Rectal endometriosis: predictive MRI signs for segmental bowel resection



To retrospectively determine the accuracy of MRI rectal and pararectal signs in predicting the necessity for segmental resection in the case of lesions located in the rectum.


MR images of consecutive patients treated for rectal endometriosis over a 5-year period were reviewed in consensus by two blinded readers. A systematic analysis of 7 rectal (lesion length, transverse axis, thickness and circumference, and presence of a convex base, submucosal oedema and hyperintense cystic areas) and 4 pararectal (posterior vaginal fornix, parametrial, ureteral and sacro-recto-genital septum involvements) signs was performed for each lesion. MRI results were compared to the surgical procedure performed (shaving versus segmental resection).


Among 61 patients studied, 32 received a segmental resection and 29, a shaving. Receiver operating characteristic curve analysis allowed determining cut-off values for length (≥ 32 mm), transverse axis (≥ 22 mm), thickness (≥ 14 mm) and circumference (≥ 3/8 radii). The 7 rectal signs, and only the sacro-recto-genital septum pararectal sign, were significantly associated with segmental resection in univariate analysis, nodular thickness ≥ 14 mm and circumference ≥ 3/8 radii being the most predictive signs (odds ratio 94.5 and 60.4, respectively). These 2 signs remained positively associated with segmental resection in multivariate analysis and, when combined, were predictive of segmental resection with an accuracy of 90.2%.


Assessing MRI rectal and pararectal signs may accurately predict the need for segmental resection versus a more conservative approach such as shaving for rectal lesion management.

Key Points

• MRI analysis of rectal endometriosis, taking into account rectal and pararectal signs, may assist surgeons in the decision-making process, in counselling patients regarding the surgical procedure and in adequately allocating resources.

• Among rectal signs, nodular thickness ≥ 14 mm and a circumference ≥ 38% were the most predictive signs of segmental resection.

• Among pararectal signs, only the sacro-recto-genital septum involvement was significantly associated with segmental resection.

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Fig. 1
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Fig. 3


95% CI:

95% confidence interval


Deep infiltrating endometriosis


Odds ratio

PPV and NPV:

Positive and negative predictive values






Transvaginal sonography


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The authors state that this work has not received any funding.

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Corresponding author

Correspondence to Pascal Rousset.

Ethics declarations


The scientific guarantor of this publication is Pr Pascal Rousset (MD, PhD).

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise: Pr Jean-Christophe Lega (MD, PhD).

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

Some study subjects included between June 2012 and July 2013 in this paper have been previously reported/included in “Bowel endometriosis: preoperative diagnostic accuracy of 3.0-T MR enterography—initial results. Rousset P, Peyron N, Charlot M, Chateau F, Golfier F, Raudrant D, Cotte E, Isaac S, Réty F, Valette PJ. Radiology. 2014 Oct;273(1):117–24.”

However, in this last paper, only lesions located above the recto-sigmoid junction were studied, while in the present paper, only lesions of the rectum or the recto-sigmoid junction were studied.


• retrospective

• diagnostic study/observational

• performed at one institution

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Rousset, P., Buisson, G., Lega, JC. et al. Rectal endometriosis: predictive MRI signs for segmental bowel resection. Eur Radiol 31, 884–894 (2021).

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  • Endometriosis
  • Rectum
  • Digestive system surgical procedures
  • Magnetic resonance imaging