Structured manual for MRI assessment of deep infiltrating endometriosis using the ENZIAN classification



Proposal of a systematic approach to assess Deep infiltrating endometriosis (DIE) through pelvic Magnetic resonance imaging (MRI) using the Enzian classification and examination of inter-rater agreement.


Three radiologists reviewed 23 MRI of patients with pelvic DIE at one tertiary referral center retrospectively and independently. Inclusion criteria were intraoperative confirmation of DIE and MR imaging according to ESUR (European Society of Urogenital Radiology) guidelines. Assessment of the anatomical pelvic compartments was performed using a manual based on the Enzian classification with step-by-step instructions using recommended planes and sequences presented here. Interrater agreement was measured using kappa statistics.


According to the intraoperative site lesions in 53 anatomical compartments were present. Interrater agreement was best for compartments A (0.255) and FB (0.642). For FI (0.204) and B (0.146) it was slight, there was poor agreement for C (− 0.263), FA (− 0.022), and FO (− 0.030), respectively, and as for FU, no ureter infiltration was described.


MRI as a noninvasive diagnostic tool offers essential advantages regarding classification and therapy planning for patients with DIE. However, its assessment is difficult and a more systematic approach is needed. Our proposed manual based on the Enzian classification is reproducible and could support radiologists and gynecologists.

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Author information




LB: data collection, manuscript writing/editing. DS: data analysis, critically revision. AMH and AM: examining radiologist, critically revision. DF: protocol/project development, critically revision. AB: examining radiologist, critically revision, protocol/project development, supervision. PI: manuscript writing/editing, protocol/project development, supervision.

Corresponding author

Correspondence to Laurin Burla.

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Conflict of interest

Author Laurin Burla declares that he has no conflict of interest. Author David Scheiner declares that he has no conflict of interest. Author Andreas M Hötker declares that he has no conflict of interest. Author Andreas Meier declares that he has no conflict of interest. Author Daniel Fink declares that he has no conflict of interest. Author Andreas Boss declares that he has no conflict of interest. Author Patrick Imesch declares that he has no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved prior to its initiation by the cantonal ethics committee of Zurich (2016-00613).

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Informed consent was obtained from all individual participants included in the study.

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Burla, L., Scheiner, D., Hötker, A.M. et al. Structured manual for MRI assessment of deep infiltrating endometriosis using the ENZIAN classification. Arch Gynecol Obstet (2020).

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  • Endometriosis
  • Deep infiltrating endometriosis
  • Enzian classification
  • MRI assessment of deep infiltrating endometriosis
  • Interrater agreement MRI endometriosis
  • Interobserver agreement MRI endometriosis