Diagnostic accuracy of sliding sign for detecting pouch of Douglas obliteration and bowel involvement in women with suspected endometriosis: systematic review and meta-analysis

Endometriosis MDC: role of the radiologist

Endometriosis presents a common and significant health burden affecting approximately 1 in 10 reproductive age patients who are assigned female at birth. Recently guidelines have begun shifting away from laparoscopy as the first-line diagnostic tool and instead recommend imaging for initial diagnosis and presurgical mapping of endometriosis. This shift places the radiologist in a central role for diagnosis and assessment of management efforts. During this comprehensive review article, we discuss the importance of MDC in the treatment of advanced endometriosis, the radiologist 's role at endometriosis MDC as well as the opportunities that exist for the radiologist to add-value in an endometriosis service.

Endometriosis imaging in the community setting: implementation of the SRU consensus recommendations on routine pelvic US

Endometriosis is a common gynecologic disorder with a significant burden of morbidity that is often subject to substantial diagnostic delay. While transvaginal ultrasound (TVUS) is the first-line imaging tool for symptoms like chronic pelvic pain and infertility, it has limitations in detecting deep endometriosis. In 2024, the Society of Radiologists in Ultrasound (SRU) issued recommendations to enhance detection by incorporating additional techniques into standard TVUS. This article outlines practical adaptations to improve diagnostic accuracy with minimal extra scan time in community practices. It covers patient selection, stakeholder involvement, training, and quality assurance while addressing implementation challenges. Community ultrasound practices play a key role in early detection, guiding patients toward appropriate care.

Proposed simplified protocol for initial assessment of endometriosis with transvaginal ultrasound

Linked article: There is a comment on this article by Guerriero et al. Click here to view the Correspondence.

Quality Improvement Report: The Sliding Sign Initiative-Facilitating Earlier Detection of Deep Endometriosis in an Academic US Department

A delayed diagnosis of endometriosis can significantly impact a patient's quality of life. To facilitate an earlier diagnosis, we implemented a modified pelvic US protocol that included use of the dynamic sliding sign (SS) maneuver to screen at-risk populations. The aim of this initiative was to improve both SS maneuver performance and SS reporting consistency to 80% and determine the number of new endometriosis cases identified after US. A quality improvement framework based on the plan-do-study-act (PDSA) methodology was used to develop and evaluate interventions. Eligible pelvic US studies were reviewed at regular intervals to track SS maneuver performance and SS reporting, with control charts used to detect intervention-related variation. A chart review of all abnormal SS cases was also performed. The project initiation (PDSA cycle 1) included protocol development and educational sessions. Reminder posters were placed during cycle 2 and revised in cycle 3, and the eligibility criteria were revised. Cycles 4 and 5 consisted of in-person discussions, distribution of a reference guide, and creation of a dictation software macro. In terms of results, sonographers performed the SS maneuver correctly in 52.1% of eligible patients after cycle 1, increasing to 83.9% by cycle 5. In the cases in which the SS maneuver was performed by the sonographer, after PDSA cycle 1, the SS was reported by the radiologist in 69% of cases (including both correct and incorrect interpretations), and both reported and interpreted correctly in 59% of cases, reaching 79.5% by cycle 3, and plateauing thereafter. Thirty-seven patients were newly diagnosed with endometriosis after undergoing US of the SS. The objectives of our SS initiative were met, with improved SS US performance, improved SS reporting and interpretation, and a number of new endometriosis cases diagnosed. ©RSNA, 2024 Supplemental material is available for this article. See the invited commentary by Jha and VanBuren in this issue.

Postmenopausal Endometriosis: Clinical Insights and Imaging Considerations

Endometriosis is a chronic systemic condition characterized by the presence of ectopic endometrial-like tissue outside of the uterus. It occurs most often in reproductive-aged patients and less frequently in postmenopausal women. In postmenopausal patients, endometriosis is more common in those undergoing hormone replacement therapy or taking tamoxifen. The risk of malignant transformation of endometriosis is higher in this older population, especially in those undergoing estrogen-only hormone replacement therapy. Many theories on the postmenopausal pathogenesis of endometriosis have been proposed, ranging from reactivation of premenopausal disease to de novo manifestation. Compared with premenopausal disease, postmenopausal endometriosis is typically less active and extensive, with fewer hemorrhagic components. Patients may be symptomatic, with chronic pelvic pain, or may receive the diagnosis after imaging performed for other indications such as an incidental ovarian lesion. Treatment is typically surgical resection or estrogen-blocking medications. Although the diagnosis requires pathologic confirmation, radiologists play an important role in diagnosing both benign endometriosis and malignant transformation. Pelvic US following a dedicated protocol is an accessible screening tool, with high sensitivity for diagnosis of bowel-invasive disease. MRI has better anatomic resolution and allows simultaneous characterization of adnexal and extrapelvic lesions, thereby providing excellent assessment for malignant transformation.

ACR Appropriateness Criteria® Endometriosis

Endometriosis is a common condition impacting individuals assigned female at birth. Though incompletely understood, the disorder is caused by endometrial-like tissue located outside of the endometrial cavity, associated with inflammation and fibrosis. Clinical presentation is variable, ranging from asymptomatic to severe pelvic pain and infertility. Treatment is determined by the patient's individualized goals and can include medical therapies to temporize symptoms or definitive surgical excision. Imaging is used to help diagnose endometriosis and for treatment planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Surgical treatment of colorectal endometriosis: an updated review

PURPOSE OF REVIEW

This review aims to summarize recent literature on the surgical treatment of colorectal endometriosis.

RECENT FINDINGS

The last decade has seen a surge in the number of studies on bowel endometriosis, with a focus on preoperative evaluation, perioperative management, surgical approach, and surgical outcomes. Many of these studies have originated from large-volume referral centers with varying surgical approaches and philosophies. Colorectal surgery for endometriosis seems to have a positive impact on patient symptoms, quality of life, and fertility. However, these benefits must be weighed against a significant risk of postoperative complications and the potential for long-term bowel or bladder dysfunction, especially for more radical procedures involving the lower rectum. Importantly, most studies regarding surgical technique and outcomes have been limited by their observational design.

SUMMARY

The surgical management of bowel endometriosis is complex and should be approached by a multidisciplinary team. Methodical preoperative evaluation, including appropriate imaging, is vital for surgical planning and patient counseling. The decision to perform a more conservative or radical excision is nuanced and remains an area of controversy. High quality studies in the form of multicenter randomized controlled trials are needed before clear recommendations can be made.

Transvaginal ultrasound with bowel preparation versus transvaginal ultrasound with bowel preparation and water contrast for diagnosing Recto-Sigmoid endometriosis. A systematic review and Meta-Analysis

Transvaginal ultrasound is effective in diagnosing endometriosis involving the rectosigmoid bowel. Some authors suggest enhanced detection of rectosigmoid involvement with bowel preparation. Conversely, conflicting views argue that bowel preparation may not improve diagnostic precision, yielding similar results to rectal water contrast. No existing meta-analysis compares these approaches. Our study aims to conduct a meta-analysis to evaluate the diagnostic performance of transvaginal ultrasound with bowel preparation, with and without rectal water contrast. Studies published between 2000 and 2023 were searched in PubMed, Scopus, Cochrane and Web of Science. From 561 citations, we selected nine studies to include in this meta-analysis. The study quality was assessed using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2). The mean prevalence of endometriosis rectosigmoid was 43.6% (range 17,56-76,66%) in the group with bowel preparation and 64,80% (50,0-83,60%) for the group with bowel preparation and rectal water contrast. Pooled sensitivity and specificity were 93% and 94% for bowel preparation and 92% and 95% and for bowel preparation with water contrast. We conclude that, there was no significant difference between performing transvaginal ultrasound with intestinal preparation with and without water contrast. In clinical practice, the absence of a significant difference between these methods should be taken into account when making recommendations.

Advances in Imaging for Assessing Pelvic Endometriosis

In recent years, due to the development of standardized diagnostic protocols associated with an improvement in the associated technology, the diagnosis of pelvic endometriosis using imaging is becoming a reality. In particular, transvaginal ultrasound and magnetic resonance are today the two imaging techniques that can accurately identify the majority of the phenotypes of endometriosis. This review focuses not only on these most common imaging modalities but also on some additional radiological techniques that were proposed for rectosigmoid colon endometriosis, such as double-contrast barium enema, rectal endoscopic ultrasonography, multidetector computed tomography enema, computed tomography colonography and positron emission tomography-computed tomography with 16α-[18F]fluoro-17β-estradiol.

Effectiveness of ultrasound for endometriosis diagnosis

PURPOSE OF REVIEW

Endometriosis is a chronic benign gynaecological condition characterized by pelvic pain, subfertility and delay in diagnosis. There is an emerging philosophical shift from gold standard histopathological diagnosis through laparoscopy to establishing diagnosis through noninvasive imaging.

RECENT FINDINGS

The ENZIAN classification system was updated in 2021 to be suitable for both diagnostic imaging and laparoscopy. The accuracy of transvaginal ultrasound (TVUS) in diagnosing endometriosis varies depending on location of the lesion. A recent international pilot study found that when ultrasound is performed in accordance with the IDEA consensus, a higher detection of deep endometriosis is seen, with an overall sensitivity of 88% and specificity of 79% compared with direct surgical visualization.

SUMMARY

Although ultrasound can detect adenomyosis, deep endometriosis and endometriomas, it is not possible to reliably detect superficial endometriosis. In the instance of a negative ultrasound with persistence of symptoms despite medical therapy, laparoscopy should be considered for diagnosis and treatment.