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Normal anatomy of the female pelvis. (a, b) Axial (a) and sagittal (b) T2-weighted MR images show the uterosacral ligaments (arrows in a), rectovaginal pouch ( * in b), and retrocervical area (outlined in b). (c, d) Laparoscopic images show the uterosacral ligaments (arrows in c), rectovaginal pouch ( * in c), and retrocervical area (outlined in d). (e) Drawing of the female pelvis (oblique coronal view, superoinferior orientation) shows the ureters (arrows), uterosacral ligaments (arrowheads), cardinal ligaments and parametrium (black * ), and round ligaments (white * ). Note that the ureters course lateral to the uterosacral ligaments and immediately caudal to the cardinal and broad ligaments.
Source publication
Deep pelvic endometriosis is an important gynecologic disorder that is responsible for severe pelvic pain and is defined as subperitoneal invasion that exceeds 5 mm in depth. Deep pelvic endometriosis can affect the retrocervical region, uterosacral ligaments, rectum, rectovaginal septum, vagina, urinary tract, and other extraperitoneal pelvic site...
Contexts in source publication
Context 1
... rectouterine folds contain considerable fibrous tissue and nonstriated muscular fibers that are attached to the front of the sacrum and constitute the uterosacral ligaments. The lat- ter structures are visible at MR imaging as thin, semicircular hypointense cords that originate from the lateral margin of the uterine cervix and the vaginal vault and course dorsocranially to- ward the sacrum (Fig 3) (15). The torus uterinus is a small transverse thickening that binds the original insertion of the uterosacral ligaments behind the posterior cervix; however, it is not clearly defined on MR images in the absence of pathologic thickening (17). ...
Context 2
... retrocervical area is a virtual extraperito- neal space behind the cervix, situated in the same plane as the rectovaginal pouch and above the rectovaginal septum (Fig 3). The vaginal fornices are the deepest portions of the vagina and extend into the recesses created by the extension of the cervix into the vaginal space. ...
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Objective:
The aim of this study was to estimate the efficacy of elagolix, an oral gonadotropin-releasing hormone (GnRH) antagonist, for the treatment of endometriosis-associated pelvic pain.
Methods:
This was a phase II, randomized, placebo-controlled parallel group study conducted at 37 US centers, consisting of an 8-week double-blind period f...
The objective of this study was to evaluate the quality of life (QOL) of patients with
deep infiltrating endometriosis (DIE) using EuroQOL (EQ-5D) and its correlation
with symptoms and locations of endometriotic lesions.
One hundred and fifty-nine patients referred for DIE from January 2011 to April 2011
were prospectively invited to complete ques...
Introduction
Deep dyspareunia occurs in half of women with endometriosis, a condition present in 10% of reproductive-age women and associated with negative effects on sexual quality of life (SQoL). However, women with endometriosis can have other clinical factors (eg, superficial dyspareunia, other pelvic pains, and psychological or pain conditions...
The 'posterior fornix syndrome', as studied in 28 patients, is described. It consists of multiple symptoms of pelvic pain and abnormal urinary symptoms deriving from laxity in the posterior fornix of vagina. The symptoms encompassed include pelvic pain (32%), deep dyspareunia (39%), symptoms of stress (32%) and urge (39%) incontinence, those associ...
Background
Endometriosis is a disabling disease of reproductive-age women. Dysmenorrhea, dyspareunia, and pelvic pain are the main symptoms of endometriosis. Its etiology is not clear. Endometriosis may have various causes, including vitamin D deficiency, but its effect is controversial.
Material/Methods
In this double-blind clinical trial, we enr...
Citations
... Clinically, "adenomyosis externa" at the rectosigmoid, Douglas' pouch, uterosacral ligament, rectovaginal septum, vesico-uterine pouch, etc. is considered deep endometriosis [28]. Deep endometriosis of the peritoneum, ligaments, or organs may cause solid masses exhibiting T2-low signal intensity and intense contrast enhancement reflecting fibromuscular hyperplasia around sparse ectopic endometrial glands (Fig. 3) [29][30][31][32][33][34][35]. The cyclic hemorrhage of the ectopic endometrial tissue may cause a variable inflammatory response and fibrous reaction. ...
... The cyclic hemorrhage of the ectopic endometrial tissue may cause a variable inflammatory response and fibrous reaction. The endometrial tissue infiltrates the adjacent fibromuscular tissue and induces smooth muscle proliferation and fibrous reaction, resulting in the formation of T2-low signal intensity solid masses as "adenomyosis extern" with irregular, indistinct, or stellate margins, or T2-low signal intensity soft tissue thickening [29][30][31][32][33][34][35]. T1-high signal intensity hemorrhagic foci and SWI-signal voids due to hemosiderin deposits may be observed. ...
Endometriosis is a benign, common, but controversial disease due to its enigmatic etiopathogenesis and biological behavior. Recent studies suggest multiple genetic, and environmental factors may affect its onset and development. Genomic analysis revealed the presence of cancer-associated gene mutations, which may reflect the neoplastic aspect of endometriosis. The management has changed dramatically with the development of fertility-preserving, minimally invasive therapies. Diagnostic strategies based on these recent basic and clinical findings are reviewed. With a focus on the presentation of clinical cases, we discuss the imaging manifestations of endometriomas, deep endometriosis, less common site and rare site endometriosis, various complications, endometriosis-associated tumor-like lesions, and malignant transformation, with pathophysiologic conditions.
... Задний компартмент малого таза -наиболее частая локализация глубокого инфильтративного эндометриоза таза. Точная МРТ-оценка этого пространства имеет решающее значение, так как доступ к нему с помощью лапароскопии затруднен, в особенности когда оно облитерировано глубоким инфильтративным эндометриозом [7]. ...
Objective . To identify the correlation between magnetic resonance (MR) semiotics and the intensity of pelvic pain syndrome in female patients with deep infiltrating endometriosis of the posterior pelvic compartment. Material and methods . We performed a retro- and prospective analysis of MR studies of pelvic organs in 77 female patients with pelvic pain syndrome, aged from 24 to 39 years. We assessed the intensity of the pain syndrome using a visual analog scale (VAS). The patients were divided into 2 groups: 1st-patients with external genital endometriosis (EGE) without involving the posterior pelvic compartment, 2nd-patients with EGE of the posterior pelvic compartment. The patients of the second group were divided into subgroups: 1 – endometriosis of the posterior pelvic compartment without MR signs of intestinal wall invasion, 2 – posterior compartment endometriosis with MR signs of intestinal wall invasion. The study was conducted on a GE Signa 1.5 Tesla MRI scanner. Results. In the second group of patients with endometriosis of the posterior pelvic compartment, the pain syndrome (8.00 (7.00–9.00) was more intense than in the first group of patients without endometriosis of the posterior pelvic compartment 7.00 (5.00–7.00), p<0.001 and we evaluated a retrovaginal, retrocervical and posterior uterine localization. In the second subgroup of patients with signs of the intestinal wall invasion, the pelvic pain syndrome on the VAS was statistically significantly more intense 8.00 (8.00-10.00) than in the first subgroup of patients without signs of the intestinal wall invasion 7.00 (6.00–7.00) (P<0.001). Conclusion . Patients with identified deep infiltrating endometriosis of the posterior pelvic compartment have more pronounced manifestations of the pelvic pain syndrome then patients with endometriosis of other localizations.
... Up to now, no real consensus has been established on the imaging anatomy of USLs. On MR T2-weighted images (T2WI), normal USLs are not visible [15] or are depicted as thin, regular, semicircular hypointense cords that originate from the lateral aspect of the uterine cervix and the vaginal vault and course dorsocranially toward the sacrum [16]. USL endometriosis is depicted as nodularity within the ligament or as unilateral or bilateral hypointense thickening of the ligament, with regular or irregular margins [15,16]. ...
... On MR T2-weighted images (T2WI), normal USLs are not visible [15] or are depicted as thin, regular, semicircular hypointense cords that originate from the lateral aspect of the uterine cervix and the vaginal vault and course dorsocranially toward the sacrum [16]. USL endometriosis is depicted as nodularity within the ligament or as unilateral or bilateral hypointense thickening of the ligament, with regular or irregular margins [15,16]. ...
Background: Up to now, no consensus has been established on the imaging anatomy of uterosacral ligaments (USLs). A classification scheme describing the typical aspect of USL involvement in patients with endometriosis including representative MRI images is strongly needed.
Purpose: This study aimed to establish the first-ever MRI classification of USL involvement in deep infiltrating endometriosis (DIE), based on reliable preoperative MRI features correlated with positive predictive values (PPVs) determined through histopathological analysis.
Materials and methods: 22 women underwent surgery with histopathology due to symptoms highly suggestive of endometriosis. The 22 preoperative MRIs were analyzed retrospectively, blinded to histopathology, and a classification of preoperative aspect of USLs linked to PPVs was designed.
Results: According to their aspect, six radiological types of USL were identified. The “L-category” corresponded to linear types, with regular or irregular margins, including types 1, 2, 3A and 3B. The “N-category” corresponded to hemorrhagic or nodular types, including types 4, 5A, 5B and 6. For the L-category, PPVs ranged from 75% to 88%, depending on the USL radiological type. For the N-category, PPVs were 100% for each type. In women with endometriosis symptoms, MRI underestimated USL involvement, especially for type 1. Among the six uterus with lateral deviation, only one false positive result concerning the stretched USL was induced.
Conclusion: In women with endometriosis symptoms, our MRI classification identified two USL categories, corresponding to two kinds of PPV; in these symptomatic patients, a normal MRI does not rule out a DIE diagnosis.
Advances in knowledge: Our MRI classification of USL involvement in endometriosis may be used as a non-invasive staging of the disease, much clearer for clinicians and patients. Hence, we are able to propose a suitable diagnostic and therapeutic procedure for each radiological type.
... Since surgery is the best treatment for endometriosis, detection and localizing of endometriosis lesions (foci) is very important, but detecting the severity of DIE by physical examination and laparoscopy is difficult. The evaluation of DIE in occult spaces and subperitoneal areas is limited by pelvic adhesion (7,11). MRI is an appropriate imaging modality because it provides high spatial resolution, a large field of view, and multi-planar imaging and tissue differentiation. ...
Background
Endometriosis is a multifocal gynecologic disorder during the fertility period in women. Magnetic resonance imaging (MRI) is an important diagnostic modality for this disease and can either be used alone or along with transvaginal ultrasonography.
Objective
This study aims to compare the accuracy of pelvis MRI in pelvic deep endometriosis with laparoscopic findings in women referred to Shahid Sadoughi hospital in one year.
Materials and Methods
This cross-sectional study was conducted on 40 women suspicious of endometriosis who referred to Shahid Sadoughi hospital, Yazd, Iran from November 2020-2021. Based on clinical findings and history, participants were referred to the imaging center for pelvic MRI. Finally, the results of MRI and diagnostic laparoscopy were compared with pathologic findings.
Results
The sensitivity and specificity of MRI for pelvic endometriosis were 94.8% and 20%, respectively. Also, the positive predictive value and negative predictive value of MRI were 90.2% and 33.3%, respectively.
Conclusion
Laparoscopy is still the gold standard of endometriosis diagnosis, but MRI with susceptibility-weighted imaging sequence is the best noninvasive diagnostic method.
... However, MRI may lack specificity, leading to a 10% false positive rate overall [10], which increases to 23% in cases of DIE when compared to surgical findings [3]. In the dedicated recommended MRI protocol [11], DIE lesions are well-identified as T2-hypointense solid nodular or fibrotic thickening lesions, with potential associated microcystic or hemorrhagic foci due to the presence of active ectopic glandular tissue [12]. However, other pelvic conditions including in particular anatomic variations or infectious diseases, can exhibit T2-hypointense findings similar to DIE, which may lead to misdiagnosis. ...
... Colorectal cancer typically presents with polypoid, circumferential, and/or semi-circumferential lesions that originate from the mucosa and invade the inner layers. In contrast, rectosigmoid endometriosis rarely exhibits circumferential growth pattern or mucosal invasion [12]. Instead, it begins at the serosa and develops a specific "mushroom cap" sign over time, providing a highly specific indication [31]. ...
Endometriosis is a common crippling disease in women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While its sensitivity, especially in deep infiltrating endometriosis, is superior to that of ultrasonography, many sources of false-positive results exist, leading to a lack of specificity. Hypointense lesions or pseudo-lesions on T2-weighted images include anatomical variants, fibrous connective tissues, benign and malignant tumors, feces, surgical materials, and post treatment scars which may mimic deep pelvic infiltrating endometriosis. False positives can have a major impact on patient management, from diagnosis to medical or surgical treatment. This educational review aims to help the radiologist acknowledge MRI criteria, pitfalls, and the differential diagnosis of deep pelvic infiltrating endometriosis to reduce false-positive results.
Critical relevance statement
MRI in deep infiltrating endometriosis has a 23% false-positive rate, leading to misdiagnosis. T2-hypointense lesions primarily result from anatomical variations, fibrous connective tissue, benign and malignant tumors, feces, surgical material, and post-treatment scars.
Key points
• MRI in DIE has a 23% false-positive rate, leading to potential misdiagnosis.
• Anatomical variations, fibrous connective tissues, neoplasms, and surgical alterations are the main sources of T2-hypointense mimickers.
• Multisequence interpretation, morphologic assessment, and precise anatomic localization are crucial to prevent overdiagnosis.
• Gadolinium injection is beneficial for assessing endometriosis differential diagnosis only in specific conditions.
Graphical Abstract
... DIE can affect almost any organ or structure, although most lesions are found in the pelvic cavity, particularly in the posterior compartment. DIE consists of lesions comprised of glandular, stromal, and fibrotic tissue [19], readily identifiable on MRI as T2-hypointense fibrotic lesions. Such lesions often contain microcystic changes, with variations in the number of T2-hyperintense and T1-hyperintense hemorrhagic foci dependent on ectopic glandular tissue activity. ...
Endometriosis is a chronic and disabling gynecological disease that affects women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While MRI offers higher sensitivity compared to ultrasonography, it is prone to false-positive results, leading to decreased specificity. False-positive findings can arise from various T1-hyperintense conditions on fat-suppressed T1-weighted images, resembling endometriotic cystic lesions in different anatomical compartments. These conditions include hemorrhage, hyperproteic content, MRI artifacts, feces, or melanin. Such false positives can have significant implications for patient care, ranging from incorrect diagnoses to unnecessary medical or surgical interventions and subsequent follow-up. To address these challenges, this educational review aims to provide radiologists with comprehensive knowledge about MRI criteria, potential pitfalls, and differential diagnoses, ultimately reducing false-positive results related to T1-hyperintense abnormalities.
Critical relevance statement
MRI has a 10% false-positive rate, leading to misdiagnosis. T1-hyperintense lesions, observed in the three phenotypes of pelvic endometriosis, can also be seen in various other causes, mainly caused by hemorrhages, high protein concentrations, and artifacts.
Key points
• MRI in endometriosis has a 10% false-positive rate, leading to potential misdiagnosis.
• Pelvic endometriosis lesions can exhibit T1-hyperintensity across their three phenotypes.
• A definitive diagnosis of a T1-hyperintense endometriotic lesion is crucial for patient management.
• Hemorrhages, high protein concentrations, lipids, and artifacts are the main sources of T1-hyperintense mimickers.
Graphical Abstract
... It is typically employed as a secondary diagnostic approach following TVS to acquire a precise anatomical representation of the entire pelvic organs [5]. When conventional clinical examination and TVS are unable to detect abnormalities in individuals experiencing symptoms, MRI provides precise information for the staging of DIE, especially in cases involving parametrial lesions [11]. ...
Endometriosis, an intriguing gynecological illness, poses a substantial health concern for women of reproductive age, despite its widespread occurrence and limited comprehension. The objective of this study is to assess the diagnostic precision of transvaginal sonography (TVS) and pelvic magnetic resonance imaging (MRI) for the identification of deep infiltrated endometriosis (DIE). This study encompassed a cohort of 256 patients exhibiting signs and symptoms of endome-triosis, with the aim of assessing the diagnostic accuracy over a span of four years. Both TVS and pelvic MRI were employed in the same centers to analyze each subject. The histopathologic analysis and laparoscopy were the most reliable and widely accepted methods for evaluation. TVS is a reliable diagnostic tool for ovarian endometriomas, obviating the necessity for MRI confirmation. The specificity of TVS in diagnosing ovarian endometriomas is 57.14%, while its sensitivity is 93.78%, resulting in an overall accuracy of 84.47%. In relation to parametrial lesions, the sensitivity, speci-ficity, and accuracy of TVS and MRI were as follows: TVS: 9%, 97%, 32%, MRI: 27.14%, 89.19%, and 40.11%. Concerning the uterosacral lesions, the sensitivity, specificity, and accuracy of TVS and MRI were as follows: TVS:14.63%, 94.74%, and 55%, while MRI: 65.88%, 66.30%, and 66.1%. Regarding rectal endometriosis, the sensitivity, specificity, and accuracy of TVS and MRI were as follows: 69.72%, 76.87%, and 73.82% for TVS, and 66.28%, 94.51%, and 80.79% for MRI. The results of the present study indicate that whereas MRI generally exhibits superior capability in assessing the severity of endometriosis, TVS demonstrates sufficient diagnostic accuracy in DIE comparable to MRI.
... 4 Deep infiltrating endometriosis (DIE) is defined as a subperitoneal invasion by endometrial tissue, and It usually affects the uterosacral ligaments, urinary tract, retro-cervical region, rectum, rectovaginal space, vagina, and extraperitoneal pelvic sites. 5,6 DIE may result in dysmenorrhea, dyspareunia, urinary tract infection (UTI) symptoms, and infertility. 5 Endometriosis may be the result of retrograde flow of menstrual blood through the fallopian tubes into the pelvic cavity and lymphatic drainage can induce the development of endometrial tissue in ectopic areas. ...
... 5,6 DIE may result in dysmenorrhea, dyspareunia, urinary tract infection (UTI) symptoms, and infertility. 5 Endometriosis may be the result of retrograde flow of menstrual blood through the fallopian tubes into the pelvic cavity and lymphatic drainage can induce the development of endometrial tissue in ectopic areas. 5 Imaging modalities include transvaginal ultrasound (TVUS), computed tomography (CT) scans, and magnetic resonance imaging (MRI). ...
... 5 Endometriosis may be the result of retrograde flow of menstrual blood through the fallopian tubes into the pelvic cavity and lymphatic drainage can induce the development of endometrial tissue in ectopic areas. 5 Imaging modalities include transvaginal ultrasound (TVUS), computed tomography (CT) scans, and magnetic resonance imaging (MRI). 6 MRI can detect lesions in rare sites such as the pelvic nerves. ...
Deep infiltrating endometriosis (DIE) is a subperitoneal intrusion of endometrialtissue. Resulting endometrial nodules may develop on the uterosacral ligament,urinary tract, rectovaginal, and retrocervical areas, and less commonly in the uri-nary bladder, thoracic, and neural regions. Genetics, age, and environmental fac-tors determine the progression of the disease. DIE manifests with numeroussymptoms, which are similar to unrelated diseases, namely dysmenorrhea, dys-pareunia, urinary tract infections, and infertility. Transvaginal ultrasound, mag-netic resonance imaging, computed tomography, and physical examination maydetect and differentiate endometriosis lesions from other diseases. Its clinicalmanagement typically involves laparoscopic surgery and hormonal therapy.These are designed to improve the quality of life and to address individual repro-ductive goals. This pictorial essay aims to provide clinical cases to highlight thecharacteristic radiological findings in each diagnostic modality and in addition toelucidate the current clinical management of DIE.
Key Words—CT; deep infiltrating endometriosis; DIE; endometrioma;endometriosis; MRI; nodules; ultrasound (TVUS
... Moreover, the implants of endometriotic tissue have the potential to erode through inner layers and lead to fibrosis changes of the muscularis propria. Therefore, folding and thickening signs of the rectal wall presenting on MRI images would be typical changes for BE [26]. ...
Objective:
To evaluate MRI features of bowel endometriosis (BE) and verify its clinical significance compared with pathological diagnosis.
Materials and methods:
Since 2018, patients clinically diagnosed with deep endometriosis (DE) and planned to undergo surgery were enrolled prospectively. MRI parameters including traction, thickening sign of the rectum, obliteration of the Douglas Pouch, sign of adenomyosis, and pelvic adhesion were extracted. Uni- and multi-variate analyses were performed to explore their association with pathological diagnosis of BE. ROC curve was utilized to ascertain the appropriate cutoff value for predicting the presence and assessing the severity of BE.
Results:
A total of 226 patients with DE were recruited, and 154 BE cases were pathologically confirmed. Logistic regression analysis revealed that thickness of the rectal wall, traction sign of the rectum, and obliteration of the Douglas Pouch were independent factors to predict the presence of BE with the OR 1.59 (95% CI: 1.29-1.96), 0.24 (95% CI: 0.09-0.67), and 0.17 (95% CI: 0.07-0.40), respectively (p all < 0.01). A cutoff value of 6.0 mm for the thickness of rectal wall resulted in the highest predictive value of BE (specificity: 90.3%; sensitivity: 78.6%). For patients with measured thickness of the rectal wall over 6.0 mm, 72.1% (93/129) was confirmed BE with lesions infiltrated more than muscular layer.
Conclusion:
This prospective study indicates that based on precise definition of visualized features on MRI images, BE could be recognized pre-operatively. DE patients with thickness of rectal wall exceeding 6.0 mm have a greater probability of BE.
Clinical relevance statement:
Based on precise definition of visualized features and accurate measurement on MRI images, bowel infiltrating among deep endometriosis patients could be recognized pre-operatively.
Key points:
• Precise definition of measurable MRI parameters made it possible for early detection of bowel endometriosis. • Thickening sign, traction sign of the rectum, and obliteration of the Douglas Pouch were typical radiological indicators for bowel endometriosis. • Bowel involvement is more sensitive to be detected among pelvic deep endometriosis patients with the thickness of the rectal wall over 6.0 mm.
... On T1 sequences, signal intensity may be equal to or slightly increased in comparison to muscle tissue, with synchronous presence of hyperintense foci suggestive of subacute bleeding within the above-mentioned ectopic endometrial glands. 26,38 In the absence of bleeding, the lesions may demonstrate a homogeneously intermediate T1 signal, 39 and the foci may appear hypointense if present, 38 thus making them less conspicuous on T1-weighted imaging. It is important to note that the aforementioned T1 hyperintensities will maintain that appearance on both non-fat saturated and fat-saturated T1-weighted sequences, as they are the result of haemorrhage. ...
... On T1 sequences, signal intensity may be equal to or slightly increased in comparison to muscle tissue, with synchronous presence of hyperintense foci suggestive of subacute bleeding within the above-mentioned ectopic endometrial glands. 26,38 In the absence of bleeding, the lesions may demonstrate a homogeneously intermediate T1 signal, 39 and the foci may appear hypointense if present, 38 thus making them less conspicuous on T1-weighted imaging. It is important to note that the aforementioned T1 hyperintensities will maintain that appearance on both non-fat saturated and fat-saturated T1-weighted sequences, as they are the result of haemorrhage. ...
Caesarean-section scar endometriosis (CSSE) is a form of extra-pelvic endometriosis developing through endometrial cell implantation anywhere along the route of a previous caesarean section (CS) surgery, including the skin, subcutaneous tissue, abdominal wall muscles, intraperitoneally, and the uterine scar itself. Synchronous intra-abdominal endometriosis is not a prerequisite. Given the rising prevalence of CS, CSSE may be underrepresented in the literature and occur more frequently than previously thought. Locating a painful soft-tissue mass-like lesion along the path of a previous CS scar is the most indicative sign that should initially alarm physicians towards suggesting CSSE, especially if symptoms are typical (cyclically reoccurring with menstruation). The detection of hyperintense (haemorrhagic) foci on T1 fat-saturated sequences will strongly support the diagnosis on magnetic resonance imaging (MRI), the most sensitive imaging method for CSSE assessment. A non-specific, contrast-enhancing, hypodense nodule with spiculate edges may be suggestive if the lesion was originally detected on computed tomography (CT). Although ultrasound is frequently the first imaging method used, the findings are non-specific; therefore, making it more useful for ruling out other differentials and for image-guided biopsy. In any case, histopathology provides the definitive diagnosis. Surgical excision is the mainstay of treatment; however, minimally invasive, percutaneous techniques have also been implemented successfully.
