Ultrasound Imaging for Ovarian and Deep Infiltrating Endometriosis

Caterina Exacoustos, Errico Zupi, Emilio Piccione, C. Exacoustós
Seminars in reproductive medicine · 2017 · vol. 35(01) , pp. 005–024 · doi:10.1055/s-0036-1597127 · PMID:28076877 · W2573482834
review OA: closed CC0 ⤵ 59 in-corpus citations
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⚙ AI-generated summary by claude@2026-06, 2026-06-07 ⓘ

Transvaginal ultrasonography (TVS) effectively assesses ovarian and deep infiltrating endometriosis, including adenomyosis, by visualizing endometriomas, adhesions, bladder involvement, and rectal nodules, though expertise is required.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-07 ⓘ

This paper reviews ultrasound imaging approaches for ovarian endometriosis and deep infiltrating endometriosis, focusing on transvaginal ultrasonography (TVS) for detecting nonovarian disease and mapping extension into pelvic structures. It describes key sonographic appearances such as typical endometriomas (unilocular cysts with “ground glass” echogenicity) and the use of color Doppler to help distinguish endometriomas from malignancy, as well as dynamic TVS assessment techniques like the sliding sign for pouch of Douglas (POD) obliteration and the evaluation of adhesion-related findings. It also outlines how TVS can visualize bladder, rectal, and vaginal compartments and how adenomyosis may be assessed using 2D TVS myometrial features and 3D junctional zone evaluation, while explicitly noting that although TVS sensitivity/specificity for deeply infiltrating endometriosis and adenomyosis is high, imaging assessment is difficult and requires substantial expertise. This paper is centrally about endometriosis — it provides an ultrasound imaging overview for ovarian and deep infiltrating disease and includes adenomyosis imaging considerations.

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Abstract

The main challenges of imaging for endometriosis are the detection of nonovarian disease and the evaluation of the extension of the disease into pelvic structures. Transvaginal ultrasonography (TVS) has been proposed as the first-line imaging technique because it allows extensive exploration of the pelvis. The "typical" endometrioma is a unilocular cyst with homogeneous low-level echogenicity (ground glass echogenicity) of the cyst fluid. The use of color Doppler helps avoid classifying malignancies as endometriomas, defining the presence of vascular flow in papillations. The real-time dynamic TVS examination of adhesions and pouch of Douglas (POD) obliteration, using the sliding sign technique, seems to be useful in the identification of women at increased risk for bowel endometriosis. Transvaginal ultrasound allows an accurate assessment of the vagina, particularly the areas of the posterior and lateral vaginal fornixes, the retrocervical area with torus uterinum and uterosacral ligaments, and the rectovaginal septum. The slightly filled bladder permits an evaluation of the bladder walls and the presence of endometriotic nodules which appear as hypoechoic linear or spherical lesions bulging toward the lumen, involving the serosa, muscularis, or (sub)mucosa of the bladder. Deep nodules of the rectum appear as hypoechoic lesions, linear or nodular retroperitoneal thickening with irregular borders, penetrating into the intestinal wall distorting its normal structure with the presence of few vessels observed with power Doppler evaluation. Adenomyosis can be observed with the two-dimensional (2D) TVS showing the typical myometrial features and 3D evaluation of the junctional zone. Although the sensitivity and specificity of TVS in the prediction of deeply infiltrating endometriosis and adenomyosis is high, their assessment by TVS is difficult and needs a great expertise.

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Condition tags

endometriosisadenomyosisdie_deep_infiltratingendometriomabowel_endometriosis

MeSH descriptors

Endometriosis Ovarian Diseases Ultrasonography, Doppler Disease Progression Endometriosis Endometriosis Female Humans Image Interpretation, Computer-Assisted Imaging, Three-Dimensional Ovarian Diseases Ovarian Diseases Predictive Value of Tests Prognosis Ultrasonography, Doppler

Citation neighborhood

Papers in the corpus that this work cites (lower rings, blue) and that cite this one (upper rings, green). Dot size scales with the paper's in-corpus citation count — bigger dot = more influential within the endo/adeno field. Click a dot to open that paper. [ expand to 2 hops ] — adds papers reached through this work's immediate citers/citees. Heavier; up to 60 extra dots.

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