Optimizing endometriosis detection: a review of technical approaches and interpretative pitfalls

Zeyad Elias, Elias Z, Ania Kielar, Ania Z. Kielar, Kielar A, Hina Arif‐Tiwari, Arif-Tiwari H, Hina Arif-Tiwari, Anuradha S. Shenoy‐Bhangle, Anuradha Shenoy-Bhangle, Shenoy-Bhangle A, Priyanka Jha, Emily Pang, Pang E, Scott W. Young, Scott Young, Young S
Abdominal radiology (New York) · 2025 · vol. 51(1) , pp. 329–345 · doi:10.1007/s00261-025-05084-7 · PMID:40576666 · W4411742709
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⚙ AI-generated summary by claude@2026-06+body, 2026-06-11 ⓘ

This review analyzes imaging modality strengths, pitfalls, and preparation strategies for detecting endometriosis, focusing on technical factors and challenging anatomic areas.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-11 · read from full text ⓘ

This paper is a narrative review examining technical approaches and interpretative pitfalls of imaging modalities used to detect and characterize endometriosis, focusing on ultrasound, MRI, and CT, and on factors such as patient preparation and standardized reporting. It finds that ultrasound can provide dynamic, real-time assessment but depends on experienced operators and standardized protocols, while MRI offers comprehensive soft-tissue evaluation yet is limited by static imaging and artifacts, and CT has more narrow utility such as bowel involvement. The review highlights “anatomic blind spots” in thoracic, gastrointestinal, abdominal wall, urinary tract, and neurovascular involvement and emphasizes that standardized templates are needed to communicate findings for surgical planning. A key stated limitation is that the evidence is synthesized as a review rather than reporting new datasets or analyses. This paper is centrally about endometriosis — it reviews imaging strengths, technical factors, anatomic blind spots, and interpretative pitfalls for detecting endometriotic lesions.

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Abstract

Endometriosis, affecting approximately 10% of reproductive-age women, presents significant diagnostic challenges due to its variable clinical presentation and anatomic distributions. Despite advances in imaging technology, accurate detection and characterization of endometriotic lesions remain complex, with diagnostic delays averaging 7-12 years from symptom onset. This review analyzes the spectrum of imaging strengths and potential pitfalls across imaging modalities used to assess endometriosis focusing on technical factors and anatomic blind spots that can impact diagnostic accuracy and clinical management. Strengths of ultrasound include dynamic capabilities and real-time assessment with patient feedback, though it requires experienced operators and standardized protocols. MRI offers comprehensive evaluation with excellent soft tissue contrast and multiplanar capabilities but faces challenges with static imaging and artifact interference. CT, while limited by radiation exposure and intermediate contrast resolution, shows promise in specific scenarios, particularly evaluation of endometriosis deposits on the bowel. This review details optimal patient preparation strategies, including the role of vaginal and rectal gel opacification, bowel preparation, and contrast administration. Special attention is given to challenging anatomic areas including thoracic, gastrointestinal, abdominal wall, urinary tract and neurovascular involvement. The manuscript emphasizes the importance of standardized reporting templates for communication of findings to facilitate surgical planning. A multidisciplinary approach to imaging patients with known deep invasive endometriosis helps ensure the best modality is chosen for the clinical question at hand.
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Abstract

Endometriosis, affecting approximately 10% of reproductive-age women, presents significant diagnostic challenges due to its variable clinical presentation and anatomic distributions. Despite advances in imaging technology, accurate detection and characterization of endometriotic lesions remain complex, with diagnostic delays averaging 7–12 years from symptom onset. This review analyzes the spectrum of imaging strengths and potential pitfalls across imaging modalities used to assess endometriosis focusing on technical factors and anatomic blind spots that can impact diagnostic accuracy and clinical management. Strengths of ultrasound include dynamic capabilities and real-time assessment with patient feedback, though it requires experienced operators and standardized protocols. MRI offers comprehensive evaluation with excellent soft tissue contrast and multiplanar capabilities but faces challenges with static imaging and artifact interference. CT, while limited by radiation exposure and intermediate contrast resolution, shows promise in specific scenarios, particularly evaluation of endometriosis deposits on the bowel. This review details optimal patient preparation strategies, including the role of vaginal and rectal gel opacification, bowel preparation, and contrast administration. Special attention is given to challenging anatomic areas including thoracic, gastrointestinal, abdominal wall, urinary tract and neurovascular involvement. The manuscript emphasizes the importance of standardized reporting templates for communication of findings to facilitate surgical planning. A multidisciplinary approach to imaging patients with known deep invasive endometriosis helps ensure the best modality is chosen for the clinical question at hand. Similar content being viewed by others Data availability No datasets were generated or analysed during the current study.

References

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Yeungnam Univ J Med. 2021;38(1):10–18. doi: https://doi.org/10.12701/yujm.2020.00444. Epub 2020 Aug 7. PMID: 32764213; PMCID: PMC7787892. Author information Authors and Affiliations Contributions AK, ZE, EP, SY, ASB, PJ, HAT wrote individual sections of the manuscriptEvery author edited all sections of the finalized manuscript.AK and ZE prepared Figs. 1, 3, 4, 5, 6, 7, 8 and 9, and 13SY prepared Figure 2ASB prepared Figs. 10, 11 and 12. Corresponding authors Ethics declarations Competing interests Ania Kielar is president of the Canadian Association of Radiologists. Other authors have no conflict of interest. Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Electronic supplementary material Below is the link to the electronic supplementary material. Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Elias, Z., Kielar, A., Arif-Tiwari, H. et al. Optimizing endometriosis detection: a review of technical approaches and interpretative pitfalls. Abdom Radiol 51, 329–345 (2026). https://doi.org/10.1007/s00261-025-05084-7 Received: Revised: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00261-025-05084-7

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