Pelvic pain and endometriosis
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Abstract
Here, we introduce a method for estimating a 'growth chart' of the fetal cortex, i.e. for estimating the average cortical growth as well as the anatomical variability around this average during pregnancy.Methods: We use 148 healthy fetal brain MRI with gestational ages ranging from 17 to 37 weeks, originating from the FeTa dataset and the LUMIERE Plateform (Necker Hospital, Paris).Images are motion-corrected to reconstruct a volume of the fetal brain.After automatic segmentation of the cortex, a mesh of the cortical surface is generated.Our continuous model of the cortical growth is based on a geometrical deformation model, namely geodesic regression, a model analoguous to linear regression for shapes.Our construction method is compared with a conventional method, kernel regression, which estimates independent reference cortices at each gestational week.We assess the stability of each method, the similarity between the two models and the degree of realism of the modelled gyrification process.Results: Our method can generate stable results and has the ability to represent cortical folding as reliably as kernel regression, continuously and without introducing temporal inconsistencies.We also publish 21 reference cortices for the gestational weeks 17 to 37.Conclusions: Our open-source method is able to generate highly accurate reference cortices of the fetal brain during pregnancy.Compared to classical atlas building methods, it can also estimate the anatomical variability around the mean trajectory, which is promising for identifying gyrification delays in pathological subjects.
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Objectives
Transvaginal Ultrasound (TVUS) and MRI each have inherent strengths and limitations in the diagnosis of deep endometriosis (DE). Multimodal artificial intelligence (AI) tools hold potential to exploit the strength of both modalities, maximising diagnostic accuracy, however few data sets exist with paired data. This study presents the creation of a multimodal multi-label AI classification tool to detect pouch of Douglas (POD) obliteration and rectal DE utilising unpaired TVUS and MRI data.
Methods
Our dataset comprised of; 8,984 T2-weighted unlabelled MRIs of general pelvis, 171 T2 SPACE sequence MRIs with a specific endometriosis protocol (63 POD obliteration, 11 rectal DE), 749 TVUS videos of the sliding sign (103 POD obliteration) and 519 TVUS videos of the rectosigmoid colon (35 rectal DE). We developed a multimodal, multi-label knowledge distillation algorithm for classifying POD obliteration and rectal DE. Initially, separate encoders were trained to extract features from MRI and TVUS data. To enhance generalisation, we employed a multi-label mix-up strategy to pair multimodal images based on their labels. During training, a worst-student-oriented teacher election mechanism dynamically selected the superior modality per iteration. The stronger modality's encoder then acted as a teacher, guiding the weaker modality via cross-modal supervision.
Results
Our method achieved a mean AUC of 0.8481 across both POD obliteration and rectal DE detection when tested with single modality data. The performance of our method, was superior to single-modal, single-label methods (mean AUC 0.7714 ± 0.0903) and single-modal, multi-label methods (mean AUC 0.8349 ± 0.0727). Additionally, the model had an inference time of only 0.018 seconds suggesting excellent potential for clinical integration.
Conclusions
Combining unpaired data from MRI and TVUS can increased accuracy of AI algorithms for the diagnosis of POD obliteration and rectal DE.
OC05.02: Value of “elasto strain ratio” ultrasound elastography in the diagnosis of adenomyosis
P.R. Szkodziak1, F.P. Szkodziak1, A. Wozniak1, S. Wozniak1, M. Szkodziak1, T. Paszkowski1
1Department of Gynecology, Medical University of Lublin, Lublin, Poland
Objectives
Elastography is imaging technique visualising stiffness of examined region that has found its use mainly in imaging of tumours. Elastography allows for subjective assessment of tumour elasticity based on a colour map. "Elasto Strain Ratio" provides quantitative information. It is calculated by comparing the strain of a lesion to the surrounding normal tissue (measured in %). Soft tissue will have higher strain values than stiff tissue. Adenomyosis is uterus wall pathology characterised by specific stiffness of myometrium changes seen by ultrasonography. Aim of the study was to assess the accuracy of “Elasto Strain Ratio” in adenomyosis diagnosis.
Methods
It is a retrospective observational study. Transvaginal ultrasound examinations were performed among 210 women aged 22–46 years. 102 women who presented without any uterine pathology in ultrasonography were included in a control group and 108 women suspected of having adenomyosis were included in the study group. Diagnosis of adenomyosis was set in presence of globular uterine configuration, myometrial anterior-posterior asymmetry, heterogeneous myometrial echotexture, subendometrial cysts and poor definition of the endometrial-myometrial interface and presence of dysmenorrhea, and/or menorrhagia. Finally, the elastography option was activated. Elastographic evaluation of the myometrium was performed using an Alpinion ultrasound system equipped with “Elasto Strain Ratio” software. The stiffness of adenomyosis changes was compared to the stiffness of normal myometrium and “Elasto Strain Ratio” was calculated.
Results
“Elasto Strain Ratio” of myometrium in the group of healthy women was calculated as 0.96 (range 0.80–1.00). In the group of women suffering from adenomyosis “Elasto Strain Ratio” was 0.70 (range 0.50–0.90).
Conclusions
The results of the study indicate a decrease of the myometrial stiffness estimated in patients with adenomyosis. This study showed that, the use of elastography in addition to conventional ultrasound could help to diagnose uterine adenomyosis.
OC05.03: A new era in endometriosis diagnosis: validating sonoPODography for superficial endometriosis
S.M. Freger1, I. Mick1, A. Mosher1, M. Leonardi1
1McMaster University, Hamilton, ON, Canada
Objectives
Advances in non-invasive diagnostic methods for endometriosis, such as transvaginal ultrasound (TVS), have improved detection rates for deep (DE) and ovarian endometriosis (OE), yet superficial endometriosis (SE) remains elusive. SonoPODography (SPG), which introduces saline into the pouch of Douglas (POD), has shown promise in improving SE diagnoses, though it has required validation.
Methods
This prospective diagnostic accuracy study evaluated the accuracy (Acc), sensitivity (Sens), specificity (Spec), positive predictive value (PPV), and negative predictive value (NPV) of SPG for SE detection. We compared two approaches—TVS alone and TVS with SPG—using laparoscopy and histology as reference standards in diagnosing SE. Both ultrasounds and surgeries were performed by the same surgeon-sonologist, though the histologist was blinded. Participants were scheduled for laparoscopy, excluding cases with non-patent fallopian tubes or POD obliteration.
Results
Among 65 participants, pathologically confirmed SE was present in 80% (52/65) of participants. The accuracy of TVS alone, using laparoscopy as the reference, was Acc 42.1%, Sens 39.6%, Spec 75.0%, PPV 95.5%, and NPV 8.6%. Compared to histology, TVS accuracy was Acc 53.6%, Sens 45.5%, Spec 83.3%, PPV 90.9%, and NPV 29.4%. With SPG, accuracy using laparoscopy as the reference was Acc 93.1%, Sens 94.0%, Spec 87.5%, PPV 86.2%, and NPV 97.9%. Compared to histology, SPG accuracy was Acc 86.0%, Sens 91.5%, Spec 60.0%, PPV 91.5%, and NPV 60.0%. SPG was successfully performed in 92% of cases, failing in 8% due to inadequate fluid accumulation in the POD.
Conclusions
SE remains the most common subtype of endometriosis yet often evades detection, contributing to diagnostic delays. SPG, a non-invasive outpatient technique, may significantly enhance the diagnostic accuracy of TVS for SE, supporting its potential to reduce delays and enable earlier management.
OC05.04: Comparison of the preoperative diagnostic accuracy of transvaginal ultrasound and magnetic resonance imaging in patients undergoing surgery for deep endometriosis
G. Szabo1, B. Pete1, I. Madár1, L. Lipták1, J. Rigó1, A. Bokor1, G. Grecchi3, I. Kalina2, K. Turtoczki2
1Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary; 2Medical Imaging Centre, Semmelweis University, Budapest, Hungary; 3Obstetrics and Gynecology, IRCCS San Raffaele Hospital, Milan, Italy
Objectives
To determine whether transvaginal sonography (TVS) according the IDEA approach or magnetic resonance imaging (MRI) is more effective in the preoperative diagnosis of deep endometriosis (DE) in different #Enzian locations.
Methods
Prospective single tertiary referral-centre – Semmelweis University – comparative diagnostic test accuracy study including consecutive symptomatic women undergoing both TVS by expert sonologist with IDEA approach and MRI by expert radiologist according to European Society of Urogenital Radiology guideline for clinically suspected pelvic deep endometriosis before laparoscopic surgical treatment from April 2021 to May 2024. Sonologist and radiologist were blinded to each other results. Findings were analysed with the #Enzian classification and compared with those obtained by laparoscopy and confirmed histologically.
Results
463 patients were included in the study. In the #Enzian compartment A (vagina, rectovaginal septum, uterine torus) TVS had a sensitivity (SN) 92.2%, specificity (SP) 90.6%, positive predictive value (PPR) 89.7%, negative predictive value (NPR) 92.9%, accuracy 91.4%, while with MRI SN: 90.4%. SP: 93.5%,PPV: 92.5%, NPV: 91.6% and accuracy: 92%. For compartment B (sacrouterine ligaments, parametrium, pelvic sidewall), on the left side with TVS, SN: 88.8%, SP: 96.7%, PPV: 91.5%, NPV: 94.5%, accuracy: 94.4.1%, while for MRI, SN: 88.1%, SP: 96.1%, PPV: 87.3%, NPV: 96.2% accuracy: 93.9%. On the right side TVS showed SN: 86.8%, SP: 96.9%, PPV: 89.3%, NPV: 96.1%, accuracy: 94.6%, while MRI SN: 90.6%, SP: 95%, PPV: 84.2%, NPV: 97.1% accuracy: 94%. For compartment C (rectum), TVS had SN: 95.8%, SP: 92.5%, PPV: 93.8%, NPV: 97%, accuracy: 95.7%, while for MRI SN: 94.2%, SP: 94.1%, PPV: 91.8%, NPV: 95.9% accuracy: 94.2%. McNemar's test showed no significant difference between the two methods in either location.
Conclusions
Both TVS and MRI are highly accurate for presurgical diagnosis of DE. #Enzian classification is suitable for comparing the two imaging modalities.
OC05.05: Performance of an ultrasound-based endometriosis staging system for predicting anterior and lateral deep infiltrating endometriosis
M. Scarrone1,2, A. Afraoucene2,3, B. Fedida2,3, A. Paternostre2,3, F. Arnaud2,3
1University of Milan, Milan, Italy; 2Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal (CHI) Poissy Saint-Germain-en-Laye, UVSQ, Poissy, France; 3Department of Clinical Research, CHI Poissy-Saint-Germain-en-Laye, Poissy, France
Objectives
Preoperative assessment of endometriosis is crucial to plan a proper surgical approach. This article aims to evaluate the performance of an ultrasound-based endometriosis staging system (UBESS) in the prediction of urinary endometriosis, associated surgical complexity and postoperative complications.
Methods
This monocentric prospective observational study was conducted on patients with endometriosis who underwent a surgical procedure for endometriosis between 1 January 2016 and 31 December 2022 in a tertiary Referral Centre in France. We analysed ultrasonographic predicting factors of urinary endometriosis (i.e. ureteral or vesical), surgical complexity and postoperative complications.
Results
A total of 223 patients were included. N = 71 (31.8%) patients had confirmed intraoperative ureteral/vesical endometriosis. We compared the 5 different domains included in the UBESS ultrasound protocol between the two groups. We found a significantly (p < 0.05) higher proportion of non intestinal deep infiltrating endometriosis (DIE) (95.7% vs. 79.6%) including the bladder (7% vs. 1.3%;), the uterosacral ligaments (91.4% vs. 78.8%) and the torus (77.1% vs. 60.3%) in the urinary group. At multivariate analysis the presence of deep non intestinal endometriosis remained the only significant risk factor for urinary endometriosis with an OR of 6.7 (95% CI 1.52–29.67, P 0.01). The urinary group had a higher rate of AFS stage 4, ureterolysis, intestinal resection and postoperative urinary voiding dysfunction.
Conclusions
In our series, 50% of urinary endometriosis did not have any intestinal DIE and were thus classified as UBESS 2. The presence of non-intestinal DIE at ultrasound increased the risk of intraoperative diagnosis of urinary endometriosis with an OR of 6.7, even in the absence of direct visualisation of parametrial lesions at ultrasound. Patients with urinary endometriosis have more complex surgeries and a higher risk of postoperative urinary voiding dysfunction, even when adjusted for the presence of intestinal DIE.
OC05.06: Endometriosis as a risk factor for severe pelvic inflammatory disease
C. Ros1, M. Camacho1, M. Rius1, M. Gracia1, C. De Guirior1, M. Martinez1, F. Carmona1
1Gynecology, Hospital Clinic de Barcelona, Barcelona, Spain
Objectives
To evaluate the impact of endometriosis in the course of women hospitalised due to pelvic inflammatory disease (PID).
Methods
Patients hospitalised due to PID between January 1st 2018 to December 30th 2023 at our institution (a tertiary referral centre for endometriosis) were retrospectively analysed. Patients with endometriosis were compared to patients without endometriosis. Diagnosis of endometriosis was suspected at the time of admission and confirmed with a subsequent ultrasound by an expert sonographer one month later, once the acute PID episode was resolved.
Results
A total of 159 patients were included in the study, divided into two groups: 48 with endometriosis (E) and 111 without endometriosis (NE). Women with endometriosis were older (37.5 vs 32.5, p = 0.04) and had higher rates of adnexal findings in the ultrasound (95.8% vs 73.8, p = .0.01). Cervical or vaginal bacterial cultures (C. trachomatis, Mycoplasma or N. gonorrhoeae) in this group were more frequent negative (72.9% vs 31.5%, p = 0.00), and only one patient tested positive for sexually transmitted disease. Women with endometriosis had significantly worse outcomes, including higher treatment failure rates (35.4% vs 17.1%, p = 0.01), longer hospital stays (6.1 + 4.4 vs 3.9 + 1.6, p = 0.00), and higher recurrence rate (31.3% vs 11.7%, p = 0.01). Urgent surgery was more frequent in endometriosis patients (12.5% vs 4.5%, p = 0.08), though not statistically significant.
Conclusions
According to our results, women with endometriosis are at increased risk for a severe course of PID compared with non-endometriosis patients, requiring more often longer hospitalisation, adjustments in antibiotic treatment and urgent surgical intervention. Our results also suggest that PID in women with endometriosis is less likely to be caused by a sexually transmitted disease bacteria, thus, suggesting a different mechanism of pathogenesis. Clinicians should be aware as patients with endometriosis may require more aggressive management when diagnosed with PID.
OC05.07: Accuracy of ultrasound using the MUSA consensus in the diagnosis of adenomyosis compared to histopathological diagnosis in a Latin American hospital
A.L. Esquivel2,1, K.D. Cepeda2, A. Muñoz2, C. Buritica4,1, L.S. Cruz4, L. Torres3, V. Zuluaga1, N. Rodriguez2,1
1Medical School, Universitu of the Andes, Bogota, Colombia; 2Gynecology and Obstetrics, Fundacion Santa Fe de Bogota, Bogota, Colombia; 3University of La Sabana, Bogota, Colombia; 4Fundacion Santa Fe de Bogota, Bogota, Colombia
Objectives
Evaluate the diagnostic accuracy of the direct and indirect characteristics of the MUSA consensus using transvaginal ultrasound for adenomyosis compared to the histopathological diagnosis in a university hospital.
Methods
A retrospective descriptive cross-sectional study was conducted to evaluate the performance of a diagnostic test, including symptomatic patients with a median age of 47 years, scheduled for hysterectomy between 2023 and 2025, with an ultrasound report performed at our institution. They were included (n = 404). Patients who underwent surgery at an external institution or who did not have a surgical pathology report or ultrasound report performed at our institution were excluded. We took into account whether they also had myomatosis and menstrual disorder and whether they had received hormone therapy. These findings were compared with the surgical pathology report. Sensitivity, specificity, positive predictive value and negative predictive value of transvaginal ultrasound and each of the ultrasound signs were calculated using statistical tools.
Results
Transvaginal ultrasound has a sensitivity of 35%, a specificity of 86%, a positive predictive value of 69% and a negative predictive value of 60%, LR+ 2.54, LR- 0.65 for adenomyosis. False positives were 14%.
Conclusions
Transvaginal ultrasound has a good specificity for adenomyosis and a good sensitivity for the morphological findings related by the MUSA consensus. This diagnosis comes from the overall analysis of the sonographer.
OC05.07: Table 1.
| Finding | Sensitivity | Specificity |
|---|---|---|
| Myometrial cyst | 10% | 98% |
| Hyperechogenic island | 89% | 23% |
| Echogenenic subendometrial lines | 99% | 4% |
| Globular uterus | 89% | 25% |
| Asymmetrical thickening | 92% | 19% |
| Fan shaped shadowing | 98% | 7% |
| Translesional vascularity | 98% | 5% |
| Irregular JZ | 95% | 19% |
| Interrupted JZ | 94% | 16% |
OC05.08: Role of the ‘follicular ring sign’ in the diagnosis of ovarian torsion
A. Karthik Nagesh1, V. Priti3, L. Kaur2, G. Karthik Nagesh1, M. Sibal3
1Obstetrics and Gynecology, Manipal Hospital, Bangalore, India; 2Prime Diagnostic Centre, Chandigarh, India; 3Fetal Medicine and Obstetric and Gynecological Ultrasound, Manipal Hospital, Bangalore, India
Objectives
Whirlpool sign, ovarian stromal edema, and absent Doppler flow are widely recognised ultrasound features used to diagnose torsion. We aimed to investigate the efficacy of a fourth, more recent follicular ring sign (FRS) as compared to the other three standard ultrasound markers.
Methods
Cases with clinically suspected adnexal torsion, evaluated by ultrasound in two centres (by three expert sonologists) that underwent surgery for suspected or diagnosed torsion on ultrasound were analysed retrospectively. The above mentioned 4 features were specifically observed as a part of routine protocol in these centres.
Results
The study included 100 cases, of which 87 were surgically confirmed cases of torsion. 73 were cases of ovarian torsion, 14 were cases of non-ovarian torsion (paraovarian and hydrosalpinx). As seen in table 1, for ovarian torsion, FRS demonstrated the highest positive predictive value and negative predictive value with a relatively high sensitivity and specificity, compared to the other markers. In 24 cases of confirmed ovarian torsion where FRS was absent, antral follicles were not visualised primarily due to the presence of a large mass in the ovary with minimal ovarian tissue. In cases of non-ovarian torsion, FRS was consistently absent, further validating its specificity for ovarian torsion.
Conclusions
FRS is a reliable and simple ultrasonographic marker for ovarian torsion, when specifically looked for. Incorporating FRS into ultrasonographic protocols in cases with suspected ovarian torsion, especially in the presence of antral follicles, will enhance diagnostic precision of torsion.
OC05.08: Table 1. Ultrasonographic markers in ovarian torsion
| Ultrasonographic markers in ovarian torsion | Sensitivity | Specificity | Positive predictive value | Negative predictive value |
|---|---|---|---|---|
| Follicular ring sign | 67.10% | 90.90% | 98% | 29.4% |
| Whirlpool sign | 79.40% | 45.40% | 90.6% | 25% |
| Absent Doppler flow | 38.30% | 90.90% | 96.5% | 18.1% |
| Ovarian stromal edema | 68.40% | 63.60% | 87.7% | 23.3% |
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