Sonography and MR imaging for the assessment of deep pelvic endometriosis

Deep pelvic endometriosis may involve the uterosacral ligaments, the pouch of Douglas, the vagina, the rectum, and occasionally the bladder. Assessment by physical examination is difficult, and imaging techniques are needed to evaluate the location and extent of endometriosis. In this review, we describe transvaginal and rectal endoscopic sonographic and magnetic resonance imaging features suggestive of deep pelvic endometriosis and their diagnostic performance.     

Routine clinical examination is not sufficient for diagnosing and locating deeply infiltrating endometriosis

STUDY OBJECTIVE: To determine whether routine clinical examination is sufficient for the diagnosis and establishing the location of deeply infiltrating endometriosis (DIE). DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. Patients. One hundred sixty women with histologically proved deeply infiltrating endometriosis. MEASUREMENTS AND MAIN RESULTS: Speculum examination allowed endometriotic lesions to be viewed in only 14.4% (23) of patients, and a classic, painful, spheric nodule was palpated in only 43.1% (69). Results of routine clinical examination varied significantly with location of DIE. Whereas a nodule was found in 80.0% (24) of patients with vaginal endometriosis, this rate dropped to only 35.3% (6) and 33.3% (34) in those with DIE of the digestive tract and uterosacral ligaments, respectively (p <0.0001). CONCLUSION: High locations of DIE lesions at the level of uterosacral ligaments, bottom of the pouch of Douglas, and upper one-third of the posterior vaginal wall explain why results of routine clinical examination are so poor. The term "deep endometriosis infiltrating the rectovaginal septum" is generally incorrect in the true anatomic sense.     

Isolated Endometriosis on the Rectus Abdominis Muscle in Women without a History of Abdominal Surgery: a Rare and Intriguing Finding

We report 2 rare cases of endometriosis on the rectus abdominal muscle diagnosed incidentally during an operation for inguinal hernia repair in women with no surgical history. Two women sought medical attention for a mass found in the pubic abdominal wall. Only 1 woman reported occasional pain. At physical examination in both women, an ovoid swelling in the right pubic area was felt. One woman experienced pain on palpation, and one reported slight discomfort. Ultrasonography demonstrated a heterogeneous hypoechogenic formation with indistinct edges; diagnosis was difficult. Routine clinical and instrumental (pelvic ultrasonography) gynecologic examination in both patients performed shortly before hospitalization had not revealed any macroscopic focus of endometriosis in the pelvic region. At surgery, a lesion consistent with the diagnosis of endometriosis was found, which was confirmed at histologic analysis. These cases could represent the consolidation of different theories of endometriosis diffusion. We suggest including endometriosis in the differential diagnosis of a symptomatic mass in the abdominal wall in women with and without a surgical history.     

Sigmoid endometriosis in a postmenopausal woman

Bowel obstruction resulting from endometriosis is an infrequently observed phenomenon in postmenopausal women. A 69-year-old woman without hormone replacement had clinical and radiologic findings consistent with a pelvic tumor invasive into the wall of the sigmoid colon. The patient underwent resection of the sigmoid colon and total hysterectomy. Histologic examination revealed endometrioma. This case documents the possible occurrence of symptomatic bowel endometriosis after years of a hormonally castrated state.     

Müllerian adenosarcoma of vagina arising in persistent endometriosis: report of a case and review of the literature

BACKGROUND: Primary adenosarcoma arising in vaginal endometriosis poses a diagnostic challenge, especially in superficial vaginal biopsies. CASE: A 56-year-old woman, with a prior diagnosis of ovarian endometriosis, presented with a rapidly enlarging mass of the vaginal vault. Two prior biopsies were benign and showed endometriosis. The third vaginal biopsy revealed benign endometriotic glands cuffed by a cellular stroma with moderate cytologic atypia, a histological appearance diagnostic of Müllerian adenosarcoma. A 16-cm vaginal mass that had infiltrated the pelvic structures was resected. CONCLUSIONS: Close clinical follow-up of extrauterine endometriosis and clinical-pathologic correlation is necessary. Histological features such as cellular stromal cuffing around benign endometriotic glands are critical in arriving at a timely diagnosis of adenosarcoma in patients with persistent extrauterine endometriosis, even in superficial vaginal biopsies.     

卵巢子宫内膜异位症恶变26例临床病理分析

目的 探讨探讨卵巢子宫内膜异位症（内异症）恶变的临床病理特征。方法 回顾分析26例卵巢内异症恶变患者的临床和病理资料。结果 患者以痛经和检查发现盆腔肿块为主要临床表现。行B超或彩色多普勒超声检查者18例,其中10例发现盆腔肿块中含实质性结构。肿瘤组织类型以内膜样腺癌和透明细胞癌常见。58％（15／26）患者的肿瘤显微镜下可见不典型内异症。协际妇产科联盟分期：Ⅰ期21例（81％）,Ⅱ期3例（12％）,Ⅲ期2例（8％）。结论 卵巢内异症恶变早期临床诊断存在困难,B超或彩色多普勒超声检查有重要参考价值。重视观察异位内膜组织形态变化,有利于认识卵巢内异症恶变的发生和发展过程,提高诊断和治疗水平。     

Diagnosis and treatment of endometriosis. A review

The correct approach for endometriosis management is still unclear. This review explores recent data concerning diagnosis and treatment of endometriosis, trying to define guidelines for the most appropriate diagnostic approach and therapeutic regimen. At present, laparoscopy is still considered the gold standard in endometriosis diagnosis. The risks and the diagnostic limitations of laparoscopy and the inaccuracy of clinical examination justify the considerable efforts made to improve the diagnosis with imaging techniques. The therapeutic approach is still far from being defined as causal and focuses on management of clinical symptoms of the disease rather than on the disease itself. A first-line medical therapy should be tried in patients with pelvic pain not asking for a pregnancy. Surgical treatment is considered the best treatment for women with pain and or pelvic mass who wish to become pregnant in a short time. For infertile patients, medical therapy has a limited role. The 2 treatment options include surgery or in vitro fertilization (IVF). According to our results, it seems that correct management of infertile women with endometriosis is a combination of surgery and IVF in women who did not obtain post-surgery pregnancy spontaneously.     

Diagnosis and treatment of rectovaginal endometriosis: an overview

Rectovaginal endometriosis can be a cause of severe pain, dyspareunia and intestinal problems. A thorough examination is needed and should include diagnostic imaging, such as transvaginal or transrectal ultrasound or magnetic resonance imaging. Medical therapies, such as oral contraceptives, progestins and levonorgestrel-releasing intrauterine devices, all seem to reduce pain and should always be considered. Surgical treatment is challenging and implies a risk of severe complications. It is preferable to treat endometriotic lesions with superficial infiltration into the rectal wall by local laparoscopic excision, while segmental rectal resection is needed in the case of severe intestinal infiltration. This review describes available diagnostic tools, the possibilities for medical treatment and the alternative surgical approaches.     

Incisional endometriosis after cesarean section, episiotomy and other gynecologic procedures

AIM: To report 11 cases of incisional endometriosis after cesarean section, episiotomy and other gynecologic procedures. The diagnostic approaches and therapies for incisional endometriosis are also evaluated. METHODS: Eleven patients who presented with a painful nodule that was increasing in size during menstruation on the scar of a previous gynecologic procedure were examined retrospectively. RESULTS: All patients presented with a palpable painful lesion, located on the cesarean section incision, perineal episiotomy incision or the vaginal cuff after hysterectomy. All masses were increasing during menstruation and all patients had been having cyclical pain that worsened during menstrual periods. The mean age of the patients was 28.2 years. The onset of symptoms was referred at variable intervals after surgery ranging between 2 and 11 years (mean: 5.72 years). Ultrasound examination confirmed hypoechoic mass septated with cystic and solid components in the abdomen without intra-abdominal communications. All endometriotic masses were completely excised under general anesthesia. The excised masses were sent for microscopic examination which confirmed the diagnosis of endometriosis. CONCLUSION: Incisional endometriosis seems to be common in women who have had a cesarean section, although it does occur after other procedures and de novo. It is suggested that caution is exercised during gynecologic procedures to avoid transplantation of endometrium to the anterior abdominal wall. The preferred management is to excise the lesion completely even if this necessitates fascial excision.     

Endometriosis causing extensive intestinal obstruction simulating carcinoma of the sigmoid colon: a case report and review of the literature

Endometriosis with intestinal serosal involvement is not uncommon in women of childbearing age, however, presentation as colon obstruction is rare. Lack of pathognomonic symptoms makes diagnosis difficult, the main problem being differential diagnosis with neoplasm, even intraoperatively. Reported here is a case of extensive bowel obstruction due to sigmoid colon endometriosis in a 43-year-old woman who presented with signs and symptoms of bowel obstruction. Barium enema showed sigmoid obstruction; subsequent exploratory laparotomy showed the sigmoid colon surrounded by fibrous tissue, leading to its angulation and extensive lumen obstruction. Left oophorectomy and radical resection of descending and sigmoid colon as for bowel carcinoma were successfully employed. Pathological examination revealed endometriosis in the bowel wall with preservation of the mucosa. Aetiology, clinical presentation, differential diagnosis and therapeutic options for intestinal obstruction due to endometriosis are discussed.     

Ultrasound diagnosis of endometriosis and adenomyosis: State of the art

Transvaginal ultrasonography has become the primary test in the diagnosis of pelvic endometriosis and adenomyosis. A review of the literature on the diagnostic accuracy of ultrasonography in pelvic endometriosis and adenomyosis, as well as a comparison with magnetic resonance imaging, will be presented. Criteria for diagnosis of an endometrioma according to robust prospective data together with guidelines as to adequate reporting of the location of deep infiltrating endometriosis will be given. The sonographic features of adenomyosis including the differential diagnosis between focal adenomyosis and a uterine fibroid are reviewed. The available data in the literature on ultrasound diagnosis of pelvic endometriosis and adenomyosis, their clinical relevance, and their limitations are discussed.     

A Practical Guide to the Clinical Evaluation of Endometriosis-Associated Pelvic Pain

Endometriosis-associated pain (EAP) has a significant impact on the quality of life of those affected and their families. Recognizing that endometriosis is a chronic condition associated with an impairment in function and negative social impact, there is a shift toward reducing diagnostic delays and initiating timely management. This article provides a comprehensive and practical approach to the clinical diagnosis of EAP, which can subsequently facilitate prompt and directed treatment. The key components of the history, physical examination, and high-quality imaging to evaluate suspected EAP and related pain conditions are presented. Currently, biomarkers have limited utility in the diagnosis of endometriosis, but research in this area continues; development of a reliable noninvasive test for endometriosis may further improve early identification of this condition.     

Diagnostische Tests für Endometriosis

Even today, the time-lag between the appearance of the first symptoms of endometriosis and its definitive diagnosis by laparoscopy is about 6–7 years. We seem to be in urgent need of a diagnostic test – preferably using peripheral blood. Fortunately, more and more studies are leading to reports of noninvasive tests with high sensitivity and specificity. The following parameters are suggested as markers: CA 125, CA 19–9, IL-6, ICAM-1 and CCR-1 mRNA. Regression models also use clinical data, such as length of cycle and number of pregnancies, in association with the aforementioned serum markers. The possible benefits of a noninvasive diagnostic test would be: earlier detection, easier surgery because of a less advanced stage of endometriosis and a lower recurrence rate, all combining to mean, ultimately, reduced costs. Until such a test is available, we can only continue to use the tried and tested techniques, such as medical history-taking, thorough gynaecological examination, ultrasound and finally diagnostic laparoscopy, for the diagnosis of endometriosis.     

Correlation of endoscopic interpretation of endometriosis with histological verification

INTRODUCTION: In this study we correlate the laparoscopic findings of endometriosis with the histological confirmation of the disease over a period of two years. MATERIALS AND METHODS: One hundred and sixty-four laparoscopies performed at the Department of Gynecology & Obstetrics, University of Kiel, over a two-year period were reviewed for laparoscopic findings and histological confirmation of endometriosis. RESULTS: The majority of patients suspected of endometriosis at laparoscopy were confirmed by histological examination, i.e. 138 out of 164 patients (84.1%). CONCLUSION: Laparoscopy is the easiest diagnostic tool for the diagnosis of endometriosis which can be confirmed by histological examination.     

Recidiva de endometriosis en pared abdominal. Reporte de caso

IntroductionAbdominal wall endometriosis is an uncommon pathology, which usually develops in a surgical scar following a gynaecological and/or gynaecological-obstetric procedure.Case studyFemale, 29 years old, G3C2A1V2, history of surgical sterilization. One year after her last cesarean section, she presented with chronic pelvic pain associated with the menstrual cycle, accompanied by heavy menstrual bleeding and a sensation of a mass in the hypogastrium. She was diagnosed with endometriosis in the abdominal wall, and resection was performed. However, one year after the procedure, the endometriosis in the abdominal wall recurred, this time requiring wide fascia resection, mesh placement and layered closure.ConclusionsAbdominal wall endometriosis is difficult to diagnose, since it is a comparatively infrequent entity, which has not received adequate attention. It is important to suspect it in women with cyclic abdominal pain and the presence of a mass in the abdominal wall, in addition to the use of diagnostic imaging. Surgical resection is the ideal treatment, however, it is important to emphasize the importance of a wide margin resection to avoid recurrence. Layered closure is also important to avoid defects in the abdominal wall.     

Evaluation of a Combination Study of a Noninvasive Scoring System and Transrectal Ultrasonography to Detect Deeply Infiltrating Endometriosis

Objective:  Noninvasive evaluation must be required for deeply infiltrating endometriosis, typically accompanied by pelvic pain, dyspareunia, and bowel retraction. To explore noninvasive diagnostic methods for deeply infiltrating endometriosis, we employed a combination study of a diagnostic scoring system and transrectal ultrasonography.
Methods:  A prospective diagnostic study was designed for deeply infiltrating endometriosis by noninvasive diagnostic scoring and transrectal ultrasonography ( n  = 40).
Results:  Sixteen out of twenty-four women with positive points in the diagnostic scoring had deeply infiltrating endometriosis on uterosacral ligaments. Uterosacral ligaments were thickened in 83.3% of patients with deeply infiltrating endometriosis on uterosacral ligaments. The patients who had both thickened uterosacral ligaments and a positive diagnostic score were limited to patients with deeply infiltrating endometriosis on uterosacral ligaments.
Conclusion:  Our findings showed that thick uterosacral ligaments associated with a positive diagnostic score strongly designated that the women were affected by deeply infiltrating endometriosis. It is concluded that this combination study has clinical diagnostic value for deeply infiltrating endometriosis at the outpatient department.
ACTA OBST GYNAEC JPN Vol. 54, No. 7, pp. 919–924, 2002     

Spontaneous abdominal wall endometriosis: A Case Report and review of the literature

ObjectiveWe present a case of spontaneous abdominal wall endometriosis presenting as a painless nodular mass in a woman with no prior history of abdominal surgery.Case reportAbdominal wall endometriosis (AWE) is an uncommon form of endometriosis, usually arising due to a past history of cesarean section or abdominal hysterectomy. However, in rare cases, abdominal wall endometriosis can arise in women with no prior history of abdominal surgery. A 48-year-old woman presented to our obstetrics and gynecology clinic with a painless nodular mass in the right lower quadrant of the abdomen. Abdominal wall ultrasound showed a hypoechoic heterogenous mass under the skin. Wide surgical resection of the mass was conducted and post-operative histopathological report revealed abdominal wall endometriosis.ConclusionSpontaneous abdominal wall endometriosis is an uncommon pathologic condition in which accurate diagnosis is difficult. As an increasing number of obstetrical and gynecological procedures are conducted worldwide, surgeons should keep this clinical entity in the differential diagnosis of any abdominal mass in reproductive-aged females regardless of their past surgical history.     

Clear cell carcinoma arising in extraovarian endometriosis: report of three cases and review of the literature

The literature on malignancy arising in extraovarian endometriosis comprises only three cases of clear cell carcinoma. We wish to report the clinical features and pathologic findings of an additional three cases. The first concerns a 39-year-old oriental pregnant woman who presented with a large intraluminal obstructing lesion of the sigmoid colon, the second case deals with an abdominal wall mass that appeared in a cesarean section scar of a 45-year-old black woman, and the third case describes an ulcerating lesion of the perineum and the buttock in a 43-year-old white woman with a long history of endometriosis in an episiotomy scar. Our observations support the notion that clear cell carcinoma arising in extraovarian endometriosis behaves differently from its counterpart in ovarian endometriosis, but more in line with clear cell carcinoma of the endometrium.     

Umbilical endometriosis after unprotected removal of uterine pieces through the umbilicus

We reviewed the frequency of umbilical endometriosis after laparoscopic-assisted subtotal hysterectomy with unprotected removal of uterine segments through the umbilical incision. Retrospective analysis of surgical records was followed by recall and clinical examination of 10 patients. Two women developed umbilical endometriosis. One was the only patient operated during menstruation. The other was one of two women operated in the late luteal phase and with subsequent adequate exposure to endogenous or exogenous estrogens. From 1976-1997, 22 reports of umbilical endometriosis were published: 18 cases were spontaneous, 2 occurred after ring sterilization, and 2 after diagnostic laparoscopy. These data lend support to the concept that implantation and the potential development of menstrual endometrium are increased after surgery. It is speculated that procedures that expose menstrual endometrial cells to nonepithelialized areas could be associated with an increased risk of endometriosis.     

Endometriosis in adolescents and young women. Can we afford to delay the diagnosis?]

Retrospective analysis performed on medical records of 129 adolescents and young women treated surgically at I Dept. of Surgical Gynaecology during the nine years period (1989-1998) revealed 22 cases (17%) of endometriosis. Main indication for surgical intervention, apart from dysmenorrhoea and cyclic abdominal pain, had been the presence of endometriod cyst, as disclosed by ultrasound investigation (66%). Despite of negative result of imaging or clinical examination subjective complaints necessitated laparotomy in 27% of cases. According to American Fertility Society endometriosis classification, 17% subjects presented endometriosis in I stage, 17%--in stage II and remaining 66%--endometrioid cysts with stage III. Authors conclude, that in cases with persistent abdominal pain, not responding to conventional therapy, diagnostic laparoscopy/laparotomy in young women should not be delayed, unless endometriosis is suspected.