The Predictive Value of the Sliding Sign in the Evaluation of Deep Infiltrating Endometriosis

Objective: To evaluate preoperative real-time dynamic transvaginal sonography (TVS) in the prediction of pouch of Douglas (POD) obliteration in women undergoing laparoscopy for suspected endometriosis. Methods: This prospective controlled study was conducted in the department of Obstetrics and Gynecology, Faculty of Medicine, Minia University. All women with symptoms suggestive of endometriosis who were scheduled for laparoscopy underwent detailed preoperative TVS, in particular to ascertain whether the POD was obliterated. POD obliteration was assessed using a real-time TVS technique called the ‘sliding sign’. Preoperative TVS sliding sign findings were then compared to gold standard laparoscopic POD findings. Results: Initially, fifty-eight (58) patients in their reproductive age were enrolled into this study, but eight patients (8) were excluded as some of them refuse to do laparoscopy and some get pregnant . Thus, This study included fifty (50) patients aged between 18-40 years (29.2+6.7). The frequency of relevant symptoms include dysmenorrhea (66%), It iliac fossa pain (17%), rt iliac fossa pain (16%), dyschezia (22%), diarrhea (14%), constipation (8%), rectal bleeding (5%), and dyspareunia (28%). The results of TVS include positive sliding sign which means POD is patent in 39 patients (78%), negative sliding sign which means POD is obliterated in 11 patients (22%), endometrioma was present in 9 patients (18%), bowel DIE was present in 3 cases (6%) and adenomyosis was present in 6 patients (12%). The laparoscopic results include patent POD in 35 patients (70%), obliterated POD in 15 patients (30%), endometrioma was present in 9 patients (18%), bowel DIE was present in 5 cases (10%) and adenomyosis was present in 8 cases (16%). The sensitivity, spechficity, PPV and NPV for the use of the sliding sign to predict POD obliteration were 73.3% , 100%, 100% and 89.7%. Conclusions: Preoperative real-time dynamic TVS evaluation using the sliding sign seems to establish with a high degree of certainty whether the POD is obliterated. Given the increased risk of deep infiltrating endometriosis in women with POD obliteration, the TVS sliding sign technique may also be useful in the identification of women who may be at a higher risk for bowel endometriosis.