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

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1 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, N.MNIF Radiology Department, Charles Nicole Hospital, Tunis Tunisia

2 Introduction Endometriosis: presence of endometrial glands and stroma outside the uterus. Cause of pelvic pain, dysmenorrhoea, dyspareunia, dyschesia and urinary symptoms Endometriosis is associated with infertility The aim of this study is to assess the accuracy of transvaginal ultrasound and MRI in the diagnosis and the extension of pelvic endometriosis and to illustrate the main pelvic locations

3 Materials, Methods and Results six patients aged between 27 and 42 years complain of dysmenorrhrea and dyspaneuria; two patients complain of pain during evacuation and micturation. All patients underwent clinical examination, transvaginal ultrasound and pelvic MRI. MRI technique: 4mm-thick sections and 1mm gap Field of view 224x512pixels Sagittal and transverse SET2 Transverse SET1 with and without fat suppression Transverse SET1 with fat suppression after intravenous injection of gadolinium

4 patients age symptoms transvaginal ultrasound MRI IVU N 1 42years Left pelvic pain Left endometrioma Left endometrioma Uterosacral ligaments, vagina N 2 27years dysmenorrhoea Left endometrioma Left endometrioma N 3 37years dysmenorrhoea dyspareunia Non specific heterogenous ovarian cysts, thickening of posterior vaginal wall Non hemorragic ovarian cysts, mass of the Torus uterosacral ligaments, posterior Vaginal wall, rectum N 4 29years chronic pelvic pain Right endometrioma Bilateral endometriomas Right ureteral endometriosis Uterosacral ligaments N 5 39years Chronic pelvic pain Bilateral endometriomas Torus nodule Sigmoid implant endometriomas Uterosacral ligaments Vagina, torus, rectum N 6 35years Infertility Bilateral endometriomas Bilateral endometriomas

5 Patient N 1 Sagittal SE T2: thickening of posterior vaginal wall containing hyperintense T2 foci Sagittal SE T2: thickening of uterosacral ligament hypointense T2 transverse SE T2: left ovarian endometrioma hypointense T2 transverse SE T1 with FS: left ovarian endometrioma hyperintense T1FS

6 Patient N 2 transverse SE T2: left ovarian endometrioma hypointense T2 transverse SE T1: left ovarian endometrioma hyperintense T1

7 Patient N 3 Transvaginal sonography:multiple hetregenous cysts Transvaginal sonography: thickening of posterior vaginal wall containing little cysts

Patient N 3 Sagittal SE T2: hypointense mass in the

containing hyperintense T2 foci and extending to

hemorragic left ovarian cysts and adhesion with

ovarian hemorragic signal T1 transverse SE T1:

8 Patient N 3 Sagittal SE T2: hypointense mass in the torus uterinus and posterior vaginal wall containing hyperintense T2 foci and extending to the anterior wall of rectum transverse SE T2: non hemorragic left ovarian cysts and adhesion with posterior wall of uterus transverse SE T1: no ovarian hemorragic signal T1 transverse SE T1: thickening of posterior vaginal wall containing hyperintense T1 foci (hemorragic)

(star), hypointense mass of the torus and

little cysts hyperintense T2 sagittal SE

hyperintense foci sagittal SE T1 FS Gado:

mass of the torus with enhancement after

9 Patient N 4 Sagittal and coronal SE T2: bilateral endometriomas hypointense T2 (star), hypointense mass of the torus and posterior vaginal wall (arrow) containing little cysts hyperintense T2 sagittal SE T1: hyperintense T1 endometriomas, hypointense mass of the torus and posterior wall of vagina containing hyperintense foci sagittal SE T1 FS Gado: ovarian endometriomas hyperintense T1, mass of the torus with enhancement after injection of gadolinium transverse SE T1 FS: bilateral endometriomas hyperintense T1

10 Patient N 4 Pelvic sonography: right ovarian heterogenous cyst Intravenous urography: right pelvic ureteral stenosis due to ureteral endometriosis

11 Patient N 5 Transvaginal sonography: thickening of the torus and the right uterosacral ligament and hypoechoic implant of endometriosis in the anterior wall of rectum Rectal sonography: hypoechoic mass of the anterior wall of rectum

12 Patient N 5 Sagittal SE T2: hypointense mass in the torus uterinus extending to the anterior wall of rectum Transverse SE T2: hypointense mass in the torus uterinus, thichning of right uterosacral ligament and mass of the anterior wall of rectum Transverse SE T1 gado: mass in the torus uterinus, thichning of right uterosacral ligament and mass of the anterior wall of rectum

13 Patient N 6 Sagittal and coronal SE T2: hypointense T2 bilateral ovarian endometriomas Sagittal SE T1 and transverse SE T1FS: hyperintense T2 bilateral ovarian endometriomas

14 Discussion: Pelvic endpmetriosis include ovarian endometriomas, superficial peritoneal lesions and deep infiltrating endometriosis (DIE). DIE can be anterieor involving the bladder or posterior involving the uterosacral ligaments, the vagina and the intestine especially the rectum and the sigmoid colon

15 Anatomical distribution of pelvic endometriosis Colorectal endometriosis Péritoneal endometriosis Torus endometriosis Ovarian endometrioma Recto vaginal septum bladder implant

16 Physical examination Posterior pelvic endometriosis is diagnosed by physical examination in 60% reported by Chapron et al (2002). Extent of involvment of DIE remains difficult to determine by physical examination and requires further exploration as transvaginal sonography, rectal sonography and pelvic MRI.

17 Transvaginal sonography First investigation in pelvic disorders: explore the whole pelvic cavity; well tolerated by patients It is sufficient to diagnose ovarian endometriomas as in all our cases ( Mais et al, 1993; Guerriero et al, 1996) The most accurate investigation for the diagnosis of bladder endometriosis (Fedele et al,1997; Balleyguier et al, 2002) Accuracy in the diagnosis of endometriosis involving uterosacral ligaments and the colorectum ranges from 77 to 97% (Bazot and al, 2003)

18 Transvaginal sonography(2) Limits: Requires a great experience from the operator Virginity Impossibility of determining the distance between rectal lesion and the anal margins and the depth of rectal wall involvment Rectal endoscopic sonography can accurrately diagnose posterior pelvic lesions but miss anterior pelvic lesions, implant in the pouch of Douglas and endometriomas Rectal implant in patient n 5 was detected with both transvaginal and endorectal sonography in the second look after MRI.

19 pelvic MRI (1) Main limitation of sonographic techniques: focus on limited anatomic area of the pelvis MRI: evaluation of overall pelvic extension: anterior and posterior deep pelvic endometriosis Involvment of the torus and the uterosacral ligaments is the most frequent location of deep endometriosis seen in Four of our patients: Mass or thickening of the torus uterinus: insertion of the uterosacral ligaments on the posterior wall of uterus: hypointense T1 and T2 with hemorragic or cystic foci. Nodule or thickening of uterosacral ligaments with regular or irregular margins

20 pelvic MRI (2) Vagina: mass or thickening of posterior vaginal wall with or without foci Anterior wall of rectum or sigmoid colon: Disappearance of the fat tissue lying between the uterus and the rectum Disappearance of the hypointense signal T2 of the anterior wall of the rectum Mass extending on the anterior wall of the rectum MRI precises degree of extension and distance between the lower limit of the fibrotic mass and the rectal-anal junction Pouch of Douglas: partial or complete obliteration with or without fluid collection

21 pelvic MRI (3): Rectovaginal septum: nodule or mass passing through the lower border of the posterior lip of the cervix Bladder involvment: nodule or mass of the vesico-uterine pouch Obliteration of the hypointense signal T2 of the bladder wall Protrusion of the nodule in the lumen with invasion of the mucosal layer Intestinal tract involvment: intraperitoneal locations: sigmoid colon, rectum, adhesions to the posterior wall of the uterine body Frozen pelvis: extension of endometriosis to multiple adjacent pelvic structures

22 Conclusion physical examination is fundamental for establishing the initial diagnostic suspicion of deep infiltrating endometriosisanddefinesexaminationsthatwillbe requested Transvaginal sonography is the first investigation in this pelvic disorder: sufficient in ovarian endometriomas and in anterior pelvic involvment but less accurate in the posterior pelvic endometriosis and depends on the operator experience MRI has the advantages of aiding in the detection of all deep pelvic sites of endometriosis and providing accurate depiction of extension of the disease for the surgeon to warn him in extensive cases that dissection can be particularly difficult.

ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN

ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN M.Basta Nikolić, S. Stojanović, O. Nikolić, T. Mrđanin, D. Donat, V. Žigić Center for Radiology, Clinical Center of Vojvodina Novi Sad Chronic pelvic pain