Endometriosis, ultrasound and #Enzian classification: the need for a common language for non-invasive diagnostics

J. Keckstein, Jörg Keckstein, Markus Hoopmann
Ultraschall in der Medizin (Stuttgart, Germany : 1980) · 2023 · vol. 44(03) , pp. 233–239 · doi:10.1055/a-2055-6712 · PMID:37279767 · W4379522971
editorial OA: bronze CC0 ⤵ 7 in-corpus citations
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⚙ AI-generated summary by claude@2026-06, 2026-06-07 ⓘ

This paper advocates for a common diagnostic language, highlighting transvaginal ultrasonography's capability to reliably diagnose deep endometriosis and adenomyosis, which can aid in earlier detection.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-07 ⓘ

This paper discusses how transvaginal ultrasound (TVS) enables non-invasive visualization of deep endometriosis and related compartments, and argues that structured, shared classification is needed to replace the idea that diagnosis requires surgery. It outlines evidence that TVS—when performed by trained experts—can assess ovarian and deep disease, including adenomyosis, and compares TVS with MRI while noting key limitations tied to examiner expertise, technical requirements, and variability in findings across anatomical sites. The author contrasts the inadequacy of ASRM for non-invasive deep disease documentation with the use of the Enzian system and its updated #Enzian classification, which is presented as more reproducible and suitable for coding localization and size, supported by prospective and multicenter comparisons and agreement studies with operative findings (with some remaining scientific testing for lateral pelvic wall findings). This paper is centrally about endometriosis — specifically advocating TVS-based non-invasive diagnostics and the #Enzian classification as a common language for deep endometriosis.

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Abstract

Endometriosis is a benign disease with a wide variety of manifestations and symptoms, which primarily affects women of childbearing age and in some cases has a fundamental and permanent impact on their quality of life. Although the genesis is still unclear despite a wide variety of explanatory models, we know that the disease can have a progressive character and that diagnosis is not infrequently made far too late, which can have devastating consequences for the woman. The mechanism underlying this problem is multifactorial, but the most likely factor is the persistent belief that the diagnosis can only be made by surgery. Transvaginal ultrasonography (TVS) is the standard diagnostic procedure used by gynecologists. While it was previously clear that this could accurately visualize ovarian endometriosis, there is increasing recognition that transvaginal ultrasound (TVS) can also reliably diagnose deep endometriosis (DE) [1] [2] [3] [4] [5]. This includes all important structures of the internal genital tract (vagina, uterus, ovary, tube, ligamentous structures) [1] [6] [7], and especially the visualization of adenomyosis [8] [9] [10]. In addition, all other anatomical structures of the pelvis with the various compartments including the extragenital organs (bladder, bowel, ureter) [11] [12] [13] and the connective tissue support structures can be sonographically well depicted and their infiltration by endometriosis can be differentiated. A structured system, such as the IDEA [14] or MUSA [15] criteria, is very helpful for the evaluation of the pelvis and documentation including classification. The sometimes very high sensitivity and specificity depends on the one hand on the organs to be examined and the size of the findings and on the other hand on the examination setting (expertise of the examiner and technical requirements).

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Outcome instruments

MUSA

Condition tags

endometriosisadenomyosis

MeSH descriptors

Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Female Female Female Female Female Female Female Female Humans Humans Humans

Citation neighborhood

Papers in the corpus that this work cites (lower rings, blue) and that cite this one (upper rings, green). Dot size scales with the paper's in-corpus citation count — bigger dot = more influential within the endo/adeno field. Click a dot to open that paper. [ expand to 2 hops ] — adds papers reached through this work's immediate citers/citees. Heavier; up to 60 extra dots.

References (38)

Cited by (7)

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