Sonography for pelvic endometriosis

The main diagnostic problems for endometriosis are detection of the disease, especially in the absence of ovarian endometriotic cysts, and evaluation of the extent of disease in the pelvis. Transvaginal ultrasonography (TVS) has been proposed as the first line-line imaging technique thanks to its wide availability and because it enables extensive exploration of the pelvis. The “typical” endometrioma is a unilocular cyst with homogeneous low-level echogenicity (ground-glass echogenicity) of the cyst fluid. The use of color Doppler helps to avoid the classification of malignancies as endometriomas by defining the presence or not of flow in papillations. Real-time dynamic TVS examination of adhesions and pouch of Douglas (POD) obliteration, using the sliding sign technique, may be useful in the identification of women at increased risk for bowel endometriosis. Utilizing TVS, an accurate assessment of the vagina—particularly the areas of the posterior and lateral vaginal fornices, the retrocervical area with torus uterinum and uterosacral ligaments as well as the rectovaginal septum—should be made. A slightly filled bladder facilitates evaluation of the structure of the bladder walls and the presence of endometriotic nodules, which appears as hypoechoic linear or spherical lesions bulging toward the lumen, involving the serosa, muscularis, and/or (sub)mucosa of the bladder. Deep nodes of the rectum appear as hypoechoic lesions, linear or nodular retroperitoneal thickening with irregular borders and a few vessels at power Doppler evaluation, penetrating into the intestinal wall distorting its normal structure. Sonographic evaluation of the pelvis also allows a noninvasive classification of the disease to be made, according the Enzian and the AAGL classification, in order to perform presurgical staging. Zusammenfassung Die wesentlichen diagnostischen Herausforderungen bei Endometriose bestehen in der Entdeckung der Erkrankung, v. a. wenn keine Endometriosezysten des Ovars vorliegen, und in der Beurteilung des Krankheitsausmaßes im Becken. Der transvaginale Ultraschall (TVS) wurde wegen seiner großen Verfügbarkeit und weil er die ausgedehnte Exploration des Beckens ermöglicht als bildgebende Erstlinientechnik vorgeschlagen. Das „typische“ Endometriom ist eine unilokuläre Zyste mit homogener geringer Echogenität (Mattglasechogenität) der Zystenflüssigkeit. Der Einsatz des Farbdopplers trägt durch Feststellung eines Flusses in papillären Fortsätzen oder das Nichtvorliegen eines solchen dazu bei, die Klassifikation von Malignomen als Endometriome zu vermeiden. Die dynamische Echtzeit-TVS-Untersuchung von Adhäsionen und einer Obliteration des Douglas-Raums unter Verwendung der Sliding-Sign-Technik (Beurteilung der Verschieblichkeit der Organe) kann hilfreich bei der Erkennung von Frauen mit erhöhtem Risiko für eine Endometriose des Bauchraums sein. Mithilfe des TVS sollte eine genaue Untersuchung der Vagina erfolgen – insbesondere der Bereiche des posterioren und lateralen Scheidengewölbes, der retrozervikalen Region mit dem Torus uterinus und den uterosakralen Ligamenten sowie dem rektovaginalen Septum. Eine leicht gefüllte Harnblase erleichtert die Untersuchung der Struktur der Blasenwand und des Vorliegens von Endometrioseknoten, die sich als hypoechogene lineare oder sphärische Läsionen zeigen, die ins Lumen vorspringen, mit Beteiligung der Tunica serosa, Tunica muscularis und/oder Tunica (sub)mucosa der Harnblase. Tief gelegene Rektumknoten erscheinen als hypechogene Läsionen, lineare oder noduläre retroperitoneale Verdickungen mit irregulären Grenzen und wenigen Gefäßen in der Power-Doppler-Untersuchung, welche die Darmwand durchdringen und ihre normale Struktur deformieren. Die sonographische Untersuchung des Beckens ermöglicht auch eine noninvasive Klassifizierung der Erkrankung nach der Enzian-Klassifikation und der Klassifikation der American Association of Gynecological Laparoscopists (AAGL), um ein präoperatives Staging durchzuführ Similar content being viewed by others

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Exacoustos declares that he/she has no competing interests. For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case. Additional information Redaktion Ludwig Kiesel, Münster Wolfgang Küpker, Baden-Baden Ricardo Felberbaum, Kempten Brigitte Leeners, Zürich Scan QR code & read article online Rights and permissions About this article Cite this article Exacoustos, C. Sonography for pelvic endometriosis. Gynäkologische Endokrinologie 21, 165–175 (2023). https://doi.org/10.1007/s10304-023-00523-4 Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s10304-023-00523-4