ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are...

ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN

M.Basta Nikolić, S. Stojanović, O. Nikolić, T. Mrđanin, D. Donat, V. Žigić

Center for Radiology, Clinical Center of VojvodinaNovi Sad

Chronic pelvic pain (CPP)

• Presence of pain >6m localized to the anatomic pelvis

• Severe enough to cause functional disability and require medical or surgical treatment

• Cause of ~40% laparoscopies and 10-15% hysterectomies

CAUSE OF CPP

1. Gyn and Obs

2. Urologic

3. GI

4. Vascular

5. MS

6. Neuro

7. Psychological

1/3 endometriosis

1/3 adhesions

Neis KJ,Neis F. Chronic pelvic pain: cause, diagnosis and therapy from a gynaecologist’s and an endoscopist’s point of view. Gynecol Endocrinol.2009;25(11):757-761.

ENDOMETRIOSIS

-presence of functional endometrial glands and stroma outside the uterine cavity

• Infertility• pelvic pain

• Unusual symptoms• gastrointestinal involvement: catamenial diarrhoea,

rectal bleeding and constipation• vesical involvement: urgency, frequency, haematuria• thoracic involvement: pleuritic chest pain,

pneumothorax, pleural effusions or cyclic haemoptysis• asymptomatic: especially if disease is isolated to the

peritoneum

SYMPTOMS

AETHIOPATHOGENETIC MECHANISMS OF ENDOMETRIOSIS-ASSOCIATED CPP

• Nociceptive

• Inflammatory

• Neuropathic mechanisms

• metastatic theory

• metaplastic theory

• induction theory

PATHOGENESIS

radiopedia.org

PREVALENCE

• 1 in 10 women

• Strongly linked to infertility

• 25-50% of infertile women have endometriosis

• 30-50% of women with endometriosis is infertile

• OVARIAN

• SUPERFICIAL

• DEEP

LOCATION

SUPERFICIAL ENDOMETRIOSIS

• superficial plaques scattered across the peritoneum, ovaries and uterine ligaments

DEEP PELVIC ENDOMETROSIS

• subperitoneal invasion by endometriotic lesions that exceeds 5 mm in depth and comprises nodules, cysts and secondary scarring

Antônio Coutinho, et al. MR Imaging in Deep Pelvic Endometriosis: A Pictorial EssayRadioGraphics 2011 31:2, 549-567

• Most common: ovaries, pelvis, peritoneum

• Less common: C section scar, deep subperitoneal tissue, GI tract, bladder, chest, subcutaneous tissue

• Most common sites of pelvic involvement: Douglas pouch, uterosacral ligaments and torus uterinus

LOCATION

• ULTRASOUND

TRANSABDOMINAL

TRANSVAGINAL

TRANSRECTAL

• MRI

• CT

• CLASSIC RADIOLOGICAL METHODS

COLONOGRAPHY, ENTEROCLISIS, CHEST X RAY...

IMAGING

ENDOMETRIOSIS

TRANSVAGINAL US TRANSRECTAL US

• OVARIES

• URINARY BLADDER

• RECTOVAGINAL

• UTEROSACRAL

• RECTOSYGMOID

BAZOT M ET AL.; DEEP PELVIC ENDOMETRIOSIS: MR IMAGING FOR DIAGNOSIS AND

PREDICTION OF EXTENSION OF DISEASE; RADIOLOGY 2004.

ULTRASONOGRAPHY

• Good for endometriomas

• Homogenous hypoechoic lesion

• No Doppler signal

• Unilocular

• May be multiple

• Poor for peritoneal implants

ENDOMETRIOMA

“CHOCOLATE” CYST

TRANSVAGINAL US MACROSCOPICALLY

THICK SEPTATIONS

TRANSVAGINAL US MACROSCOPICALLY

MRI

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• T1

– hyperintense

– high SI T1 FS

• T2

– hypointense -shading sign

– T2 dark spot sign

• DWI

– variable restricted diffusion

• T1C+

– may have wall enhancement

– the presence of an enhancing mural nodule is suggestive of malignant transformation

METHOD OF CHOICE!

• haemorrhagic “powder burn” lesions appear bright on T1 fat saturated sequences

• small solid deep lesions– may be hyperintense on T1 and hypointense on T2

• adhesions and fibrosis

MRI CHARACTERISTICS OF ENDOMETRIOSIS

uterosacral involvement

• irregular margins

• asymmetry

• nodularity and thickening

• altered T2 signal: isointense (50%), hypointense (40%) or hyperintense (10%) cf. myometrium

vaginal involvement

• loss of hypointense signal of posterior vaginal wall on T2WI

• thickening, nodules and/or masses

M Bazot et al. Accuracy of magnetic resonance imaging and rectal endoscopic sonography for the prediction of location of deep pelvic endometriosis. Human reproduction , 2007; 22:. 1457-63.

BLEEDING FOCI IN VAGINA

Pouch of Douglas

– partial to complete obliteration

– suspended or lateralisedfluid collections

Rectovaginal septum

– nodules or masses that passed through the lower border of the posterior lip of the cervix

Gastrointestinal tract

rectal wall thickening

anterior displacement of the rectum

abnormal angulation

loss of fat plane between uterus and bowel

inflammatory response due to repeated haemorrhage can lead to adhesions, strictures and bowel obstruction

Urinary tract

– bladder

• localised or diffuse bladder wall thickening

• signal intensity abnormality, nodules or masses usually located at the level of the vesicouterine pouch

• involvement of bladder mucosa is rare

KISSING OVARIES

• chest

– catamenial pneumothorax

– haemothorax

– lung nodules

• cutaneous tissues

– nodules

• malignant transformation

– solid enhancing components

PULMONARY ENDOMETRIOSIS- CATAMENIAL SY

CHEST X RAY THORACIC CT

ENDOMETRIOSIS OF ANTERIOR ABDOMINAL

WALL

US CONTRAST CT

Hematosalpinx

Hydrosalpinx

SENSITIVITY SPECIFICITY

UTEROSACRAL LIGAMENT 86 % 77 %

VAGINA 80 % 93%

RECTOVAGINAL SEPTUM 80 % 97 %

BOWEL 88 % 98 %

ENDOMETRIOSIS

ACCURACY OF MRI IN DIFFERENT LOCALIZATIONS 1

1. BAZOT M ET AL.; DEEP PELVIC ENDOMETRIOSIS: MR IMAGING FOR DIAGNOSIS AND

PREDICTION OF EXTENSION OF DISEASE; RADIOLOGY 2004.

• VISUALIZATION OF SMALL PERITONEAL IMPLANTS

• VISUALIZATION OF ADHESIONS

1. DIRECT – PRESENCE OF FLUID ON BOTH SIDES

2. INDIRECT

-ANGULATION OF BOWEL LOOPS

-ELEVATION OF POSTERIOR VAGINAL FORNIX

-CHANGE OF UTERUS AND OVARIES POSITION

-TRIANGULAR PULLING OF ANTERIOR RECTAL WALL

LIMITATIONS OF MRI EXAMINATION

LAPAROSCOPY-GOLDEN STRANDARD!

12/7/2017 41

� Total rate of recurrence of endometriosis after operative

treatment is:

30-40%

� Paolo Vercellini Surgery for endometriosis-Associated infertility: a pragmatic approach. Human Reproduction, Vol.24, No.2 pp. 254–269, 2009.

Up to 10 years for diagnosis!!!

Every woman who has endometriosis knows another one with the same problem.

Every doctor has different opinion

and advice. However, satisfactory

treatment is still a distant dream

for many patients!

PROBLEMS

What to say?Sometimes difficult to

diagnose

Right choice of therapy-does it exist?

„Find a way to send them to someone else“

„Remember one among all colleagues who you do not like“

• ADDITIONAL SEQUENCES

1. FAT SUPPRESSED

2. GRADIENT ECHO

3. SUSCEPTIBILITY WEIGHTED 1 : 93 % SENSITIVITY

100 % SPECIFICITY

• INTRAVAGINALLY - US GELLY

• INTRARECTAL - CONTRAST OR WATER

• INTRAMUSCULAR – ANTIPERISTALTIC AGENS

ENHANCEMENT OF MRI EXAMINATION

1. TAKEUCHI ET AL.; SUSCEPTIBILITY WEIGHTED MRI OF ENDOMETRIOMA: PRELIMINARY RESULTS; AJR 2008.

1. Multiple T1- Hyperintense adnexal cysts are specific for endometriomas

2. Female pelvis MR imaging protocols should include T1-weighted Fat-suppressed sequences

3. Low SI of adnexal masses on STIR MR images is not specific for mature cystic teratoma and does not exclude endometrioma

Ten Imaging Pearls

MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675–1691

4. Benign endometriomas show restricted diffusion

5. Hematosalpinx should be considered specific for pelvic endometriosis

6. Obstruction of antegrade menstrual flow increases the risk for endometriosis

7. Decidualized endometriosis may mimic ovarian malignancy in pregnant women

MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675–1691

8. Endometriomas can transform into clear cell or endometrioid epithelial ovarian carcinomas

9. Solid fibrotic masses of endometriosis are common and easily overlooked

10. Solid invasive endometriosis of the posterior uterus can mimic posterior segmental adenomyosis

MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675–1691

CONCLUSION

• Consider endometriosis

in the presence of gynecological symptoms such as dysmenorrhoea,pelvic pain, dispareunia, infertility and fatigue in the presence of any of the above

Or in women of reproductive age with non-gynecological cyclical symptoms (dyschezia,dysuria, haematuria, rectal bleeding, shoulder pain)

• MR is the imaging method of choice

• Laparoscopy is the golden standard of both diagnosis and treatment

G.A.J. Dunselman et al. ESHRE guideline: management of women with endometriosis , Human Reproduction, 2014; 29 (3): 400–412.