Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group

The IDEA (International Deep Endometriosis Analysis group) statement is a consensus opinion on terms, definitions and measurements that may be used to describe the sonographic features of the different phenotypes of endometriosis. Currently, it is difficult to compare results between published studies because authors use different terms when describing the same structures and anatomical locations. We hope that the terms and definitions suggested herein will be adopted in centers around the world. This would result in consistent use of nomenclature when describing the ultrasound location and extent of endometriosis. We believe that the standardization of terminology will allow meaningful comparisons between future studies in women with an ultrasound diagnosis of endometriosis and should facilitate multicenter research. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Enfoque sistemático para la evaluación ecográfica de la pelvis en mujeres con posible endometriosis, incluyendo términos, definiciones y mediciones: una opinión consensuada del Grupo Internacional de Análisis de la Endometriosis Profunda La declaración del Grupo Internacional de Análisis de la Endometriosis Profunda (IDEA, por sus siglas en inglés) es una opinión basada en un consenso sobre los términos, definiciones y medidas que se pueden utilizar para describir las características ecográficas de los distintos fenotipos de la endometriosis. Actualmente es difícil comparar los resultados entre los estudios publicados porque los autores utilizan términos diferentes para describir las mismas estructuras y localizaciones anatómicas. Esperamos que los términos y definiciones propuestas en este documento se adopten en centros de investigación de todo el mundo. Esto resultaría en un uso uniforme de la nomenclatura para describir la ubicación y el alcance de la endometriosis en la evaluación ecográfica. Creemos que la normalización de la terminología permitirá realizar comparaciones significativas entre futuros estudios de mujeres con diagnóstico de endometriosis mediante ecografía y debería facilitar la investigación entre múltiples centros de investigación. Endometriosis is a common gynecological problem, affecting approximately 5% of women1. The disease can be found in many sites throughout the pelvis, in particular the ovaries, pelvic peritoneum, pouch of Douglas (POD), rectum, rectosigmoid, rectovaginal septum (RVS), uterosacral ligaments (USLs), vagina and urinary bladder. Correct site-specific diagnosis is fundamental in defining the optimal treatment strategy for endometriosis. Non-invasive imaging methods are required to map accurately the location and extent of endometriotic lesions. The recent consensus statement produced by the World Endometriosis Society recommended the establishment of centers of expertise for the management of higher-stage disease2. This recommendation requires a reliable preoperative system of triage which enables immediate understanding of the location and severity of disease. Increasingly, endometriosis is being managed medically and surgery can be avoided or delayed in a growing proportion of cases. Transvaginal sonography (TVS) is the first-line imaging technique in the diagnosis of pelvic endometriosis and in particular for deep infiltrating endometriosis (DIE)3. It is important to note, however, that there is substantial heterogeneity in the reported sensitivity and specificity of TVS with regard to detection of DIE, irrespective of its location4, 5. Adding ultrasound examination by an experienced operator to history and pelvic examination improves the accuracy of diagnosis of pelvic endometriosis6, 7. In their meta-analysis, Hudelist et al.8 concluded that TVS with or without the use of prior bowel preparation is an accurate test for non-invasive, presurgical detection of DIE of the rectosigmoid. Although the diagnostic performance of ultrasound for detecting DIE reported by individual units is excellent for certain anatomical locations9-11, the lack of standardized definitions in the sonographic classification and diagnosis of DIE is a general cause for concern. This lack of uniformity when classifying anatomical location and extent of disease contributes to the considerable variation in the reported diagnostic accuracy of TVS in the diagnosis of endometriosis. The aim of this consensus opinion is to ensure that the ultrasound examination of a woman with potentially underlying endometriosis is performed in a standardized manner, that the measurement of endometriotic lesions is standardized and that the terminology used when describing the location of DIE and the sonographic features of DIE and other manifestations of endometriosis (endometriomas, adenomyosis, pelvic adhesions) is uniform. This consensus opinion should be useful in clinical practice as well as in research. We believe that careful definition of ultrasound-detected DIE will facilitate interpretation of research and lead to improved clinical care. This work is based on the opinion of a panel of clinicians, gynecological sonologists, advanced laparoscopic surgeons and radiologists (International Deep Endometriosis Analysis (IDEA) group) with expertise in diagnosis and management of endometriosis. Criteria used to invite the experts to participate in this consensus process included their having significant peer-reviewed publications in the field of diagnosis and management of endometriosis. An initial statement was presented in 2011 at the ISUOG congress in Copenhagen12, incorporating several suggestions from all participants. A first draft was written in December 2014 by a joint effort of the two first authors (S.G. and G.C.) and sent to all coauthors. All coauthors had the opportunity to comment within a fixed time limit. Reply was mandatory for coauthorship. Taking all comments into account, a revised draft was then sent to all coauthors. In case of conflicting opinions, a consensus was proposed after discussion between the two first authors and the last author (D.T.). This pathway was repeated until a consensus between all authors was reached. The consensus also included ultrasound images/videos and schematic drawings to illustrate the text. After 13 revisions, the manuscript was deemed ready for submission. In addition to terms, definitions and measurements to describe the sonographic features of DIE, adhesions, adenomyosis and endometriomas, this consensus opinion includes recommendations regarding how to take a history, how to perform a clinical examination, how to perform an ultrasound examination and which ultrasound modality to use when examining patients with suspected or known endometriosis. DIE anatomical locations in this consensus were modified from Chapron's anatomical distribution of pelvic DIE13. A detailed clinical history should be taken for all women with suspected endometriosis, with particular emphasis on symptoms which could be attributed to endometriosis14, 15. The following should be noted specifically: age; height; weight; ethnic origin; parity; bleeding pattern (regular, irregular or absent); last menstrual period; previous surgery for endometriosis (type, effect); previous myomectomy or Cesarean delivery (these entail increased risk of DIE in the bladder); family history of endometriosis; previous non-surgical treatment for endometriosis (type, duration, effect); subfertility including duration of subfertility; treatment for infertility and outcome of fertility treatment; pain (dysmenorrhea, dyspareunia, dysuria, dyschezia, chronic pelvic pain); hematochezia and/or hematuria. The onset and duration of symptoms should be noted and, if possible, the intensity of the pain recorded by letting the patient use a visual analog scale or investigating it with a 0–10 narrative numeric rating scale. A pelvic examination should be performed either before or after the pelvic ultrasound scan, with the aim of defining the presence or absence of vaginal and/or low rectal endometriosis7. The pelvic examination should include speculum examination (direct visualization of vaginal or cervical DIE) and vaginal palpation. Mobility, fixation and/or tenderness of the uterus should be evaluated carefully. Site-specific tenderness in the pelvis should also be evaluated. The purpose of performing an ultrasound examination in a woman with suspected endometriosis is to try to explain underlying symptoms, map the disease location and assess the severity of disease prior to medical therapy or surgical intervention. Various ultrasound approaches have been published, but to date none has been externally validated16, 17. We propose four basic sonographic steps when examining women with suspected or known endometriosis, as shown in Figure 1. Note that these steps can be adopted in this or any order as long as ALL four steps are performed to confirm/exclude the different forms of endometriosis. Using TVS as the first-line imaging tool, the operator should examine the uterus and the adnexa. The mobility of the uterus should be evaluated: normal, reduced or fixed (‘question mark sign’)18. Sonographic signs of adenomyosis should be searched for and described using the terms and definitions published in the Morphological Uterus Sonographic Assessment consensus opinion19. The presence or absence of endometriomas (Figure S1a), their size, measured systematically in three orthogonal planes (see ‘Measurement of lesions’, below), the number of endometriomas and their ultrasound appearance should be noted20. The sonographic characteristics of any endometrioma should be described using the International Ovarian Tumor Analysis terminology21. An atypical endometrioma (Figure S1b) is defined as a unilocular-solid mass with ground glass echogenicity with a papillary projection, a color score of 1 or 2 and no flow inside the papillary projection20. 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assess the when the uterus is (Figure is the using the to the the of the and vaginal the rectal the is for this location The then the in order to the uterus between the and the is in the other to assess the bowel the of the it the is also in this the is found to be in of these anatomical and the is recorded as being on TVS it is that either the rectal or the the or the at of the locations has a then the is recorded as and describing the in a uterus is different (Figure is the with the to the the the the is to be for this location The then the in order to the uterus between the and is in the other to assess the the it the is also to be in this long as the is found to be in of these anatomical the and the the is recorded as The is to for DIE in the and assess the the is in the of the endometriosis is suspected on the of symptoms, patients should be to their before the ultrasound A of the of the and detection and of endometriotic the is in the of the vagina and the vagina to allow 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vaginal and/or vaginal should be suspected when a DIE is on TVS in the rectovaginal the the of the of the of the pouch of and the the of the of the the in Figure vaginal or endometriosis is suspected if the vaginal is or if a is found in the of the vaginal (Figure The may be or with or without (Figure and there may or may be the Figure is an ultrasound vaginal The of the vaginal DIE should be measured in three orthogonal or when DIE lesions in the vaginal into the rectal (Figure the of the DIE in the rectal is the same as the in the vaginal (Figure is a but between these two of the lesions are the of the and are on are on ultrasound (Figure DIE lesions can be in the of the uterus (Figure these are by the in the vaginal in the in the and then the to the are to be by DIE when a with or irregular is within the the The may be or may be of a into the vagina or into other The of a can be measured in the at the of the on the that the can be from structures (Figure In the DIE the is at the 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rectal DIE lesions, this being as at rectal DIE lesions, at the of the being as DIE lesions and the of the being as DIE lesions (Figure The of the rectal and/or DIE should be recorded in three orthogonal planes and the between the of the and the should be measured using bowel DIE may the bowel at different other bowel lesions should be for when there is a DIE affecting the (Figure or rectosigmoid. that rectal DIE lesions may be associated with a in of diagnosis of has been in this The can be as or on or or a an experienced operator can the of in an it is at the of the uterus and/or and, in a it is at the uterus and/or We propose that endometrioma and DIE should be measured systematically in three orthogonal to the and (Figure This of in three planes to DIE lesions in the and rectosigmoid. in of endometriosis in the it is important to the between the and a DIE which a the can be by either or the is the of the should be at this and the other at the for measurement (Figure In of bowel DIE 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Currently, it is difficult to compare results between published because authors use different terms when describing the same structures and locations. We hope that the terms and definitions suggested herein will be adopted in centers around the world. This would result in consistent use of nomenclature when describing the ultrasound location and extent of endometriosis. We believe that the standardization of terminology should allow meaningful comparisons between future studies in women with an ultrasound diagnosis of endometriosis and should facilitate multicenter Figure Transvaginal sonographic a endometrioma with and ground glass echogenicity of and an atypical endometrioma within the with ground glass echogenicity of Figure two endometriomas are fixed to other by adhesions in the pouch of Figure ultrasound of endometrioma in Figure drawings deep infiltrating endometriosis of of of bladder. Figure and ultrasound location of endometriotic Figure location of the the then the is and the is as Figure measurement of from to of in of deep infiltrating endometriosis in the by is Figure drawings and ultrasound location and different of deep infiltrating endometriosis in vaginal A ultrasound is shown for by increased of vaginal of of Figure and ultrasound of deep infiltrating endometriosis in vaginal into rectal Figure and schematic drawings deep infiltrating endometriosis of the uterosacral ligaments and are on of DIE in the of DIE in the in of DIE at the in a the Figure drawings and ultrasound deep infiltrating endometriotic rectal lesions. DIE in the DIE in the Figure of with shown in ultrasound of a bowel with of deep infiltrating endometriosis in the bowel Figure drawings and ultrasound different of of the pouch of Douglas in an the is also the and signs are also the is also in a Figure and ultrasound within of deep infiltrating endometriosis in results in of of and, in in of of bowel by Figure and ultrasound measurement of from to deep infiltrating endometriotic of Figure rectal with Figure rectal ultrasound in a woman with deep infiltrating endometriosis. Figure in a woman without pouch of Figure of pelvic as by ultrasound with with endometriotic in rectovaginal between and Figure Transvaginal of of rectal deep infiltrating endometriosis; has with The is for the or of any by the should be to the author for the