{"paper_id":"82484bbf-e64c-4201-85c1-82526f0ee0e3","body_text":"UCSF\nUC San Francisco Previously Published Works\nTitle\nSociety of Radiologists in Ultrasound Consensus on Routine Pelvic US for Endometriosis.\nPermalink\nhttps://escholarship.org/uc/item/95c3f7q9\nJournal\nRadiology, 311(1)\nISSN\n0033-8419\nAuthors\nYoung, Scott W\nJha, Priyanka\nChamié, Luciana\net al.\nPublication Date\n2024-04-01\nDOI\n10.1148/radiol.232191\n \nPeer reviewed\neScholarship.org Powered by the California Digital Library\nUniversity of California\n\nREVIEWS AND COMMENTARY • STATEMENTS AND GUIDELINES\nThis copy is for personal use only. T o order copies, contact reprints@rsna.org\nE\nndometriosis, defined as the presence of endometrium-\nlike tissue outside the uterus, is a common condition \nestimated to affect 10% of those of reproductive age and \noccurs in 21% of female patients undergoing hysterectomy \nwith chronic pelvic pain (1). It is also associated with in-\nfertility and subfertility, affecting 20%–50% of patients \nwith these conditions (2). Deep endometriosis (DE), tra-\nditionally considered to extend more than 5 mm under the \nperitoneal surface but redefined in 2021 as extending to \nany depth beneath the peritoneal surface, is the most severe \nform of endometriosis (3).\nT ransvaginal sonography is used worldwide as a first-line \nmodality for pelvic pain and infertility evaluation. It has also \nbeen advocated as a second-line modality for preoperative \nmapping of endometriomas and DE observations, after an \ninitial diagnosis of DE has been established (4–7). Yet, in \nthe United States, there is a delay longer than 7 years be-\ntween the onset of symptoms and diagnosis of endometrio-\nsis (8,9). Although transvaginal US is commonly interpreted \nby sonologists (radiologists and gynecologists) in the United \nStates, few centers use US as a screening modality for DE \n(10). Existing scan protocol limitations and lack of aware-\nness lead to suboptimal detection of DE on pelvic US images \n(11). Detailed and systematic approaches for diagnosing en-\ndometriosis published previously are not widely used in the \nUnited States (6,7,12), most notably the recommendations \nfrom the 2016 International Deep Endometriosis Analysis \ngroup (13). These protocols involve an expert sonologist \nwho obtains numerous additional images that are outside \nof the current interdisciplinary guideline, the typical time \nallotted for pelvic imaging, and reimbursement models. \nFailure to diagnose DE at routine sonography likely con-\ntributes to diagnostic delay (14). Moreover, gynecologic \nsurgical societies now recommend advanced endometriosis \nimaging before laparoscopic evaluation (15). This is par-\nticularly important because extensive dissection may be \nrequired to detect DE at laparoscopy. Preoperative imag-\ning allows for appropriate patient counseling and surgical \nplanning including the need for additional surgical exper-\ntise beyond that of a general laparoscopist (16).\nDE manifests in the posterior compartment of 93% \nof affected patients, including the uterosacral ligaments \nEndometriosis is a prevalent and potentially debilitating condition that mostly affects individuals of reproductive age, and often \nhas a substantial diagnostic delay. US is usually the first-line imaging modality used when patients report chronic pelvic pain or \nhave issues of infertility, both common symptoms of endometriosis. Other than the visualization of an endometrioma, sonologists \nfrequently do not appreciate endometriosis on routine transvaginal US images. Given a substantial body of literature describing \ntechniques to depict endometriosis at US, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts \nto make recommendations aimed at improving the screening process for endometriosis. The panel was composed of experts in the \nimaging and management of endometriosis, including radiologists, sonographers, gynecologists, reproductive endocrinologists, \nand minimally invasive gynecologic surgeons. A comprehensive literature review combined with a modified Delphi technique \nachieved a consensus. This statement defines the targeted screening population, describes techniques for augmenting pelvic US, \nestablishes direct and indirect observations for endometriosis at US, creates an observational grading and reporting system, and \nmakes recommendations for additional imaging and patient management. The panel recommends transvaginal US of the posterior \ncompartment, observation of the relative positioning of the uterus and ovaries, and the uterine sliding sign maneuver to improve \nthe detection of endometriosis. These additional techniques can be performed in 5 minutes or less and could ultimately decrease the \ndelay of an endometriosis diagnosis in at-risk patients.\n© RSNA, 2024\nSupplemental material is available for this article.\nSociety of Radiologists in Ultrasound Consensus on \nRoutine Pelvic US for Endometriosis\nScott W. Young, MD* • Priyanka Jha, MBBS* • Luciana Chamié, MD, PhD • Shuchi Rodgers, MD •  \nRosanne M. Kho, MD • Mindy M. Horrow, MD • Phyllis Glanc, MD • Myra Feldman, MD •  \nYvette Groszmann, MD • Zaraq Khan, MBBS • Steven L. Young, MD, PhD • Liina Poder, MD •  \nT atnai L. Burnett, MD • Eric M. Hu, MD • Susan Egan, RDMS • Wendaline VanBuren, MD\nFrom the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (S.W .Y.); Department of Radiology, Stanford University School of \nMedicine, Stanford, Calif (P .J.); Department of Radiology, Chamié Imagem da Mulher, São Paulo, Brazil (L.C.); Department of Radiology, Albert Einstein Medical Center, \nPhiladelphia, Pa (S.R., M.M.H.); Department of Obstetrics and Gynecology, Banner Health System, Phoenix, Ariz (R.M.K.); Department of Medical Imaging, University of \nT oronto, T oronto, Canada (P .G.); Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio (M.F .); Department of Obstetrics and Gynecology, Brigham and Women’s \nHospital, Boston, Mass (Y.G.); Department of Obstetrics and Gynecology (Z.K., T .L.B.) and Department of Radiology (W .V .B.), Mayo Clinic, Rochester, Minn; Department \nof Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (S.L.Y.); Department of Radiology and Biomedical Imaging, University of California, San \nFrancisco, San Francisco, Calif (L.P .); Department of Radiology, Intermountain Healthcare, Salt Lake City, Utah (E.M.H.); and Department of Radiology, Rutgers Robert \nWood Johnson Medical School, Piscataway, NJ (S.E.). Received August 24, 2023; revision requested October 31; revision received November 21; accepted December 22.  \nAddress correspondence to S.W .Y. (email: Young.Scott@mayo.edu).\n* S.W .Y. and P .J. contributed equally to this work.\nConflicts of interest are listed at the end of this article.\nRadiology 2024; 311(1):e232191  •  https://doi.org/10.1148/radiol.232191  •  Content codes: \n  \n\n\nConsensus Statement on Routine Pelvic US for Endometriosis\n2 radiology.rsna.org ■ Radiology: Volume 3 1 1: Number 1—April 2024\n(USLs) (69%) and rectum and rectosigmoid junction (10%–\n20%) (17,18). These areas are easily accessible with transvagi-\nnal US, and focused imaging of these regions is likely to have \nthe greatest impact on expediting the diagnosis. The current in-\nterdisciplinary imaging guideline does not specify sonographic \ntechniques or scanning protocols targeted to diagnosing en-\ndometriosis (19). Many prospective cohort studies and meta-\nanalyses have shown good sensitivity and excellent specificity \nfor the diagnosis, depending on location (5,20–31).\nMost of these studies have been performed in patient popu-\nlations at high risk for DE, often by experienced physician so-\nnologists. The sensitivity and specificity for the detection of DE \nin a symptomatic patient by sonographers and subsequently \ninterpreted by sonologists are not well known. However, in one \nstudy of average-risk patients (high-risk, tertiary care patients \nunderwent endometriosis protocol MRI [32] or physician-\nacquired US-based DE mapping after bowel preparation [6]), \nthe introduction of uterine sliding sign and static imaging of \nthe posterior compartment with a review of cervicouterine cine \nclips performed solely by nonphysician sonographers and in-\nterpreted remotely by radiologists increased the detection of \nposterior compartment DE by three-fold and yielded sensitiv-\nity and specificity of 68% and 98%, respectively (33).\nThe purpose of this consensus panel is to recommend \nmethods that increase the diagnostic sensitivity for endome-\ntriosis at pelvic US by increasing awareness, improving inter-\npretation, adding simple techniques that are high yield for \nDE, and improving protocols to triage patients. The recom-\nmendations are expected to add minimal time to the current \nrecommended protocols. This statement defines the targeted \nscreening population, describes techniques for augmenting \npelvic US, establishes direct and indirect observations for \nendometriosis at US, creates an observational grading and \nAbbreviations\nDE = deep endometriosis, O-RADS = Ovarian-Adnexal Reporting and \nData System, USL = uterosacral ligament\nSummary\nThe Society of Radiologists in Ultrasound expert consensus provides \nrecommendations for augmenting routine pelvic US examinations \nthrough additional maneuvers and imaging to improve diagnosis of \ndeep endometriosis.\nEssentials\n ■ The Society of Radiologists in Ultrasound expert panel \nrecommends performing augmented pelvic US in premenopausal \nor early postmenopausal individuals (<5 years since the cessation \nof menses) who are symptomatic for or have a history of \nendometriosis or infertility.\n ■ Additional techniques to augment pelvic US examinations include \ntransvaginal US of the posterior compartment, observation of \nthe relative positioning of the uterus and ovaries, and the uterine \nsliding sign maneuver.\n ■ Direct and indirect observations of deep endometriosis should be \nassessed during the examination and results should be reported \nusing four categories: Incomplete (augmented pelvic US, or  \nAPU-0), normal (APU-1), equivocal (APU-2), and positive  \n(APU-3) with associated management recommendations.\nreporting system, and makes recommendations for additional \nimaging and patient management.\nMaterials and Methods\nNote on Terminology\nThe Society of Radiologists in Ultrasound panel recognizes that \nthere are individuals who may be affected by endometriosis who \nare transgender, who do not identify with the term female, who \ndo not menstruate, or who have undergone hysterectomy. The \nterms female and reproductive age are used in this statement to \nmaintain consistency with the existing literature and their use is \nnot intended to exclude or marginalize any individual affected \nby this debilitating disease.\nExpert Panel\nIn June 2022, the Society of Radiologists in Ultrasound con-\nvened a panel of 16 experts in imaging and management of \nendometriosis. The panel included gynecologic US experts \nfrom both radiology and gynecology; a community radiolo-\ngist; a registered diagnostic medical sonographer; board mem-\nbers or practice guideline chairs from key stakeholder societies \nsuch as the Society for Reproductive Endocrinology and In-\nfertility (2), the American Society for Reproductive Medicine \n(1), the Society of Gynecologic Surgeons (1), the American \nAssociation of Gynecologic Laparoscopists (1), the Society of \nReproductive Surgeons (1), the American Institute of Ultra-\nsound in Medicine (1), and the Society for Assisted Reproduc-\ntive T echnology (1); minimally invasive gynecologic surgeons \nwith expertise in the resection of advanced-stage DE (3);  \nand cochairs or members of Society of Abdominal Radiology \ndisease–focused panel on endometriosis (8). All the solicited \nexperts agreed to join the panel.\nLiterature Search\nA literature review was conducted to obtain the following in-\nformation regarding the use of pelvic US in detecting endo-\nmetriosis: sensitivities and specificities for detection in various \nlocations, technique descriptions, and examples of direct ob-\nservations (ie, the presence of ectopic endometrial tissue) and \nindirect observations (ie, a fibrotic reaction induced by endo-\nmetriosis). A librarian performed a comprehensive English-lan-\nguage search in PubMed for literature published from January \n1994 to December 2022. The following search strategy was \nused: ((((“deep infiltrating endometriosis”) OR ((“deep infiltrat-\ning”) AND (“Endometriosis”[Mesh])) AND (English[Filter])) \nOR (“deep* infiltrat* endometriosis” AND (English[Filter]))) \nOR (“deep* endometriosis” AND (English[Filter])) AND \n(English[Filter])) AND (ultrasound AND (English[Filter])) ± \nFilters: Meta-Analysis, Systematic Review, English. The results \nyielded 637 general literature articles and 21 meta-analyses. \nOf the 637 articles, 205 were excluded because they were \nolder than 10 years or were case reports. T wo authors (S.W .Y. \nand R.M.K.) reviewed the abstracts of the remaining 432 ar-\nticles and excluded an additional 289 publications and four \nmeta-analyses because they did not directly study US of DE. \nSeventy-five articles described site-specific or multisite direct \n\nYoung and Jha et al\nRadiology: Volume 3 1 1: Number 1—April 2024 ■ radiology.rsna.org 3\nobservations. These articles were categorized into six groups \nbased on endometriosis site (Table 1; structured literature flow \ndiagram, Fig S1). Each of the site-specific groups was assigned \nto one panel member who reviewed the full article. Those panel \nmembers also reviewed the full articles reporting on multisite \ndirect observations. Meta-analyses reporting the sensitivity and \nspecificity of direct transvaginal US observations were iden-\ntified (Table 2). The remaining studies included 14 learning \ncurve articles, 16 mobility and indirect observations articles, \nand 55 other articles that were deemed relevant to US-based \nDE. One panel member reviewed these articles. All panel \nmembers reviewed the meta-analyses.\nExpert Consensus\nSimultaneously with the structured literature review, panel \nmembers completed a survey to gather expert opinions to \naugment the literature review. Panelists answered 35 multiple-\nchoice questions based on the following topics: general goals \nof the recommendations for pelvic US examinations, patient \ninclusion criteria for augmented pelvic US, imaging techniques \nfor endometriosis, time constraints for image acquisition, and \ndirect and indirect observations of endometriosis at US and \nTable 1: Distribution of Studies Identified During \nStructured Literature Review Based on Sites of Deep \nEndometriosis and Endometrioma\nDeep Endometriosis Site No. of Publications Reviewed\nRetrocervical area, uterosacral  \nligaments, or multiple sites\n44\nRectosigmoid colon or  \nrectovaginal septum\n10\nUterus or adenomyosis 10\nAnterior compartment 5\nEndometrioma 3\nDistant sites 3\nTable 2: Meta-Analysis–derived Sensitivities and \nSpecificities for Deep Endometriosis Observations at \nTransvaginal US\nLocation Sensitivity (%) Specificity (%) Reference No.\nDeep  \nendometriosis \n(all areas)\n57–98 87–100 20–23\nBladder 55–72 99–100 20,24–26\nUterosacral  \nligaments\n56–67 86–93 20,25,27,28\nVaginal 52–58 96–98 21,25\nRectosigmoid  \ncolon\n80–91 94–97 5,20,27,29,30\nOvarian  \nendometrioma\n93 96 31\nTable 3: Consensus Definitions of Pelvic US Types and Categorization of Imaging Signs Relevant to the Imaging-based \nDetection of Endometriosis\nT erminology Definition\nImaging procedures\n Routine pelvic US Conventional examination for all conditions pertaining to the uterus, ovary, adnexa, and the overall pelvis.\nIndications include all conditions pertaining to the pelvic organs for which imaging is required for diagnosis.\nMinimum standard US views should be obtained as mandated by practice guidelines.\nAllotted time varies between 30 and 45 min among the panelists’ institutions.\n Augmented pelvic US A routine pelvic US augmented by additional maneuvers when clinical suspicion of endometriosis exists.\nIndications include chronic pelvic pain, infertility, and clinically or radiographically suspected endometriosis.\nSimple additional maneuvers such as uterine sliding cine, longitudinal and transverse sweeps of the uterus \nand cervix that include the posterior compartment structures can be used to assess endometriosis.\nExpected additional time: 2–5 min.\n Advanced  \nendometriosis imaging\nSecond line imaging evaluation, performed to diagnose endometriosis, evaluate disease extent, and aid in \nsurgical planning when clinically indicated.\nMay be either US or MRI performed/assessed by an expert, based on institutional practice patterns and \navailable technology and expertise.\nUS should include expert mapping of DE following a prescribed pattern of search (eg, IDEA protocol [13]).\nMRI should include endometriosis-specific MRI with expert interpretation.\nDetailed discussion of expert examinations is beyond the scope of current consensus (4,6,13,32,69).\nImaging signs  \nof endometriosis\n Direct US observation US observations indicating presence of ectopic endometrium-like tissue outside the uterus with visualization \nof DE implants.\n Indirect US observation Signs at US suggestive of or secondary to endometriosis without direct visualization of DE implants, such as \nadhesions or fixed uterine retroflexion.\nNote.—DE = deep endometriosis, IDEA = International Deep Endometriosis Analysis.\n\nConsensus Statement on Routine Pelvic US for Endometriosis\n4 radiology.rsna.org ■ Radiology: Volume 3 1 1: Number 1—April 2024\nwhen to recommend advanced endometriosis imaging or gy-\nnecologic referral. The panel achieved consensus utilizing the \nmodified Delphi method, which included up to seven rating \nrounds of multiple-choice questions with two to 10 options \neach and free text answers (Appendix S1). Panel-wide discus-\nsion of the survey created agreement regarding terminology \nand narrowed the options until consensus was achieved. Vir-\ntual discussions were recorded for those not able to attend in \nreal time, with an opportunity to comment on the final con-\nsensus results. After consensus was reached regarding the rel-\nevant observational categories, the imagers (ie, radiologists and \ngynecologists) created diagnostic categories to stratify risk and \nneed for follow-up based on expert opinion. Subsequently, the \nclinicians (gynecologists and gynecologic surgeons) achieved \nconsensus regarding the appropriate management recommen-\ndations for the diagnostic categories.\nConsensus Summary and Recommendations\nFor the purposes of the consensus, definitions for routine pel-\nvic US, augmented pelvic US, advanced endometriosis im-\naging, and direct and indirect signs of DE were developed \n(Table 3) (34–39).\nThe consensus panel unanimously agreed that routine pel-\nvic US techniques have not been optimized for the depiction \nof endometriosis and can thus exacerbate diagnostic delay in \nsymptomatic patients. The panel agreed to raise awareness of \nthe signs of endometriosis on all pelvic US images and list addi-\ntional sonographic maneuvers that can augment the examina-\ntion to depict DE. Table 4 lists a summary of consensus panel \nrecommendations. Management recommendations should be \nguidance rather than requirements and are based on patients \nwith average risk (nontertiary care) and typical symptoms.\nIdentifying the Screening Population\nRecommendation: Perform augmented pelvic US only in pre-\nmenopausal or early postmenopausal patients (<5 years since \nthe cessation of menses). Patients should be symptomatic or \nhave a history of infertility based on imaging indication or \npatient-provided history (40).\nThe panel identified patient history and symptoms that met the \ncriteria for screening for DE at augmented pelvic US in premeno-\npausal or early postmenopausal patients based on literature search \nand expert consensus (Table 5) (40–42). Although the predictive \nvalue of the listed endometriosis symptoms is low (41), current \nTable 4: Summary of Panel Consensus Recommendations for Augmented Pelvic US for Detection of Endometriosis\nRecommendation \nCategory Recommendation Summary\nScreening population Perform augmented pelvic US only in premenopausal or early postmenopausal individuals (<5 years since \nthe cessation of menses). Patients should have chronic pelvic pain symptoms, infertility, or clinically or \nradiographically suspected endometriosis.\nThe panel does not recommend performing augmented maneuvers routinely for all pelvic US.\nAugmented pelvic  \nUS technique\nThe panel unanimously agreed that an augmented pelvic US would have the greatest acceptance and impact in \ngeneral US-based screening for DE.\nAdditional imaging to enhance the detection of DE during augmented pelvic US focuses on the transvaginal \nevaluation of the posterior compartment, the relative positioning of the uterus and ovaries, and the uterine \nsliding sign.\nT ransvaginal US is essential for screening detection of DE and transabdominal examination alone is insufficient. \nWhen transvaginal imaging is not feasible or technically inadequate, use expert MRI if there is high clinical \nsuspicion for endometriosis.\nThe panel does not recommend bowel preparation for augmented pelvic US.\nAugmented pelvic  \nUS observations\nAssess direct and indirect signs during augmented pelvic US.\nAugmented pelvic  \nUS reporting  \nand clinical  \nrecommendations\nReport augmented pelvic US using four categories: incomplete (APU-0), normal (APU-1), equivocal (APU-2),  \nand positive (APU-3).\nAny single direct imaging observation (category A) of endometriosis should lead to endometriosis diagnosis, \nrecommendation for advanced endometriosis imaging, and referral to a reproductive endocrinologist and/or \ngynecologic surgeon familiar with DE, as appropriate.\nIn the absence of category A observations, findings are suggestive of endometriosis when two or more indirect \nobservations (category B) or one category B and one endometriosis-associated observation (category C) \nare noted; referral to gynecology for further evaluation and possible advanced endometriosis imaging is \nrecommended.\nWhen only category C observations are present, a gynecology referral is appropriate. Given the nonspecific nature \nof these findings, advanced endometriosis imaging is not recommended but may be obtained if there is high \nclinical suspicion of endometriosis.\nAdvanced endometriosis imaging consists of either expert US mapping of endometriosis following a prescribed \npattern of search and/or endometriosis-specific MRI with expert interpretation (4,6,13,32,69).\nNote.—APU = augmented pelvic US, DE = deep endometriosis.\n\nYoung and Jha et al\nRadiology: Volume 3 1 1: Number 1—April 2024 ■ radiology.rsna.org 5\nguidelines do not recommend surgical or medical treatment for \nasymptomatic endometriosis (15). In clinical practice, patients \nmeeting the criteria for screening can be identified by the clinical \nproviders at the time of ordering the examination, by the sonog-\nrapher during patient intake and scanning, and, ultimately, by the \nsonologist, who will be interpreting the examination. The sonolo-\ngist should serve as the final checkpoint to identify if a patient who \nmet the inclusion criteria for screening received the augmented \nmaneuvers and include their observations and grading in the re-\nport. The panel acknowledged that there may be observations of \nDE at routine pelvic US in a patient who did not report any of the \neligible history or symptoms. In this scenario, the recommenda-\ntion is to report the observations with a suspicion of DE. Patients \nwith a long history of contraceptive use may also have DE with \nminor or no symptoms (41,43,44). Augmented pelvic US may be \nindicated by other symptoms or history and may be performed at \nthe discretion of the ordering or reading clinician.\nAdditional Imaging Techniques for Augmented Pelvic US\nRecommendation: The panel unanimously agreed that an aug-\nmented pelvic US examination would have the greatest feasi-\nbility, acceptance, and impact in general US-based screening \nfor DE.\nAugmented pelvic US should include additional imaging fo-\ncusing on the posterior compartment, the relative positioning of \nthe uterus and ovaries, and the uterine sliding sign (transducer \npressure or bimanual demonstration of uterine mobility).\nT ransvaginal evaluation is essential for screening detection of \nDE and transabdominal examination alone is insufficient. The \npanel recommends MRI when transvaginal imaging is not fea-\nsible and there is high clinical suspicion of endometriosis.\nThe panel recommended no bowel preparation for aug-\nmented pelvic US.\nRoutine pelvic US examinations are conventionally per-\nformed for all conditions requiring imaging of the pelvis. \nMinimum standard US views are mandated by multisociety \npractice guidelines but make no specific DE-focused imaging \nrecommendations (19,45). Institutional protocols vary, but the \nallotted time for these examinations typically ranges from 30 to \n45 minutes. Augmented pelvic US focuses on transvaginal so-\nnography of the posterior compartment to optimally assess the \nmost common sites of DE (Fig 1). Dynamic maneuvers that use \nthe real-time imaging capability of US, including a uterine slid-\ning cine (Movies 1–3) and a sweep of the posterior compart-\nment (which includes the torus uterinus and retrocervical space \n[including USLs]), parametrial, midrectal, and pararectal regions \nare recommended (Table 6, Movies 4–6). These are in addition \nto standard images obtained in accordance with the 2020 Amer-\nican College of Radiology, American College of Obstetricians \nand Gynecologists, American Institute of Ultrasound in Medi-\ncine, Society for Pediatric Radiology, and Society of Radiologists \nin Ultrasound practice parameter (19). Uterine position influ-\nences probe placement and image acquisition (Table 6).\nT wo-dimensional images may be obtained with a two- or \nthree-dimensional transducer. Cine sweeps are preferred in ad-\ndition to routine transverse and longitudinal static images of the \nuterus in routine pelvic US. If a cine sweep cannot be recorded \nor stored for review, representative static images should be stored \nand the sonographer should make a note of the uterine sliding \nsign as normal, abnormal, equivocal, technically inadequate, or \nnot performed.\nTable 5: Patient Symptoms or History That Meet Criteria \nfor Augmented Pelvic US\nParameter\nSymptom\n Cyclical or noncyclical chronic pelvic pain\n Cyclical abdominal and/or pelvic pain\n Deep dyspareunia\n Dyschezia\n Dysmenorrhea\n Abdominal wall mass with cyclic pain\n Unexplained dysuria\nHistory\n Endometriosis\n Infertility\n Suspected endometriosis on clinical examination\n Radiologically suspected endometriosis\nNote.—Criteria based on references 40–42.\nFigure 1:  Transvaginal US images show the posterior compartment in a \n25-year-old patient with dysmenorrhea, on the retrocervical field of view (area of \ninterest outlined in yellow), 4–5-cm deep to the cervix. Longitudinal (A) and trans-\nverse (B) views. The transducer is in the anterior fornix. Longitudinal and transverse \nsweeps were acquired to include these areas.\n\nConsensus Statement on Routine Pelvic US for Endometriosis\n6 radiology.rsna.org ■ Radiology: Volume 3 1 1: Number 1—April 2024\nTable 6: Technical Recommendations for Augmented Pelvic US\nParameter Recommended 2D Cine Sweep\nAlternative  \nAutomated 3D Cine Tips and Hints\nRecommended  \n additional imaging\n Uterine sliding maneuver\n  Posterior fornix Anteverted uterus: Obtain longitudinal  \nuterine sliding cine angled toward  \nthe posterior cervix.\nDoes the cervix move relative to \nthe rectum, perirectal adipose, \nother bowel, or posteriorly \npositioned ovaries?\n  Posterior fornix Retroverted/retroflexed uterus: Obtain \nlongitudinal uterine sliding cine centered \nat cervicouterine junction.\n Posterior compartment \nevaluation\n  Anterior fornix Anteverted uterus: T ransverse cine sweep \nfrom the uterine fundus as far as \npossible inferiorly through the cervix. \nLongitudinal cine sweep of the uterus \nand cervix obtained angling as far \nlaterally right and left as feasible.  \nInclude posterior compartment \nstructures, 4–5 cm posterior to  \nthe uterus.\nInitiate a transverse wide-field \nacquisition centered at the \nposterior cervicouterine \njunction.\nInitiate a longitudinal wide-\nfield acquisition at the \nmidline endometrium/\nendocervix.\nInclude posterior compartment \n4–5 cm deep to the uterus  \nin anteverted uteri.\nAre there any hypoechoic DE \nobservations?\nPay special attention to posterior \nuterine serosa in midline at \nlevel of cervicouterine junction, \nretrocervical space, anterior \nwall rectum, USLs.\nAssess ovaries for posterior or \n“kissing” position.\n  Posterior fornix Retroverted/retroflexed uterus: T ransverse \ncine sweep from the uterine fundus \nas far as possible through the cervix. \nLongitudinal cine sweep of the uterus \nand cervix obtained angling as far \nlaterally right and left as feasible.\nOptional additional imaging\n Uterine sliding maneuver \n(alternative)\n  Anterior fornix Anteverted uterus: Longitudinal uterine \nsliding cine centered just inferior to \nthe cervicouterine junction, transducer \npressure on anterior cervix. Useful  \nwhen posterior fornix transducer \npositioning is difficult or painful.\nDoes the cervix move relative to \nthe rectum, perirectal adipose, \nother bowel, or posteriorly \npositioned ovaries?\n Anterior compartment \nbladder sliding maneuver\n  Anterior fornix Longitudinal uterine sliding cine  \ncentered on the inferior aspect  \nof the urinary bladder.\nDoes the bladder move relative \nto the uterus? Are there \nhypoechoic DE observations of \nthe posterior bladder wall or in \nthe space between the bladder \nand anterior uterine serosa?\n Middle compartment \n(ovarian) sliding maneuver\n Anterior, lateral or \nposterior fornix\nT ransverse cine applying transducer \npressure and/or manual pressure with the \nnonscanning hand over the ovary/adnexa \nto evaluate mobility. Longitudinal cine \nmay also be useful.\nDoes the ovary move relative to \nthe uterus, bowel, and pelvic \nside wall? Are there hypoechoic \nDE observations especially on \nthe USLs or bowel, adhering \nthe ovary to adjacent structures \nor the contralateral ovary?\nNote.—DE = deep endometriosis, 3D = three-dimensional, 2D = two-dimensional, USL = uterosacral ligament.\n\nYoung and Jha et al\nRadiology: Volume 3 1 1: Number 1—April 2024 ■ radiology.rsna.org 7\nA modest learning curve exists for the technical aspects of \nsliding maneuver and posterior compartment image acquisition \nand adequate imaging can be obtained by education and train-\ning (46,47). Attention to probe placement (Fig 2) and suggested \nimaging techniques can lead to high-yield imaging (Table 6).\nAugmented pelvic US-based evaluation of uterine serosa.—\nThe panel recommends focusing special attention on the pos-\nterior uterine serosa during augmented pelvic US on static and \ncine images, which is a common site for endometriosis. Evalu-\nation includes assessment for serosal implants that may mimic \nadenomyosis but extend inward from the uterine serosa toward \nthe endometrium. This is in contradistinction to typical adeno-\nmyosis, which begins at the endometrial-myometrial junction \nand extends toward the uterine serosa.\nAugmented pelvic US-based evaluation of retrocervical \nspace.—Acquire static or preferably cine images focusing \non the retrocervical region to assess for USL DE. There was a \nunanimous consensus that imaging through the posterior fornix \nis favorable for DE evaluation regardless of the uterine version.\nUSL position varies depending on the uterine version. \nWhen feasible, reposition the transducer from the anterior \nvaginal fornix to the posterior vaginal fornix for optimal evalu-\nation (37). In anteverted uteri, the retrocervical space may be \nimaged from both the anterior and posterior fornices (Table 6). \nThe retrocervical space of interest is posterior and inferior to \nthe cervicouterine junction in the anterior fornix view (Fig 1). \nOn the posterior fornix view, the retrocervical space is in the \nnear field and is immediately underneath the vaginal wall. The \ntorus uterinus is an anatomic landmark located posterior to \nthe cervicouterine junction where the uterine ends of the two \nUSLs insert in the midline. Most retrocervical DE involves the \narea near the torus uterinus. Normal USLs appear as smoothly \nechogenic, homogeneous band-like structures angling laterally \nfrom just inferior to the cervicouterine junction (torus uteri-\nnus) (Fig 3) (48). If there is difficulty entering the posterior \nvaginal fornix, the area of the retrocervical space may also be \nFigure 2: Illustration shows how to position the transvaginal sonography transducer based on uterine position and uterosacral liga-\nment (USL) anatomy variations (light gray band). The relative relationship between the transducer, USLs, and cervicouterine junction is \ndemonstrated for (A) anteverted uterus, anterior fornix transducer position; (B) anteverted uterus, posterior fornix transducer position;  \n(C) retroverted uterus, posterior fornix transducer position; and (D) anteflexed/retroverted uterus, anterior fornix transducer position. Re-\nprinted, with permission, from reference 7.\n\nConsensus Statement on Routine Pelvic US for Endometriosis\n8 radiology.rsna.org ■ Radiology: Volume 3 1 1: Number 1—April 2024\nassessed by scanning transversely through the cervix from the \nanterior fornix. In this scenario, an echogenic band extending \nfrom the posterior cervical serosa and coursing laterally can be \nobserved (Movie 7). Although confident identification of the \nUSLs as a distinct echogenic band is possible on US, simply \nimaging through the retrocervical space is sufficient to observe \nDE, which frequently involves the USLs in this area.\nIn retroverted and most retroflexed uteri, longitudinal \nand axial sweeps are acquired from the posterior vaginal for-\nnix only as the probe slides and naturally comes to lie in the \nposterior fornix with the retroverted uterus anatomy ( Table \n6, Movie 5). The retrocervical space will lie in the near field \nbeneath the vaginal musculature in such individuals. Occa-\nsionally, in the setting of DE, the cervix will be anteverted \nand the uterus steeply retroflexed (question mark or horse-\nshoe-shaped uterus) (Fig 4). In such individuals, the trans-\nducer may be positioned in the anterior fornix and findings \nof retrocervical DE may be observed adhering the posterior \ncervix to the uterus and may involve the adjacent wall of the \nposterior vaginal fornix.\nUterine and ovarian relative positioning.—T wo- and three-\ndimensional static and cine images may be acquired to help \nassess the relative positioning of the uterus and ovaries (Movies \n4, 5). The panel advocated for but did not mandate the acqui-\nsition and review of cine clips to evaluate the pelvic anatomy \nwhenever possible. Alternatively, when available, one may use \na three-dimensional transducer to obtain rapid, standardized \nviews, storing them as cine clips (Movie 6). Normally, ovaries \nare located at the sides of the uterus along the pelvic side walls. \nEvaluation for DE should include assessing the ovarian posi-\ntion and noting a location posterior to the uterus, adjacent to \neach other (ie, kissing ovaries configuration), near the cervix, \nor low in the posterior compartment. When a kissing ovaries \nconfiguration or abnormal ovarian position is noted, optional \ndynamic imaging can be performed by applying direct probe \npressure with the intent to separate the ovaries and record the \ntethering of the ovaries to each other, the pelvic side wall, or \nthe uterus (Movie 8).\nWhen the ipsilateral ovary is retropositioned close to the cervix \nor cervicouterine junction, the retrocervical space should be as-\nsessed for DE. This is because adhesion of the ovary to DE in the \nUSL in the retrocervical space is a common cause of retropositioned \novary, especially in the presence of an endometrioma. Careful inter-\nrogation of the edge of the malpositioned ovary or endometrioma \nmay reveal adjacent solid tissue outside the ovary, which is typically \nDE on the USL. Bilateral retrocervical DE is common when both \novaries are retropositioned and in contact with each other (kissing \novaries) (Fig 5). In such individuals, the anterior rectal wall should \nbe carefully reviewed for serosal or muscularis DE observations, \npreferably identified on cine clips (29). Adhesions present as hy-\npoechoic bands and lines between DE implants and adjacent struc-\ntures. Adhesions to the rectosigmoid wall, even in the absence of an \ninvasive bowel observation, are often recognized by tenting of the \nbowel wall toward the torus uterinus with or without a retrocervical \nDE observation (Movie 9).\nFigure 3: Transvaginal US in normal right and left uterosacral ligaments (USL) \nin a 32-year-old patient with chronic pelvic pain and echogenic bands insert near \nthe posterior cervicouterine junction (arrows, A and B). Transverse oblique images \nshow the (A) right and (B) left anterolateral fornices.\nFigure 4: Transvaginal US in a 41-year-old patient with chronic pelvic \npain and dyschezia shows the “question mark sign” uterine configuration. \nLongitudinal view shows an abnormal uterine configuration in which the \nuterus is sharply retroflexed because of deep endometriosis that is tethering \nthe posterior cervix to the uterine corpus. This observation is usually identi-\nfied by abnormal endometrial axis with sharp retroflection of the uterine \nfundus (dashed blue line) and constitutes a category B (ie, indirect endo-\nmetriosis) observation.\n\nYoung and Jha et al\nRadiology: Volume 3 1 1: Number 1—April 2024 ■ radiology.rsna.org 9\nEvaluation of uterine sliding sign.—The sliding maneuver \nshould be performed to evaluate adhesions in the posterior \ncul-de-sac and represents an integral component of aug-\nmented pelvic US. The uterine sliding maneuver increases \nthe detection of DE-related pouch of Douglas obliteration on \nUS (49,50). The sonographer should explain to the patient \nthe pushing technique and its clinical importance in diagnos-\ning endometriosis before proceeding and remain cognizant \nof and responsive to patient discomfort. In anteverted uteri, \npreferably obtain the sliding maneuver from the posterior \nfornix view with the transducer pressure technique (Movies 1, \n2). If there is difficulty placing the transducer in the posterior \nfornix, it is possible to obtain a cine of the sliding maneu-\nver from the anterior fornix (Movie 3). In this situation, it is \nimportant to place enough pressure inferiorly on the cervix \nto create a clear slide between the uterus and posterior com-\npartment structures. Avoid merely compressing the posterior \ncompartment structures through the uterus. Always focus at-\ntention on the posterior cervicouterine junction. If the trans-\nducer push is equivocal, consider using the illustrated biman-\nual technique (Fig 6). In retroflexed and retroverted uteri, the \nsliding cine is best obtained by pressing with steep posterior \nangulation in the posterior fornix and then quickly releasing \ntransducer pressure, looking for mobility between the cervix \nand retrocervical perirectal adipose or physiologic fluid pool-\ning in the retrocervical area (Movie 2) (37). An absence of \nsliding is an indicator of posterior cul-de-sac adhesions (49).\nSonologists can apply the sliding maneuver to the anterior \nand middle compartments, including the vesicouterine space \nand ovaries (Movies 8, 10). The panel does not mandate these \noptional views because of the time constraints of augmented \npelvic US. Immobility of the ovary relative to the uterus, \npelvic sidewall, bowel, or contralateral ovary can be demon-\nstrated, which is a useful indirect observation of endometriosis \n(35,51,52). Focused evaluation on the areas of tethering may \nFigure 5: Transvaginal US through the posterior fornix in a 43-year-old patient \nwith deep dyspareunia. Serosal adhesions to the adjacent rectum are shown (curved \nblue arrows). (A) Longitudinal and (B) transverse views show kissing ovaries with-\nout endometriomas, a category B (indirect endometriosis) observation. Deep endo-\nmetriosis of the torus uterinus and posterior uterine serosa is shown (yellow arrows,  \nA and B), a category A (direct endometriosis) observation. L = left, R = right.\nFigure 6:  Illustration  \nshows the uterine sliding ma-\nneuver, posterior fornix trans-\nducer position, anteverted \nuterus (A) and retroflexed \nuterus (B). Adapted, with \npermission, from reference 7.\n\n\nConsensus Statement on Routine Pelvic US for Endometriosis\n10 radiology.rsna.org ■ Radiology: Volume 3 1 1: Number 1—April 2024\ndepict direct DE observations. Similarly, the panel encourages \nbut does not mandate ovarian mobility assessment, especially \nwhen other endometriosis features are observed. The panel \nnotes that ovarian tethering and fixation is sometimes inciden-\ntally observed during the uterine sliding maneuver and should \nbe reported when present.\nThe role of color Doppler.—Color Doppler imaging of the \nadnexa is routinely performed and should be done so in com-\npliance with societal guidelines. The panel made no specific \nrecommendations regarding color Doppler imaging for DE \nand deferred to previously published guidelines (19). Color \nDoppler imaging can help assess solid-appearing elements in \nsuspected endometriomas. Color Doppler is not necessary for \nidentifying or categorizing DE observations, which are typi-\ncally hypovascular.\nEvaluation of the anterior compartment and urinary blad-\nder.—The panel did not make any specific recommendations \nabout imaging the anterior compartment and urinary blad-\nder. The anterior compartment is the least common site of \npelvic DE involvement. Therefore, the panel recommended \nthat the augmented maneuvers focus on the posterior com-\npartment where DE most frequently occurs. Images of the \nurinary bladder can either be acquired transabdominally or \ntransvaginally as a part of the routine pelvic US and reviewed \nfor the presence of nodularity, particularly at the vesicouter-\nine space and posterior bladder wall. Although uncommon, \nUS has been reported to distinguish bladder endometriosis \nwith high accuracy (18,26,53).\nUS-based Observations and Interpretation for \nEndometriosis: Direct and Indirect Observations\nRecommendation: Assess direct and indirect observations dur-\ning augmented pelvic US.\nThe panel considered the results from the literature search, \nincluding published sensitivity and specificity data ( Table 6), \nalong with expert opinion, and reached a consensus on direct \nand indirect imaging observations of DE (Table 7).\nEndometriosis implants are typically hypoechoic with punc-\ntate echogenic foci. These may have regular, irregular, lobulated, \nor stellate margins. Linear hypoechoic bands of tissue may be \nobserved extending peripherally from the implants secondary \nto surrounding fibrosis. Vascularity at color Doppler imaging is \nvariable, and DE implants are usually hypovascular. Specific im-\naging observations vary by location.\nWe organized endometriosis observations into categories \nbased on the highest association with DE (Table 7).\nCategory A: Direct endometriosis observations.—Direct obser-\nvations result from the presence of ectopic endometrial glands \nand/or stroma outside the uterus. These include ovarian endo-\nmetriomas and DE observations in characteristic, commonly \nencountered locations on pelvic US, such as posterior uterine \nserosa, retrocervical space and USLs, rectovaginal space, rectosig-\nmoid colon, posterior bladder, or uterovesical space.\nOvarian endometriomas: Ovarian endometriomas are typically be-\nnign, cystic ovarian lesions with low-level, homogeneous (ground \nglass) internal echoes and no internal vascularity (Fig 7). Any \nsolid-appearing areas should be evaluated with color Doppler, \nTable 7: Direct and Indirect US Observations in Deep Endometriosis\nCategory and Observation Reference No.\nCategory A: direct endometriosis observation\n Ovarian endometrioma 76\n DE implant of the uterine serosa with an outside-in pattern 77\n Retrocervical DE (torus uterinus and/or USL) implant 20,25,27,28\n Bladder DE implant in posterior location involving the detrusor muscle 20,24–26\n DE implant in the uterovesical space 78\n Rectovaginal space or rectovaginal septal DE implant 21,25\n Rectosigmoid hypoechoic DE implant with tapering ends (other descriptors: Comet tail sign) 5,20,27,29,30\nCategory B: indirect endometriosis observation\n Fixed uterine retroflexion 79,80\n Bowel tethering to posterior uterus without discrete endometriosis implant in the absence  \n of PID symptoms, inflammatory bowel disease, or prior myomectomy\n79–81\n Kissing ovaries without ovarian endometriomas 64\n Unilateral or bilateral posterior ovarian location in proximity to the cervix/retrocervical space without  \n endometrioma\n81\n Ovarian immobility if incidentally observed on uterine sliding maneuver without endometrioma 82\nCategory C: endometriosis-associated observation\n Adenomyosis, typical (nonspecific) 83\n Hydrosalpinx (nonspecific) 84\n Hematosalpinx (infrequently isolated, differentiate clinically from pyosalpinx) 84\nNote.—DE = deep endometriosis, PID = pelvic inflammatory disease, USL = uterosacral ligament.\n\nYoung and Jha et al\nRadiology: Volume 3 1 1: Number 1—April 2024 ■ radiology.rsna.org 11\noptimizing color scale and gain. Vascularized solid components \nshould be noted owing to the risk of clear cell and endometrioid \ncarcinomas (54). The risk of ovarian cancer in patients with en-\ndometriosis is 1.9%, compared with 1.3% for the general popu-\nlation (55–57). When solid or solid-appearing components are \nnoted, the panel recommends characterizing lesions with the US \nOvarian and Adnexal Risk Stratification System (58,59).\nUterine serosal DE: The posterior uterine serosa is commonly \ninvolved with posterior compartment DE, where uterine im-\nplants manifest as ill-defined hypoechoic observations, with \ninternal echogenic foci and cystic areas. The pattern is an ex-\ntension of DE from the outer myometrial serosa with an  \noutside-to-inside pattern (Fig 8). This is a direct observation \nof DE and should be differentiated from typical adenomyosis, \nwhich extends from the endometrial-myometrial junction out-\nward toward the uterine serosa (60). The panel recommends not \nusing terms such as adenomyosis externa or focal adenomyosis of \nthe outer myometrium to clarify the distinct pathophysiology of \nthe two processes.\nRetrocervical DE (including USLs): Retrocervical DE typically \noccurs near the posterior aspect of the cervix, where USLs insert, \nextending laterally and posteriorly within the posterior compart-\nment. Retrocervical DE usually manifests as hypoechoic obser-\nvations that may be smooth, irregular, or spiculated. Punctate \nechogenic foci are common. Cystic foci are less common. The \nmidline retrocervical USL insertion site, the torus uterinus, is \nfrequently involved (Fig 9). Adhesions to one or both ovaries \nmay be assessed and adhesions to the adjacent rectum are fre-\nquently observed, often with distortion of the rectal wall toward \nthe retrocervical observation (Fig 10) (48,51).\nBladder and vesicouterine space endometriosis: Bladder endometri-\nosis manifests as an isoechoic or hypoechoic, smooth or irregular, \nelongated or spherical mass invading the detrusor muscle, often \nat the base or dome (Fig 11). Such observations may or may not \nprotrude into the bladder lumen and may be cystoscopically oc-\ncult (61,62). These observations can be contiguous with DE in \nthe vesicouterine space.\nRectosigmoid endometriosis: Bowel endometriosis manifests \nas solid and markedly hypoechoic elliptical, C-shaped, or \nΩ-shaped thickenings of \nthe bowel wall with taper-\ning ends (Fig 12, Movie \n9) (37,63). Observations \noccasionally exhibit high-\ncontrast internal echoes. \nCystic components are \nrare. Depth of invasion \ncan be predicted based \non lesional thickness and \nobliteration of expected \nanatomic interfaces (60). \nInvasion of the mucosa is \nrare. Therefore, colonos-\ncopy rarely directly shows \nsuch lesions. In the rec-\ntum, implants begin on \nthe anterior wall because \nof the anterior wall’s ex-\nposure to the serosa of the \nposterior compartment. \nRectal DE implants are \nfrequently associated with \nretrocervical or USL DE. \nMultiple bowel implants \nFigure 7: Transvaginal longitudinal US scan in a 31-year-old patient with \ndeep dyspareunia shows an endometrioma with homogeneous low-level \n(ground glass) echoes (white arrows) and fluid-fluid level (black arrows). Se-\npia inset in transverse view shows similar observations, a category A (direct \nendometriosis) observation. Adapted, with permission, from reference 7.\nFigure 8: (A–C) Transvaginal US images in three reproduc-\ntive-age individuals (a 34-year-old, 41-year-old, and 37-year-\nold patient), all presenting with chronic pelvic pain, demonstrate \ndeep endometriosis of the outer uterine serosa (yellow outline) in \nretroflexed uteri, which is a category A (direct endometriosis) ob-\nservation. Images were obtained with the (A) transducer in the \nposterior fornix in longitudinal view, (B) transducer in the anterior \nfornix in longitudinal view, and (C) transducer in the posterior for-\nnix in transverse view.\n\nConsensus Statement on Routine Pelvic US for Endometriosis\n12 radiology.rsna.org ■ Radiology: Volume 3 1 1: Number 1—April 2024\nare common. Whereas sonography is excellent for the full de-\npiction of bowel implants, such depiction is beyond the scope \nof augmented pelvic US. The consensus panel recommends ad-\nvanced endometriosis imaging (expert US or expert MRI) for \nbowel endometriosis mapping (4,6,13).\nVaginal DE: Vaginal DE usually manifests in the posterior apex \nwith moderately hypoechoic echotexture similar to retrocervi-\ncal or USL DE. Vaginal DE is commonly confluent with USL \nand/or adjacent rectal DE implants (Movie 11). Cystic areas \nare sometimes present.\nCategory B: Indirect endometriosis observations.—Indirect \nobservations are associated findings or sequelae of endome-\ntriosis present at imaging without direct visualization of DE \nimplants. These include observations commonly encountered \nwith DE, such as fixed uterine retroversion, abnormal ovar-\nian location or mobility, and tethering of bowel loops to the \nFigure 9: Transvaginal US posterior compartment deep endometriosis (DE) image gallery of reproductive age individuals (19–48 years) with chronic pelvic pain, deep \ndyspareunia, dyschezia, dysmenorrhea, or infertility demonstrates the spectrum of common DE observations with schematics and color legend. US images in columns A (Ul-\ntrasound Image A) and B (Ultrasound Image B) are examples of similar observations in multiple patients (Fig 9 continues). \n\nYoung and Jha et al\nRadiology: Volume 3 1 1: Number 1—April 2024 ■ radiology.rsna.org 13\nposterior uterus but without an observation of DE. The exist-\ning literature regarding the sensitivity and specificity of these \nobservations is sparse. The identification and recommenda-\ntions are, therefore, based on expert consensus.\nFixed uterine retroversion: A retroflexed uterus that remains in this \nposition even with direct transducer pressure may be associated \nwith DE from endometriotic adhesions between the cervix and \nuterus or adhesions between the rectum and uterine fundus. In \nsevere cases, the uterus may be sharply retroflexed or appear in a \nquestion mark or horseshoe-shaped configuration.\nBowel tethering to the posterior uterus: Scarring from DE can \ncause tethering of bowel loops to the posterior uterus. However, \nFigure 9 (continued): Anteversion and retroversion refer to uterine position. AF = anterior fornix transducer position, CDS = cul-de-sac, PF = posterior fornix transducer \nposition, Long = longitudinal view, rans = Transverse view,.USL = uterosacral ligament.\n\nConsensus Statement on Routine Pelvic US for Endometriosis\n14 radiology.rsna.org ■ Radiology: Volume 3 1 1: Number 1—April 2024\nwhen there is no observa-\ntion of DE, it is essential \nto exclude other causes \nof fibrosis and adhesions \nsuch as pelvic inflamma-\ntory disease, inflamma-\ntory bowel disease, and \nprior pelvic surgery. One \nmay optionally perform \na dynamic evaluation \nwith probe pressure to \nseparate the areas of po-\ntential tethering.\nAbnormalities of ovarian \nposition and mobility: Ret-\nropositioned or kissing \novaries, in which the ova-\nries are posteriorly and \nmedially located behind \nthe uterus, can occur in \nDE, even in the absence \nof endometrioma. The \nlikelihood of advanced-\nstage endometriosis is \neight times higher with \nkissing ovaries than with \nnormally positioned \novaries, regardless of the \npresence of an endome-\ntrioma at MRI (64). Ab-\nnormal ovarian location \nmay be further evaluated for immobility with direct probe pres-\nsure or may be observed during the performance of the uterine \nsliding maneuver.\nCategory C: Endometriosis-associated observations.—These \nobservations are associated with endometriosis but are not always \na direct result of DE or are observed infrequently in isolation, \nand include adenomyosis, hydrosalpinx, and hematosalpinx.\nAdenomyosis: Historically, features of adenomyosis have been \nfound at transvaginal US in 21%–42% of patients undergoing \nsurgery for endometriosis (65). More recently, it has been re-\nported that 53% of patients with ovarian endometrioma (38) \nand 89% of patients undergoing laparoscopic surgery for endo-\nmetriosis had observations for adenomyosis at imaging (66).\nThe Morphological Uterus Sonographic Assessment group \nhas recently classified direct and indirect imaging features of ade-\nnomyosis (67). Direct features are myometrial cysts, hyperechoic \nislands, and echogenic subendometrial lines and buds. Indirect \nfeatures are a globular uterus, asymmetric myometrial thicken-\ning, fan-shaped shadowing, translesional vascularity, irregular \njunctional zone, and interrupted junctional zone. Adenomyo-\nmas are recognized as focal observations with characteristics of \nadenomyosis that create myometrial asymmetry, have ill-defined \nborders, and translesional vascularity without a mass effect  \non myometrial vessels. Sharply circumscribed borders, edge-  \nrefractive shadows, and circumferentially deviated myometrial \nvessels suggest the alternative diagnosis of leiomyoma (68). Be-\ncause the spectrum of adenomyosis observations is variable, and \ngiven the high prevalence of the disease, this panel does not rec-\nommend advanced endometriosis imaging based solely on the \nobservation of typical, inner myometrial adenomyosis.\nHydrosalpinx and hematosalpinx: Hydrosalpinges may be ob-\nserved in endometriosis either by direct involvement or adhe-\nsions. Hydrosalpinges are tubular, cystic areas separate from \nthe ovary. Incomplete septations, waist-sign, endosalpin-\ngeal folds or ridges, and chains of cysts are common features \n(58,69). The presence of low-level internal echoes is sugges-\ntive of hematosalpinx. In the absence of clinical signs of infec-\ntion or ectopic pregnancy, hematosalpinx may be an indicator \nof endometriosis in the fallopian tube. In the panel’s expert \nopinion, the multifactorial etiology of hydrosalpinx makes this \nobservation too nonspecific to warrant further evaluation for \nendometriosis when seen in isolation. Because of the difficulty \ndistinguishing pyosalpinx from hematosalpinx at imaging and \nthe infrequent isolated finding of hematosalpinx in patients \nwith endometriosis, isolated hematosalpinx was deemed too \ninfrequent to prompt advanced endometriosis imaging in the \nabsence of high clinical concern.\nFigure 10: Laparoscopic view illustrations of common posterior compartment deep endometriosis (DE) and superficial endome-\ntriosis patterns. (A) Unilateral DE in right uterosacral ligament (USL)/torus uterinus. (B) Bilateral USL/torus uterinus DE. (C) Left USL \nand rectal DE with thickening and retraction of rectal wall toward the torus uterinus. (D) Bilateral USL and torus uterinus DE. Reprinted, \nwith permission, from reference 7.\n\nYoung and Jha et al\nRadiology: Volume 3 1 1: Number 1—April 2024 ■ radiology.rsna.org 15\nReporting Augmented Pelvic US for Endometriosis  \nand Follow-up Recommendations\nThe panel recommendations for reporting and follow-up of \nendometriosis (Table 8) are based on the literature review and \nexpert consensus in the instance of limited or no data, which \npertains predominantly to indirect observations (category B) \nand endometriosis-associated observations (category C). Ap-\npropriate follow-up imaging and clinical recommendations are \nprovided for each category. The purpose is to capture a greater \nspectrum of disease presentations at US, but future research \nvalidation is needed.\nRecommendation: Reporting for augmented pelvic US ex-\naminations should include the following four categories: In-\ncomplete (APU-0), normal (APU-1), equivocal (APU-2), and \npositive (APU-3), where APU indicates augmented pelvic US \n(Table 8).\nAny single direct imaging observation (category A) of en-\ndometriosis should lead to endometriosis diagnosis, a recom-\nmendation for advanced endometriosis imaging, and referral to \na reproductive endocrinologist or gynecologic surgeon familiar \nwith DE, as appropriate. In the absence of category A observa-\ntions, findings are suggestive of endometriosis when two or more \nindirect observations (category B) or one category B and one  \nendometriosis-associated observation (category C) are noted. Re-\nferral to gynecology for further evaluation and possible advanced \nendometriosis imaging is recommended. When only category \nC observations are present, a gynecology referral is appropriate. \nGiven the nonspecific nature of these observations, advanced \nendometriosis imaging is usually not recommended but may be \nperformed if there is high clinical suspicion of endometriosis.\nAdvanced endometriosis imaging consists of either expert \nUS-based mapping of endometriosis following a prescribed pat-\ntern of search (4,6,7,13) and/or endometriosis-specific MRI with \nexpert interpretation (32,59). The International Deep Endome-\ntriosis Analysis protocol or a similar protocol can be adopted \nfor expert advanced US (13). Given large regional differences \nin training and credentialling criteria, like the Ovarian-Adnexal \nReporting and Data System (O-RADS), emphasis is placed on \nthe importance of experience in the accurate assessment of en-\ndometriosis (70). Examples include involvement in quality as-\nsurance activities and specialty conferences (ie, multidisciplinary \nand quality assurance conferences, gynecology and minimally \ninvasive surgery correlation conferences, and gynecologic-on-\ncology tumor boards) which typically denote a higher level of \ninvestment in the radiology-pathology correlation, a noteworthy \naspect of specialization as it relates to endometriosis. The Society \nof Abdominal Radiology or European Society of Urogenital Ra-\ndiology guidelines are suggested templates that can be followed \nfor expert MRI review (32,70).\nStructured reporting improves clarity, completeness, and com-\npliance (71,72). Reporting adnexal lesions using the American \nCollege of Radiology O-RADS US Risk Stratification Lexicon \nand Management System is recommended. Endometriomas \nsmaller than 10 cm and without solid components are character-\nized as O-RADS US 2 (almost certainly benign) (58).\nFeatures of adenomyosis should be reported as present or \nabsent using the descriptors from the Morphological Uterus \nSonographic Assessment group (67). A summary opinion re-\ngarding the likelihood of adenomyosis should be given based \non the observations, either absent/unlikely, possible, or very \nlikely/definite. The location and approximate size of adeno-\nmyomas should be described, including the presence of sero-\nsal involvement.\nWhen indicated, the uterine sliding sign should be reported \nas normal, abnormal, equivocal, technically inadequate, or not \nperformed. The quality and confidence assessments are subjec-\ntive, and confidence is expected to increase over time. The learn-\ning curve for performance and off-line interpretation of uterine \nsliding, as well as most aspects of DE assessment, is around 40 \ncases (47,73,74). Patient obesity and inadequate or improperly \ndirected compression of the tissues may impair sliding sign as-\nsessment. One may observe normal sliding in cases of incom-\nplete posterior compartment obliteration (75). An example of \nstructured reporting for augmented pelvic US is provided in Ap-\npendix S2 and Movie 12.\nConclusion\nEndometriosis is a common condition with substantial di-\nagnostic delay, leading patients to experience pain, infer-\ntility, lost wages, and interrupted relationships. US is the \nFigure 11: Transvaginal US images of bladder endometriosis in a 31-year-\nold patient with dysuria shows a midechogenicity nodule (yellow outline) extending \nfrom vesicouterine space into the detrusor muscle, longitudinal (A) and transverse \n(B). Three-dimensional US virtual cystoscopic view is shown (inset, arrows). This is a \ncategory A (direct endometriosis) observation.\n\nConsensus Statement on Routine Pelvic US for Endometriosis\n16 radiology.rsna.org ■ Radiology: Volume 3 1 1: Number 1—April 2024\nfirst-line imaging modality to evaluate pelvic pain. The \nSociety of Radiologists in Ultrasound consensus regard-\ning routine pelvic US for endometriosis aims to enhance \ndeep endometriosis (DE) detection even at an initial US \nand with minimal additional time during imaging and no \nspecial patient preparation. Focusing imaging on anatomic \nregions where DE is common can increase detection of DE \nand decrease diagnostic delay.\nThese guidelines are meant for symptomatic patients (ie, \npain and infertility) at typical risk for endometriosis. Patients \nat high risk for endometriosis because of prior diagnostic or \ntherapeutic laparoscopy for endometriosis or strong clinical \nindications may benefit from proceeding directly to advanced \nendometriosis imaging, particularly if they are likely to un-\ndergo surgery or if monitoring is needed in the setting of \ninfertility and medical treatment.\nFigure 12: Transvaginal US shows deep endometriosis (DE) nodules (N) in the rectosigmoid colon. (A) Image in a 31-year-old  \npatient with dyschezia shows an elliptical DE with tapering ends (arrows), longitudinal posterior fornix. (B) Transverse image of nodule in A, \nposterior fornix. (C) Image in a 27-year-old patient with chronic pelvic pain shows an Ω-shaped DE nodule in midrectum, longitudinal poste-\nrior fornix (arrows). (D) Image in a 33-year-old patient with deep dyspareunia shows a C-shaped nodule in midrectum, longitudinal anterior \nfornix (arrows). (E) Image in a 40-year-old patient with chronic pelvic pain shows tandem nodules of rectosigmoid colon with tapering ends \n(arrows), longitudinal posterior fornix. These are category A (ie, direct endometriosis) observations.\n\nYoung and Jha et al\nRadiology: Volume 3 1 1: Number 1—April 2024 ■ radiology.rsna.org 17\nThis consensus is based on expert opinion and review of the \nliterature. Therefore, validation studies will be necessary to prove \nthe accuracy of augmented pelvic US in widespread clinical ap-\nplication. Additionally, continuing education for sonographers, \ngynecologists, and radiologists regarding recognition of common \nobservations of deep endometriosis (DE) and the applicability of \naugmented pelvic US with additional maneuvers and advanced \nendometriosis imaging will be paramount. The quality of ad-\nvanced imaging protocols and equipment as well as the expertise \nof interpreting physicians for advanced endometriosis imaging \nand laparoscopy is also important for confirming the diagnosis of \nendometriosis. Accurate diagnosis requires recognition of tissue \ndistortion and an intense, prescribed search pattern that lever-\nages knowledge of common DE sites and associated observa-\ntions. Laparoscopic surgery alone is recognized as an insufficient \nstandard for the diagnosis of DE, with many DE sites that are \noccult or suboptimally accessible at laparoscopy without preop-\nerative imaging and knowledge of their location (71). Robust \ncommunication with minimally invasive gynecologic surgeons \nis key and multidisciplinary discussions can lead to incremental \nbenefit for patients. The consensus panel is confident about the \nfeasibility of simple additional maneuvers to improve endome-\ntriosis detection in this traditionally underdiagnosed condition.\nAcknowledgment: The Society of Radiologists in Ultrasound panel acknowledges \nthe valuable contributions to the consensus panel of Beryl Benacerraf, MD, prior \nto her death in October 2022. She was a professor of obstetrics, gynecology, and \nreproductive biology and radiology at Harvard Medical School and Brigham and \nWomen’s Hospital.\nAuthor contributions:  Guarantors of integrity of entire study, S.W .Y., P .J., \nL.C., M.M.H., Y.G., E.M.H., S.E., W .V .B.; study concepts/study design or data \nTable 8: Augmented Pelvic US Reporting for Endometriosis: Diagnostic Categories, Imaging Criteria, and Management \nRecommendations\nDiagnostic Category Description\nManagement\nClinical Imaging\nAPU-0: Incomplete Unable to perform TV US, \ncine sweeps, or uterine \nsliding maneuver; technically \ninadequate; patient factors \nimpacted imaging (eg, extensive \nfibroids, nonvisualization of one \nor both adnexa)\nSymptom management Repeat augmented pelvic US or \nadvanced endometriosis; Imaging \nmay be considered  \non an individualized basis\nAPU-1: No imaging \nevidence of \nendometriosis\nNo direct (category A)  \nor indirect (category B) \nobservations\nSymptom management Imaging follow-up based on other \nnonendometriosis observations  \n(eg, follow-up of any \nendometriosis-associated \nobservation [category C] or \nconcomitant pelvic pathology); \nabsence of imaging features \ndoes not exclude endometriosis; \nadvanced endometriosis imaging \nmay be considered on an  \nindividual basis\nAPU-2: Equivocal  \nfor endometriosis\nOnly 1 category  \nB observation\nSymptom management; gynecology  \nreferral with optional referral  \nto a deep endometriosis  \nspecialist and consideration of  \nendometriosis surgery, minimally  \ninvasive gynecology surgery,  \nand/or reproductive endocrinology  \nconsultation, based on patient goals  \nof care\nImaging follow-up based on other \nnonendometriosis observations; \nadvanced endometriosis imaging \ncan be considered on an  \nindividual basis or whenever \nsurgery is planned\nAPU-3: Positive  \nfor endometriosis\nAny category A observation,  \ntwo category B observations,  \nor one category B observation \nwith one category  \nC observation\nSymptom management; gynecology  \nreferral to endometriosis specialist,  \nconsideration of endometriosis  \nsurgery, minimally invasive  \ngynecology surgery, and/or  \nreproductive endocrinology  \nconsultation, based on patient  \ngoals of care\nRecommend further evaluation with \nadvanced endometriosis imaging\nNote.—APU = augmented pelvic US, TV = transvaginal.\n\nConsensus Statement on Routine Pelvic US for Endometriosis\n18 radiology.rsna.org ■ Radiology: Volume 3 1 1: Number 1—April 2024\nacquisition or data analysis/interpretation, all authors; manuscript drafting or \nmanuscript revision for important intellectual content, all authors; approval of final \nversion of submitted manuscript, all authors; agrees to ensure any questions related \nto the work are appropriately resolved, all authors; literature research, S.W .Y., P .J., \nL.C., S.R., R.M.K., M.M.H., P .G., M.F ., Y.G., S.L.Y., L.P .; clinical studies, P .J., \nM.M.H.; experimental studies, E.M.H.; statistical analysis, P .J.; and manuscript \nediting, all authors\nDisclosures of conflicts of interest:  S.W .Y. No relevant relationships. P .J. Pay-\nment for lectures from World Class CME. L.C. No relevant relationships. S.R. \nRoyalties from Elsevier. R.M.K. Payment for lectures from Sumitomo Pharmacy \n(formerly Myovant/Pfizer). M.M.H. Payment for lectures from Clinical Educa-\ntional Symposia—Ultrasound Course; leadership or fiduciary role of Ultrasound \nfor RadioGraphics; spouse is employee of Bristol Meyers Squibb. P .G. Payment for \nchapter on fetal musculoskeletal disorder from UpT oDate. M.F . No relevant re-\nlationships. Y.G. Book royalties from Elsevier; consultant for Femasys; honoraria \nfrom World Class CME; vice-president of the AIUM and chair of the Gynecol-\nogy section. Z.K. No relevant relationships. S.L.Y. Grants from the Eunice Kennedy \nShriver National Institute of Child Health and Human Development/National Institutes \nof Health (P01HD106485, R01HD100329, R44 HD097750); r oyalties from Cicero \nDiagnostics; patent issued (Methods And Compositions For Sirt1 Expression As \nA Marker For Endometriosis And Subfertility. Steven L Young, Bruce A Lessey, \nJae-Wook Jeong. U.S. Patent No. 11,474,105; Issued October 18, 2022. UNC Ref. \n16-0123; MB Ref. 5470.810); president, Society for Reproductive Endocrinology \nand Infertility (SREI); board member, American Society for Reproductive Medicine \n(ASRM); board member, Society for Assisted Reproductive T echnology (SART). \nL.P . No relevant relationships. T .L.B. No relevant relationships. E.M.H. Patents \nplanned, issued, or pending from IHC. S.E. Patents planned, issued, or pending \nfrom Rutgers/RWJ Medical School. W .V .B. 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Manieri Rocha R, Leonardi M, Eathorne A, Armour M, Condous G. \nAnatomical distribution of endometriosis: A  cross-sectional analysis of \ntransvaginal ultrasound in symptomatic patients. Australas J Ultrasound \nMed 2023;26(3):131–141.\n 83. Kobayashi H, Matsubara S, Imanaka S. Clinicopathological features of \ndifferent subtypes in adenomyosis: Focus on early lesions. PLoS One \n2021;16(7):e0254147.\n 84. Qi H, Zhang H, Zhang D, et al. Reassessment of prevalence of tubal en-\ndometriosis, and its associated clinicopathologic features and risk factors \nin premenopausal women received salpingectomy. Eur J Obstet Gynecol \nReprod Biol X 2019;4:100074.","source_license":"CC0","license_restricted":false}