
remains elusive. There is an increasing demand to the collaborative effort to strengthen the clini-
on researches to reduce the effect of bias and to cally relevant diagnostic research in
demonstrate clinical value of the tests in future endometriosis.
evaluations.
It is important that future authors focus on
clinically relevant population comprising the
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Clinical Cases and Videos
17
Mauricio León, Hugo Sovino,
and Juan Luis Alcazar
17.1 Introduction 17.2 Clinical Case Number 1
The diagnosis of deep endometriosis (DE) using AGE: 28 years.

transvaginal ultrasound (TVS) is an operator- Ethnic Origin: Latina.
dependent technique. For this method to be opti- Surgical Antecedents: no.
mized, it must be done in a standardized way by Family History of Endometriosis: no.
an experienced operator. This standard approach
in obtaining and analyzing the images has been History
recently published by a group of world experts,
the International Deep Endometriosis Analysis Nulligravida, with past history of using contra-
(IDEA) group, and this consensus statement is ceptive pills in the context of severe dysmen-
reviewed in detail in Chap. 3 [1]. orrhea of 4 years of evolution. Dyspareunia
This chapter aims to show some of examples (+); dyschezia (+); without hematuria, hema-
of different clinical scenarios in women with dif- tochezia, or dysuria; with chronic pelvic pain
ferent types of DE lesions diagnosed using since 2 years ago.
TVS. Each case will also discuss the subsequent Currently under study for infertility.
management implemented.
Vaginal Examination
of this chapter (https://doi.org/10.1007/978-3-319-71138- Presence of palpable nodule in the posterior vagi-
6_17) contains supplementary material, which is available nal fornix of 2 cm in diameter. In addition, it
to authorized users. can be observed a vagina with complete longi-
M. León (*) tudinal septum and, in the bottom of it, can be
Ultrasound Unit, Department of Gynaecology and observed two cervices.
Obstetrics, Clinica INDISA, Santiago, Chile
H. Sovino Video
Department of Obstetrics and Gynecology, Human
Reproduction Unit, Clìnica INDISA, Santiago, Chile Explanation (video): complete septate uterus,
J. L. Alcazar rectovaginal nodule with involvement of vagi-
Department of Obstetrics and Gynecology, Clínica nal posterior wall, uterosacral ligaments, and
Universidad de Navarra School of Medicine,
University of Navarra, Pamplona, Spain anterior rectum wall (diabolo-like nodule).
e-mail: jlalcazar@unav.es

https://doi.org/10.1007/978-3-319-71138-6_17
186 M. León et al.
Management .anuterovesical region nodule of 3 cm was

also confirmed and resected.
Laparoscopy and hysteroscopy were done in the
same surgery. Resection of the uterus septum
was done. Rectovaginal nodule was confirmed 17.4 Clinical Case Number 3
during surgery, and only was necessary a shav-
ing rectal procedure. Evolution: satisfactory. AGE: 41 years.
Ethnic Origin: Latina.
Surgical Antecedents: ovarian cystectomy for
17.3 Clinical Case Number 2 endometriosis (2010).
Family History of Endometriosis: no.
AGE: 30 years.
Ethnic Origin: Latina. History
Surgical Antecedents: no.
Family History of Endometriosis: no. Multiparous of two vaginal births, with past his-
tory of dysmenorrhea for 7 years and use of
History contraceptive pills, diverse analgesics, and
anti-inflammatories. Dysmenorrhea (+), dys-
Nulligravida, with history of using contraceptive pareunia (+), dyschezia (+), without hematu-
pills in the context of polycystic ovary syn- ria, hematochezia, or dysuria.
drome. After leaving contraceptives, the
patient had severe dysmenorrhea for 1 year. Vaginal Examination
Dyspareunia (+), dyschezia (+), without hema-
turia, hematochezia, or dysuria. No infertility. Palpable nodule in the posterior vaginal fornix of
3 cm in diameter.
Vaginal Examination
Video
Palpable nodule in the posterior vaginal fornix of
1.5 cm in diameter and involvement of utero- Explanation (video): Presence of fixed ovaries,
sacral ligament insertion. right atypical endometrioma with solid com-
ponent without vascularization. Corpus
Video luteum in the left ovary and presence of two
anterior rectal wall nodules of 12 × 11 × 8 mm
Explanation (video): Presence of negative slid- and 13 × 7 × 9 mm, respectively (multifocal
ing sign in the anterior compartment (oblitera- lesions). Also, it can be observed another
tion of uterovesical region). Also can be lesion of 14 × 10 × 11 mm in between both
observed a uterovesical region nodule of rectal lesions. Negative sliding sign in the pos-
12 × 10 × 12 mm. terior compartment.
In the posterior compartment, it is possible to
observe a nodule of 16 × 9 × 12 mm with involve- Management
ment of left uterosacral ligament insertion.
Multidisciplinary equipment was used. Diagnostic
Management and surgical laparoscopy was done. In this pro-
cedure, extensive DIE was found, and the find-
Laparoscopy was done. In this procedure, deep ings visualized in the transvaginal ultrasound
endometriosis (DE) was found. Left uterosac- were confirmed. Hysterectomy was performed,
ral ligament resection was necessary due to and a discoidal resection was necessary to
presence of nodule in these site of 2 comes remove the rectal lesion.
17 Clinical Cases and Videos 187
17.5 Clinical Case Number 4 History
AGE: 32 years. Nulligravida, with antecedents of the use of con-

Ethnic Origin: Latina. traceptive pills during 1 year. She refers pro-
Surgical Antecedents: no. gressive dysmenorrhea, with dyspareunia and
Family History of Endometriosis: no. dyschezia, without hematuria, hematochezia,
or dysuria.
History
Vaginal Examination
Nulligravida, with antecedents of using contra-
ceptive pills for 2 years, with infertility history Palpable rectovaginal nodule of 2.5 cm of higher
and failed treatment. Also since 6 months ago, diameter, painful on palpation.
the patient refers progressive dysmenorrhea,
with dyspareunia and dyschezia, without Video
hematuria, hematochezia, or dysuria.
Explanation (video): The measurement of ante-
Vaginal Examination rior rectal wall nodule was 22 × 9 × 14 mm,
without involvement of submucosa. Another
Palpable nodule in the posterior vaginal fornix lesion of 14 × 9 × 10 mm, fixed to the previous
and pouch of Douglas of 3 cm in diameter. one, involving the uterosacral ligaments was
found.
Video
Management
Explanation (video): Multifocal compromise of
rectosigmoid with anterior rectal wall nodules Multidisciplinary equipment was used. In lapa-
with complete septate uterus. In addition, you roscopic surgery was found an anterior rec-
can observe another lesion with compromise tal nodule of 2 cm in diameter with
of the left uterosacral ligament and posterior uterosacral ligament involvement. A shav-
vaginal wall. ing resection was necessary to remove the
rectal lesion.
Management
Multidisciplinary equipment was used. In lapa-

roscopic surgery, an anterior rectal nodule of 17.7 Clinical Case Number 6
4 cm with uterosacral ligament and vaginal
involvement was found. A discoidal resec- AGE: 37 years.
tion and termino-terminal resection were Ethnic Origin: Latina.
necessary to remove the rectal lesion Surgical Antecedents: no.
completely. Family History of Endometriosis: no.
History
17.6 Clinical Case Number 5
Multiparous of one vaginal birth, with anteced-
AGE: 35 years. ents of 1 year with left lumbar pain associated
Ethnic Origin: Latina. to dysmenorrhea and occasional dysuria,
Surgical Antecedents: LIE I surgery. without dyspareunia, dyschezia, hematuria, or
Family History of Endometriosis: no. hematochezia.
188 M. León et al.
Vaginal Examination of 9 × 6 × 7 mm, fixed to the posterior vaginal

wall.
Vaginal examination: normal.
Management
Video
Multidisciplinary equipment was used (urologist-
Explanation (video): Bladder dome nodule of gynecologist). In laparoscopic surgery was
10 × 7 × 10 mm. resected a bladder base nodule of 4 cm of
Ureteral intravesical segment nodule (extrinsic higher diameter, without mucosa involvement.
compromise) of 18 × 9 × 10 mm. A right uterosacral ligament nodule of 1 cm
was resected.
Management
Multidisciplinary equipment was used (urologist- 17.9 Clinical Case Number 8

gynecologist). In laparoscopic surgery, the
findings visualized in the transvaginal ultra- AGE: 31 years.
sound were confirmed. A laparoscopic resec- Ethnic Origin: Latina.
tion of both lesions was realized. A ureteral Surgical Antecedents: no.
neo-implant was required. Family History of Endometriosis: no.
History
Nulligravida, referring with dysmenorrhea, dys-
AGE: 28 years. pareunia, dyschezia, and anal catamenial pain,
Ethnic Origin: Latina-Amerindian. without hematochezia, hematuria, or dysuria,
Surgical Antecedents: NO. for 2 years.
Family History of Endometriosis: no.
Vaginal Examination
History
Palpable nodule in the posterior vaginal fornix
Nulligravida, with antecedents of 2 years with and pouch of Douglas of 2.5 cm in diameter.
progressive dysmenorrhea accompanied by
dysuria, without dyspareunia, dyschezia, Video
hematuria, or hematochezia.
Explanation (video): A rectosigmoid anterior
Vaginal Examination rectal wall nodule of 43 × 13 × 14 mm with
involvement of vagina and uterosacral liga-
A painful nodule of 1.5 cm behind the cervix was ment. In addition, you can observe another
palpated. lesion of 16 × 16 × 11 mm.
Video Management
Explanation (video): Bladder base intramural Multidisciplinary equipment was used. In lapa-
nodule of 19 × 20 × 21 mm, without compro- roscopic surgery was found an anterior rectal
mise of intravesical ureters. Also can be nodule of 4 cm in diameter with uterosacral
observed a right uterosacral ligament nodule ligament and vaginal involvement. A discoi-
17 Clinical Cases and Videos 189
dal resection and termino-terminal resection necessary to remove the rectal lesion
were necessary to remove the rectal lesion completely.
completely.

AGE: 30 years.
AGE: 39 years. Ethnic Origin: Latina.
Ethnic Origin: Latina. Surgical Antecedents: no.
Surgical Antecedents: left nephrectomy second- Family History of Endometriosis: no.
ary to chronic urinary obstruction.
Family History of Endometriosis: no. History
History Nulligravida, with history of 3 years of infertility

and of 3 years with progressive and severe
Multiparous of one vaginal birth, with anteced- dysmenorrhea, which has worsened in the last
ents of one missed abortion. A clinical history 4 months. Dyspareunia (+), dyschezia (+),
of chronic pelvic pain (7 years of evolution) hematochezia (+), without hematuria, or
with severe dysmenorrhea, dyspareunia (+), dysuria.
dyschezia (+), without hematochezia, hematu-
ria, or dysuria. Vaginal Examination
Vaginal Examination Very difficult vaginal examination due to severe

pain.
Very difficult vaginal examination due to severe
pain. Video
Video Explanation (video): Retroverted uterus. A recto-

sigmoid anterior rectal wall nodule with trans-
Explanation (video): At seven centimeters from mural compromise with involvement of
the anal verge, it can be seen a rectosigmoid submucosa of 30 × 10 × 22 mm. It can be
anterior rectal wall nodule with involvement observed a lesion involving the uterosacral lig-
of vagina and uterosacral ligaments of aments with superficial vaginal involvement.
42 × 7 × 19 mm. Also you can observe vaginal
lesion of 17 × 8 × 12 mm. Management
Management Multidisciplinary equipment was used

(proctologist-gynecologist). In laparoscopic
Multidisciplinary equipment was used surgery was found an anterior rectal nodule of
(proctologist-gynecologist). In laparoscopic 2 cm of higher diameter (with involvement of
surgery was found an anterior rectal nodule submucosa) with uterosacral ligament and
of 4 cm of higher diameter with uterosacral vaginal involvement. A rectal shaving was
ligament and vaginal involvement. A vagi- performed, and termino-terminal resection of
nal shaving was performed, and termino- the rectosigmoid lesion (with immediate
terminal resection of the rectosigmoid reanastomosis) was necessary to remove the
lesion (with immediate reanastomosis) was rectal lesion totally.
190 M. León et al.
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AJ, Martins WP, Abrao MS, Hudelist G, Bazot M,
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PMID: 27349699.
Index
A C
Abdominal wall endometriosis CA-125, 172, 173, 176
appendiceal endometriosis, 126 Cabergoline, 18
causes, 122 Canal of nuck endometriosis, see Inguinal endometriosis
definition, 121 Case studies, 185–189
evaluation of localization, 127 Chocolate cyst, 47
hepatic endometriosis, 126 Chocolate cysts, see Ovarian endometrioma
HIFU ablation, 128 Cochrane Library diagnostic test review, 170, 172, 173,
inguinal endometriosis, 122, 125 175, 176
intra-abdominal endometriosis, 125 Color score, 41, 42
MRI, 128 Combined technique, 18
oral contraceptives, 126 Computed tomography (CT), 148, 163
rectus abdominis endometriosis, 125, 126, 130 CYP19 biomarker, 175
scar endometriosis, 122–124, 128, 129 Cystic lesion, 47, 48
symptoms of, 122 Cystoscopy, 69
technical guidelines, 127, 128 Cytokeratin 19 (CK 19 or CYFRA 21-1), 173
3D sonography, 128
transabdominal sonography, 127
ultrasonographic findings, 127 D
Villar’s nodule, 122, 124, 129 Danazol, 16
Acoustic streaming, 51 Decidualized endometriosis, 51, 54, 153, 154
Add-back therapy, 16 Deep endometriosis, 28, 57, 67
Adenomyosis, 37–45, 161 anatomical locations, 156
Allodynia, 3, 4 anterior compartment, 156
Anterior compartment endometriosis, see Urinary tract anterior pelvic compartment (see Urinary badder
endometriosis (UTE) endometriosis)
Antiangiogenic agents, 17–18 bladder involvement, 156
Appendiceal endometriosis, 126 clinical and functional requirements, 156
Aromatase inhibitors, 17 contrast enhancement, 161
Asymptomatic ovarian endometrioma, 47 cyclic haematuria, 156
Atypical endometriomas, 50 endometrial tissue, 156
Avascular pelvic spaces, 7 endometriotic implants, 155, 161
fibrous tissue, 160
inflammatory reaction, 161
B intestinal wall infiltration, 162
Benign endometriomas, 51 middle compartment, 158
Biomarkers MRI, 155, 156
endometrial biomarkers, 174–176 nonstriated muscular fibres, 160
peripheral biomarkers, 172–174 posterior compartments, 158, 160
Bladder endometriosis, 19, 68–70 pouch of Douglas, 161
Bladder endometriotic nodule, 69–74 presurgical planning, 162
Bowel endometriosis, 9–10, 33 rectal opacification, 158

https://doi.org/10.1007/978-3-319-71138-6
192 Index
Deep infiltrating endometriosis (cont.) pelvic endometriosis, 176, 177

rectosigmoid, 161 Dichorionic-diamniotic twin pregnancies, 48
rectouterine pouch, 161 Doppler mapping, 52
retractile adhesions, 157 Double-contrast barium enema (DCBE), 177
retrocervical area, 159
symptoms, 155
torus uterinus, 160 E
treatment, 155 Echogenic bands, 49
of uterus, 158 Echogenic rim, 41
vesicovaginal septum, 156 Edge shadows, 40
Deep intestinal endometriosis Endometrial biomarkers, 174–176
computerized tomography, 104 Endometrioma decidualization, 51
cul-de-sac block blockage, 114, 115 Endometriosis, 147
definition, 103 clinical assessment, 4
differential diagnoses, 116 definition, 1
double discoid resection, 114 examination, 3
exam time, 116 family history, 2
false positives, 116 forms, 28
MRI, 104 prevalence, 1
multifocal bowel lesions, 103 signs and symptoms, 2
noninvasive diagnosis, 104 Endometriotic involvement
pain reduction factors, 117, 118 in abdominal and pelvic wall scars, 163
rectosigmoidectomy, 114 chest, 163
right iliac fossa examination, 112 cutaneous variants, 163
slow development curve, 115 Endometriotic nodules, 31
suprapubic examination, 112, 113 Enolase 1 (NNE), 173
symptoms, 103 Extra-abdominal bladder, 68, 69
3D equipment, 118 Extraovarian endometriosis, 163, 164
three-dimensional transducers, 113 Extrapelvic endometriosis, 2, 121
transvaginal transducer, 113, 115
treatment, 104
TVUS examination F
anal verge, 109–111 Fallopian tubes, 28, 29
bowel circumference, 106–108 Fan-shaped shadowing, 40
bowel layers, 105, 106 Fibroids, 37–39, 42, 45
deep lesions, 105–107 Forniceal-vaginal deep endometriosis
distal segment of colon, 104, 105 classification, 89, 90
infiltrated intestinal layer, 109, 110 gel sonovaginography, 94
learning process, 118 histologic findings, 89
lesion size, 106, 108 location, 89
number of lesions, 106, 108 tenderness-guided ultrasound examination, 93
rectal and sigmoid lesions, 110 TVS
stenosis, 109 diabolo-like nodule, 92, 93
ultrasound examination, 110–112 forniceal nodule, 91–93
Deep pelvic endometriosis, see Deep infiltrating 3D TVS, 93, 94
endometriosis
Dermoid cysts, 154
Diagnosis G
imaging, 6 Gastrointestinal stromal tumor (GIST), 116
limitations, 1, 2 Gel sonovaginography, 80, 81
triage patients, 4 Gonadotropin-releasing hormone analogues, 16
Diagnostic test for endometriosis, 172, 176–178 Ground-glass echogenicity, 47, 48, 51, 54
biomarkers (see Biomarkers)
future perspectives, 180
laparoscopic visualization, 169 H
quantifying performance, 170–171 Haematocrit effect, 151
tenderness-guided TVUS, 177 Haemorrhagic cyst, 152, 154
TVUS and MRI Hematuria, 67
DIE, 177, 178 Hepatic endometriosis, 126
ovarian endometriosis, 177 Hidden disease, 6
Index 193
High-intensity-focused ultrasound (HIFU) ablation, 128 Mature cystic ovarian teratomas, 154
Hormone replacement treatment (HRT), 16 Mature cystic teratoma, 152
Hydronephrosis, 68, 74 Mean gray value (MGV), 53
Hydroureteronephrosis, 30 Medical management
Hyperalgesia, 3, 4 antiangiogenic agents, 17, 18
Hyperechogenic islands, 41 aromatase inhibitors, 17
Hypoestrogenizing drugs, 14 GnRH analogues, 16
NSAIDs, 16, 17
oral contraceptives, 14, 15
I progestins, 15–16
Ill-defined lesions, 37–40 risk and side effects, 13
Infiltrating endometriosis of the terminal ileum, 163 SERMs, 17
Inguinal endometriosis, 122, 125 vs. surgical treatment, 14
Inner lesion-free margin (IFM), 39 Medroxyprogesterone acetate (MPA), 15
Internal shadows, 40 miRNA biomarkers, 173
International Deep Endometriosis Analysis (IDEA), 28, Modified SVG technique, 135
30, 34, 57, 66, 89, 90, 94, 99 Morphological Uterus Sonographic Assessment (MUSA)
Intra-abdominal endometriosis, 125 consensus, 28
MRI jelly method, 176, 178
Mucinous lesions, 154
J Multi-detector computerized tomography enema
Junctional zone (JZ)/inner myometrium, 41 (MDCT-e), 178
Multiple corpora lutea, 154
Multiple endometriomas, 48
K Muscularis propria, 161
Kissing ovaries, 29, 51, 151, 153 Myometrial cysts, 39–41
Myometrial lesions, MUSA
adenomyosis cyst, 40, 41
L circumferential flow, 42, 43
Lambda sign, 50 color score, 41, 42
Lambda sing, 48 cyst, 41
Latzko’s space, 8 echogenicity, 37, 40
Letrozole, 17 future perspectives, 45
Levonorgestrel-releasing intrauterine device (LNG-IUD), IFM, 39
15, 16 ill-defined lesion, 39, 40
Low-invasive tests for endometriosis, 170 junctional zone/inner myometrium, 41, 44
location, 39
myometrial walls, 37
M OFM, 39
Magnetic resonance imaging radial vessels, 44
antispasmodic agents, 149 shadowing, 40
bladder distension, 149 sliding sign, 43
bowel preparation, 149 3D acquisition, 43
diffusion-weighted imaging, 150 uterine corpus, 43
endovaginal coil, 149 uterus total length, 43
half-Fourier single-shot turbo-spin-echo vessel morphology, 42
acquisition, 150 well-defined lesions, 39
indications, 148
intravenous contrast-enhanced MRI, 150–151
1.5-T magnet, 149 N
patient positioning, 149 Neoangiogenesis, 17
patient preparation, 149 Non-menstrual pelvic pain (NMPP), 2
pelvic phased-array coils, 149 Nonsteroidal anti-inflammatory drugs (NSAIDs), 16
susceptibility-weighted imaging, 150 Norethindrone acetate (NETA), 15
3.0-T magnet, 149 Norethisterone acetate, 17
timing of, 149
2D-T2-weighted sequences, 150
vaginal/rectal opacification, 150 O
Matrix-enhanced laser desorption/ionization time-of- Obliterated cul-de-sac fibroids, 5
flight mass spectrometry Okabayashi’s space, 8
(MALDI-TOF-MS), 173 Oral contraceptives, 14, 15
194 Index
Outer lesion-free margin (OFM), 39 Pouch of Douglas (POD), 29, 30, 34

Ovarian carcinoma, 154 description, 63
Ovarian endometrioma, 18–19 future perspectives, 65, 66
acute abdomen, 153 rectal/rectosigmoid deep endometriosis, 63
ADC values, 153 technical guidelines, 65
adhesions, 153, 159 TVS, 63, 64
chemical-selective T1-weighted fat-saturated uterine sliding sign, 65
sequences, 151–152 in women, 63
complications, 153 Presacral space/retrorectal space, 8
description, 151 Prevesical space, 7, 8
differential diagnosis, 154 Progestins, 15–16
DWI imaging, 152
malignant transformation, 153
menstrual cycles, 151 Q
MR imaging, 151, 153 Quinagolide, 18
multiple cysts, 151
mural nodules enhancement, 153
ovarian torsion, 153 R
reduced fertility, 153 rASRM classification, 58
restricted diffusion, 153 Rectal endoscopic sonography (RES), 98
short-tau inversion recovery sequences, 152 Rectal hypoechoic endometriotic nodule, 141
Ovarian endometriosis Rectal water contrast transvaginal ultrasonography
depth, 53 (RWC-TVS), 137–142
diagnosis, 52 Rectosigmoid endometriosis, 162
Doppler ultrasound, 52 Rectovaginal septum (RVS) endometriosis, 32
future research, 54 anatomy, 97, 98
incidence, 47 DE nodules, 100
machine settings, 54 definition, 97
pathogenesis, 47 drawing, 99
sonographic spectrum four-step systematic approach, 99
anechoic cyst, 48, 49 future perspective, 101, 102
atypical endometrioma, 50 prevalence, 98
benign endometriomas, 51 TVS
echogenic bands, 48, 49 hyperechogenic layer, 100
endometrioma decidualization, 51 RES, 98
hyperechoic foci, 50 sensitivity rates, 98, 99
kissing ovaries, 51 3D, 98
low-level echogenicity, 48, 49 visualization of, 100
multilocular endometrioma, 48, 49 vaginal examination, 98, 99
multiple endometriomas, 48, 50 Rectovaginal space, 8
ovarian parenchyma, 49 Rectus abdominis endometriosis, 125, 126, 130
septate endometrioma, 48, 50 Retrocervical endometriosis, 97
unilocular cyst, 48 Retroperitoneal/retrocervical lesion, 89, 90
symptoms, 47 Retropubic space, 7
3D ultrasound, 52, 53 Retzius, see Retropubic space
transvaginal ultrasound, 48 Round ligaments of the uterus (RLUs), 158
Ovarian mobility, 28, 29, 57–58
S
P Saline contrast sonography, 98
Pain mapping, 73 Scar endometriosis, 122–124, 128, 129
Pararectal space, 8 Selective estrogen receptor modulators (SERMs), 17
Pelvic endometriosis, 7, 156 Septate endometrioma, 50
Pelvic floor hypertonicity, 3 Shadowing, 40
Pelvic sidewall anatomy, 8–9 Site-specific tenderness (SST), 28, 29, 58
Pelvic spaces, 7–8 Sliding sign technique, 29, 30, 43, 44, 63–66
Peripheral biomarkers, 172–174 SnOUT test, 170, 171
Peristalsis, 71–74 Soft marker, TVS, 28
Peritoneal endometriosis, 154, 155 ovarian mobility, 57–59
PGP 9.5 biomarker, 175 SST, 58, 59
Index 195
technical tips, 59, 60 Ureteral endometriosis, 19, 20, 68, 70–73

UBESS, 60 Ureteral jet, 71
usefulness, 60 Ureteroneocystostomy, 19, 20
Sonovaginography (SVG), 80, 81, 134–137 Urinary badder endometriosis, 68–70
SpIN triage test, 170–172, 176–178 Urinary tract endometriosis (UTE), 156
Standoff technique, 93 bladder endometriosis, 68–70
Stromal endometriosis, 155 incidence, 67
Subendometrial echogenic lines and buds, 41 pathogenesis, 67
Surgical layers, 8, 9 surgical management, 19
Surgical management technical guidelines, 73
bladder endometriosis, 19 ureteral endometriosis, 70–73
bowel endometriosis, 20, 21 Uterine abnormalities, 28
vs. medical therapies, 14 Uterine corpus, 43
ovarian endometrioma, 18–19 Uterine fibroids, 39
ureteral endometriosis, 19, 20 Uterine fluid, 175
urinary tract endometriosis, 19 Uterosacral ligament (USL) endometriosis
uterosacral endometriosis, 20 clinical history, 77
Symptomatic endometrioma, 47 clinical pelvic examination, 77
future perspectives, 82
preoperative diagnosis, 77
T sonovaginography with saline/gel, 80, 81
Tenderness-guided transvaginal ultrasonography 3D-transvaginal sonography, 81, 82
(tg-TVS), 133, 134, 177 transrectal sonography, 81
Three-dimensional rectosonography (3D-RSG), 142 2D-TVS, 77–80
Three-stage technique, 18 Uterosacral ligaments (USL), 57
3.0Tesla Magnetom system (3.0 T MRI), 176
Tomographic ultrasound imaging (TUI), 82
Transrectal sonography, 81 V
Transvaginal ultrasound (TVS), 27 Vaginal and rectal opacification, 164
Transvaginal ultrasound with bowel preparation Vaginal fornix, 33
(TVUS-BP), 105–108, 110, 112, 115, 116, Vaginal nodule, 3, 4
118, 176–179 Vaginal/rectal opacification, 150
Tubo-ovarian abscess, 154 Vesicovaginal space, 8
Tumor necrosis factor-a (TNF-a), 17 Villar’s nodule, 124, 129
Virtual organ computer-aided analysis (VOCAL) mode,
53, 142
U Vitamin D binding protein
Ultrasound-based endometriosis staging system (VDBP), 173
(UBESS), 60 Volume contrast imaging (VCI), 82
Umbilical endometriosis, see Villar's nodule Volume rendering analysis, 82

How To Perform Ultrasonography in Endometriosis 2018

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What is the purpose of the book?

What is the purpose of the book?

What are some of the anatomical locations of endometriosis that are discussed?

What are some of the anatomical locations of endometriosis that are discussed?

How to Perform

ISBN 978-3-319-71137-9 ISBN 978-3-319-71138-6 (eBook)

Library of Congress Control Number: 2018950453

© Springer International Publishing AG, part of Springer Nature 2018

Printed on acid-free paper

How to Perform Ultrasonography in Endometriosis is an international col-

evaluation of specific deep endometriosis anatomical locations, including the

Cagliari, Italy Stefano Guerriero

1 Endometriosis: Clinical and Anatomical Considerations���������� 1

13 Other Locations of Deep Endometriosis�������������������������������������� 121

Video 1.1 Scar endometriosis—An example of a post cesarean section inci-

Video 7.2 (a) Transvaginal ultrasound is used to demonstrate a negative

Video 13.10 Sonographic features of right inguinal endometriosis present-

Video 17.7 Bladder base intramural nodule of 19 × 20 × 21 mm, without

1.1 Introduction One of the key challenges for the individual

© Springer International Publishing AG, part of Springer Nature 2018 1

1.3.1 Key Examination Tips care. Empirical medical management for

Fig. 1.5 Complex pelvis disease: Often there are multi-

1.5 Role of Clinical Diagnosis

1.6 Imaging in Endometriosis Traditional imaging that is general or nonspe-

• Identify ovarian and deep endometriosis 1.7.1 Pelvic Spaces

1.7.2  elevant Pelvic Sidewall

In superficial, ovarian, or deep endometriosis, the

1.7.3 Bowel Endometriosis

Endometriosis may also affect the gastrointesti-

7. Singh SS, Suen MW. Surgery for endome-

2.1 Introduction they should effectively treat pain and have an

© Springer International Publishing AG, part of Springer Nature 2018 13

References 15. Vercellini P, Crosignani P, Somigliana E, Vigano`

Mathew Leonardi and George Condous

3.1 Introduction participate based on their expertise in the diagno-

Prior to beginning the ultrasound scan, one

© Springer International Publishing AG, part of Springer Nature 2018 27

Fig. 3.1 “Kissing”

3.2.4 Fourth Step transabdominal scan of the kidney is necessary

UTEROSACRAL LIGAMENT TORUS UTERINUS

POUCH OF DOUGLAS OBLITERATION

RECTUM & RECTOSIGMOID cm 0

Bowel (rectum & sigmoid)

Fig. 3.5 Ultrasound

the cervix [2]. Normal USLs are not usually visu-

this is a dynamic ultrasound involving testing 3.4 Future Perspectives

Thierry Van den Bosch

4.1 Introduction This chapter gives an overview of how to

© Springer International Publishing AG, part of Springer Nature 2018 37

Fig. 4.1 Ultrasound images of fibroids

Irregular junctional zone

Fan shaped shadowing

Myometrial lesions may be well-defined or In clinical practice, an accurate lesion map-

and the size of each lesion. However, in a poly-

Fig. 4.6 Inner lesion-free margin (IFM) (From Van den

Well-defined lesions are measured in three

Edge shadows Internal shadows

Fig. 4.11 Ultrasound image of adenomyosis: irregular

diameter of the largest cyst are recorded. In ade-

Cagliari, Italy Stefano Guerriero

1 Endometriosis: Clinical and Anatomical Considerations�� 1

13 Other Locations of Deep Endometriosis�� 121

1.1 Introduction One of the key challenges for the individual

1.3.1 Key Examination Tips care. Empirical medical management for

1.5 Role of Clinical Diagnosis

1.6 Imaging in Endometriosis Traditional imaging that is general or nonspe-

• Identify ovarian and deep endometriosis 1.7.1 Pelvic Spaces

1.7.2 elevant Pelvic Sidewall

1.7.3 Bowel Endometriosis

2.1 Introduction they should effectively treat pain and have an

3.1 Introduction participate based on their expertise in the diagno-

3.2.4 Fourth Step transabdominal scan of the kidney is necessary

this is a dynamic ultrasound involving testing 3.4 Future Perspectives

4.1 Introduction This chapter gives an overview of how to

4.4 Future Perspectives on fibroid morcellation: a literature review. Gynecol

5.1 Introduction Ovarian endometrioma usually appears in

5.2 How We Do It homogeneous echogenic content, representing the

5.2.2 Spectrum of Sonographic

5.2.4 Role of Doppler Ultrasound

5.3.2 Machine Settings 5.4 Future Perspectives

6.2 Ovarian Mobility

6.4.4 Future Directions

7.1 Introduction rectum). In this case, a portion of the POD may

7.2 How We Do It rectosigmoid bowel glides smoothly over the

8.1 Introduction colon) or both [7]. The expression of urinary tract

9.1 Introduction 9.2 How We Do It

Endometriosis occurs in 15–30% of patients with 9.2.1 Clinical History

10.1 Introduction rounds foci of endometriosis, and the foci

11.1 Introduction SVSe

which entails an acoustic window created by 11.2 How We Do It

11.3 Important Technical Tips

12.1 Introduction and small intestine, cecum, and/or appendix).