Abstract
The main diagnostic problems for endometriosis are detection of the disease, especially in the absence of ovarian endometriotic cysts, and evaluation of the extent of disease in the pelvis. Transvaginal ultrasonography (TVS) has been proposed as the first line-line imaging technique thanks to its wide availability and because it enables extensive exploration of the pelvis. The “typical” endometrioma is a unilocular cyst with homogeneous low-level echogenicity (ground-glass echogenicity) of the cyst fluid. The use of color Doppler helps to avoid the classification of malignancies as endometriomas by defining the presence or not of flow in papillations. Real-time dynamic TVS examination of adhesions and pouch of Douglas (POD) obliteration, using the sliding sign technique, may be useful in the identification of women at increased risk for bowel endometriosis. Utilizing TVS, an accurate assessment of the vagina—particularly the areas of the posterior and lateral vaginal fornices, the retrocervical area with torus uterinum and uterosacral ligaments as well as the rectovaginal septum—should be made. A slightly filled bladder facilitates evaluation of the structure of the bladder walls and the presence of endometriotic nodules, which appears as hypoechoic linear or spherical lesions bulging toward the lumen, involving the serosa, muscularis, and/or (sub)mucosa of the bladder. Deep nodes of the rectum appear as hypoechoic lesions, linear or nodular retroperitoneal thickening with irregular borders and a few vessels at power Doppler evaluation, penetrating into the intestinal wall distorting its normal structure. Sonographic evaluation of the pelvis also allows a noninvasive classification of the disease to be made, according the Enzian and the AAGL classification, in order to perform presurgical staging.
Zusammenfassung
Die wesentlichen diagnostischen Herausforderungen bei Endometriose bestehen in der Entdeckung der Erkrankung, v. a. wenn keine Endometriosezysten des Ovars vorliegen, und in der Beurteilung des Krankheitsausmaßes im Becken. Der transvaginale Ultraschall (TVS) wurde wegen seiner großen Verfügbarkeit und weil er die ausgedehnte Exploration des Beckens ermöglicht als bildgebende Erstlinientechnik vorgeschlagen. Das „typische“ Endometriom ist eine unilokuläre Zyste mit homogener geringer Echogenität (Mattglasechogenität) der Zystenflüssigkeit. Der Einsatz des Farbdopplers trägt durch Feststellung eines Flusses in papillären Fortsätzen oder das Nichtvorliegen eines solchen dazu bei, die Klassifikation von Malignomen als Endometriome zu vermeiden. Die dynamische Echtzeit-TVS-Untersuchung von Adhäsionen und einer Obliteration des Douglas-Raums unter Verwendung der Sliding-Sign-Technik (Beurteilung der Verschieblichkeit der Organe) kann hilfreich bei der Erkennung von Frauen mit erhöhtem Risiko für eine Endometriose des Bauchraums sein. Mithilfe des TVS sollte eine genaue Untersuchung der Vagina erfolgen – insbesondere der Bereiche des posterioren und lateralen Scheidengewölbes, der retrozervikalen Region mit dem Torus uterinus und den uterosakralen Ligamenten sowie dem rektovaginalen Septum. Eine leicht gefüllte Harnblase erleichtert die Untersuchung der Struktur der Blasenwand und des Vorliegens von Endometrioseknoten, die sich als hypoechogene lineare oder sphärische Läsionen zeigen, die ins Lumen vorspringen, mit Beteiligung der Tunica serosa, Tunica muscularis und/oder Tunica (sub)mucosa der Harnblase. Tief gelegene Rektumknoten erscheinen als hypechogene Läsionen, lineare oder noduläre retroperitoneale Verdickungen mit irregulären Grenzen und wenigen Gefäßen in der Power-Doppler-Untersuchung, welche die Darmwand durchdringen und ihre normale Struktur deformieren. Die sonographische Untersuchung des Beckens ermöglicht auch eine noninvasive Klassifizierung der Erkrankung nach der Enzian-Klassifikation und der Klassifikation der American Association of Gynecological Laparoscopists (AAGL), um ein präoperatives Staging durchzuführ
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References
Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J (2012) Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril 98:564–571
American Fertility Society (1979) Classification of endometriosis. Fertil Steril 32:633–634
The American Fertility Society (1985) Revised American Fertility Society classification of endometriosis. Fertil Steril 43:351–352
Adamson GD, Pasta DJ (2010) Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril 94:1609–1615
Abrao MS, Andres MP, Miller CE et al (2021) AAGL 2021 Endometriosis classification: an anatomy-based surgical complexity score. J Minim Invasive Gynecol 28:1941–1950
Keckstein J, Saridogan E, Ulrich UA, Sillem M, Oppelt P, Schweppe KW et al (2021) The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand 100:1165–1175
Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L et al (2022) ESHRE guideline: endometriosis. Hum Reprod Open 2022:hoac9
Di Donato N, Montanari G, Benfenati A, Leonardi D, Bertoldo V, Monti G et al (2014) Prevalence of adenomyosis in women undergoing surgery for endometriosis. Eur J Obstet Gynecol Reprod Biol 181:289–293
Naftalin J, Hoo W, Pateman K, Mavrelos D, Holland T, Jurkovic D (2012) How common is adenomyosis ? A prospective study of prevalence using transvaginal ultrasound in a gynaecology clinic. Hum Reprod 27:3432–3439
Lazzeri L, Di Giovanni A, Exacoustos C, Tosti C, Pinzauti S, Malzoni M et al (2014) Preoperative and postoperative clinical and transvaginal ultrasound findings of adenomyosis in patients with deep infiltrating endometriosis. Reprod Sci 21:1027–1033
Guerriero S, Condous G, van den Bosch T, Valentin L, Leone FPG, Van Schoubroeck D et al (2016) 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 48:318–332
Mais V, Guerriero S, Ajossa S, Angiolucci M, Paoletti AM, Melis GB (1993) The efficiency of transvaginal ultrasonography in the diagnosis of endometrioma. Fertil Steril 60:776–780
Guerriero S, Mais V, Ajossa S, Paoletti AM, Angiolucci M, Melis GB (1996) Transvaginal ultrasonography combined with CA-125 plasma levels in the diagnosis of endometrioma. Fertil Steril 65:293–298
Patel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA (1999) Endometriomas: diagnostic performance of US. Radiology 210:739–745
Valentin L (2004) Use of morphology to characterize and manage common adnexal masses. Best Pract Res Clin Obstet Gynaecol 18:71–89
Guerriero S, Ajossa S, Mais V, Risalvato A, Lai MP, Melis GB (1998) The diagnosis of endometriomas using colour Doppler energy imaging. Hum Reprod 13:1691–1695
Van Holsbeke C, Van Calster B, Guerriero S, Savelli L, Paladini D, Lissoni AA et al (2010) Endometriomas: their ultrasound characteristics. Ultrasound Obstet Gynecol 35:730–740
Guerriero S, Van Calster B, Somigliana E, Ajossa S, Froyman W, De Cock B et al (2016) Age-related differences in the sonographic characteristics of endometriomas. Hum Reprod 31:1723–1731
Testa AC, Timmerman D, Van Holsbeke C, Zannoni GF, Fransis S, Moerman P et al (2011) Ovarian cancer arising in endometrioid cysts: ultrasound findings. Ultrasound Obstet Gynecol 38:99–106
Fruscella E, Testa AC, Ferrandina G, Manfredi R, Zannoni GF, Ludovisi M et al (2004) Sonographic features of decidualized ovarian endometriosis suspicious for malignancy. Ultrasound Obstet Gynecol 24:578–580
Mascilini F, Moruzzi C, Giansiracusa C, Guastafierro F, Savelli L, De Meis L et al (2014) Imaging in gynecological disease. 10: Clinical and ultrasound characteristics of decidualized endometriomas surgically removed during pregnancy. Ultrasound Obstet Gynecol 44:354–360
Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS (1998) Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound Obstet Gynecol 12:56–66
Johnson N, van Voorst S, Sowter MC, Strandell A, Mol BWJ (2010) Surgical treatment for tubal disease in women due to undergo in vitro fertilisation. Cochrane Database Syst Rev 20:CD2125
Guerriero S, Ajossa S, Garau N, Alcazar JL, Mais V, Melis GB (2010) Diagnosis of pelvic adhesions in patients with endometrioma: the role of transvaginal ultrasonography. Fertil Steril 94:742–746
Exacoustos C, Zupi E, Carusotti C, Rinaldo D, Marconi D, Lanzi G et al (2003) Staging of pelvic endometriosis: role of sonographic appearance in determining extension of disease and modulating surgical approach. J Am Assoc Gynecol Laparosc 10:378–382
Holland TK, Yazbek J, Cutner A, Saridogan E, Hoo WL, Jurkovic D (2010) Value of transvaginal ultrasound in assessing severity of pelvic endometriosis. Ultrasound Obstet Gynecol 36:241–248
Okaro E, Condous G, Khalid A, Timmerman D, Ameye L, Huffel SV et al (2006) The use of ultrasound-based “soft markers” for the prediction of pelvic pathology in women with chronic pelvic pain—Can we reduce the need for laparoscopy? BJOG 113:251–256
Reid S, Lu C, Casikar I, Reid G, Abbott J, Cario G et al (2013) 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 41:685–691
Reid S, Lu C, Casikar I, Mein B, Magotti R, Ludlow J et al (2013) The prediction of pouch of Douglas obliteration using offline analysis of the transvaginal ultrasound “sliding sign” technique: inter- and intra-observer reproducibility. Hum Reprod 28:1237–1246
Menakaya U, Condous G (2013) The retroverted uterus: refining the description of the real time dynamic “sliding sign”. Australas J Ultrasound Med 16:97
Hudelist G, Fritzer N, Staettner S, Tammaa A, Tinelli A, Sparic R et al (2013) Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating endometriosis of the rectum. Ultrasound Obstet Gynecol 41:692–695
Menakaya U, Infante F, Lu C, Phua C, Model A, Messyne F et al (2016) Interpreting the real-time dynamic ‘sliding sign’ and predicting pouch of Douglas obliteration: an interobserver, intraobserver, diagnostic-accuracy and learning-curve study. Ultrasound Obstet Gynecol 48:113–120
Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset B, Pansini V et al (2003) Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 18:157–161
Querleu D, Cibula D, Abu-Rustum NR (2017) 2017 update on the Querleu-Morrow classification of radical hysterectomy. Ann Surg Oncol 24:3406–3412
Guerriero S, Ajossa S, Gerada M, D’Aquila M, Piras B, Melis GB (2007) “Tenderness-guided” transvaginal ultrasonography: a new method for the detection of deep endometriosis in patients with chronic pelvic pain. Fertil Steril 88:1293–1297
Hudelist G, Ballard K, English J, Wright J, Banerjee S, Mastoroudes H et al (2011) Transvaginal sonography vs. clinical examination in the preoperative diagnosis of deep infiltrating endometriosis. Ultrasound Obstet Gynecol 37:480–487
Fedele L, Bianchi S, Raffaelli R, Portuese A (1997) Pre-operative assessment of bladder endometriosis. Hum Reprod 12:2519–2522
Savelli L, Manuzzi L, Pollastri P, Mabrouk M, Seracchioli R, Venturoli S (2009) Diagnostic accuracy and potential limitations of transvaginal sonography for bladder endometriosis. Ultrasound Obstet Gynecol 34:595–600
Ceccaroni M, Clarizia R, Roviglione G, Ruffo G (2013) Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery. Surg Endosc 27:4386–4394
Vu D, Haylen BT, Tse K, Farnsworth A (2010) Surgical anatomy of the uterosacral ligament. Int Urogynecol J 21:1123–1128
Di Giovanni A, Casarella L, Coppola M, Falcone F, Iuzzolino D, Rasile Malzoni MM (2022) Ultrasound Evaluation of retrocervical and parametrial deep endometriosis on the basis of surgical landmarks. J Minim Invasive Gynecol 35:1231–1237
Bazot M, Thomassin I, Hourani R, Cortez A, Darai E (2004) Diagnostic accuracy of transvaginal sonography for deep pelvic endometriosis. Ultrasound Obstet Gynecol 24:180–185
Maccagnano C, Pellucchi F, Rocchini L, Ghezzi M, Scattoni V, Montorsi F et al (2013) Ureteral Endometriosis: proposal for a diagnostic and therapeutic algorithm with a review of the literature. Urol Int 91:1–9
Knabben L, Imboden S, Fellmann B, Nirgianakis K, Kuhn A, Mueller MD (2015) Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical classification. Fertil Steril 103:147–152
Reid S, Condous G (2015) Should ureteric assessment be included in the transvaginal ultrasound assessment for women with suspected endometriosis? Australas J Ultrasound Med 18:21–22
Carmignani L, Vercellini P, Spinelli M, Fontana E, Frontino G, Fedele L (2010) Pelvic endometriosis and hydroureteronephrosis. Fertil Steril 93:1741–1744
Leonardi M, Condous G (2019) A pictorial guide to the ultrasound identification and assessment of uterosacral ligaments in women with potential endometriosis. Australas J Ultrasound Med 22(3):157–164
Bignardi T, Condous G (2008) Sonorectovaginography: a new sonographic technique for imaging of the posterior compartment of the pelvis. J Ultrasound Med 27(10):1479–1483
Reid S, Lu C, Hardy N, Casikar I, Reid G, Cario G et al (2014) Office gel sonovaginography for the prediction of posterior deep infiltrating endometriosis: a multicenter prospective observational study. Ultrasound Obstet Gynecol 44(6):710–718
Guerriero S, Ajossa S, Gerada M, Virgilio B, Angioni S, Melis GB (2008) Diagnostic value of transvaginal “tenderness-guided” ultrasonography for the prediction of location of deep endometriosis. Hum Reprod 23(11):2452–2457
Exacoustos C, Malzoni M, Di Giovanni A, Lazzeri L, Tosti C, Petraglia F et al (2014) Ultrasound mapping system for the surgical management of deep infiltrating endometriosis. Fertil Steril 102(1):143–150.e2
Hudelist G, Tuttlies F, Rauter G, Pucher S, Keckstein J (2009) Can transvaginal sonography predict infiltration depth in patients with deep infiltrating endometriosis of the rectum? Hum Reprod 24(5):1012–1017
Exacoustos C, Manganaro L, Zupi E (2014) Imaging for the evaluation of endometriosis and adenomyosis. Best Pract Res Clin Obstet Gynaecol 28(5):655–681
Belghiti J, Thomassin-Naggara I, Zacharopoulou C, Zilberman S, Jarboui L, Bazot M et al (2015) Contribution of computed tomography enema and magnetic resonance imaging to diagnose multifocal and multicentric bowel lesions in patients with colorectal endometriosis. J Minim Invasive Gynecol 22(5):776–784
Valenzano Menada M, Remorgida V, Abbamonte LH, Nicoletti A, Ragni N, Ferrero S (2008) Does transvaginal ultrasonography combined with water-contrast in the rectum aid in the diagnosis of rectovaginal endometriosis infiltrating the bowel? Hum Reprod 23(5):1069–1075
Ferrero S, Biscaldi E, Morotti M, Venturini PL, Remorgida V, Rollandi GA et al (2011) Multidetector computerized tomography enteroclysis vs. rectal water contrast transvaginal ultrasonography in determining the presence and extent of bowel endometriosis. Ultrasound Obstet Gynecol 37(5):603–613
Bergamini V, Ghezzi F, Scarperi S, Raffaelli R, Cromi A, Franchi M (2010) Preoperative assessment of intestinal endometriosis: A comparison of transvaginal sonography with water-contrast in the rectum, transrectal sonography, and barium enema. Abdom Imaging 35(6):732–736
Piketty M, Chopin N, Dousset B, Millischer-Bellaische A‑E, Roseau G, Leconte M et al (2009) Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod 24(3):602–607
Hudelist G, Montanari E, Salama M, Dauser B, Nemeth Z, Keckstein J (2021) Comparison between sonography-based and surgical extent of deep endometriosis using the enzian classification—A prospective diagnostic accuracy study. J Minim Invasive Gynecol 28:1643–1649
Di Giovanni A, Montanari E, Hudelist G, Malzoni M, Keckstein J (2021) Comparison between sonography-based and surgical evaluation of endometriotic lesions using the #Enzian classification—A retrospective data analysis. Ultraschall Med 44:290–229
Montanari E, Bokor A, Szabó G, Kondo W, Trippia CH, Malzoni M et al (2022) Accuracy of sonography for non-invasive detection of ovarian and deep endometriosis using #Enzian classification: prospective multicenter diagnostic accuracy study. Ultrasound Obstet Gynecol 59:385–391
Abrao MS, Andres MP, Gingold JA, Di Giovanni A, Malzoni M, Carmona F (2023) Preoperative ultrasound scoring of endometriosis by AAGL 2021 endometriosis classification is concordant with laparoscopic surgical findings and distinguishes early from advanced stages. J Minim Invasive Gynecol 30:363–373
Bindra V, Madhavi N, Mohanty GS, Nivya K, Balakrishna N (2023) Pre-operative mapping and structured reporting of pelvic endometriotic lesions on dynamic ultrasound and its correlation on laparoscopy using the #ENZIAN classification. Arch Gynecol Obstet 307:179–186
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C. Exacoustos declares that he/she has no competing interests.
For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case.
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Ludwig Kiesel, Münster
Wolfgang Küpker, Baden-Baden
Ricardo Felberbaum, Kempten
Brigitte Leeners, Zürich
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Exacoustos, C. Sonography for pelvic endometriosis. Gynäkologische Endokrinologie 21, 165–175 (2023). https://doi.org/10.1007/s10304-023-00523-4
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DOI: https://doi.org/10.1007/s10304-023-00523-4