Endometriosis
8 min read

Optimizing Ultrasound for Recto-Vaginal Endometriosis

Last updated:

Table of Contents

Video Description

This video demonstrates expert tips and tricks to enhance ultrasound imaging of recto-vaginal endometriosis, leveraging two distinct techniques.

Presented By

Female doctor avatar
Dr. Francesca Donders
Female doctor avatar
Dr. Kristina Arendas
male doctor avatar
Dr. Antoine Netter
Female doctor avatar
Dr. Madeleine Lemyre
Female doctor avatar
Dr. Marie-Ève Lachance
Female doctor avatar
Valérie Allard
male doctor avatar
Dr. Philippe Laberge
Female doctor avatar
Dr. Sarah-Maheux Lacroix

Affiliations

Université Laval

Watch on YouTube

Click here to watch this video on YouTube.

What is Optimizing Ultrasound for Recto-Vaginal Endometriosis?

Optimizing ultrasound for recto-vaginal endometriosis focuses on enhancing detection and assessment techniques through specialized methods:

  1. Transvaginal Ultrasound (TVUS): The primary tool for detailed imaging of the pelvic region, crucial for identifying signs of endometriosis between the rectum and vagina.
  2. Specialized Training: Sonographers require advanced training to recognize subtle indicators of recto-vaginal endometriosis.
  3. Patient Preparation: Proper preparation and positioning improve the quality of imaging, aiding in more accurate diagnoses.
  4. Use of Advanced Modalities: Integrating TVUS with MRI and other technologies like Doppler and elastography provides comprehensive insights, improving diagnostic accuracy and treatment planning.

What are the Risks of Optimizing Ultrasound for Recto-Vaginal Endometriosis?

Optimizing ultrasound for recto-vaginal endometriosis primarily carries risks related to the limitations and challenges of the imaging technique rather than direct physical risks to the patient. Here are some potential issues:

  • Diagnostic Accuracy: Even with optimized techniques, ultrasound may not always conclusively detect recto-vaginal endometriosis. There’s a risk of both false negatives, where the condition is not identified when it is present, and false positives, leading to unnecessary treatments.
  • Operator Dependency: The effectiveness of ultrasound significantly depends on the skill and experience of the operator. Misinterpretation of sonographic findings due to less experienced sonographers can lead to incorrect diagnoses.
  • Patient Discomfort: Although generally non-invasive, transvaginal ultrasound can be uncomfortable or cause anxiety, particularly in patients with severe pelvic pain or those who may have experienced previous trauma.
  • Complacency in Imaging: There’s a risk that reliance on ultrasound alone might lead to underutilization of other diagnostic modalities like MRI, which can provide different types of information crucial for comprehensive assessment and treatment planning.
  • Resource Allocation: Optimizing ultrasound involves investments in training and technology, which might not be feasible in all healthcare settings due to cost constraints, potentially leading to inconsistent diagnostic capabilities across different regions.

Addressing these risks involves ensuring high-quality training for ultrasound operators, using a multidisciplinary approach for diagnosis and treatment, and maintaining an open dialogue with patients about the benefits and limitations of ultrasound imaging.

Video Transcript: Optimizing Ultrasound for Recto-Vaginal Endometriosis

Tips and tricks to optimise ultrasound imaging of recto-vaginal endometriosis. This is a video presented by the minimal invasive team at the Laval University Hospital in which two possible techniques will be discussed that will help you improve your assessment of recto-vaginal endometriosis.

Endometriosis is a disease affecting about 10% of reproductive-aged women. This accounts for a total of 190 million women worldwide, according to recent WHO estimates. It is a benign yet very invasive disease which has been under-recognised for a long time, even within the field of gynaecology.

Especially, the need for expertise imaging has led to and still leads to important delays in diagnosis. The average delay of diagnosis is between seven to ten years, meaning that patients are often diagnosed when they already have extensive disease, presenting not only with severe dysmenorrhea but often already in a stage of chronic dysfunctional pain and/or infertility.

A very common presentation of women presenting with deep infiltrating endometriosis is a presence of recto-vaginal nodules, often missed on routine imaging studies. Our goal is thus, in this video, to improve our transvaginal ultrasound technique to be able to better evaluate the presence and extent of recto-vaginal endometriosis.

We will discuss two techniques that can be used to optimise your standard transvaginal ultrasound imaging, the first one being what we call vaginal gel sonography, in which we create a gel plane between our ultrasound probe and the vaginal wall to allow us for better evaluation of the vaginal wall and the presence of potential endometriosis.

The second technique is what we call transvaginal rectal hydrosonography, meaning that we will inject water into the rectum while performing a transvaginal ultrasound. The water will create a plane which will allow us to improve the distinction between the rectal lumen and the rectal walls. It allows us to clearly see the different layers of the rectum and allows us to better estimate the intramural extent of a rectal nodule.

The transvaginal approach allows us to work in a way that we are used to working in the field of gynaecology and is thus easy to learn. Additionally, it allows us to evaluate the relationship of the nodule compared to surrounding structures, like the posterior vaginal fornix, the uterine torus, the uterosacral ligaments and the ovaries.

We will start with the ultrasound appearance of normal vaginal and rectal tissue, and then secondly, we’ll discuss our two techniques in detail. For the ease of the video, I will describe shades of white and grey to describe the different layers, understanding that white means hyperechoic and dark means hypoechoic.

On ultrasound, the vaginal mucosa will appear grey. The thickness will depend on oestrogen status. When reaching the posterior fornix, we note the millimetre-thin white line of the overlaying serosa of the Douglas pouch. Note that there are no irregularities of the vaginal wall.

The serosa or outer layer of a normal rectal wall, as seen in this image, is identified as a white millimetre-thin line, followed by thicker, dark grey muscularis propria layers. Underneath the muscularis, you will find the lighter grey submucosa, and ultimately a thin white line depicting the mucosa.

So how to improve our visualisation? Our first technique is the vaginal gel sonography. For this technique, we need only two things, a routine large examination glove and an ultrasound gel that does not contain air bubbles. We will introduce a large chunk of ultrasound gel into the thumb of the glove to fill up the entire tip.

 The goal is to have a large mass of gel between the probe and the glove tip. Because the material of an examination glove is more rigid than the routinely used ultrasound condoms, the gel plane is preserved better and allows for better visualisation of vaginal nodules.

We always start our exam with the evaluation of the posterior vaginal wall and fornix. The most important part of the examination is to introduce the probe very slowly, scanning sagittal, focusing on unrolling the posterior vagina until reaching the posterior fornix. Generally, endometriosis nodules will make the vaginal wall appear thickened and uneven. They generally consist of a darker grey.

In this video, you see a dark grey hypoechoic recto-vaginal nodule. Note the irregularity of the vaginal wall. It also infiltrates the underlying uterosacral ligament and reaches even the muscularis layer of the rectum. This video shows the same nodule, but without the gel. Note how it is more difficult to pick up on the vaginal irregularity, making it harder to identify transmural disease without the gel.

In the second part, we will present the transvaginal rectal hydrosonography technique. For this technique, we essentially need four things, a 60 cc syringe with a cone tip, luke tap water, a bowl to contain the water and a lubricant gel to apply to the tip of the syringe upon inserting it into the rectum. Pre-examination, a saline enema can be used about three hours prior to the exam, but it is not obligatory, mainly to consider in patients with a history of constipation.

We start with rectally injecting a total of three syringes, or 180 cc of water. This can be done by the patient herself or by the provider, depending on the patient’s preference. We will then return to the transvaginal ultrasound. Just as for the previous technique, it is important to slowly introduce our probe. Following the rectal windings, try to notice if there are any signs of thickening of the rectal wall or extreme fold swells scanning through.

This is another case in which you see nicely the different layers of the rectum. In this fragment, we did not yet inject the water into the rectum. We follow the windings. At some point, we suspect a thickening, but it is difficult to have a clear image on whether or not the muscularis layer is affected.

This is another fragment of the same patient, but after the water injection. It allows for a better visualisation of the lumen, and in this case, we do have a clear visualisation of the nodule. Note how it infiltrates the muscularis layer.

Here, you see a second case of an important rectal nodule, affecting all layers but the mucosa, in which the water injection allowed us to easily see the extent. The ultrasound image correlates perfectly to the image of the specimen after bowel resection. Note how the mucosa is intact.

 Finally, we asked our patients how they tolerated this exam. All of our patients so far said that they preferred the ultrasound examination over the MRI. Even if causing certain discomfort, the fact of having live feedback about your condition and having the interaction with your healthcare provider had their preference.

So in summary, we think, in general, that the alertness for correctly diagnosing endometriosis should be improved. Improving our ultrasound skills is herein a powerful tool. Transvaginal ultrasound is easily accessible and well tolerated.

For diagnosing recto-vaginal endometriosis, the two techniques of vaginal gel sonography and transvaginal rectal hydrosonography are particularly useful as they are cheap and require minimal material, are a little invasive, are easy to learn and allow us to improve our diagnostic accuracy. I would like to thank my entire team for their cooperation on this video and thank you for your attention.