Endometriosis
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Ultrasound in the Diagnosis of Endometriosis

Ultrasound in the Diagnosis of Endometriosis
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Table of Contents

Video Description

This video discusses the various levels and techniques of ultrasound in the setting of endometriosis and highlights specifics markers of endometriosis to investigate for.

Presented By

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Dr. Sugandha Agarwal
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Dr. Vincent della Zazzera
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Dr. Margaret Ann Fraser
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Dr. Sukhbir Sony Singh

Affiliations

University of Ottawa, The Ottawa Hospital

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What is Ultrasound in the Diagnosis of Endometriosis?

Ultrasound in the Diagnosis of Endometriosis involves using transvaginal ultrasound (TVUS) to identify and assess endometriotic lesions and cysts. Here’s a concise overview:

  • Procedure:
    • TVUS is a non-invasive technique where a probe is inserted into the vagina to obtain detailed images of the pelvic organs.
  • Diagnosis:
    • Detects endometriotic lesions, cysts (endometriomas), and adhesions on pelvic organs.
    • Identifies deep infiltrating endometriosis (DIE) affecting structures like the bowel and bladder.
    • Assesses overall pelvic anatomy and the extent of the disease.
  • Advantages:
    • Non-invasive and avoids the need for immediate surgery.
    • Provides real-time imaging of lesions and their relation to other structures.
    • Cost-effective compared to other imaging methods like MRI.
  • Limitations:
    • May not detect all forms of endometriosis, particularly small or superficial lesions.

What are the Risks of an Ultrasound in the Diagnosis of Endometriosis?

Risks of Ultrasound in the Diagnosis of Endometriosis are minimal due to its non-invasive nature, but there are some considerations to keep in mind:

  • False Negatives: Small or superficial lesions may not be detected, potentially leading to missed diagnoses.
  • False Positives: Non-specific findings might be incorrectly interpreted as endometriosis, leading to unnecessary worry or further testing.
  • Discomfort: The transvaginal ultrasound procedure can cause discomfort or mild pain, especially in women with severe endometriosis or pelvic pain.
  • Limited Visualization: While effective for many cases, ultrasound may not provide complete visualization of all pelvic structures compared to other imaging modalities like MRI.

Despite these risks, ultrasound remains a valuable, low-risk tool in the diagnostic process for endometriosis.

Video Transcript: Ultrasound in the Diagnosis of Endometriosis

The Ottawa Minimally Invasive Gynaecology Group, University of Ottawa, presents ultrasound in the diagnosis of endometriosis. The objectives of the video are to review the proposed levels of ultrasound in the diagnosis of endometriosis. To demonstrate our technique of ultrasound specifically performed for endometriosis. As well as to demonstrate the various level I and level II markers for diagnosis on ultrasound.

In this section, we discuss the proposed levels of ultrasound. Level I ultrasound is performed as a general gynae ultrasound when clinically indicated to specifically look for soft markers of endometriosis. These markers include the assessment of uterus for uterine position, mobility as determined by sliding sign, and adenomyosis that is often seen in conjunction with endometriosis.

Ovarian assessment should include mobility, tethering due to underlying additions, and presence of ovarian endometrioma. Pouch of Douglas should also be assessed for additions or obliteration, and sliding sign is a useful marker for the same. If the level I scan findings are indicative of endometriosis, and if clinically indicated, then a level II scan is performed. In addition to the markers scanned at level I, level II ultrasound involves assessment of bladder, vagina, uterosacral ligaments and bowel to look for endometriotic nodules or plaques.

It is also important to assess kidneys and ureter for hydroureteronephrosis, as ureteral involvement is often silent and may present as renal failure. When a level II scan is positive for disease involvement, a more advanced imaging is usually performed by an expert radiologist in the field of endometriosis. This provides us with a detailed assessment of lesions in terms of size, site, depth of infiltration, distance from anus or trigone, that helps a surgeon in preoperative planning.

We will now discuss the technique of ultrasound. This usually includes infiltration of 10 to 20ml of ultrasound gel in the posterior vaginal fornix. The transvaginal probe is then introduced and directed posteriorly to trace the rectum, anorectal verge, and linear aspect of bowel. The gel in vagina also helps to better delineate the anterior and posterior vaginal cuff, as well as fornices, to look for pathology in comparison to imaging without gel.

The uterus is then assessed for its position, findings of adenomyosis, as well as its mobility on sliding sign. The sliding sign is assessed by manipulating the uterus between our hand placed on the abdomen and ultrasound probe. Pressure on the probe tends to slide the uterus off the peritoneum in absence of any additions. This is followed by moving the probe to each side to assess the ovaries for endometrial mass. Probe pressure is also applied to look for ovarian mobility from uterus, as well as pelvic sidewall. The probe is then directed anteriorly to assess the bladder. Lastly, bilateral kidneys are assessed for hydronephrosis using a transabdominal probe.

In this section, we will review some of the markers of endometriosis on ultrasound. Here we see an acutely retroflexed uterus that can be a sign of underlying additions. Inability to slide the uterus over the anterior, as well as posterior peritoneum demonstrates a negative sliding sign. This again suggests adhesions due to underlying endometriosis, causing obliteration of the cul-de-sac posteriorly and vesico-uterine recess anteriorly.

Ovarian imaging can commonly reveal ovarian endometrial mass, and sometimes can show both ovaries tethered to the back of the uterus, known as kissing ovaries. Pressure applied by probe shows a negative ovarian sliding sign, suggesting ovarian additions. When uterine and ovarian markers are seen, a level II ultrasound should image other organs to look for endometriotic involvement. Here we see an endometriotic nodule appearing as a hypoechoic lesion involving the anterior wall of rectosigmoid. A similar hypoechoic endometrial lesion is seen involving the posterior vaginal fornix. Anteriorly, endometriotic nodules can be seen involving the full thickness of bladder wall, including mucosa.

In summary, ultrasound is a simple and an effective modality to diagnose endometriosis. And an advanced level of ultrasound increases the likelihood of detecting endometriosis, especially the deep form involving organs other than ovaries and uterus. Thank you.