Endometriosis: Endometriosis. Overview 2/24/19. Systematic approach to scanning for deep infiltrating endometriosis

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Vivien Alexander
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Endometriosis Endometriosis: Superficial endometriosis Ovarian

accurate and reliable diagnostic tool for diagnosing DIE Diagnostic

Jing Fang Monash Health Endometriosis Clinical indications Bowel

practice Benefits Pelvic pain Irregular periods Menorrhagia

Bladder/Ureters Dysuria Cyclical hematuria Asymptomatic!

1 Endometriosis 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 sonographers guide for general practice Jing Fang Monash Health Endometriosis Clinical indications Bowel preparation is NOT essential nor necessary for detection of DIE (Hudelist, et al., 2011) Endometriosis assessment should be incorporated into general practice Benefits 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 Uterus and adnexa Pouch of Douglas (POD) Posterior pelvic Anterior pelvic 1

associated with 50% DIE lesions (Chapron et

2 1. Uterus & Adnexa Anteverted and retroflexed uterus Association with POD obliteration (Reid et al., 2013) Adenomyosis Loss of junctional zone Myo. cysts Venetian blind 1. Uterus & Adnexa 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 1. Uterus & Adnexa Ovaries Mobility Ovaries Mobility 1. Uterus & Adnexa Overview Hydrosalpinx Pseudo-peritoneal cysts Uterus and adnexa Pouch of Douglas (POD) Posterior pelvic Anterior pelvic 2

3 POD where is it? Sliding sign What is it? Non-obliteration Obliteration - partial or complete accurate and sensitive 93% accuracy Positive sliding sign does not exclude DIE in the post 12% w/o POD obliteration had DIE Sliding sign Anterior fornix Sliding sign Posterior fornix Sliding sign Posterior fornix Animation courtesy of Karl Rombauts 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) 3

Overview 1 2 3 4 Uterus and adnexa Pouch of Douglas

affected by DIE: vaginal wall posterior vaginal fornix

rectum anterior rectosigmoid (Chapron et al.

, 2010) Vagina Thin and hypoechoic Techniques Posterior

sensitivity and specificity: Vaginal endometriosis: 58%

4 Overview Uterus and adnexa Pouch of Douglas (POD) Posterior pelvic Anterior pelvic 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) Vagina Thin and hypoechoic Techniques Posterior fornix Scan from left to right Overall pooled sensitivity and specificity: Vaginal endometriosis: 58% and 96% Rectovaginal septum endometriosis: 49% and 98% USL endometriosis: 53% and 93% Vaginal nodule Mimic of vaginal nodule 4

Rectovaginal Septum space between the posterior vaginal

involving just the RVS is uncommon Measurement: distance of

the anus) associated with significant post-operative

, 2013) Image courtesy of Karl Rombauts Vaginal nodule

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

involved in DIE Uterosacral ligaments technique Posterior

5 Rectovaginal Septum space between the posterior vaginal wall and the anterior rectal wall 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 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 Uterosacral ligaments technique Posterior fornix Sweep from right to left Uterosacral ligaments technique Animation courtesy of Karl Rombauts 5

6 USL nodule stuck to vagina USL nodule stuck to vagina USL nodule stuck to vagina, ovary and a bowel nodule 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 Focal nodule Echogenic focus within nodule (Hudelist et al., 2011) Bowel wall thickening and tethering to ovary Focal linear thickening of bowel wall 6

7 Bowel nodule Bowel nodule multiple Bowel nodule multiple Bowel - technique Bowel measuring distance of the nodule from anus Low lying bowel lesions (5-8cm from anus) Measurements taken in short sections & total distance is added Bowel nodule measuring distance of the nodule from anus 7

8 Bowel - pitfalls Bowel - pitfalls Overview Uterus and adnexa Pouch of Douglas (POD) Posterior pelvic Anterior pelvic Bladder Most frequently affected with DIE in the anterior 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) Bladder normal Bladder nodule 8

Vesico-uterine pouch Vesico-uterine pouch normal

the anterior fornix Vesico-uterine pouch

Summary Ureters endometriotic nodules infiltrate

diagnose r/o hydronephrosis Use the posterior

9 Vesico-uterine pouch Vesico-uterine pouch normal Sliding test - mobility of the VUP TV probe in the anterior fornix Vesico-uterine pouch obliteration Vesico-uterine pouch obliteration Summary Ureters endometriotic nodules infiltrate or compress the ureter à strictures difficult to diagnose r/o hydronephrosis Use the posterior fornix Extend the scan into the posterior and anterior s Be systemic 9

10 Acknowledgements Dr. Sofie Piessens Karl Rombauts References Koninckx PR, Martin D. Treatment of deeply infiltrating endometriosis. Curr Opin Obstet Gynecol. 1994;6(3): Kondo W, Bourdel N, Tamburro S, Cavoli D, Jardon K, Rabischong B, et al. Complications after surgery for deeply infiltrating pelvic endometriosis. BJOG. 2011;118(3): Guerriero S, Condous G, van den Bosch T, Valentin L, Leone FP, Van Schoubroeck D, et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol. 2016;48(3): Hudelist G, English J, Thomas AE, Tinelli A, Singer CF, Keckstein J. Diagnostic accuracy of transvaginal ultrasound for non-invasive diagnosis of bowel endometriosis: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2011;37(3): Reid S, Lu C, Casikar I, Reid G, Abbott J, Cario G, et al. Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound technique: the sliding sign. Ultrasound Obstet Gynecol. 2013;41(6): Chapron C, Pietin-Vialle C, Borghese B, Davy C, Foulot H, Chopin N. Associated ovarian endometrioma is a marker for greater severity of deeply infiltrating endometriosis. Fertil Steril. 2009;92(2): Ghezzi F, Raio L, Cromi A, Duwe DG, Beretta P, Buttarelli M, et al. "Kissing ovaries": a sonographic sign of moderate to severe endometriosis. Fertil Steril. 2005;83(1): Khong SY, Bignardi T, Luscombe G, Lam A. Is pouch of Douglas obliteration a marker of bowel endometriosis? J Minim Invasive Gynecol. 2011;18(3): Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher-Lavenu MC, et al. Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution. Hum Reprod. 2006;21(7): Chamié LP, Pereira RMA, Zanatta A, Serafini PC. Transvaginal US after Bowel Preparation for Deeply Infiltrating Endometriosis: Protocol, Imaging Appearances, and Laparoscopic Correlation. RadioGraphics. 2010;30(5): Reid S, Lu C, Hardy N, Casikar I, Reid G, Cario G, et al. Office gel sonovaginography for the prediction of posterior deep infiltrating endometriosis: a multicenter prospective observational study. Ultrasound Obstet Gynecol. 2014;44(6): Ruffo G, Scopelliti F, Scioscia M, Ceccaroni M, Mainardi P, Minelli L. Laparoscopic colorectal resection for deep infiltrating endometriosis: analysis of 436 cases. Surg Endosc. 2010;24(1):63-7. Moawad NS, Caplin A. Diagnosis, management, and long-term outcomes of rectovaginal endometriosis. Int J Womens Health. 2013;5: Bazot M, Malzy P, Cortez A, Roseau G, Amouyal P, Darai E. Accuracy of transvaginal sonography and rectal endoscopic sonography in the diagnosis of deep infiltrating endometriosis. Ultrasound Obstet Gynecol. 2007;30(7): Remorgida V, Ferrero S, Fulcheri E, Ragni N, Martin DC. Bowel endometriosis: presentation, diagnosis, and treatment. Obstet Gynecol Surv 2007; 62: Hudelist G, Tuttlies F, Rauter G, Pucher S, Keckstein J. Can transvaginal sonography predict infiltration depth in patients with deep infiltrating endometriosis of the rectum? Hum Reprod. 2009;24(5): Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher-Lavenu MC, et al. Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution. Hum Reprod. 2006;21(7): Moro F, Mavrelos D, Pateman K, Holland T, Hoo WL, Jurkovic D. Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section. Ultrasound Obstet Gynecol. 2015;45(2): Pateman K, Holland TK, Knez J, Derdelis G, Cutner A, Saridogan E, et al. Should a detailed ultrasound examination of the complete urinary tract be routinely performed in women with suspected pelvic endometriosis? Hum Reprod. 2015;30(12):

Accuracy of transvaginal ultrasound and magnetic resonance imaging in diagnosis and extension of pelvic endometriosis

Accuracy of transvaginal ultrasound and magnetic resonance imaging in diagnosis and extension of pelvic endometriosis A.Salem, Kh. Fakhfakh, S. Mehiri, Y. Ben Brahim, F. Ben Amara, H. Rajhi, R. Hamza,