Pelvic pain and endometriosis

Currently, the literature lacks direct sonographic criteria for diagnosing tubal endometriosis. Tubal involvement is primarily assessed using indirect ultrasound findings, such as hydrosalpinx, ovarian endometriomas, or periadnexal adhesions. This study aims to propose novel ultrasound diagnostic criteria for evaluating tubal involvement in endometriosis and introduce a classification system for affected fallopian tubes.

A retrospective analysis was conducted on 968 patients (aged 18–42 years) who underwent surgical treatment for symptomatic, treatment-resistant endometriosis between January 1 and December 31, 2024. Among them, 224 patients (23.1%) underwent unilateral or bilateral salpingectomy, with intraoperative findings confirming tubal damage due to direct endometriotic infiltration or adhesions. Preoperative transvaginal ultrasound (TVUS) reports and imaging, performed by trained operators, were reviewed and compared with intraoperative findings.

TVUS identified tubal anomalies in 135 cases (60.3%), whereas 89 cases (39.7%) exhibited no detectable sonographic abnormalities of the fallopian tubes. Based on sonographic morphology, affected tubes were categorised into three distinct ultrasound phenotypes: Solid tubal involvement (n = 55, 40.7%): Tubular, solid, isoechoic structures with colour Score 1–2. Endometriotic content (n = 38, 28.1%): Elongated formations with ground-glass echogenic content and CS 1–2. Hydrosalpinx (n = 67, 49.6%): Tubular formations with anechoic content, incomplete septa, and CS 1–2. Tubal involvement was significantly associated (p < 0.0001) with the presence of ovarian endometriomas in 75 cases (55.6%) and bowel endometriosis in 91 (67.4%).

TVUS is a valuable tool for detecting tubal alterations secondary to endometriosis. Recognising the sonographic characteristics of affected tubes enhances the preoperative assessment, counselling for fertility planning, and differential diagnosis. EP14.03: Association between location of endometriosis lesions and adenomyosis with patient symptoms L. Jokubkiene1,2, Y. Cerne2, P. Sladkevicius3,2 1Department of Obstetrics and Gynecology, Skane University Hospital, Malmo, Sweden; 2Lund University, Lund, Sweden; 3Obstetrics and Gynecology, Lund University, Malmo, Sweden

Association between the extent of endometriosis disease and patient symptoms is difficult to be assessed as majority of patients present have endometriosis lesions at several locations. We aimed to investigate association between isolated endometriosis lesions in the pelvis and presence of patient symptoms.

Patients with symptoms suggestive of endometriosis and adenomyosis were examined using transvaginal ultrasound according to IDEA consensus. Presence of symptoms (dysmenorrhea, chronic pelvic pain (CPP), dyspareunia, dysuria and dyschezia were assessed using visual analogue scale (VAS). Chi-squared-test for categorical data was used to assess relation between endometriosis lesions and adenomyosis in patients with lesions in only one location, isolated lesions.

In all, 228 patients with isolated endometriosis and adenomyosis lesions were included: 131 (58%,CI 95% 50.9–64.0) endometrioma, 11 (5%,CI 95% 2.2–7.9) in the sacrouterine ligaments, 23 (10%,CI 95% 6.6–14.0) in the bowel, 2 (1%,CI 95% 0.0–2-2) in the vagina and 2 (1%, CI 95% 0.0–2.2) in the rectovaginal septum. None of the patients had isolated lesions in the urinary bladder. In patients with isolated endometriomas CPP and dyschezia were less common compared to patients with isolated lesions in other locations (96 (75%) vs 86 (89%), p = 0.010) and (80 (62) vs 72 (74%), p = 0.053). CPP and dyschezia tended to be more common in patients with isolated adenomyosis than those with isolated endometriosis in any location (52 (88%) vs (130 (78%) and 45(76%) vs 107 (64%), p = 0.099 and p = 0.086, respectively). There was no association observed between the presence of dysmenorrhea, dyspareunia and dysuria and isolated endometriosis lesions in different locations.

Chronic pelvic pain and dyschezia were less common in patients with isolated endometriomas but tended to be more common in women with isolated adenomyosis compared to patients with isolated endometriosis lesions in other locations. No association observed between other symptoms and isolated endometriosis lesions in different locations. EP14.04: “Snake under the endometrium” sign to identify tubercular endometritis on power Doppler: a single centre prospective study L. Kaur1, M. Preet2,1 1Prime Diagnostic Centre, Chandigarh, India; 2Fetal Medicine, Prime Diagnostic Centre, Chandigarh, India

Tuberculous endometritis is one of the causes of infertility which is a major problem in the developing countries. The objective of the study was introducing a novel pattern of spiral vessels on power Doppler called as “Snake under the endometrium” for detection of endometritis on ultrasound.

Prospective study conducted at our institution from Dec 2020 to Dec 2022 included 150 patients undergoing TVS for the workup of primary and secondary infertility. Particular attention was paid to the pattern of the spiral arteries on power Doppler. Normally spiral vessels showed a vertical course perpendicular to the endometrial cavity (figure 1). In tubercular endometritis linear course of spiral vessels were seen parallel to the endometrial cavity. We coined it as the “Snake under the endometrium “Sign (figure 2). All patients showing parallel course of vessels were offered endometrial biopsy.

9 of 150 patients lost to follow up. Remaining (n = 141) reviewed for “Snake under the endometrium “Sign”. Normal vertical course of spiral vessels perpendicular to the endometrial cavity was seen in 133 (94%) of 141 patients.8 (5.6%) patients showed linear course of spiral vessels parallel to the endometrial cavity called as The “Snake under the endometrium “Sign. These 8 patients were offered endometrial biopsy which showed tuberculosis. Hence strong correlation was seen between Snake under the endometrium “Sign and was found to be statistically significant (p < 0.01).

Supporting information can be found in the online version of this abstract EP14.05: Rare cause of radiculopathy: symptomatic tarlov cysts M. Preet1, L. Kaur1 1Fetal Medicine, Prime Diagnostic Centre, Chandigarh, India Supporting information can be found in the online version of this abstract EP14.06: Comparison of MV-Flow™ and power Doppler for assessing lesion vascularisation in rectal endometriosis J. Alcazar1, R. Orozco1, I. Brunel1, J. Vilches1, M. Lozano1, L. Alonso-Pacheco1, S. Guerriero2 1Obstetrics and Gynecology, Quironsalud Malaga Hospital, Malaga, Spain; 2Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy

To compare the vascularisation of rectal endometriotic nodules using MV-Flow™ and conventional power Doppler.

Thirty consecutive women diagnosed with deep endometriosis involving the rectum were recruited for this prospective study. All women underwent transvaginal ultrasound using a Samsung V8 ultrasound system (Samsung Medison, Co., Ltd., Seoul, Republic of Korea). The scanning protocol was performed according to the IDEA consensus. Endometriotic lesions involving the rectum were identified as hypoechoic lesions with blurred margins. Then, power Doppler was activated and the vascularisation of the lesion was assessed (figure 1A). Immediately after, the MV-Flow™ with the LumiFlow™ was activated and the vascularisation was assessed again (figure 1B). Vascularisation assessment was undertaken based to the subjective examiner's impression, using the vascular score proposed by IOTA group.

The vascular score using conventional power Doppler was score 1 in 87% (n = 26) and score 2 in 13% (n = 4) of the lesions, respectively. The vascular score using MV-Flow™ was score 1 in 6% (n = 2), score 2 in 27% (n = 8), score 3 in 40% (n = 12) and score 4 in 27% (n = 8) of the cases. Grouping cases into score 1–2 versus score 3–4, there was a statistically significant difference with score 3–4 when using MV-Flow™ (67% versus 0%, p < 0.01).

Supporting information can be found in the online version of this abstract EP14.07: Optimising the diagnosis of deep infiltrating endometriosis: the role of three-dimensional transvaginal ultrasound with VCI-A and OmniView modes J. Lee1, S. Park2, M. Kim1 1Obstetrics and Gynecology, Ewha Woman's University, Koyangsi, Kyung-ki do, Republic of Korea; 2Obstetrics and Gynecology, Ewha Woman's University Seoul Hospital, College of Medicine, Seoul, Republic of Korea The objective of this case study is to highlight the diagnostic utility of three-dimensional (3D) transvaginal ultrasound (3D TVUS), specifically Volume Contrast Imaging in the A-plane (VCI-A) and OmniView modes, in detecting deep infiltrating endometriosis (DIE) affecting the posterior vaginal fornix in a patient with cyclical anal pain and suspected menstrual rectal bleeding. A 34-year-old woman with severe anal pain before menstruation and suspected rectal bleeding presented despite a negative colonoscopy biopsy. 3D TVUS with VCI-A and OmniView modes revealed a 0.89 × 0.88 cm hypoechoic lesion in the posterior vaginal fornix, aiding localisation and biopsy guidance. Colposcopy confirmed bleeding nodules, and histopathology showed endometrial glands and stroma. A rectosigmoid lesion 5 cm from the anal verge revealed endometriosis in the mucosal tissue, confirming multifocal DIE. Supporting information can be found in the online version of this abstract EP14.08: Exploring individuals' preferences for endometriosis diagnostic tests: a mixed methods study T. Yeretsian2, S.M. Freger2, P. Romeo1, J. Maas3, M. Leonardi2 1University of Messina, Messina, Sicily, Italy; 2McMaster University, Hamilton, ON, Canada; 3Institution Maastricht University Medical Center+, Maastricht, Netherlands

Endometriosis is a highly prevalent and often onerous disease, yet its diagnosis remains complex and often delayed. Diagnostic modalities include surgery, histopathology, imaging, and biomarkers, each with distinct advantages and limitations. This study, part of the Individuals' preferences for endometriosis diagnostic tests (IPEDT) initiative, aimed to explore patient preferences for diagnostic approaches to inform best clinical practices and enhance patient-centred care.

The IPEDT study employed a mixed-methods design, initiating semi-structured focus groups involving individuals diagnosed with endometriosis and those referred for evaluation. Data were analysed using grounded theory, involving iterative coding to extract themes. Transcripts were independently reviewed by two authors, with discrepancies resolved through discussion to ensure analytical robustness.

- diagnostic challenges and delays, highlighting prolonged symptom dismissal; - patient advocacy, emphasising proactive roles in seeking diagnosis; - provider expertise and trust, stressing the need for specialised care; - desire for visual confirmation, reflecting preferences for imaging-based validation; - emotional impact, addressing the psychological toll of delayed diagnosis; - diagnostic preferences and risk tolerance, indicating favour for non-invasive methods; - institutional needs for formal diagnosis, underlining its importance for access to care; and - educational needs, calling for improved early symptom recognition.

This study highlights significant patient preferences for non-invasive, timely, and transparent diagnostic methods. Insights will inform the next phase of IPEDT, involving a discrete choice experiment, and guide clinicians in aligning diagnostic practices with patient-centred priorities to optimise care. EP14.09: Dyspareunia in women with symptoms suggestive of endometriosis P. Sladkevicius1, A. Liljefjord1, L. Jokubkiene1 1Department of Obstetrics and Gynecology, Skanes University Hospital, Malmo, Sweden

Dyspareunia, pain during intercourse, is classified as deep, superficial, or combined. Deep dyspareunia is particularly associated with endometriosis, but these women may also have a superficial dyspareunia. This study aims to identify differences in clinical findings among women with symptoms suggestive of endometriosis having deep and/or superficial dyspareunia.

This prospective cross-sectional study included 561 women with dyspareunia and symptoms suggestive of endometriosis, and underwent ultrasound examinations in 2019–2024. Women completed a questionnaire on pain symptoms, with pain intensity measured by visual analog scale (VAS). Endometriotic lesions were identified and described according to the IDEA consensus. Data analysis was performed for groups of women with deep, superficial, or combined dyspareunia and compared for clinical differences. Comparison in women with and without hormonal treatment was also done.

Pain intensity across all symptoms was the lowest in women with superficial dyspareunia compared to those with other dyspareunia groups. In women without hormonal treatment the severe dyspareunia intensity (VAS 71–100) was less frequent in women with the superficial dyspareunia (45.3%) than deep (55.5%) and combined (69.7%) (p = 0.002). Dyschezia and dysuria were less common in the women with superficial dyspareunia than in the deep and combined dyspareunia (p < 0.001 and p = 0.002, respectively). No differences in findings of deep endometriosis lesions were observed between groups of women with different dyspareunia (p = 0.478). Endometriomas were less frequent in the combined dyspareunia group of women (17.2%) than those with the deep (26.0%) or superficial (28.6%) (p = 0.048).

Women with superficial dyspareunia reported lower pain levels for other endometriosis pain symptoms and had less common dysuria and dyschezia compared to women with deep or combined dyspareunia. No differences in ultrasound findings of deep endometriosis lesions were observed between the women having the different type of dyspareunia. EP14.10: Effect of endometriosis lesions in the posterior compartment on patient symptoms L. Jokubkiene1,3, Y. Cerne3, P. Sladkevicius2,3 1Obstetrics and Gynecology, Skane University Hospital, Malmo, Sweden; 2Obstetrics and Gynecology, Lund University, Malmo, Sweden; 3Lund University, Lund, Sweden

Women with endometriosis findings may experience different symptoms and its intensity correlates poorly with the extent of the disease. The aim of our study was to investigate if women with endometriosis lesions solely in the posterior compartment experience different symptoms from women with endometriosis lesion in any location.

Women with symptoms suggestive of endometriosis and adenomyosis underwent transvaginal ultrasound examination according to IDEA consensus. Presence of symptoms (dysmenorrhea, chronic pelvic pain, dyspareunia, dysuria and dyschezia) were self-assessed using visual analogue scale (VAS). Patient symptoms were compared between women having endometriosis lesions solely in the posterior compartment and women with endometriosis in any location in the pelvis.

Out of 490 included patients, endometriosis lesions only in the posterior compartment were found in 75 (15 %, CI 95% 12.4–18.6) patients. In all, 238 patients were on hormonal therapy. Prevalence of endometriosis lesions in solely posterior compartment was higher in patients on current hormonal therapy (46 (19%)) compared to those without (27 (11%)), (p = 0.009). There were no differences in any patient symptom in women with endometriosis lesions solely in the posterior compartment compared to women with lesions in any location.

No association between presence of dysmenorrhea, chronic pelvic pain, dyspareunia, dysuria and dyschezia and location of endometriosis lesions, either solely in the posterior compartment or any location, was observed. Studies with larger patient groups are needed to investigate association between the disease and patient symptoms. EP14.11: Sonographic changes of peritoneal endometriosis lesions in pregnancy: a prospective observational study M. Zajicek1, R. Bahar1, V. Yulzari1, E. Kassif1, N. Gonen1, B. Weisz1, S. Elizur1, E. Berkowitz1 1Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel

Endometriosis lesions may undergo decidualisation in pregnancy, potentially mimicking malignancy. While deep nodules appear hypertrophic and hypervascularised, decidualised endometriomas may present with round, vascularised papillary projections on transvaginal sonography (TVS). This study evaluates the sonographic evolution of peritoneal endometriosis lesions in pregnancy.

This prospective cohort study was conducted at a tertiary hospital from December 2018 to March 2024. Pregnant women with preconception peritoneal endometriosis underwent standardised TVS and Doppler imaging once per trimester and 2–3 months postpartum. Lesions were classified as peritoneal if they had been identified as peritoneal before conception or if, at least once during pregnancy or postpartum, they appeared hypoechogenic (≤5 mm) or as peritoneal irregularities. New lesions >5mm emerging in pregnancy but resolving postpartum were also considered peritoneal.

Eighteen women had preconception peritoneal endometriosis (13 diagnosed surgically, 5 by TVS). During pregnancy, 13/18 (72.2%) had detectable peritoneal lesions, including all five with a preconception TVS diagnosis. In total, 5/18 (27.8%) had vascularised lesions, 8/18 (44.4%) had non-vascularised lesions, and 5/18 (27.8%) had none. Postpartum evaluation in 17 women identified peritoneal lesions in 5 cases. Two lesions observed during pregnancy regressed, while three were newly detected postpartum. One ongoing pregnancy had a lesion that enlarged and became highly vascularised.

Peritoneal endometriotic lesions may enlarge and become vascularised during pregnancy, likely due to decidualisation. These changes appear to be transient and regress postpartum. The number of peritoneal lesions observed during pregnancy was more than twice that seen postpartum, suggesting that hormonal adaptations in pregnancy may enhance peritoneal endometriosis lesions visibility. Further research is needed to determine the clinical significance of these findings. EP14.12: Usefulness of subjective evaluation of the junctional zone on transvaginal ultrasound in the diagnosis of adenomyosis S. Wozniak1, P.R. Szkodziak1, A. Wozniak1, F.P. Szkodziak1, T. Paszkowski1 1Department of Gynecology, Medical University of Lublin, Lublin, Poland

Adenomyosis (AD) is otherwise known as internal endometriosis. In this form of the disease, the endometrial cells are located in the muscular layer of the uterine wall. Patients who suffer from AD usually complain of painful periods and heavy bleeding. AD has its point of grip at the border between the muscular membrane and the mucous membrane of the uterus. Nowadays, non-invasive visualisation methods, primarily 2D and 3D ultrasound and MR imaging, form the basis of initial diagnosis.

We examined 46 women referred to the hospital for surgical treatment for heavy menstrual bleeding, with a preliminary diagnosis of AD. In all the women studied, an endometrial biopsy was performed early to rule out endometrium pathology. Considering that all the patients completed the size of their family were qualified for elective surgery. All women underwent transvaginal ultrasound (TVUS) prior to scheduled surgery to evaluate the junctional zone (JZ) on 3D imaging. JZ is a hormone-dependent zone located between the endometrium and myometrium undergoing cyclic changes in its thickness. In our study, we evaluated the regularity of the JZ outline in ultrasonographic evaluation. TVUS examinations were performed using Samsung Hera W10 Elite or Voluson E10 BT18 GE. All patients underwent histopathological evaluation after surgery to confirm the diagnosis.

Postoperative histopathological evaluation confirmed the presence of AD in 43 of patients studied (93,5%). In the group of patients with histopathologically confirmed AD, JZ irregularity was observed in 39 patients (86,7%). On the other hand, in the group of patients in whom AD was not confirmed on postoperative histopathological examination, the irregularity of the JZ image was not visible on TVUS.

Our experiment, was confirmed that subjective evaluation of the JZ can be a useful TVUS tool in the imaging diagnosis of AD. EP14.13: Abstract withdrawn EP14.14: Umbilical scar endometriosis: a case report on diagnosis and imaging findings J.B. Leão3, J. Leão1, M. Brock Leao2, M.F. Brock1 1Saúde da Mulher, Universidade do Estado do Amazonas, Manaus, Brazil; 2University of South Florida, Tampa, FL, USA; 3Federal University of Minas Gerais, Belo Horizonte, Brazil Deep endometriosis is characterised by infiltration beyond 5 mm and can be classified into typical deep lesions and external adenomyosis nodules. Its prevalence varies depending on diagnostic recognition. Common symptoms include pain, ranging from mild to severe, and infertility. Treatment options include surgical intervention and oral medication. This report presents a rare case of umbilical scar endometriosis, emphasising the importance of the physician-patient relationship in diagnosing endometriosis. A 41-year-old, G0 P0, was referred for transvaginal ultrasound with bowel preparation due to cyclic pelvic pain during the menstrual cycle. She had undergone surgery two years earlier to remove an endometrioma in the left ovary. The transvaginal scan identified an intestinal endometriosis nodule in the sigmoid colon, diffuse adenomyosis, a right ovarian endometrioma, right hematosalpinx, and uterosacral ligament alterations. Abdominal convex probe evaluation showed no new findings. Examination of the abdominal wall revealed a subcutaneous nodular lesion at the previous surgical scar, suggesting endometriosis. Given the patient's report of umbilical pain, a smaller transducer (11 MHz) identified an 8.8 × 7.0 × 6.5 mm intraumbilical endometriotic focus inside the umbilicus (figure 1). Supporting information can be found in the online version of this abstract EP14.15: Mayer-Rokitansky-Küster-Hauser syndrome with adenomyosis in rudimentary horn: a case report T.T. Pham1, H. Phan1, T. Nguyen2 1Diagnostic Imaging, Vietnam National Hospital of Obstetrics and Gynecology, Hanoi, Vietnam; 2Vietnam National Hospital of Obstetrics and Gynecology, Hanoi, Vietnam Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare congenital malformation that affects about 1:4500 female newborns. This syndrome is characterised by complete or partial vaginal agenesis, tubal and uterine-cervical abnormalities. The rudimentary uterus present in MKRH may still have functioning endometrium tissue. Rarely, MRKH has a rudimentary horn and adenomyosis in a rudimentary horn. A 31-year-old female went to Vietnam National Hospital of Obstetrics and Gynecology with primary amenorrhoea. She complained about cyclic low abdominal pain for 2 years, for which she had previously experienced multiple emergency room visits but was misdiagnosed. Transabdominal and transvaginal ultrasonography showed aplasia of the uterus and cervix. Ultrasound findings have shown the presence of two distinct rudimentary uterine horns with functional endometrium and adenomyosis. Ovaries are malpositioned, and there is an endometrioma in each ovary. The kidneys were normal in size and position. Further evaluation was advised. Magnetic resonance imaging findings (MRI) confirmed the diagnosis of MRKH and adenomyosis in the rudimentary horn and endometriosis in both ovaries. MRKH syndrome is a rare disorder described as aplasia of the uterus, cervix, and upper two-thirds of the vagina due to early arrest in the development of the Mullerian duct. Adenomyosis in the rudimentary horn of MRKH syndrome has been reported in the literature; however, in most instances, the proper diagnosis is missed. Patients are either misdiagnosed with endometriosis, ovarian masses, or ovarian fibroma. In conclusion, this was a rare case of MRKH with functioning endometrium in the remnant horn. Non-invasive imaging modalities, such as ultrasound, CT, and MRI, are the first choices for the diagnosis of pelvic tumours. Experienced and skilled imaging physicians are critical in diagnosing MRKH syndrome. EP14.16: Spontaneous hemoperitoneum in endometriosis-complicated pregnancies: a review with case presentations N. Feldman Leidner2, R. Nagar3, J. Hartoov1, I. Wolman1, A. Cohen2, R. Amster4, Y. Gil2, I. Levin2, K.K. Haratz1 1Ultrasound in Obstetrics and Gynecology, Lis Maternity Hospital – Tel Aviv, Medical Center, Tel Aviv-Yafo, Israel; 2Obstetrics and Gynecology, Tel Aviv, Sourasky Medical Center, Tel Aviv-Yafo, Israel; 3Obstetrics and Gynecology, Tel Aviv University, Tel Aviv-Yafo, Israel; 4Lis Maternity Hospital, Tel Aviv-Yafo, Israel Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare but potentially life-threatening complication strongly associated with endometriosis. This review presents 2 contrasting cases highlighting different clinical presentations, management approaches, and outcomes based on bleeding source and timing. The first case involves a 30-year-old primigravida with deep endometriosis who presented at 23 weeks with severe abdominal pain. Imaging revealed hemoperitoneum and a contained ruptured aneurysm of the right uterine artery. The patient remained hemodynamically stable and underwent successful angiographic embolisation, resulting in pregnancy continuation and term vaginal delivery of a healthy infant. The second case describes a 32-year-old woman with surgically treated deep infiltrating endometriosis who presented at 15.5 weeks (IVF pregnancy) with abdominal pain and hematuria. Initially managed conservatively with antibiotics, she subsequently required laparoscopies at 16 and 19 weeks due to persistent hemoperitoneum. Surgical exploration revealed extensive pelvic adhesions (“frozen pelvis”) and actively bleeding endometriotic nodules on uterine surfaces. Despite interventions, the pregnancy could not be salvaged and was terminated at 22 weeks. These cases illustrate how timing, bleeding source, and management approach significantly influence outcomes in endometriosis-related SHiP. Discrete vascular lesions appear amenable to targeted interventions with successful pregnancy continuation, while diffuse bleeding from multiple endometriotic implants presents greater challenges despite repeated surgical interventions. The review emphasises that prompt diagnosis and individualised management strategies based on bleeding etiology are critical for optimising outcomes. A multidisciplinary approach involving obstetricians, interventional radiologists, and surgeons offers the best chance for successful management of this rare but serious complication of endometriosis in pregnancy. EP14.17: Anatomical distribution and clinical features of ovarian and deep endometriosis through specialist ultrasound using #Enzian classification in Peru R. Albinagorta1, P. Llancari2, S. Chacon-Byrne3, J. Castañeda-Apolinario4, E. Rojas2, C. Villanueva4, R. Novoa5 1Centro de Diagnostico Avanzado de Endometriosis y Dolor Pelvico, Lima, Peru; 2Instituto Nacional Materno Perinatal, Lima, Peru; 3University of Valencia, Valencia, Spain; 4Universidad Peruana Cayetano Heredia, Lima, Peru; 5Universidad Peruana de Ciencias Aplicadas, Lima, Peru

Determine the anatomical distribution of ovarian and deep endometriosis (DE) using specialised ultrasound according to #Enzian classification and evaluate some association with clinical characteristics.

Retrospective analysis of 395 consecutive patients who underwent specialised ultrasound by a single expert operator for suspected endometriosis. Anatomical distribution of lesions was described according to #Enzian classification, and the association between main symptoms was analysed using bivariate analysis and multivariate logistic regression.

Main clinical characteristics: mean age (33.1y [16–53]), median time of disease (7y [3–15]), nulliparity (40.5%), prior hormonal treatment (30.8%), prior surgical treatment (44.0%), and infertility (22.2%). DE was identified in 48.8% of the cases. The distribution of lesions according to #Enzian compartments was as follows: O (46.5%); T (68.6%); A (2.2%); B (26.5%); C (14.6%); FA (36.7%); FB (1.5%); FI (2.2%); and FU (1.5%). Negative sliding-sign was significantly more frequent in patients who presented the association of ovarian and DE (82% [p < 0.001]). Regarding the symptoms, heavy menstrual bleeding was the symptom most widely correlated with endometriosis locations, showing links to ovarian, rectovaginal septum, and uterosacral ligament lesions.

Supporting information can be found in the online version of this abstract EP14.18: Novel ultrasound and surgical based endometriosis severity staging systems: a retrospective cohort pilot study J.N. Mak1, A. Eathorne2, P. McClenahan3, A. Gil3, M. Espada4, S. Reid5, C. Uzuner6, G. Condous7 1Gynecology, Nepean Blue Mountains Local Health District, Penrith, NSW, Australia; 2Medical Research Institute of New Zealand, Wellington, Wellington, New Zealand; 3Endometriosis Ultrasound and Advanced Endosurgery Unit, Nepean Hospital, Penrith, NSW, Australia; 4Acute Gynecology Service, Sydney, Medical School Nepean, Eastwood, NSW, Australia; 5Obstetrics and Gynecology, Western Sydney University – Campbelltown Campus, Campbelltown, NSW, Australia; 6Obstetrics and Gynecology, Nepean Hospital, Penrith, NSW, Australia; 7Obstetrics and Gynecology, Acute Gynecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia

Primary: Develop novel endometriosis severity staging systems with both ultrasound and surgical arms, using multi and univariate analysis. Secondary: Internally validate the novel systems for agreement with surgical complexity, compare performance with existing systems.

Phase 1: Retrospective cohort study, database of women with prospectively collected ultrasound and surgical endometriosis features. AAGL surgical complexity level (A-D) apportioned. Univariate and multivariate analysis to identify features that best predict surgical complexity. Novel ultrasound and surgical based staging systems then developed, including threshold based, decision tree based, 3 and 4 stage systems. Phase 2: Internal validation. Assessors blinded to surgical complexity level staged each woman according to 8 novel systems + four known systems (rASRM), and AAGL, UBESS, mUBESS. Concordance of staging systems and surgical complexity assessed by kappa, weighted kappa, accuracy, sensitivity, and specificity.

Phase1: n = 586 after 54 excluded (negative for endometriosis). Divided into test set and validation set. Based on univariate analysis, 8 novel staging systems developed. Phase 2: Weighted kappa (+ 95% CI) for each system were; Surgical based: 3 stage tree 0.78 (0.57–0.74), 4 stage tree 0.66 (0.57–0.74), 3 stage threshold 0.67 (0.62–0.71), 4 stage threshold (0.54–0.63), AAGL 0.44 (0.39–0.50), rASRM 0.40 (0.35–0.46). Ultrasound based: 3 stage tree 0.53 (0.43–0.63), 4 stage tree 0.59 (0.50–0.68), 3 stage threshold 0.53 (0.48–0.58), 4 stage threshold 0.50 (0.45–0.55), 3 stage UBESS 0.51 (0.46–0.56), 4 stage mUBESS 0.42 (0.37–0.47).

Experimental endometriosis staging systems can be developed using univariate analysis. Multivariate ordinal regression was unsuccessful, given the large number of predictors. Internal validation showed that these systems have potential to outperform existing systems for predicting surgical complexity. A larger, prospective study is needed to confirm these findings and assess prediction of pain/fertility. EP14.19: Uterosacral ligament assessment skill acquisition: assessing learning curves in identifying uterosacral ligaments and endometriosis on ultrasound D. Nassar2, S.M. Freger1, M. Leonardi1 1McMaster University, Hamilton, ON, Canada; 2University of California Los Angeles, Los Angeles, CA, USA

Accurate identification of the uterosacral ligaments (USLs) and associated endometriosis is crucial for diagnosis and management. However, many minimally invasive gynecologic surgery (MIGS) fellows lack formal training in advanced transvaginal ultrasound (TVUS), resulting in variable skill acquisition rates. Understanding the learning curves for USL identification on TVUS can inform competency-based training programs.

This retrospective study evaluated three first- and second-year MIGS fellows (T1, T2, T3) without formal advanced ultrasound training. Fellows performed TVUS as part of routine practice following independent review of educational materials on USL identification. Each scan was compared in real-time to an expert standard. Learning progress was assessed using learning curve cumulative sum (LC-CUSUM) analysis (H = 7, H0/P0 = 0.2, Ha/P1 = 0.05, K = 0.5, with adjusted baselines).

Fellows T1 and T2 achieved competency thresholds, with T1 requiring more scans but maintaining competency thereafter. T3 consistently fell short of the threshold. For left USL identification, T1 and T2 showed steady improvement above the competency threshold, while T3 did not. In the right USL assessment, T1 and T2 maintained high scores, contrasting with T3's performance. USL endometriosis prevalence was 46.5% (right) and 43.3% (left). The variability in performance suggests that some trainees can achieve competency with practice while others may need additional support.

The study highlights significant variability in the acquisition of TVUS skills for USL identification among MIGS fellows. The gradual improvement in accuracy with practice suggests potential for progressive skill development. Individualised training strategies may be beneficial to ensure all trainees reach competency in USL assessment. EP14.20: “Too young to have endometriosis”: what transvaginal ultrasound reveals about the prevalence of endometriosis within an adolescent population A. Deslandes1, C. Panuccio2, J. Avery1, H. Chen3, G. Condous1,4, M.L. Hull1 1Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia; 2Specialist Imaging Partners, Adelaide, SA, Australia; 3University of Adelaide Faculty Sciences Engineering and Technology, Adelaide, SA, Australia; 4Endometriosis Ultrasound and Advanced Endosurgery Unit, Napean Hospital, University of Sydney Nepean Clinical School, Sydney, NSW, Australia

Transvaginal ultrasound (TVUS) is a valuable diagnostic tool in the investigation of endometriosis. However, most studies of this technique have been conducted within an adult population. As such, our understanding of the value of TVUS for teenagers is limited. This retrospective audit aimed to evaluate the prevalence and subtype of endometriosis in adolescents undergoing TVUS.

The ultrasound reports of all people aged 10–19 years who presented for gynecological ultrasound for any reason between January 2022 and December 2024 were reviewed. Information regarding whether endometriosis was detected, subtype and location was collected.

The study revealed 376 records of gynecological ultrasound for people aged 10–19 years (mean 17.45 years), 49.2% (n = 185) of whom underwent TVUS in line with the International Deep Endometriosis Analysis (IDEA) group consensus (eTVUS). Endometriosis was detected in 18.3% (n = 34/185). Superficial endometriosis (SE) was detected in 9.7% (n = 18/185), deep endometriosis (DE) in 9.7% (n = 18/185) and ovarian endometriomas in 0.5% (n = 1/185). The most common location of DE was the uterosacral ligaments. All cases of SE were detected in the POD. The youngest person to have endometriosis detected was 15.36 years. The distribution of endometriosis detection and subtype by age is shown in figure 1.

Supporting information can be found in the online version of this abstract EP14.21: Abstract withdrawn EP14.22: Failure rate of transvaginal ultrasound amongst adolescent people aged 16–19 years A. Deslandes1,2, C. Panuccio2, J. Avery1, H. Chen3, G. Condous1,4, M.L. Hull1 1Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia; 2Specialist Imaging Partners, Adelaide, SA, Australia; 3School of Mathematical and Computer Sciences, University of Adelaide, Adelaide, SA, Australia; 4Endometriosis Ultrasound and Advanced Endosurgery Unit, Napean Hospital, University of Sydney Nepean Clinical School, Sydney, NSW, Australia

Transvaginal ultrasound is a valuable diagnostic tool in the investigation of gynecological conditions, yet hesitance to offer TVUS to adolescents exists due to concerns about the appropriateness and tolerability of this examination. This retrospective audit aimed to evaluate the failure rate of TVUS amongst adolescent people who consented for the examination.

A retrospective cohort study was performed. Ultrasound reports of all people aged 16–19 years who presented for gynecological ultrasound, for any reason between January 2022 and December 2024 were reviewed. Transvaginal ultrasound (TVUS) was routinely offered at this examination in line with local consent rules and TVUS was offered irrespective of history of prior penetrative sexual intercourse. Information regarding whether TVUS was attempted and successful was collected.

The study revealed 296 records of gynecological ultrasound for people aged 16–19 years (mean 18.26 years, range 16.06–19.90). Of these, 52.7% (n = 156/296) underwent TVUS only, 34.5% (n = 102/296) TAUS only and 12.5% (n = 37/296) TAUS+TVUS. TVUS was attempted in 208/296 (70.3%) but was unable to be performed 15 (7.8%, CI 4.4–11.6%), with failure to be able to insert the transducer due to pain the cause of all failures. There was no association between age and TVUS failures (p = 0.286) (figure 1).

Supporting information can be found in the online version of this abstract EP14.23: Ultrasound monitoring of female genital tuberculosis with bilateral tubo-ovarian abscess but unaffected endometrial cavity A.J. Sigue1, B.L. Balaguer1, P.M. Kho1 1Obstetrics and Gynecology, St Luke's Medical Center Global City, Taguig, City, Philippines A 28-year-old G1P1 (1001) with a history of pulmonary tuberculosis (TB) presented with chronic pelvic pain. Ultrasound showed tubo-ovarian abscess on the right adnexa, 5.25 × 3.84 × 5.44 cm in size and tubo-ovarian complex on the left adnexa, 5.93 × 3.84 × 5.44 cm in size. Endometrium measures 14.6mm, uniform homogeneous, hyperechoic, linear midline echo, with regular endomyometrial junction, colour score = I, no flow. Endometrial biopsy was negative for tuberculosis, but histopathology of the tubo-ovarian complex confirmed chronic granulomatous inflammation with necrosis. MTB DNA of pelvic fluid was positive. Currently, patient is being treated with anti-TB therapy for 12 months, with monthly ultrasound monitoring for disease progression. Latest transvaginal ultrasound showed elongated, thick-walled structures with low level echoes, to consider pyosalpinges measuring as follows: medial to the right ovary measuring 1.8x 2.2x 1.3cm and lateral to the left ovary measuring 2.7x 2.4x 1.7cm. Genital TB affects the fallopian tube in 90–100% of the cases and rarely does it not involve the endometrium which commonly affects 50–70% of the cases (Sharma et al., 2018). The abundant blood supply and extensive lymphatic drainage of the fallopian tubes make it highly susceptible to tuberculosis, while the limited blood supply, restricted lymphatic drainage, and cyclical shedding of the endometrium offer protection against persistent TB infection (Jones & Lukies, 2018). Transvaginal ultrasound aids in the diagnosis of pelvic inflammatory disease (PID) with 81–100% specificity and 78–100% sensitivity (Sharma et al., 2021). Genital TB may present with sonographic findings similar to PID, including tubo-ovarian masses, adnexal adhesions, endometrial fluid collection, calcifications, and synechiae. Transvaginal ultrasound is also essential for monitoring disease progression, as persistent masses or newly affected gynecologic structures may indicate treatment failure. EP14.24: Ultrasound-guided microwave ablation for abdominal wall endometriosis: a novel minimally invasive approach T. Ee Ping1, D. Sue-Jian1, S. Jaafar1 1Department of Women Health, Hospital Picaso, Selangor, Malaysia

Abdominal wall endometriosis (AWE) is a rare condition involving subcutaneous deposits of endometrial tissue. While conventional management typically involves surgical excision, microwave ablation (MWA) has emerged as a minimally invasive alternative. This case series examines ultrasound-guided MWA in eight patients (mean age: 39 years) presenting with symptomatic AWE.

All patients had well-defined, ultrasound-visible lesions (mean baseline volume: 1.4 cm3) causing cyclical pain. Under continuous ultrasound guidance, a microwave antenna was positioned to deliver targeted thermal energy, minimising injury to surrounding tissue. Lesion volume reduction and symptom resolution were assessed at 1 week, 1 month, 3 months, and 6 months post-procedure.

Volumetric analyses showed marked shrinkage: a 51% reduction at 1 week, 69% at 1 month, 92% at 3 months, and 96% at 6 months. Clinical symptoms improved in parallel, with complete pain resolution reported by all patients. No reinterventions were required, indicating effective treatment. Minor procedural discomfort and transient local tenderness were the only adverse effects, and all patients were discharged the same day.

This case series underscores the value of real-time ultrasound guidance in ensuring precise ablation and preserving normal tissue. By offering rapid symptom relief and substantial lesion volume reduction, MWA addresses key limitations of surgical excision which can be complex especially in larger lesions situated at the rectus sheath or muscle. The favourable safety profile and efficacy observed suggest that ultrasound-guided MWA may be a valuable, minimally invasive option for AWE. Larger studies are needed to standardise protocols and confirm these promising outcomes. EP14.25: Co-designing artificial intelligence-enhanced ultrasound training for endometriosis: a thematic analysis of end-user perspectives A. Deslandes1, J. Avery1, H. Chen2, M. Leonardi3,1, G. Condous1,4, M.L. Hull1 1Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia; 2University of Adelaide Faculty Sciences Engineering and Technology, Adelaide, SA, Australia; 3Department of Obstetrics and Gynecology, McMaster University Faculty of Health Sciences, Hamilton, ON, Canada; 4Endometriosis Ultrasound and Advanced Endosurgery Unit, Napean Hospital, University of Sydney Nepean Clinical School, Sydney, NSW, Australia

Artificial intelligence (AI) is playing an ever-increasing role in medical ultrasound. It has the potential to revolutionise ultrasound training, addressing the significant learning curve associated with performing transvaginal ultrasound for endometriosis (eTVUS). However, the effective integration of AI in ultrasound education requires input from end-users. To explore this, we conducted a co-design workshop to inform the development of an AI-driven training tool for eTVUS.

A co-design workshop was held on 4 October 2024 via Zoom as part of an iterative co-design process. The workshop included 20 participants from 11 countries, including sonographers, radiologists, gynecologists, ultrasound educators and trainees. The workshop was led by a facilitator experienced in co-design. Participants engaged in structured activities to address the following: How AI could address current challenges with learning and be integrated into training; and How such a tool would look, feel and function? Participants were also encouraged to “brain dump” future focused ideas to improve training with technology solutions. Discussions were video-recorded and transcribed verbatim using AI transcription software. A thematic analysis was conducted using an inductive approach, with data independently coded to identify recurring themes.

- Simulation; - Provide feedback; - Anatomy identification assistance; and - Disease recognition assistance. - Be on accessible platforms; - Provide real-time feedback; - No barrier with cost; - Provide staged training; and - Have a human element.

Ultrasound users would want AI tools to assist with feedback and pattern recognition in the training of eTVUS. Discussion indicated tools need to be accessible and provide feedback on skill development with a need to retain a human element in AI tool development. EP14.26: Is non-invasive diagnosis of endometriosis by imaging possible? S. Guerriero1, I. Rodríguez2, M. Pascual2, B. Graupera2, M. Pagliuca1, C. Lai3, S. Ajossa3, J. Alcazar4, L. Saba3 1Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy; 2Obstetrics, Gynecology and Reproduction, Institut Universitari Dexeus, Barcelona, Spain; 3University of Cagliari, Cagliari, Italy; 4Obstetrics and Gynecology, University of Navarra, Pamplona, Spain

The aim of the present study is to evaluate the role of the combination of transvaginal ultrasonography (TVS) and magnetic resonance (MR) in the diagnosis of deep endometriosis.

Patients with a high suspicion of deep endometriosis due to the presence of severe dysmenorrhoea underwent transvaginal ultrasonography (TVS) and magnetic resonance (MR). The different sites were evaluated according to the IDEA protocol in the rectosigmoid, forniceal, rectovaginal septum, uterosacral ligaments and bladder. We also evaluated for the presence of adenomyosis according to MUSA criteria.

We included 174 patients in the present study (mean age + SD: 34+9 years). In 121 patients with an ultrasound diagnosis of endometriosis (deep endometriosis and/or adenomyosis) the concordance with MR was 93%. In 53 patients, the ultrasound was negative, and MR showed the presence of endometriosis and/or adenomyosis in a further 41 patients (77%). These patients were younger than the ultrasound positive patients (31+8 years versus 36+8 years, p < 0.001). Specifically, in these patients, MR revealed a lesion in the uterosacral ligament in 24 (45%) and a forniceal lesion not seen on TVS in 12 (23%). Only 12 patients seem to be negative with both techniques (7%).

In a population at high risk for the presence of endometriosis and adenomyosis, the combined use of TVS and MR allows the identification of lesions in patients negative on ultrasound in most cases, defining a fundamental role for the combination of imaging techniques mainly in patients with negative ultrasound evaluation. EP14.27: Abstract withdrawn EP14.28: Vaginal vault endometrioma presenting as postcoital bleeding C.A. Valdelamar2, B.M. Salas Ramirez1, Y. Shih Chiou2, C.D. Quiroz-Soto2, S. Córdoba-Vives3, Y. Chang-Castro3 1Gynecology and Obstetrics, Caja Costarricense de Seguro Social, San José, Costa Rica; 2Gynecology, Caja Costarricense de Seguro Social, San José, Costa Rica; 3Maternal-Fetal Medicine, Caja Costarricense de Seguro Social, San José, Costa Rica A 45-year-old patient, carrier of May Thurner Syndrome, with a history of total abdominal hysterectomy with ovarian conservation due to myomatosis, consulted 10 years later with a history of postcoital bleeding, vaginal bleeding and dyspareunia. A gynecologic exam was performed, the speculoscopy revealed a violaceous nodule in the vaginal vault. The transvaginal ultrasound showed a homogeneous hypoechoic nodule with irregular edges measuring 18 × 13 × 14 mm without peripheral vascularisation which did not appear to involve neighbouring structures, in relation with a probable endometriotic nodule in the vaginal vault. Due to these findings, an exploratory laparoscopy was performed. The endometrioma was located in the superoposterior third of the vaginal vault and ressected. Supporting information can be found in the online version of this abstract EP14.29: Endometriosis in African women: findings from a cohort of reproductive age women attending an endometriosis ultrasound training program U. Menakaya1 1Acute Gynecology, Early Pregnancy and Advanced Endoscopic Unit, Nepean Hospital Australia, Penrith, NSW, Australia

To report the findings from a cohort of reproductive age women attending a capacity building program in endometriosis ultrasound in Sub Saharan Africa.

A capacity-building workshop in endometriosis ultrasound was conducted for reproductive health care practitioners in Nairobi Kenya. The workshop included theoretical and practical training on TVUS for endometriosis, utilising pelvic ultrasound phantoms and live scanning sessions. The program was adapted from the ISUOG advanced ultrasound training program. Women with clinical symptoms of endometriosis were recruited via social media and invited to attend the live scanning sessions. An inclusion and exclusion criteria were used to identify women for invitation. Data were collected from 34 participants who underwent TVUS during the live scanning sessions. Demographic data and ultrasound findings were recorded and analysed.

The mean age of participants was 29 years, with 73.5% being nulliparous. All participants reported severe dysmenorrhea, and 85.3% experienced non-cyclical pelvic pain. TVUS findings revealed adenomyosis in 86% and deep endometriosis in 54% of participants. Of these, 20.6% had endometriomas, 38% had non-bowel deep endometriosis, and 23.5% had bowel deep endometriosis. Participants with a history of prior surgery for endometriosis were significantly more likely to have higher-stage disease, particularly bowel endometriosis.

The high prevalence of significant endometriosis-related pathologies despite prior surgeries highlights the need for continuing training in endometriosis ultrasound in sub-Saharan Africa. Social media recruitment was effective in the region, indicating growing recognition of endometriosis symptoms among young African women. EP14.30: Does the size of rectosigmoid endometriosis lesions and the status of pouch of Douglas on ultrasound affect prediction of disease in this location? M.K. Alotaibi1, A. Eathorne3, M. Armour2, G. Condous1 1Obstetrics and Gynecology, Nepean Blue Mountains Local Health District, Penrith, NSW, Australia; 2Western Sydney University, Penrith, NSW, Australia; 3Medical Research Institute of New Zealand, Wellington, New Zealand

The aim of this study was to evaluate the effect of the increasing size of rectosigmoid deep endometriosis (DE) lesions and the status of the pouch of Douglas (POD) on transvaginal ultrasound (TVS) to predict disease these locations.

This was a retrospective multicentre study. Patients with possible endometriosis in the rectosigmoid who had complete ultrasound, surgical and histological data were included in final analysis. All bowel with maximal diameter in longest plane ≥ 5 mm, ≥ 10 mm, ≥ 15 mm, ≥ 20 mm, ≥ 25 mm, ≥ 30 mm on TVS were included. The presence of a positive or negative ‘sliding’ sign (marker for POD obliteration) was also recorded. We then examined the data to assess the performance of TVS to predict rectosigmoid DE when the POD was predicted to be either non-obliterated or obliterated. Reference standard was histological confirmation of endometriosis. The overall performance of ultrasound to predict DE in the rectosigmoid were determined using the area under the receiver operating curve (AUC). Data were analysed using SAS version 9.4.

190 lesions for rectosigmoid were identified. The AUCs for prediction of rectosigmoid without and with POD obliteration were 0.58 and 0.60, respectively. As DE lesion size on ultrasound increases for rectosigmoid specificity and PPV increase but sensitivity decreases.

POD obliteration is associated with improved diagnostic performance of ultrasound in predicting rectosigmoid DE. EP14.31: Focaccia-shape abdominal wall hematoma L. Savelli2, R. Arianna1, S. Di Santo2, L. Pace1, L. Spanò Bascio1, A. Aru1, E. De Crescenzo1, G. Magnarelli1, F. Varliero1, I. Giaquinto1, G. Sergenti2, E. Fontana1 1Morgagni-Pierantoni Hospital, Forli, Italy; 2Obstetrics and Gynecology, University of Bologna, Bologna, Italy

To describe the ultrasound features of abdominal wall hematomas that can occur as complication of open abdominal gynecological surgery.

Ten consecutive women with an ultrasound diagnosis of abdominal wall hematoma were included in the study. All the patients underwent open gynecological surgery for different indications between January 2024 and December 2024 and were evaluated after abdominal pain or swelling was reported. The collection was sonographically evaluated by means of transabdominal 3.5–5.0 Mhz probe by one expert operator who followed up the patients until resolution. Position, size, echotexture of the hematoma were measured and described.

All women (mean age 47.8 yrs, range 61–26) presented with abdominal pain and a palpable abdominal mass; fever was present in 4/10 cases (40%) and 9/10 (90 %) of them had a drop of hemoglobin compared to postoperative level (mean: 3.8 g/dl). Two patients (20%) were obese (BMI > 30) and 3 out of 10 patients (30%) had a malignant histological diagnosis after surgery. Three patients (30%) had a Kustner laparotomic incision while seven women had a Pfannestiel incision (70%). Time lapse from surgery to diagnosis was 12.5 days. The mean diameters of the hematoma were: 86 mm in longitudinal diameter, 50 mm anteroposterior diameter and 62 mm in transverse diameter (longitudinal range: 60–140 mm, anteroposterior range: 23–80 mm, transverse range: 20–100 mm). In six cases the hematoma was located above the abdominal fascia and in 4 cases beneath. In all women the collection was hypoechoic, not vascularised at power Doppler, while in 2/10 cases hyperechoic spots were found in the context of the mass. These ultrasound features resembled a “focaccia-shape” collection. All women underwent drainage of the fluid collected confirming the ultrasound diagnosis and excluding the presence of an abscess or incisional hernias or hemoperitoneum.

Abdominal wall hematomas can occur after laparotomic surgery and show peculiar features at transabdominal ultrasound which can help in the differential diagnosis with other conditions. EP14.32: Use of intraoperative ultrasound to aid in diagnosis and management of unusual endometrioma R. Nagar1, S. Aharoni2, M. Leonardi2 1Obstetrics and Gynecology, Tel Aviv University, Tel Aviv-Yafo, Israel; 2McMaster University, Hamilton, ON, Canada Ovarian endometriomas, have a distinct sonographic appearance However, various ovarian and non-ovarian pathologies, can mimic their appearance, leading to diagnostic challenges A 41-year-old woman with a regular menstrual cycle presented with severe dysmenorrhea, deep dyspareunia, cyclic dyschezia, bloating, and catamenial rectal bleeding. Over time, her symptoms worsened. Transvaginal ultrasound identified adenomyosis, superficial endometriosis in the bladder peritoneum and rectouterine pouch, and a deep endometriotic nodule in the rectouterine pouch, with no bowel or ovarian involvement Laparoscopic total hysterectomy, bilateral salpingectomy, and excision of endometriosis were planned. Intraoperative ultrasound revealed a new 14 × 12 × 12 mm unilocular cystic lesion with a “ground glass” appearance near the uterus, distinct from the ovary. Laparoscopy-guided intraoperative transvaginal ultrasound was repeated. Using Reverse Trendelenburg positioning, the lesion was identified as a normal segment of the small bowel. Surgery proceeded without complications. In this case, a targeted ultrasound examination under general anesthesia revealed a cystic pelvic lesion not previously identified. Although the lesion's “ground glass” appearance suggested an endometrioma, its separation from the ovary and absence on earlier imaging prompted a broader differential diagnosis This case exemplifies the diagnostic complexity and clinical variability of endometriosis—or when something mimics endometriosis but is not. The necessity of side-by-side use of transvaginal ultrasound and laparoscopy emphasises the limitations of imaging modalities alone, particularly when sonographic findings are unusual, and the importance of integrating multiple diagnostic techniques, including surgery. In future instances, when an endometrioma-appearing structure does not have classic features, bowel can be considered as an alternative structure being visualized. EP14.33: Bilateral pyosalpinx: a rare and challenging diagnosis M. Preet1, L. Kaur1 1Fetal Medicine, Prime Diagnostic Centre, Chandigarh, India Supporting information can be found in the online version of this abstract EP14.34: Challenges associated with learning to perform transvaginal ultrasound for endometriosis: does artificial intelligence have a role? A. Deslandes1, J. Avery1, R. O'Hara1, H. Chen3, M. Leonardi4, G. Condous1,2, M.L. Hull1 1Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia; 2Gynecology, Nepean Hospital, Hamiton, ON, Canada; 3University of Adelaide Faculty Sciences Engineering and Technology, Adelaide, SA, Australia; 4Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada

Performing transvaginal ultrasound (TVUS) to detect endometriosis (eTVUS) carries a significant learning curve. Artificial intelligence (AI) holds potential to assist with teaching ultrasound skills. This study aimed to investigate current training health professionals are undertaking for eTVUS, identify barriers/ enablers encountered to performing eTVUS, and understand how AI tools could help fill these gaps.

A global online cross-sectional survey of health professionals who perform TVUS was performed. The survey contained a combination of multiple choice and free-text questions regarding demographics information, experience and training undertaken for eTVUS, familiarity with AI in ultrasound and feelings of participants towards how AI could help with learning and performing eTVUS.

Four hundred and seven responses, from 33 different countries were included. The survey revealed Online self-directed learning (53.3%) was the most undertaken training method while Working with a skilled mentor was rated as the most helpful training method (mean 4.49 [range, 3–5]) as well as being the most desired, yet most difficult to access (42.3%). Lack of confidence in recognising the appearance of endometriosis on ultrasound (37.1%) and Inadequate training/ education in the eTVUS technique (37.1%) were the most common barriers reported. Training/ education in the eTVUS technique was the strongest facilitator (58.7%). Most respondents (64.3%) stated they would use an AI tool to assist with learning eTVUS if available. Overwhelmingly, respondents desired a tool built into an ultrasound machine (56.6%) to help recognise disease (68.3%).

Most healthcare professional undertook online self-directed learning to perform eTVUS, with access to skilled mentors challenging, presenting a significant barrier to eTVUS implementation. However, education facilitates successful implementation of eTVUS into clinical practice and most professionals would use AI tools for learning eTVUS if available. EP14.35: A survey on the classifications of endometriosis: current practice among the ISGE members B. Ferro2, G. Noé5,6, B. Van Herendael3,4, D. Djokovic1,7 1Hospital CUF Descobertas, Lisbon, Portugal; 2Unidade Local de Saude de Coimbra, Coimbra, Portugal; 3Hospital on the River (ZAS), Antwerp, Belgium; 4University of Insubria, Varese, Italy; 5Rheinland Klinikum Dormagen, Dormagen, Germany; 6Universitat Witten/Herdecke, Witten, Germany; 7Universidade Nova de Lisboa Medical School, Lisbon, Portugal

To explore current attitudes towards endometriosis classifications among members of the International Society for Gynecologic Endoscopy (ISGE) while identifying potential barriers to their use.

An anonymous electronic survey was sent to the ISGE members between September 1 and October 31, 2024 to gather data on physician demographics, clinical experience, familiarity with endometriosis classification systems, preferences and perceived barriers. Responses were analysed using descriptive statistics and Fisher's exact test for categorical variables.

We received 116 responses (response rate: 22.1%), with the majority of participants (80.2%) having over five years of clinical experience and 44.0% working in certified endometriosis centres. The most common areas of clinical activity among responders were General Gynecology (66.4%), Endometriosis (46.6%) and Oncological Gynecology (43.1%). Most participants performed endometriosis operations (>5 cases per month). The preferred classification system was the #Enzian (75%), followed by the rASRM (16.4%), EFI (6.0%) and AAGL classification (2.6%). Regarding available endometriosis classification systems, reported limitations included lack of user-friendliness (25.9%), reproducibility (8.6%) and clinical relevance (7.8%). Only 38.8% of respondents were familiar with the #Enzian-based ISGE recommendation for structured reporting of ultrasound findings in patients with suspected or known endometriosis.

This study highlighted a strong preference for the #Enzian classification among the ISGE members, reflecting its applicability in both non-invasive and invasive procedures. Future improvements should particularly focus on the ease of use and reproducibility of the endometriosis classification system. EP14.36: Some pitfalls in our everyday endovaginal ultrasound M. Amaral1,2, A.J. Meireles3, L. Guzzi1, M. Simoes4 1Radiology, Unique by Amaral Costa, Belém, Brazil; 2Radiology, Hospital da Mulher do Pará, Belém, Brazil; 3Pronatus, Belem, Brazil; 4Santa Casa de Misericordia do Para, Belém, Brazil

Ultrasound is an excellent low cost highly accurate method for investigating endometriosis when performed by an experienced examiner. One of the patients biggest problems faced is the difficulty finding qualified professionals to diagnose and map the lesions. Our goal is to create describe some pitfalls and strategies to avoid them in everyday life.

We searched PubMed for articles published from 2000 to 2023 using the following search terms: “PITTFALLS” or “endometriosis ultrasound”.

Endometriosis in the ovarian fossa and the fallopian tube: endometriotic thickening in the ovarian fossa presents as irregular and hypoechoic tissue in the peritoneum with ecogenic points and is localised in the anterior wall, otherwise the tube are hipoecogenic, opens medially into the upper angle of the uterus and are located superior/anterior to the ovaries, and can be elongated. Hemorrhagic cyst and endometrioma: sometimes both can be hypoechogenic, however hemorrhagic cysts may present vascularisation in a peripheral halo and usually regress within 8 weeks, while endometrioma persist with the same pattern in successive menstrual cycles and don't have vascularisation. Intra-ligamentous myoma and endometriosis in the round ligament: leiomyomas presents as a more homogeneous nodular image, with peripheral flow on Doppler, while endometriosis of the round ligament demonstrates a more irregular shape with echogenic focus and no flow on Doppler.

Supporting information can be found in the online version of this abstract EP14.37: Synchronous diaphragmatic, intestinal, bladder, appendicular, ureteral and ovarian endometriosis E. Luna Ramírez1, Y. Fernández de Lara Barrera2, M. López Ramírez3, C. Zapico Ortiz4, C. Coria Garcia6, E. Pérez Morales8, R. Reyes-Perez7, L. Becerril Cholula5 1MIGS and Robotics, ENDO-LUNA, Mexico City, Mexico; 2Radiology, ENDO-LUNA, Mexico City, Mexico; 3Colorectal Surgery, ENDO-LUNA, Mexico City, Mexico; 4Urogynecology, ENDO-LUNA, Mexico City, Mexico; 5Pathology, Angeles Lindavista Hospital, Mexico City, Mexico; 6Reproductive Medicine, ENDO-LUNA, Mexico City, Mexico; 7Anesthesiology, ENDO-LUNA, Mexico City, Mexico; 8Gynecologic Oncology, ENDO-LUNA, Mexico City, Mexico Extragenital endometriosis is a rare condition that can affect multiple organs of the body. The involvement of multiple distant sites is rare. The prevalence of diaphragmatic endometriosis ranges from 0.67% to 4.7%. We present a case of synchronous diaphragmatic, intestinal, bladder, appendicular, ureteral, and ovarian endometriosis. A 47-year-old woman presented with dysmenorrhea, heavy menstrual bleeding, and a history of chronic pelvic pain, and right upper quadrant pain during menstruation. In 2021, she underwent laparoscopic left inguinal hernioplasty, where she was diagnosed with frozen pelvis. She presented to the ENDO-LUNA laparoscopy unit for endometriosis treatment on August 27, 2024. Ultrasound mapping of the endometriosis was not performed due to her numbness and her refusal to undergo transanal examination. Therefore, a pelvic MRI was ordered for an endometriosis protocol with diaphragmatic add-on. The MRI showed Enzian Px, O1/1, T3/3, A0, B2/2, C0, FA, multifocal sigmoid IF, and FD1. Specifically, in the diaphragm, two subcapsular cystic images measuring 4 mm and 5 mm were observed adjacent to the hepatic dome, with no methemoglobinemia or fibrous tissue. The patient was scheduled for robotic-assisted laparoscopic total hysterectomy (RTH). During surgery, the entire abdomen was inspected, identifying three superficial endometriotic lesions on the right diaphragmatic dome. A multidisciplinary team, including colon and rectal surgery, gynecologic urology, and minimally invasive gynecologic surgery, performed resection of all foci of endometriosis in the abdomen. There were no intraoperative or postoperative complications. The final pathology report reported: diaphragmatic endometriosis: soft tissues with histological findings consistent with endometriosis. Diaphragmatic endometriosis is a rare condition that should be suspected for early diagnosis, even if the MRI findings are non-conclusive. A multidisciplinary is necessary to achieve a complete surgery. EP14.38: Value of transvaginal ultrasound in diagnosing deep infiltrating endometriosis of the bowel Y. Wang1, H. Wang1 1Ultrasound, Peking University Shenzhen Hospital, Shenzhen, China

This study aimed to comprehensively evaluate the diagnostic performance, limitations, and potential pitfalls of systematic transvaginal ultrasound examination in detecting and characterising deep endometriosis (DE) of the bowel. We sought to identify specific sonographic features that might lead to misdiagnosis and establish improved criteria for differential diagnosis.

All patients underwent detailed systematic transvaginal ultrasound evaluation using a standardised protocol focusing on the anterior and posterior compartments. Nine patients with ultrasound features suggestive of bowel DIE were included in this analysis. All patients subsequently underwent laparoscopic surgery. Ultrasound findings were compared with surgical observations and histopathological results to determine diagnostic accuracy and characterise imaging features associated with false-positive diagnoses.

Of the nine patients diagnosed with bowel DE by systematic ultrasound examination, histopathological confirmation was obtained in only 4 cases (44.4%). In 4 other cases (44.4%), the surgical and histopathological findings revealed adhesions between the bowel and posterior uterine surface. These adhesions demonstrated sonographic characteristics remarkably similar to DE, including hypoechoic irregular thickening and reduced sliding sign. The remaining case (11.2%) was unexpectedly diagnosed as a laterally spreading tumour (LST) of the rectum upon histopathological examination, which had presented sonographically as a hypoechoic, heterogeneous lesion with irregular margins mimicking DE.

Transvaginal ultrasound is valuable in diagnosing deep infiltrating endometriosis of the bowel, but distinguishing bowel DIE from uterine-bowel adhesions remains challenging. Combining clinical presentation and other imaging modalities can enhance diagnostic accuracy. EP14.39: Experience of adolescents and virginal patients undergoing transvaginal ultrasound with a miniature probe R. Shetty1, M. Gholiof1, S. Aharoni1, M. Leonardi1 1Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada

This study aims to assess the experience of adolescents and virginal patients undergoing transvaginal ultrasound (TVS) with a miniature probe, a less invasive alternative that may enhance diagnostic accuracy and patient acceptance. The primary objective is to assess pain levels during TVS. Secondary objectives include evaluating comfort, anxiety, autonomy in the diagnostic journey, and awareness of endometriosis diagnostic tools, including TVS.

This hybrid cross-sectional survey will recruit 152 adolescents and virginal patients with chronic pelvic pain and/or endometriosis-related symptoms undergoing TVS. Recruitment will occur at McMaster University and SUGO clinic in Hamilton, Canada. Pain will be measured using a numeric rating scale, comfort via a 5-point Likert scale, anxiety with the State-Trait Anxiety Inventory, and autonomy/awareness through survey questions.

Data collection is ongoing, with results expected in the coming months, well before the conference. To our knowledge, this is the first study exploring the experience of adolescents and virginal patients undergoing TVS with a miniature probe for the assessment of pelvic pain and endometriosis-related symptoms. Findings will provide critical insights into patient acceptance, perceived discomfort, and psychological responses, helping to identify factors that influence willingness to undergo TVS in this population.

Understanding patient experiences with TVS using a miniature probe will help identify barriers to its use, including cultural concerns, misconceptions, and clinician communication strategies. These findings will contribute to improving patient-centred care and refining approaches to gynecologic imaging in this population. By assessing pain levels, anxiety, and awareness of endometriosis diagnostic tools, this study aims to inform best practices for integrating miniature probes into diagnostic pathways, ultimately helping to reduce delays in endometriosis detection and improve care for underserved patients. EP14.40: Transvaginal ultrasound findings in colouterine fistula due to colonic diverticulitis: a case report C. Norambuena1,2, J. Peragallo1,2, M. Cornejo1,2, F. Schlageter1,2, B. Neira1,2, P. Quiñones1,2 1Hospital El Carmen de Maipu, Santiago, Chile; 2Universidy of Finis Terrae, Santiago, Chile Supporting information can be found in the online version of this abstract EP14.41: Endometriosis: correlation of ultrasound and surgical findings on three cases M.I. Alonzo1,2, V. Etchegoimberry3 1Gynecology, Hospital Britanico, Montevideo, Uruguay; 2Gynecology, Practica Practice, Montevideo, Uruguay; 3Hospital Britanico, Montevideo, Uruguay To present the results of extended ultrasound (US) using the 2016 IDEA consensus criteria for systematic evaluation of endometriosis (ED) and to correlate them with intraoperative findings. Case 1: 33-year old, Caesarean section, left salpingectomy, levonorgestrel IUS, weight loss and diarrhoea, removal of 6 polyps. US: limited mobility in the left ovary (LE); separation from the pelvic wall is impossible; examination is exquisitely painful due to adhesions that attach it to the intestinal loop (requiring a pause in the procedure). Loose adhesions in relation to the torus. Laparoscopy (LPC): LE with adhesions to the anterolateral wall and round ligament (shortened and retracted). Adhesiolysis. In Douglas, the peritoneum retracts the rectum, a fibrous lesion that is removed. Case 2: 25-year old, LPC 2023: reports foci in the uterosacral ligament (LUS) and wall and 2 endometriomas. Continuous dienogest. US 2024: tractioned uterus. Fixed ovaries in Douglas, kiss sign (endometriomas). Exquisite pain in the left LUS and burning in the rectovaginal septum (RVS). Surgery: excision of the ED focus adhering to the rectum and upper sector of RVS. Release of the sigmoid colon from the parietal peritoneum; of both ovaries and of adhesions between them and to the pelvic wall, evacuating endometriomas. Release of adhesions from the fallopian tubes. Case 3: 33-year old, moderate dysmenorrhea, diarrhoea. US: single implant in the sigmoid colon (hypoechoic image with poorly defined edges) and fixed by tracts to the rest of the intestinal loops, painless upon examination, measuring 31 × 17 × 21 mm. Surgery: intestinal resection is performed, identifying the described implant. The correlation between US findings and intraoperative findings is demonstrated. Training and systematic application of the 2016 IDEA criteria benefit women with this condition.