Diagnostic Accuracy of the Kissing Ovaries Sign on Transvaginal Ultrasound for Prediction of Bowel Endometriosis in Women with Surgically Confirmed Endometriosis

Ahmadbeigi M, Morvarid Ahmadbeigi, Padmehr R, Roya Padmehr, Khadijeh Shadjoo, Shadjoo K, Saman Mohammadipour, Mohammadipour S, Arash Mozzahab, Mozzahab A, Gorgin A, Atefeh Gorgin, Roxana Kargar, Kargar R
Journal of reproduction & infertility · 2026 · vol. 27(1) , pp. 50–56 · doi:10.18502/jri.v27i1.22121 · PMID:42633027 · PMC13498731 · W7171560996
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The kissing ovaries sign on transvaginal ultrasound demonstrated 82.8% sensitivity and 69.2% specificity in predicting bowel endometriosis and advanced-stage disease in women with surgically confirmed endometriosis.

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This retrospective diagnostic accuracy study evaluated the utility of the kissing ovaries sign on transvaginal ultrasound for predicting bowel endometriosis in 252 women with surgically confirmed disease. The researchers found that the presence of this sign was strongly associated with advanced-stage endometriosis and bowel involvement, maintaining significance as an independent predictor after multivariable adjustment. Although the marker demonstrated good sensitivity and specificity, it showed no significant association with bladder or appendiceal involvement, limiting its predictive scope to specific deep infiltrating sites. This paper is centrally about endometriosis — specifically the preoperative imaging assessment of deep infiltrating endometriosis affecting the bowel.

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Abstract

BACKGROUND: Endometriosis is a common gynecological disorder. Non-invasive imaging markers that predict disease severity and bowel involvement are clinically valuable. The purpose of the current study was to evaluate the diagnostic performance of the kissing ovaries (KO) sign on transvaginal ultrasound for predicting bowel endometriosis and advanced disease. METHODS: This retrospective diagnostic accuracy study included 252 women with surgically and histopathologically confirmed endometriosis who underwent laparoscopic surgery at Avicenna Fertility Center between 2019 and 2021. Preoperative transvaginal ultrasound findings were reviewed, and the presence of the KO sign was assessed. Associations with bowel endometriosis and disease severity were analyzed. Diagnostic performance metrics, chi-square and independent t-tests, ORs with 95% CIs, and multivariable logistic regression were used to evaluate predictors of bowel endometriosis. The p<0.05 was considered statistically significant. RESULTS: The KO sign was significantly associated with advanced-stage disease (stage IV: 88.1% vs. 22.2%) and bowel involvement (61.1% vs. 12.7%; OR=10.3, 95%CI: 5.47-19.4). It also showed significant associations with pouch of Douglas obliteration, uterosacral ligament involvement, and fallopian tube involvement. No significant association was observed for bladder or appendiceal involvement. The KO sign demonstrated a sensitivity of 82.8%, specificity of 69.2%, and accuracy of 74.2% for predicting bowel endometriosis. In multivariable analysis, it remained an independent predictor of bowel involvement (adjusted OR=8.45, 95%CI: 4.62-15.48). The area under the ROC curve was 0.76. CONCLUSION: The KO sign on transvaginal ultrasound is a useful non-invasive imaging marker for predicting bowel endometriosis and advanced-stage disease, with good diagnostic performance and potential value in preoperative surgical planning.
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Background

Endometriosis is a common gynecological disorder. Non-invasive imaging markers that predict disease severity and bowel involvement are clinically valuable. The purpose of the current study was to evaluate the diagnostic performance of the kissing ovaries (KO) sign on transvaginal ultrasound for predicting bowel endometriosis and advanced disease.

Methods

This retrospective diagnostic accuracy study included 252 women with surgically and histopathologically confirmed endometriosis who underwent laparoscopic surgery at Avicenna Fertility Center between 2019 and 2021. Preoperative transvaginal ultrasound findings were reviewed, and the presence of the KO sign was assessed. Associations with bowel endometriosis and disease severity were analyzed. Diagnostic performance metrics, chi-square and independent t-tests, ORs with 95% CIs, and multivariable logistic regression were used to evaluate predictors of bowel endometriosis. The p<0.05 was considered statistically significant.

Results

The KO sign was significantly associated with advanced-stage disease (stage IV: 88.1% vs. 22.2%) and bowel involvement (61.1% vs. 12.7%; OR=10.3, 95%CI: 5.47–19.4). It also showed significant associations with pouch of Douglas obliteration, uterosacral ligament involvement, and fallopian tube involvement. No significant association was observed for bladder or appendiceal involvement. The KO sign demonstrated a sensitivity of 82.8%, specificity of 69.2%, and accuracy of 74.2% for predicting bowel endometriosis. In multivariable analysis, it remained an independent predictor of bowel involvement (adjusted OR=8.45, 95%CI: 4.62–15.48). The area under the ROC curve was 0.76.

Conclusion

The KO sign on transvaginal ultrasound is a useful non-invasive imaging marker for predicting bowel endometriosis and advanced-stage disease, with good diagnostic performance and potential value in preoperative surgical planning.

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