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Endometriosis:sonographers’ guide for general practice

Jing Fang Monash Health

Endometriosis• Superficial endometriosis• Ovarian endometrioma• Deep infiltrating endometriosis (DIE)

• TVS is an accurate and reliable diagnostic tool for diagnosing DIE • Diagnostic performance similar to MRI

• Bowel preparation is NOT essential nor necessary for detection of DIE (Hudelist, et al., 2011)

• Endometriosis assessment should be incorporated into general practice • Benefits

Endometriosis Clinical indications• Pelvic pain• Irregular periods• Menorrhagia• Dysmenorrhea• Dyspareunia

Bowel• Dyschezia• Cyclical rectal bleeding

Bladder/Ureters• Dysuria • Cyclical hematuria

• Asymptomatic!!

Systematic approach to scanning for

deep infiltrating endometriosis Overview

1• Uterus and

adnexa

2• Pouch of

Douglas (POD)

3• Posterior pelvic

compartment

4• Anterior pelvic

compartment

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1. Uterus & Adnexa• Anteverted and

retroflexed uterus• Association with POD

obliteration (Reid et al., 2013)

• Adenomyosis • Loss of junctional zone • Myo. cysts• Venetian blind

• Ovaries• Endometrioma: associated with 50% DIE

lesions (Chapron et al., 2009)

• Kissing ovaries

• 7 fold increase in association with bowel nodule• 3 fold increase in association with POD obliteration

1. Uterus & Adnexa

• Ovaries• Mobility

1. Uterus & Adnexa• Ovaries

• Mobility

1. Uterus & Adnexa

• Hydrosalpinx • Pseudo-peritoneal cysts

1. Uterus & Adnexa Overview

1• Uterus and

adnexa

2• Pouch of

Douglas (POD)

3• Posterior pelvic

compartment

4• Anterior pelvic

compartment

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• POD – where is it?• Sliding sign

• What is it? • Non-obliteration

• Obliteration - partial or complete • accurate and sensitive

• 93% accuracy

• Positive sliding sign does not exclude DIE in the post compartment • 12% w/o POD obliteration had DIE

2. Pouch of Douglas• Sliding sign

• Anterior fornix

2. Pouch of Douglas

Animation courtesy of Karl Rombauts

2. Pouch of Douglas• Sliding sign

• Posterior fornix

2. Pouch of Douglas• Sliding sign

• Posterior fornix

2. Pouch of Douglas• Sliding sign – retroverted uterus

• Push and pull • Negative sliding sign:

• hard marker for high-grade endometriosis• Women with POD obliteration 3 times more likely to have bowel endometriosis (Khong et al.,

2011)

2. Pouch of Douglas

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Overview

1• Uterus and adnexa

2• Pouch of Douglas

(POD)

3• Posterior pelvic

compartment

4• Anterior pelvic

compartment

Sites commonly affected by DIE:

• vaginal wall• posterior vaginal fornix• rectovaginal septum• uterosacral ligament• anterior rectum• anterior rectosigmoid

(Chapron et al., 2006; Chamie et al., 2010)

3. Posterior Compartment

Overall pooled sensitivity and specificity:• Vaginal endometriosis: 58% and 96% • Rectovaginal septum endometriosis: 49% and 98%• USL endometriosis: 53% and 93%

3. Posterior Compartment

• Vagina

• Thin and hypoechoic

• Techniques • Posterior fornix• Scan from left to right

3. Posterior Compartment

• Vaginal nodule

3. Posterior Compartment 3. Posterior Compartment• Mimic of vaginal nodule

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• Rectovaginal Septum• space between the posterior vaginal wall and the anterior rectal wall

3. Posterior Compartment

• Rectovaginal septum• DIE involving just the RVS is

uncommon• Measurement:

• distance of the nodule from the anus

• Low-lying DIE lesions (<5-8cm from the anus) associated with significant post-operative complications

(Ruffo et al., 2010; Moawad, et al., 2013)

Image courtesy of Karl Rombauts

3. Posterior Compartment

3. Posterior Compartment• Vaginal nodule stuck to a bowel nodule forming a RV nodule

• Uterosacral ligaments (L&R)• insert at the level of internal os of

cervix just above the posterior vaginal fornix

• commonly involved in DIE

3. Posterior Compartment

• Uterosacral ligaments – technique• Posterior fornix• Sweep from right to left

Animation courtesy of Karl Rombauts

3. Posterior Compartment• Uterosacral ligaments – technique

3. Posterior Compartment

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• USL nodule stuck to vagina

3. Posterior Compartment 3. Posterior Compartment• USL nodule stuck to vagina

3. Posterior Compartment• USL nodule stuck to vagina, ovary and a bowel nodule

3. Posterior Compartment• USL nodule stuck to vagina, ovary and a bowel nodule

• Bowel• Affect 4%-37% of women with

endometriosis (Remorgida et al., 2007)

• Anterior rectum, rectosigmoid and the sigmoid

• Isolated, multiple• 3 layers: muscularis, submucosal &

mucosal layer• TVS detection of bowel

endometriosis• 94% sensitive; 98% specific

(Hudelist et al., 2011)

3. Posterior CompartmentFocal nodule Echogenic focus within nodule

Bowel wall thickening and tethering to ovary Focal linear thickening of bowel wall

3. Posterior Compartment

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3. Posterior Compartment• Bowel nodule

3. Posterior Compartment• Bowel nodule – multiple

3. Posterior Compartment• Bowel nodule – multiple

3. Posterior Compartment• Bowel - technique

• Low lying bowel lesions (5-8cm from anus)• Measurements taken in short sections & total distance is added

3. Posterior Compartment• Bowel – measuring distance of the nodule from anus

3. Posterior Compartment• Bowel nodule – measuring distance of the nodule from anus

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3. Posterior Compartment• Bowel - pitfalls

3. Posterior Compartment• Bowel - pitfalls

Overview

1• Uterus and

adnexa

2• Pouch of

Douglas (POD)

3• Posterior pelvic

compartment

4• Anterior pelvic

compartment

• Bladder

• Most frequently affected with DIE in the anterior compartment

• Accuracy of TVS for diagnosis of DIE in the bladder: • Meta-analysis with overall pooled sensitivity

and specificity: 65% and 100% (Guerriero, S et al., 2015)

4. Anterior Compartment

• Bladder – normal

4. Anterior Compartment• Bladder nodule

4. Anterior Compartment

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• Vesico-uterine pouch

• Sliding test - mobility of the VUP

• TV probe in the anterior fornix

4. Anterior Compartment• Vesico-uterine pouch – normal

4. Anterior Compartment

• Vesico-uterine pouch obliteration

4. Anterior Compartment• Vesico-uterine pouch obliteration

4. Anterior Compartment

• Ureters • endometriotic nodules infiltrate or compress the ureter à strictures• difficult to diagnose • r/o hydronephrosis

4. Anterior Compartment• Use the posterior fornix

• Extend the scan into the posterior and anterior compartments

• Be systemic

Summary

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Acknowledgements• Dr. Sofie Piessens

• Karl Rombauts

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