{"paper_id":"d066e904-d9c7-4e08-ab50-ce5a9c9f231c","body_text":"IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 8, August 201 3. ISSN – [0976-31 98]\nIJCRI 201 3;4(8):431 –435.\nw w w .ijc aserepo rtsandim ages.c o m\nM agnetic reso nance im aging featu res o f vaginal\nendo m etrio sis\nV aleria Fiaschetti, V alentina Cam a, L au ra Greco , M aria Fo rnari,\nGiu seppe So rrenti, Gio vanni Sim o netti\nAB STRACT\nIntro du ctio n: Deeply infiltrating endo m etrio sis\n(DIE)is defined by th e presence o f endo m etrial\nim plants penetrating u nder th e perito neal\nsu rface o r u nder th e w all o f th e pelvic o rgans to\na depth o f at least 5 m m . Th is case repo rt\ndescribes a case o f DIE invo lving vaginal w all,\nperiu reth ral tissu e, to ru s u terinu s and sigm o id\nw all. Case Repo rt: A 4 6­year­o ld fem ale w as\npresented w ith pelvic pain and deep\ndyspareu nia w h ich started six years ago , after a\nspo ntaneo u s interru ptio n o f pregnancy and\nu terine cu rettage. Th e pelvic m agnetic\nreso nance im aging (M RI)sh o w ed m u ltiple DIE\nlesio ns lo calized in th e vaginal w all m ainly in\nth e lo w er th ird o f th e vagina, betw een th e\nanterio r vaginal w all and th e u reth ra, o n th e\nco nto u r o f th e u reth ra and betw een th e to ru s\nu terinu s and th e sigm o id w all. After M RI,\nlaparo sco pic bio psies co nfirm ed th e DIE\nlesio ns. Co nclu sio n: Acco rding to th e\nim plantio n th eo ry, w e assu m e th at in o u r case\nth e vaginal endo m etrio sis w as th e resu lt o f\nim plantatio n o f endo m etrial glands into th e\nvaginal tearing du ring th e su rgical pro cedu re o f\ncu rettage. In th e cu rrent literatu re no au th o r\nh as so far described a diffu se invo lvem ento f th e\nvaginal w all in th e presence o f u terine cu rettage\nafter interru ptio n o f pregnancy.In o u r case, th e\nanterio r (peri­u reth ral tissu e), m iddle (vaginal\nw all) and po sterio r (to ru s u terinu s and bo w el\nw all) co m partm ents are invo lved. W e can\npresu m e th atth e vaginal DIE is an early lesio n,\nw h ile th e o th ers lesio ns arise fro m vaginal w alls\nby a co ntigu o u s extensio n. O n M RI w ith\nendo vaginal gel th ese lesio ns w ere m o re evident\nrath er th an w ith o u t gel.M RI w ith gel allo w s u s\nto give essential preo perative m apping fo r th e\nsu rgical rem o val o f th e DIE lesio ns.\nKeyw o rds: V aginal endo m etrio sis, Deeply\ninfiltrating endo m etrio sis (DIE), Endo vaginal\ngel\n* * * * * * * * *\nFiaschetti V , Cam a V , Greco L , Fo rnari M , So rrenti G,\nSim o netti G. M agnetic reso nance im aging featu res o f\nvaginal endo m etrio sis. Internatio nal Jo u rnal o f Case\nRepo rts and Im ages 20 1 3;4 (8):4 31 –4 35.\n* * * * * * * * *\ndo i:1 0 .534 8/ ijcri­20 1 3­0 8­34 9­CR­8\nINTRO DUCTIO N\nEndo m etrio sis is a chro nic gyneco lo gic diso rder\naffecting w o m en in repro du ctive age; in the general\npo pu latio n the prevalence o f endo m etrio sis is 1 0 % [1 ].It\nis characterized by the presence o f fu nctio nal\nCASE REPORT OPEN ACCESS\nValeria Fiaschetti1 , Valentina Cama2, Laura Greco2, Maria\nFornari2, Giuseppe Sorrenti3, Giovanni Simonetti4\nAffiliations: 1 Research, Department of Diagnostic Imaging,\nMolecular Imaging, Interventional Radiology and\nRadiation Therapy. University Hospital Tor Vergata, Rome,\nItaly; 2Resident, Department of Diagnostic Imaging,\nMolecular Imaging, Interventional Radiology and\nRadiation Therapy. University Hospital Tor Vergata, Rome,\nItaly; 3MD, Department of Gynecology and Obstetrics,\nUniversity Hospital Tor Vergata, Rome, Italy; 4Professor,\nDepartment of Diagnostic Imaging, Molecular Imaging,\nInterventional Radiology and Radiation Therapy.\nUniversity Hospital Tor Vergata, Rome, Italy\nCorresponding Author: Valentina Cama, Viale Oxford 81 ,\nRome, Italy 001 33; Ph: +390620902400; Fax:\n+390620902404; Email: valentinacama@gmail.com\nReceived: 22 November 201 2\nAccepted: 1 2 January 201 3\nPublished: 01 August 201 3\nFiaschetti et al. 431\n\nIJCRI – International Journal of Case Reports and Images, Vol. 4 No. 8, August 201 3. ISSN – [0976-31 98]\nIJCRI 201 3;4(8):431 –435.\nw w w .ijc aserepo rtsandim ages.c o m\nFiaschetti et al. 432\nendo m etrial glands and stro m a o u tside the u terine\ncavity.The m o stco m m o n lo calizatio ns o f endo m etrio sis\nare the o varies and the pelvic perito neu m , fo llo w ed by\ndeep lesio ns o f the pelvic su bperito neal space.Deeply\ninfiltrating endo m etrio sis (DIE) is a specific entity,\nhisto lo gically defined by the presence o f endo m etrial\nim plants penetrating u nder the perito neal su rface o r\nu nder the w all o f the pelvic o rgans to a depth o f atleast\n5 m m [2]. It invo lves m o re frequ ently fibro m u sco lar\nstru ctu res su ch as u tero sacral legam ents and\nrecto vaginal septu m (RV S)(69.2% o f cases), rarely the\nvagina (1 4 .5% )[3].This case repo rt describes a case o f\nDIE invo lving vaginal w all, periu rethral tissu e and to ru s\nu terinu s w ith invo lvem ento f the sigm o id w all.\nCASE REPO RT\nW e repo rted a case o f a 4 6­year­o ld fem ale. H er\nclinical histo ry co nsisted o f exacerbated pelvic pain\ndu ring her m enstru al cycle and deepdyspareu nia w hich\nstarted six years ago , after spo ntaneo u s interru ptio n o f\npregnancy and u terine cu rettage.\nThe clinical exam inatio n detected painfu l thickening\no f the vagina bu t the u ltraso no graphy did no t repo rt\nabno rm al findings exceptfo r bilateral o varian cystis and\nm u ltiple sm all u terin fibro ids. V aginal bleeding w as\no bserved after intro du ctio n o f the specu lu m .\nThe patient w as referred by the Departm ent o f\nGyneco lo gy and O bstetrics fo r clinical su spicio n o f DIE\nw hich w as based o n the detectio n o f painfu l thickening\no f the vagina o n physical exam inatio n.\nW e perfo rm ed a pelvic m agnetic reso nance im aging\n(M RI) w ith a 1 .5 T scanner (Achieva, Philips m edical\nsystem s, B EST, Netherlands) u sing a pelvic phased­\narray co il. W e u sed peristaltic inhibito rs (1 0 m g o f\nhyo scine­N­bu tylbro m ide, bu sco pan) dilu ted in 1 0 m L\nsaline to redu ce gastro intestinal tractperistaltis.\nThe im aging pro to co l inclu ded a T1 ­w eighted (W )\ntu rbo spin­echo (TSE), a T2­W TSE, a T1 ­W TSE fat­\nsatu ratio n, perfo rm ed in the transverse plane\n(perpendicu lar to axis o f cervix).A T2­W TSE sequ ences\nand a T1 ­W TSE fat­satu ratio n w ere perfo rm ed o n\nsagittal plane. The transverse and sagittal T2­W TSE\nand the transverse and sagittal T1 ­W TSE fat­satu ratio n\nsequ ences w ere perfo rm ed befo re and after the\nintro du ctio n o f u ltraso no graphic gel (1 0 0 m L )into the\nvaginal canal. No intraveno u s co ntrast m ediu m w as\nadm inistered.\nThe M RI sho w ed a hypo intense co ncentric\nthickening o f the vaginal w all o n T2­W sequ ences.The\nthickening w as m ainly evident in the lo w er third o f the\nvagina, w here it cau sed pseu do steno sis.O n the sagittal,\nT2­W sequ ence w ith endo vaginal gel this finding w as\nm o re evident than that w itho u t the u se o f the gel\n(Figu re 1 A–B ). O n T2­W sequ ence betw een anterio r\nvaginal w all and u rethra, abo ve the perineal bo dy, a\nhyperintense fo cu s w as revealed.Itw as m o re evidento n\nthe sequ ence w ith gel (Figu re 1 B ). O n the T1 ­fat,\nsatu ratio n sequ ence sho w ed a hyperintense signal\nindicating blo o dy co ntent. Urethral invo lvem ent w as\nsu spected fo r hypo intense irregu lar spicu lated m ass­like\nthickening o n the co nto u r o f the u rethra invo lving the\nanterio r vaginal w all (Figu re 2).Thin hyperintense lines\nw ere revealed in the po sterio r vaginal w all, clearly\nvisible in the T1 fat­satu ratio n sequ ence after the\nintro du ctio n o f gel into the vagina indicating blo o dy\nco ntent (Figu re 3). The T2­W sequ ence sho w ed thin\nhypo intense lines lo cated betw een the to ru s u terinu s\nand the sigm o id related to retractile adhesio ns (Figu re\n4 ).After M RI, patientu nderw entto m u ltiple bio psies to\no btain a definitive diagno se. H isto patho lo gy tests\nco nfirm ed islands o f endo m etrial tissu es and stro m a in\nthe vaginal w all, periu rethral tissu e and to ru s u terinu s.\nFigu re 1 : (A, B ) Sagittal T2­w eighted sequ ences sho w s a\ndiffu se thickening vaginal w all and a hyperintense o val lesio n\nlo calized betw een the anterio r vaginal w all and the u rethra,\nabo ve the perineal bo dy.(A)Itis po o rly detectable w itho u tgel\nThe vaginal pre­o rificial pseu do steno sis w as no t appreciable\no n the im age w itho u t gel.(B ) The im age after gel allo w s to\nbetter evalu ate the thickening o f the vaginal w all, m ainly\nevident in the lo w er third w here it cau sed pseu do steno sis\n(arro w head)and the o val fo cu s (arro w ).\nFigu re 2: Axial T2­w eighted sequ ence sho w s an hypo intense\nirregu lar spicu lated m ass­like thickening o n the co nto u r o f the\nu rethra.Itinvo lves the anterio r vaginal w all (arro w ).\n\nIJCRI – International Journal of Case Reports and Images, Vol. 4 No. 8, August 201 3. ISSN – [0976-31 98]\nIJCRI 201 3;4(8):431 –435.\nw w w .ijc aserepo rtsandim ages.c o m\nFiaschetti et al. 433\nThe excisio n o f all endo m etrio tic im plants is the\ntreatm ent cho sen to co ntro l the sym pto m ato lo gy.\nFo llo w ing the histo patho lo gical respo nse she to o k pre­\no perative ho rm o ne therapy to redu ce the size o f the\nlesio ns and decrease the risk o f po sto perative\ninco ntinence.\nDISCUSSIO N\nThe patho genesis o f endo m etrio sis rem ains\nco ntro versial and is pro bably m u ltifacto rial.The m o st\nw idely accepted theo ry is the im plantio n theo ry\n(Sam pso n 1 927).Acco rding to this theo ry, the lesio ns\nare seco ndary to the im plantatio n and the pro liferatio n\no f regu rgitated endo m etrial cells in an ecto pic po sitio n.\nAngio ­ and lym phatic theo ry, im pairm ent o f the\nim m u ne respo nse, heritable tendencies and secreted\npro du cts o f endo m etrio tic lesio ns m ay co ntribu te to\nexplain the patho genesis o f this diso rder [4 , 5].\nIn this case deepdyspareu nia and pelvic pain started\nim m ediately after spo ntaneo u s interru ptio n o f pregnancy\nand u terine cu rettage.Acco rding to the im plantio n theo ry\nw e assu m e that the vaginal endo m etrio sis w as the resu lt\no f im plantatio n o f endo m etrial glandsinto vaginal tearing\ndu ring su rgical pro cedu re o f cu rettage. In the cu rrent\nliteratu re so m e au tho rs have described cases o f\nextraperito neal lo catio ns inclu ding vagina, RVS and\nm o stly o n episio to m y scars, after o bstetrical and su rgical\ntrau m a, in particu lar after natu ral delivery [6].No au tho r\nhas so far described diffu se invo lvem ento f vaginal w all in\npresence o f u terine cu rettage after pregnancy\ninterru ptio n.O u r patient had a histo ry o f tw o cesarean\nsectio ns as w ell.\nAcco rding to a fu nctio nal and clinical classificatio n in\no u r case the anterio r, m iddle and po sterio r\nco m partm ents are invo lved.In fact, the endo m etrio tic\nlesio ns affect periu rethral tissu e (anterio r\nco m partm ent), vagina (m iddle co m partm ent)and to ru s\nu terinu s and bo w el (po sterio r co m partm ent)[7].W e can\npresu m e that the vaginal DIE w as a previo u s lesio n,\nw hile the o thers lesio ns arise fro m vaginal w alls thro u gh\na co ntigo u s extensio n.Iso lated u rethral invo lvem ent is\npo o rly described in literatu re. It is m o re frequ ently\no bserved as an extensio n fro m the o thers o rgans su ch as\nthe bladder [7].\nIn this case u ltraso no graphy w as the first diagno stic\nto o l u sed.It is reco m m ended fo r the stu dy o f the o vary\nand bladder bu tits sensitivity is lo w er than thato f M RI\nin identifying su bperito neal lesio ns extensio ns [8].\nUltraso no graphy repo rted the presence o f\nendo m etrio m a in the right adnexal, cyst in the left\nadnexal and m u ltiple no du les o f u terine fibro ids.\nThe M RIsho w ed a hypo intense co ncentric thickening\no f the vaginal w all o n T2­W im ages. The u se o f gel\nallo w ed u s to better evalu ate this finding.It w as m ainly\nevident in the lo w er third o f the vagina w here it cau sed\npseu do ­steno sis (Figu re 1 B ).The pseu do steno sis w as no t\nappreciable o n the sequ ence w itho u tgel (Figu re 1 A).\nIn ano ther recent repo rt, w e dem o nstrated that the\nu se o f intravaginal gel increases the sensitivity o f M RI\nw itho u t gel in detecting DIE lesio ns. Diagno stic\ndifficu lties o f DIE are related to the inherentfeatu res o f\nendo m etrio tic lesio ns w hich can have an M RI signal\nintensity very sim ilar to tho se o f the su rro u nding\nfibro m u scu lar anato m ic stru ctu res. Also DIE invo lves\nm u ltiple clo sely related anato m ical stru ctu res and w ith\no nly su btle signal alteratio ns. In this regard the\nadvantage o f the gel is its hypersignal o n T2­W im age\nFigu re 3: Sagittal T1 ­w eighted sequ ence sho w s a thin\nhyperintense lines o f the po sterio r vaginal w all indicating\nplaqu es blo o dy co ntent (arro w ).This finding is visible o nly\nafter vaginal distensio n.\nFigu re 4 : Axial T2­w eighted sequ ence sho w s the hypo intense\nlines lo cated betw een the to ru s u terinu s and the sigm o id\nrelated to retractile adhesio ns (arro w ).\n\nIJCRI – International Journal of Case Reports and Images, Vol. 4 No. 8, August 201 3. ISSN – [0976-31 98]\nIJCRI 201 3;4(8):431 –435.\nw w w .ijc aserepo rtsandim ages.c o m\nw hich co ntrasts the hypo signal o f the su rro u nding\nfibro m u sco lar anato m ical stru ctu res, therefo re\nfacilitating the diagno sis [9].\nSo m e au tho rs claim thatthe presence o f sm all fo ci o f\nhigh signal w ithin o f fibro tic lesio ns can facilitate the\ndiagno sis o f DIE.O u r case co ntradicts this assertio n.In\nfact, the endo m etrio tic blo o d lesio n lo calized betw een\nthe anterio r vaginal w all and the u rethra, abo ve the\nperineal bo dy, w as po o rly detected in the sequ ence\nw itho u tgel (Figu re 1 A)rather than w ith gel (Figu re 1 B ).\nThe intravaginal gel relaxing the vaginal w alls and the\nfo rnices allo w ed a better view o f the anterio r deeppelvic\narea and o f the retro cervical area, as co nfirm ed by\nliteratu re [9].\nThe thin lines o f the po sterio r vaginal w all,\nhyperintense o n T1 ­W fat satu ratio n sequ ences,\nindicating blo o d plaqu es, w as detected o nly after\nvaginal distensio n (Figu re 3).\nAn M RI w ith endo vaginal gel allo w s u s to give\nessential preo perative m apping fo r the su rgical rem o val\no f the DIE lesio ns.Fu rtherm o re, this m etho d stands o u t\nbecau se higher sensitivity co m pared to transvaginal\nu ltraso no graphy and M RI w itho u t gel, detecting m o re\nlesio ns [9].\nA w ide excisio n o f all endo m etrio tic im plants\nrem ains the cho sen treatm ent and an accu rate\npreo perative assessm ent o f the extensio n o f the\nendo m etrio sis lesio ns is necessary fo r a su ccessfu l\ntreatm entand to co ntro l the sym pto m ato lo gy.\nIn deepextraperito neal area the radical excisio n o f\nendo m etrio sis lesio ns co u ld inclu de partial excisio n o f\nthe sphincter, w hich that m ay co m pro m ise the u rinary\nco ntinence.\nIn this case, ho rm o nal therapy w as u sed befo re o f the\nsu rgical pro cedu re in o rder to decrease the risk o f\npo sto perative inco ntinence and to decrease the\nrecu rrence rate.In acase serieso f six patientsL iang etal.\no bserved recu rrence in patients treated w ith o nly\nsu rgery, w hile no ne o f the patients treated w ith su rgical\nand m edical therapy had recu rrence o fendo m etrio sis[5].\nAlso the u se o f preo perative ho rm o nal therapy co u ld\nredu ce the size and facilitate the excisio n o f the lesio n\nredu cing dam age to su rro u nding tissu e [1 0 ].\nCO NCL USIO N\nIn literatu re, m any au tho rs have described deeply\ninfiltrating endo m etrio sis bu t no ne o f them has so far\ndescribed diffu se invo lvem ento f the vaginal w all and o f\nthe periu rethral tissu e w itho u t invo lvem ent o f the\nbladder yet.\nFu rtherm o re, o u r stu dy is the first o ne to describe a\ncase o f triple co nco m itant affected co m partm ents;\nperiu rethral tissu e (anterio r co m partm ent), vagina\n(m iddle co m partm ent) and to ru s u terinu s and bo w el\n(po sterio r co m partm ent) in patient w ith deep\nextraperito neal endo m etrio sis.\n* * * * * * * * *\nAu th o r Co ntribu tio ns\nV aleria Fiaschetti – Co nceptio n and design, Acqu isitio n\no f data, Analysis and interpretatio n o f data, Critical\nrevisio n o f the article, Final appro val o f the versio n to be\npu blished\nV alentina Cam a – Co nceptio n and design, Acqu isitio n\no f data, Analysis and interpretatio n o f data, Critical\nrevisio n o f the article, Final appro val o f the versio n to be\npu blished\nL au ra Greco – Co nceptio n and design, Acqu isitio n o f\ndata, Analysis and interpretatio n o f data, Critical\nrevisio n o f the article, Final appro val o f the versio n to be\npu blished\nM aria Fo rnari – Co nceptio n and design, Acqu isitio n o f\ndata, Analysis and interpretatio n o f data, Critical\nrevisio n o f the article, Final appro val o f the versio n to be\npu blished\nGiu seppe So rrenti – Co nceptio n and design, Acqu isitio n\no f data, Analysis and interpretatio n o f data, Critical\nrevisio n o f the article, Final appro val o f the versio n to be\npu blished\nGio vanni Sim o netti – Co nceptio n and design,\nAcqu isitio n o f data, Analysis and interpretatio n o f data,\nCritical revisio n o f the article, Final appro val o f the\nversio n to be pu blished\nGu aranto r\nThe co rrespo nding au tho r is the gu aranto r o f\nsu bm issio n.\nCo nflicto f Interest\nAu tho rs declare no co nflicto f interest.\nCo pyrigh t\n© V aleria Fiaschetti et al. 20 1 3; This article is\ndistribu ted u nder the term s o f Creative Co m m o ns\nattribu tio n 3.0 L icense w hich perm its u nrestricted u se,\ndistribu tio n and repro du ctio n in any m eans pro vided\nthe o riginal au tho rs and o riginal pu blisher are pro perly\ncredited. (Please see w w w .ijcaserepo rtsandim ages.co m\n/ co pyright­po licy.phpfo r m o re info rm atio n.)\nREFERENCES\n1 . V iganò P, Parazzini F, So m igliana E, V ercellini P.\nEndo m etrio sis: epidem io lo gy and aetio lo gical\nfacto rs.B est Pract Res Clin O bstet Gynaeco l 20 0 4\nApr;1 8(2):1 77–20 0 .\n2. Co rnillie Fj, O o sterlynck D, L au w eryns JM ,\nKo ninckx PR. Deeply infiltrating pelvic\nendo m etrio sis: histo lo gy and clinical significance.\nFertil Steril 1 990 ;53(6):978–83.\n3. Del Frate C, Giro m etti R, Pittino M , et al. Deep\nretro perito neal pelvic endo m etrio sis: M R im aging\nappearance w ith laparo sco pic co rrelatio n.\nRadio graphics.20 0 6 No v­Dec;26(6):1 70 5–1 8.\n4 . Sim pso n JL , B ischo ff FZ.H eritability and m o lecu lar\ngenetic stu dies o f endo m etrio sis.Ann N Y Acad Sci\n20 0 2 M ar;955:239–51 .\n5. Giu dice L C, Kao L C. Endo m etrio sis. L ancet 20 0 4\nNo v 1 3–1 9;364 (94 4 7):1 789–99.\nFiaschetti et al. 434\n\nIJCRI – International Journal of Case Reports and Images, Vol. 4 No. 8, August 201 3. ISSN – [0976-31 98]\nIJCRI 201 3;4(8):431 –435.\nw w w .ijc aserepo rtsandim ages.c o m\n6. O do basic A, Pasic A, Iljazo vic­L atifagic E, et al.\nPerineal endo m etrio sis: a case repo rt and review o f\nthe literatu re.Tech Co lo pro cto l 20 1 0 No v;1 4 Su ppl\n1 :S25–7.\n7. Co u tinho A Jr, B ittenco u rt L K, Pires CE, et al.M R\nim aging in deep pelvic endo m etrio sis: a picto rial\nessay.Radio graphics 20 1 1 M ar­Apr;31 (2):54 9–67.\n8. B azo t M , Darai E, H o u rani R, et al. Deep pelvic\nendo m etrio sis: M R im aging fo r diagno sis and\npredictio n o f extensio n o f disease. Radio lo gy\n20 0 4 ;232(2):379–89.\n9. Fiaschetti V , Cru sco S, M eschini A, et al. Deeply\ninfiltrating endo m etrio sis: Evalu atio n o f retro ­\ncervical space o n M RI after vaginal o pacificatio n.\nEu r JRadio l 20 1 2 No v;81 (1 1 ):3638–4 5.\n1 0 . Chen N, Zhu L , L ang J, et al.The clinical featu res\nand m anagem ent o f perineal endo m etrio sis w ith\nanal sphincter invo lvem ent: a clinical analysis o f 31\ncases.H u m Repro d 20 1 2 Ju n;27(6):1 624 –7.\nFiaschetti et al. 435","source_license":"CC0","license_restricted":false}