Diagnosis of superficial endometriosis on transvaginal ultrasound by visualization of peritoneum of pouch of Douglas

OBJECTIVE

Around 80% of women with endometriosis have superficial endometriosis (SE) rather than ovarian or deep endometriosis (DE). However, to date, advances in non-invasive, imaging-based diagnosis have been limited to DE or ovarian disease. The objective of this study was to determine whether we can detect SE on transvaginal ultrasound scan (TVS) by assessing the peritoneum of the pouch of Douglas (POD).

METHODS

This was a retrospective diagnostic test study following a change in practice to include POD peritoneum assessment for SE during TVS at a tertiary London hospital. Eligible patients underwent TVS by a single clinician trained in endometriosis scanning and a subsequent surgical procedure (laparoscopy) between April 2018 and September 2021. Participants formed a consecutive series. The TVS findings were compared with those of laparoscopy as the gold standard. Comparison of TVS findings with intraoperative findings was performed by calculating the diagnostic test performance measures (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and positive and negative likelihood ratios).

RESULTS

The study included a total of 100 patients. We found that 43/100 (43.0%) patients had no endometriosis, 33/100 (33.0%) had SE and 24/100 (24.0%) had DE on laparoscopy. SE was correctly detected on TVS in 17/33 patients, with a sensitivity of 51.5% (95% CI, 33.5-69.2%), specificity of 94.0% (95% CI, 85.4-98.4%), PPV of 81.0% (95% CI, 60.8-92.1%) and NPV of 79.7% (95% CI, 73.4-84.9%). DE was correctly diagnosed in 20/24 cases, including all ovarian cases, with a sensitivity of 83.3% (95% CI, 62.3-95.3%), specificity of 97.4% (95% CI, 90.8-99.7%), PPV of 90.9% (95% CI, 71.6-97.5%) and NPV of 94.9% (95% CI, 88.3-97.8%). The detection of SE on TVS was most accurate in the POD (sensitivity, 50.0%; specificity, 96.4%; PPV, 76.9%; NPV, 88.9%).

CONCLUSIONS

This study shows that the detection of SE in the POD is possible using routine TVS. While negative TVS does not reliably confirm the absence of disease or replace diagnostic laparoscopy, positive TVS facilitates non-invasive diagnosis for a much larger group of women than was previously possible. This should help to reduce the time from the onset of symptoms to diagnosis and enable initiation of medical treatment without the risk, cost and delay associated with a surgical diagnosis. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

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

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the diagnostic accuracy of the sliding sign on transvaginal ultrasound (TVS) in detecting pouch of Douglas obliteration and bowel involvement in patients with suspected endometriosis, using laparoscopy as the reference standard.

METHODS

A search for studies evaluating the role of the sliding sign in the assessment of pouch of Douglas obliteration and/or bowel involvement using laparoscopy as the reference standard published from January 2000 to October 2021 was performed in PubMed/MEDLINE, Web of Science, CINAHL, The Cochrane Library, ClinicalTrials.gov and SCOPUS databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used to evaluate the quality of the studies. Analyses were performed using MIDAS and METANDI commands in STATA.

RESULTS

A total of 334 citations were identified. Eight studies were included in the analysis, resulting in 938 and 963 patients available for analysis of the diagnostic accuracy of the sliding sign for pouch of Douglas obliteration and bowel involvement, respectively. The mean prevalence of pouch of Douglas obliteration was 37% and the mean prevalence of bowel involvement was 23%. The pooled estimated sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of the sliding sign on TVS for detecting pouch of Douglas obliteration were 88% (95% CI, 81-93%), 94% (95% CI, 91-96%), 15.3 (95% CI, 10.2-22.9), 0.12 (95% CI, 0.07-0.21) and 123 (95% CI, 62-244), respectively. The heterogeneity was moderate for sensitivity and low for specificity for detecting pouch of Douglas obliteration. The pooled estimated sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of the sliding sign on TVS for detecting bowel involvement were 81% (95% CI, 64-91%), 95% (95% CI, 91-97%), 16.0 (95% CI, 9.0-28.6), 0.20 (95% CI, 0.10-0.40) and 81 (95% CI, 34-191), respectively. The heterogeneity for the meta-analysis of diagnostic accuracy for bowel involvement was high.

CONCLUSION

The sliding sign on TVS has good diagnostic performance for predicting pouch of Douglas obliteration and bowel involvement in women with suspected endometriosis. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

One-Size-Fits-All Approach Does Not Work for Gynecology Trainees Learning Endometriosis Ultrasound Skills

OBJECTIVES

To evaluate whether gynecologic surgical trainees (fellows) can become competent in the real-time classification of the pouch of Douglas (POD) obliteration state and direct visualization of bowel deep endometriosis (DE) during a program with a prespecified number of transvaginal ultrasound (TVUS) examinations.

METHODS

We performed a prospective study between December 2017 and December 2018. Three fellows (F1-F3) performed 50 scans each, which were all supervised by an expert sonologist, who performed the reference standard TVUS examination. The fellows performed a focused TVUS examination to assess the bowel and POD state, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's official classifications. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used.

RESULTS

A total of 150 examinations were performed on 145 patients. Twenty-six (17.9%) patients had a diagnosis of bowel DE, and 34 (23.4%) were classified as having a negative sliding sign by the reference standard. The overall accuracy of the presence/absence of bowel DE was 90% (range, 82%-94%). The overall accuracy of POD state classification was 93% (range, 90%-96%). The cumulative summation test for the learning curve for bowel DE showed that F1 did not reach competency by 50 scans, whereas F2 and F3 required 21 and 25 scans, respectively. For POD obliteration, F2 did not reach competency, whereas F1 and F3 required 40 and 22 scans.

CONCLUSIONS

Not all trainees can reach competency for TVUS evaluations of POD obliteration and bowel DE in a predefined number of scans.

Prevalence of negative sliding sign representing pouch of Douglas obliteration during pelvic transvaginal ultrasound for any indication

OBJECTIVES

Pouch of Douglas (POD) obliteration can be predicted with a high degree of certainty and reproducibility using the dynamic transvaginal ultrasound (TVS) sliding-sign technique. So far, studies on POD obliteration prediction have focused on tertiary-care populations with high prevalence of endometriosis; however, POD obliteration may exist in individuals with asymptomatic endometriosis or other conditions. Our primary aim was to determine the prevalence of a negative sliding sign, representing POD obliteration, in a cohort of patients undergoing TVS for any gynecological indication.

METHODS

This was a prospective observational study of consecutive women with an indication for gynecological TVS, conducted at a high-volume ultrasound practice between July and August 2018. Clinical and surgical history, indication for TVS and TVS findings were documented. The prevalence of TVS-confirmed POD obliteration, determined by interpretation of the sliding sign, was calculated for the entire cohort and for the subgroups of women with and without risk factors for endometriosis. High risk for endometriosis was defined as having (1) a TVS referral for endometriosis-like pelvic pain or endometriosis specifically and/or (2) clinical symptoms or signs suggestive of endometriosis. Low risk was defined as the absence of these characteristics.

RESULTS

During the study period, 1043 consecutive women underwent TVS. After excluding those who underwent transabdominal ultrasound, had a history of hysterectomy or with missing data, 909 women were analyzed. The prevalence of a negative sliding sign in the entire cohort was 47/909 (5.2%). A negative sliding sign was observed in 22/639 (3.4%) women with a low risk for endometriosis and 25/243 (10.3%) of those with a high risk for endometriosis (difference in proportions, 6.9% (95% CI 2.8-10.9%); P < 0.001).

CONCLUSIONS

We have demonstrated an overall prevalence of a negative sliding sign, suggesting POD obliteration, of 5.2% (or 1/20) in women seeking TVS for a gynecological indication. The prevalence of negative sliding sign in low-risk women is not negligible (3.4% or 1/29 women). These women are most likely to have asymptomatic endometriosis or another important etiology of POD obliteration. The prevalence of a negative sliding sign is approximately three-times higher in women with signs and/or symptoms of endometriosis (10.3% vs 3.4%). Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Predicting Pouch of Douglas Obliteration Using Ultrasound and Laparoscopic Video Sets: An Interobserver and Diagnostic Accuracy Study

OBJECTIVES

To investigate the diagnostic accuracy and interobserver agreement among sonologists when assessing offline ultrasound (US) video sets of the "sliding sign" and among gynecologic surgeons when assessing corresponding laparoscopic video sets to predict pouch of Douglas (POD) obliteration and to compare the performance of the groups.

METHODS

A diagnostic and reproducibility study was conducted, including 15 observers in 4 groups: (1) senior sonologists, (2) junior sonologists, (3) general gynecologists, and (4) advanced laparoscopists. The sonologists viewed 25 offline preoperative US video sets of the sliding sign, and the surgeons viewed the corresponding intraoperative laparoscopic videos of the same patients. Each observer was asked to classify POD obliteration in the video sets and was compared to the reference standard POD state determined at real-time laparoscopy by a single investigator (G.C.). The interobserver correlation and diagnostic accuracy were evaluated among the 15 observers and 4 groups. The Cohen κ coefficient and Fleiss κ coefficient were used for the analysis.

RESULTS

The overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for senior sonologists were 93.3%, 100%, 89.6%, 84.4%, and 100%, respectively; for junior sonologists, 70.0%, 88.9%, 59.4%, 55.2%, and 90.5%; for general gynecologists, 75.2%, 88.1%, 78.1%, 69.8%, and 91.9%; and for advanced laparoscopists, 82.4%, 91.9%, 90.8%, 82.9%, and 95.8%. The overall agreement between senior sonologists was almost perfect (Fleiss κ = 0.876); for junior sonologists and general gynecologists, it was moderate (Fleiss κ = 0.589 and 0.528); and for advanced laparoscopists, it was substantial (Fleiss κ = 0.652).

CONCLUSIONS

Interobserver agreement was superior among senior sonologists. Prediction of POD obliteration using offline US videos by senior sonologists is comparable to offline assessments of laparoscopic videos by advanced laparoscopists for prediction of POD obliteration.

A Novel Ultrasound Technique Called Saline Infusion SonoPODography to Visualize and Understand the Pouch of Douglas and Posterior Compartment Contents: A Feasibility Study

Women with infertility are often investigated with saline-infusion sonohysterography and hysterosalpingo-contrast-sonography. The high prevalence of endometriosis in this population also warrants an evaluation with transvaginal ultrasound for deep endometriosis. To minimize investigations, we prospectively evaluated the feasibility of a novel combined ultrasound technique called saline-infusion sonoPODography. In most patients, the fluid infused to assess the cavity and tubal patency spilled through patent tubes and filled the pouch of Douglas, yielding a "standoff" view of posterior compartment structures, including uterosacral ligaments, rectovaginal septum, and the pouch of Douglas. We believe this improved our ability to evaluate this space.

Accuracy of preoperative real-time dynamic transvaginal ultrasound sliding sign in prediction of pelvic adhesions in women with previous abdominopelvic surgery: prospective, multicenter, double-blind study

OBJECTIVE

To investigate the role of the transvaginal sonographic (TVS) sliding sign in predicting pelvic adhesions in women with previous abdominopelvic surgery.

METHODS

This was a multicenter, prospective, interventional, double-blind study of patients with a history of abdominopelvic surgery who were undergoing laparoscopy or laparotomy during the 6-month period from March to August 2016 in one of three academic obstetrics and gynecology departments. Prior to surgery, patients were examined by TVS to assess the vesicouterine pouch, uterus, ovaries and pouch of Douglas, using the TVS pelvic sliding sign. Ultrasound findings and medical and surgical data were recorded. We assessed the accuracy of the preoperative TVS sliding sign in the prediction of pelvic adhesions overall and in each compartment separately.

RESULTS

During the study period, complete TVS sliding sign and laparoscopic or laparotomic data were available for 107 women. Their mean age was 44.0 (95% CI, 41.6-46.4; range, 20-79) years. Their mean parity was 2.0 (95% CI, 1.7-2.3; range, 0-9) and the mean number of previous abdominal surgical procedures per patient was 1.3 (95% CI, 1.2-1.5; range, 1-4). Adhesions were noted in 27/107 (25.2%) patients. The TVS sliding sign had a sensitivity of 96.3% and specificity of 92.6% in predicting pelvic adhesions. There was a significant relationship between adhesions in each compartment and the TVS sliding sign (P < 0.05).

CONCLUSIONS

The TVS sliding sign is an effective means to detect preoperatively pelvic adhesions in patients with previous abdominopelvic surgery. Use of such a non-invasive and well-tolerated technique could help in the planning of laparoscopy or laparotomy and counseling of these patients. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Growing teratoma syndrome after ovarian inmature teratoma: a case report and review of the literature

Growing teratoma syndrome is an uncommon complication of malignant germ cell cancer, characterised by the development of large tumours during or after chemotherapy, despite normalisation of tumour marker levels and metastasis, which contain only mature teratoma. Given its low incidence, little is data available. The authors present the case of a 15-year-old girl with a growing teratoma and the literature review outlines the current knowledge of its pathogenesis, common sites, diagnosis, natural course, treatment, and prognosis.

Laparoscopic excision of rectosigmoid endometriotic plaque and cul de sac obliteration in deeply infiltrating endometriosis: a case report

Endometriosis represents a main cause of infertility and pelvic pain affecting 3-43% among reproductive age women. Deep pelvic endometriosis is defined as subperitoneal infiltration of endometrial implants in the uterosacral ligaments, rectum, rectovaginal septum, vagina or bladder. The authors present a case of a 29-year-old patient who underwent laparoscopic excision of extensive endometriotic plaque in rectovaginal septum accompanied with deeply infiltrating endometriosis (DIE) and chronic pelvic pain (CPP).

Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound technique: the sliding sign

OBJECTIVE

To evaluate preoperative real-time dynamic transvaginal sonography (TVS) in the prediction of pouch of Douglas (POD) obliteration in women undergoing laparoscopy for suspected endometriosis.

METHODS

This was a multicenter prospective observational study undertaken from January 2009 to November 2011. All women with symptoms suggestive of endometriosis who were scheduled for laparoscopy underwent detailed preoperative TVS, in particular to ascertain whether the POD was obliterated. POD obliteration was assessed using a real-time TVS technique called the 'sliding sign'. Preoperative TVS sliding sign findings were then compared to gold standard laparoscopic POD findings.

RESULTS

One hundred consecutive women with preoperative TVS and laparoscopic outcomes were included in the final analysis. Mean age was 32.8 years and mean age at diagnosis of endometriosis was 27.4 years. At laparoscopy, 84/100 (84%) were found to have some form of endometriosis (73% peritoneal endometriosis, 35% ovarian endometrioma(s), 33% deep infiltrating endometriosis). At laparoscopy, 30/100 (30%) had an obliterated POD and 19/30 (63.3%) of these women also had evidence of bowel endometriosis. The sonographic sliding sign technique had an accuracy of 93.0%, sensitivity of 83.3%, specificity of 97.1%, positive predictive value of 92.6%, negative predictive value of 93.2%, positive likelihood ratio of 29.2 and negative likelihood ratio of 0.17 in the prediction of POD obliteration (P = 1.8E-16).

CONCLUSIONS

Preoperative real-time dynamic TVS evaluation using the sliding sign seems to establish with a high degree of certainty whether the POD is obliterated. Given the increased risk of deep infiltrating endometriosis in women with POD obliteration, the TVS sliding sign technique may also be useful in the identification of women who may be at a higher risk for bowel endometriosis.

[The use of transvaginal sonography (TVS) for preoperative diagnosis of pelvic endometriosis]

Endometriosis is one the most challenging gynaecological disorders affecting 10-15% of women in their reproductive years. Considerable diagnostic delay of up to 8 years from presenting symptoms often confers a heavy economic and social price. Over the past years, additional diagnostic tools such as transvaginal scanning (TVS) and/or MRI have been recommended as an appropriate investigation to diagnose ovarian endometriomas or adenomyosis. Several lines of recent evidence strongly suggests that the use of TVS also has an important role in detecting DIE of the pelvis not only involving the ovaries but also structures such as the vagina, the rectovaginal space, the uterosacral ligaments, the bladder or the rectal wall.

Heterotopic pregnancy: simultaneous intrauterine and ectopic pregnancy following IVF treatment with the birth of a healthy child

Although spontaneous simultaneous intrauterine and ectopic pregnancy was an extremely rare event in the past, it is increasingly being diagnosed since the rate of assisted reproduction technique (ART) gestations increased. Due to the serious consequences, delayed diagnosis should be prevented in order to salvage the viable intrauterine fetus and avoid maternal morbidity and mortality. This case report demonstrates that the pitfalls of the diagnosis of heterotopic pregnancy make early diagnosis difficult and the prevention of heterotopic pregnancies by single embryo transfer should be continuously discussed. The role of high resolution ultrasound scans and the importance of close monitoring of early pregnancies following ART are emphasized because early diagnosis of heterotopic pregnancy results in a similar perinatal outcome as singleton pregnancies.

A comparison of dynamic transperineal ultrasound (DTP-US) with dynamic evacuation proctography (DEP) in the diagnosis of cul de sac hernia (enterocele) in patients with evacuatory dysfunction

BACKGROUND/AIMS

Cul-de-sac hernias (enterocele and peritoneocele) are difficult to diagnose in patients presenting with primary evacuatory difficulty. Failure to recognize their presence in patients undergoing surgery may lead to poor functional outcome. Accurate diagnosis requires specialized investigation including dynamic evacuation proctography (DEP) or dynamic magnetic resonance (MR) imaging. Recently, dynamic transperineal ultrasonography (DTP-US) has been used for this purpose. This study compares DEP with DTP-US for the diagnosis of cul-de-sac hernias in those patients presenting with evacuatory dysfunction.

MATERIALS AND METHODS

Sixty-two female patients with chronically obstructed defecation underwent blinded clinical, DEP, and DTP-US assessment to define the accuracy of diagnosis of cul-de-sac hernias.

RESULTS

Both the DEP and the DTP-US techniques show concordance for the diagnosis of cul-de-sac hernias in an unselected patient cohort. Patients in both groups have the same duration of constipation with a greater likelihood of prior hysterectomy in those with cul-de-sac hernias. The diagnosis was established separately by DEP in 88% and in 82% of the cases by DTP-US. Transperineal sonography is discordant with DEP in 45% of cases once the diagnosis of cul-de-sac hernia is made, over the contents of the hernia and over the degree of transvaginal enterocele descent, where DTP-US tends to upgrade enterocele severity. Both techniques confirm the high incidence of concomitant pelvic floor compartment pathology.

CONCLUSIONS

Both methods have accuracy for the diagnosis of cul-de-sac hernias in those patients presenting with evacuatory difficulty. Transperineal sonography tends to more readily diagnose peritoneocele and to upgrade enterocele extent. As an office procedure, it is a valuable adjunct to the clinical examination in the diagnosis of cul-de-sac hernia.

CUL-DE-SAC Pregnancy Following In Vitro Fertilization and Embryo Transfer

OBJECTIVE

We report a case of cul-de-sac pregnancy following in vitro fertilization and embryo transfer (IVF-ET) in a patient with primary infertility.

CASE REPORT

A 33-year-old primigravida woman underwent IVF-ET 4 weeks before her presentation. Serum beta-human chorionic gonadotropin (beta-hCG) on day 20 after embryo transfer was 901 mIU/mL. Ultrasound examination on day 30 after embryo transfer revealed an ectopic gestational sac with fetal heart beat in the left adnexa, without any evidence of intrauterine pregnancy. Laparoscopy was performed and revealed an ectopic mass in the congenital blind pouch that was connected to the posterior cul-de-sac. The gestational tissue was removed by forceps, and electrocauterization was used for hemostasis under laparotomy. Serum beta-hCG fell to 7 mIU/mL after surgery.

CONCLUSION

Serum beta-hCG combined with ultrasound scanning enables early diagnosis of ectopic pregnancy.

Primary omental pregnancy: case report

Omental pregnancy is a very rare form of ectopic pregnancy. Here we presented a case of primary omental pregnancy diagnosed at surgical exploration. A 28 year old woman submitted with severe abdominal pain, without any delay of menstruation. History of the patient revealed no use of contraceptive method. There was no gestational sac in the endometrial cavity and no tubal ring in the adnexa, but free peritoneal fluid in the pouch of Douglas was detected at ultrasonography. Laparotomy was done according to pre-operative diagnosis of ruptured tubal pregnancy. Bilateral tubes and ovaries were intact; omental pregnancy was detected and partial omentectomy was performed. Although 16 cases of omental pregnancy (mostly secondary) were reported in the literature, herein we describe a primary omental pregnancy without adnexial involvement.

[Abdomino-pelvic actinomycosis: a case report]

The actinomycosis is a chronic suppurative granulomatosis disease. It is owed to a bacillus gram positive; actinomycès israelli. The cervical and thoracic localizations are most frequent. The digestive localization represents 20% of cases. It interest very rarely the pelvis and the genital tracts. We bring back the observation of a patient old of 30 years admitted for mass abdominal. To the exam, the patient had a sensibility of the left hypochondriac area and we found a mass of 6 cm of diameter. To the rectal touch, we found a mass in the bag of Douglas. The echography and the computed tomography revealed a collection under the spleen and a pelvic collection. A rectotomy is performed. The bacteriological study isolates actinomycès israelli. The collection under the spleen is drained under radiological control. Actinomycès israelli is also recovered in the pus brought back by the puncture. The patient is treated by Penicillin. The patient had a favourable evolution. No etiology is found at this patient. For this observation, the collection was accessible to a drainage permitting the diagnosis and the treatment of the actinomycosis while avoiding a mutilated surgery.

Sonographic diagnosis of pelvic adhesions in patients after ovum pickup

OBJECTIVE

To evaluate the use of transvaginal sonography for the detection of pelvic adhesions by using clear free fluid in the pouch of Douglas found after ovum pickup.

METHODS

A prospective clinical study was performed in an infertility unit of an academic research facility. Sonography was performed in 50 women with infertility 3 days after ovum pickup, and the visceral peritoneum of the uterus, the ovaries, and the fallopian tubes was scanned for possible pelvic adhesions.

RESULTS

The serosal surfaces of the uterus, ovaries, and fallopian tubes were successfully observed for the presence of adhesions in 86%, 68%, and 20% of the patients, respectively. Improved visualization was associated with an increased amount of pelvic fluid for the uterus (P = .01) but not for the ovaries and fallopian tubes. The amount of fluid in the pelvis correlated with an increased number of retrieved oocytes (P = .07) and a decreased need for manual manipulation to achieve proper imaging of the uterus (P = .001).

CONCLUSION

Transvaginal sonography performed in the presence of fluid in the pelvis may show adhesions mainly attached to the uterus and ovaries. Assessment of possible mechanical factors is important in planning treatment of patients with infertility.

Malignant stromal tumour of the rectum: findings at endorectal ultrasound and MRI

This case report describes the findings on endorectal ultrasound and MRI in a patient with a giant malignant stromal tumour of the rectum. A review of imaging characteristics and histopathological findings as described in the literature is presented.

Gallstones presenting as a cul-de-sac mass

BACKGROUND

Pelvic masses requiring surgical evaluation have many different causes.

CASE

In an unusual case, a pelvic mass was found to comprise approximately 40 gallstones. Laparoscopy was performed, and the gallstones were removed easily.

CONCLUSION

Nongynecologic causes should be considered in the differential diagnosis of pelvic masses.

Peritoneocele. A radiological study with defaeco-peritoneography

REPORT STUDY: Defaecography reports from 2816 patients were evaluated. Twenty-three percent of the investigations were considered normal, 31% showed rectal intussusception, 13% rectal prolapse, 27% rectocele, and 19% enterocele. A standardised protocol is suggested to ensure a complete evaluation of defaecography. One hundred and ten reports were unclear and reviewed. The unclear reports usually concerned an unexplained widening of the rectovaginal space, and gave incitement to further studies. TECHNIQUE STUDY: Twelve patients with an unexplained widening of the rectovaginal space at defaecography were investigated using defaecography and peritoneography simultaneously, by us named defaeco-peritoneography. All investigations were carried out without complications. Defaeco-peritoneography proved the unexplained widening to be an extension of the pouch of Douglas, a peritoneocele. UNEXPLAINED WIDENING STUDY: Twenty-two patients with unexplained widening of the rectovaginal space noted at defaecography were studied using defaeco-peritoneography. The outline and movements of the peritoneum in the pelvic cavity could be visualised during the dynamic act of defaecation. The unexplained widening of the rectovaginal space was caused completely by a peritoneocele in 14 patients, partially in 6 patients and 2 remained unexplained. However, only 9 out of 22 widenings were peritoneoceles with an enterocele. Just 11 peritoneoceles only contained fluid. Three types of peritoneocele were demonstrated: vaginal, septal, and rectal, with or without enterocele. Combinations of these were also found. RECTAL INTUSSUSCEPTION STUDY: Fifty-seven patients with defaecation disorders were examined using defaeco-peritoneography. Twenty-three patients had rectal intussusception and 7 patients had a rectal prolapse. All these patients had a rectal peritoneocele in the serosal ring-pocket of the rectal intussusception or in the rectal prolapse. Twenty-seven patients had neither rectal intussusception nor rectal prolapse and none of these patients had a rectal peritoneocele. DAILY LIFE STUDY: Twenty-six female patients showing peritoneocele without a contrast-filled rectum at start at defaeco-peritoneography were investigated; 13 of them had enteroceles. Spot radiographs before and after filling the rectum with contrast medium were compared. The peritoneocele disappeared completely in 19 of the patients and was reduced in size in the remaining 7, and the enterocele disappeared completely when the rectum was distended. Defaeco-peritoneography should therefore include a radiograph before the rectum is filled, as it shows the habitual (daily life) anatomy and can disclose pathology as peritoneocele and enterocele. TRANSFORMATION STUDY: Forty-six patients with peritoneocele at defaeco-peritoneography were studied at three different stages during rectal evacuation. At start with contrast-filled rectum, 14 patients had a peritoneocele, and 32 were regarded as normal. At maximum straining, all patients had a peritoneocele and 20 of these were still present after rectal evacuation. The peritoneoceles were largest at straining and rectal types were most common. No enterocele was seen at start. At maximum straining, 21 patients developed an enterocele.

Pelvic floor procedures produce no consistent changes in anatomy or physiology

PURPOSE

Postanal repair was designed to restore both anatomy and function of the anal canal in neurogenic fecal incontinence. In most series, the degree of continence is improved in fewer than 50 percent of patients. Adding anterior levatorplasty and sphincter plication (total pelvic floor repair) is claimed to improve functional results. We performed a randomized trial comparing postanal and total pelvic floor repair for neurogenic incontinence.

METHOD

Twenty female patients were studied. All had Type D incontinence (Parks and Browning). Anal manometry, defecography, and grading of the degree of continence were repeated 12 weeks after surgery to assess changes in clinical, manometric, and radiologic parameters. Statistical analysis was done using Wilcoxon's signed-rank test and Wilcoxon's two-sample test.

RESULTS

Continence improved in eight patients. Differences among clinical, manometric, and radiologic data were not statistically significant.

CONCLUSION

Pelvic floor repair procedures produce no consistent changes in anatomy or physiology. Clinical improvement is caused by creation of a local stenosis or by the placebo effect rather than by improvement of muscle function.

Pelvic anatomy and pathology is influenced by distention of the rectum: defecoperitoneography before and after rectal filling with contrast medium

PURPOSE

The aim of the present study was to evaluate how distention of the rectum with contrast medium at defecoperitoneography affected pelvic anatomy, i.e., position, form, and size, of organs and pouch of Douglas.

PATIENTS AND METHODS

Twenty-six female patients with a peritoneocele at defecoperitoneography were selected for the present study. Radiographs taken at the start, before, and after filling the rectum with contrast medium were compared.

RESULTS

There was an obvious change in the position of the organs in the pelvis when the rectum was distended with contrast medium. The peritoneocele disappeared completely in 19 of the patients and was reduced in size in the remaining 7 patients, and the enterocele disappeared completely in 13 patients. The small bowel and vaginal portion of the uterus moved cranially.

CONCLUSIONS

A distended rectum may conceal existing pathology, such as peritoneocele and enterocele, at defecoperitoneography. Defecoperitoneography should, therefore, include a radiograph before the rectum is filled. This radiograph shows the habitual anatomy of the patient in the sitting position and may demonstrate pathologic findings.

Enterocele revealed by simultaneous evacuation proctography and peritoneography: does "defecation block" exist?

OBJECTIVE

Pelvic floor weakness may allow prolapse of the bowel into the rectogenital space, forming an enterocele. Enteroceles are believed to obstruct defecation by rectal compression and are therefore considered an abnormal finding on evacuation proctography. With a technique combine evacuation proctography and peritoneography, we prospectively studied constipated patients to reveal the pelvic peritoneal recesses during evacuation and to determine if enterocele actually impairs rectal emptying.

SUBJECTS AND METHODS

Fifty constipated patients were studied prospectively, Using 20 ml of water-soluble contrast medium, we performed peritoneography, then evacuation protography with 120 ml of intrarectal paste. Lateral evacuation and posteroanterior stress views were analyzed by computerized video capture. Anatomic features and functional measurements of rectal emptying were noted. Posteroanterior views were compared with views in 31 subjects undergoing peritoneography for investigation of groin pain.

RESULTS

Technical failure in three patients left 47 for analysis. A deep rectogenital pouch was seen in 36 patients (77%). Of these, 12 (58%) contained viscera that formed an enterocele, but the remaining 15 patients (42%) showed no visceral filling. Most pouches were apparent only during straining (31 cases, 86%). Peritoneal descent was greater than in controls (p < .0001), of whom only three had small rectogenital pouches. Patients with enterocele were compared with those who had a rectogenital pouch but no visceral filling and those who had no pouch. Standard anatomic measurements by evacuation proctography were not significantly different, but patients with enterocele evacuated more rapidly (p = .008) and completely (p = .021) than did the other two groups.

CONCLUSION

Combined evacuation proctography and peritoneography is a new technique to diagnose pelvic hernias that occur during evacuation. This technique has shown that a deep rectogenital pouch is common in constipated patients and that just over half such pouches fill with viscera. However, because an enterocele does not impair rectal evacuation, this proctographic finding should be interpreted with caution.

Colpocystodefecography

PURPOSE

To assess, in one single procedure, a complete study of the female pelvis, including the Douglas pouch.

METHODS

Colpocystodefecography (CCD) combines vaginal opacification, voiding cystography, and defecography. Three hundred examinations are reviewed.

RESULTS

Thanks to the simultaneous visualization of the pelvic structures, CCD proved to be more useful than clinical evaluation to diagnose prolapses and particularly Douglas pouch hernias (enteroceles), the clinical diagnosis of which was missed in 93 of 111 cases. Moreover, in addition to morphologic and functional information, CCD brings about a new insight in the study of pelvic organs reciprocal influences, should they be positive (supporting function) or negative (external compression). Finally, significative pelvic surgery and particularly hysterectomy enhances greatly the risk of enteroceles.

CONCLUSION

CCD is helpful in the preoperative staging, especially in the selection of the surgical procedure that will least likely predispose to possible late postoperative complications such as vaginal prolapses or enteroceles.

Transvaginal ultrasonographic quantitative assessment of accumulated cul-de-sac fluid

Preoperative quantitative assessment of pelvic fluid is an important diagnostic tool in clinical decision making. In this study, we used high-frequency transvaginal ultrasonography in 10 healthy women to assess both the correlation between various amounts of fluid installed in the cul-de-sac and ultrasonic imaging and to determine whether correct estimation of fluid volume can be reached. No fluid could be ultrasonically detected when the volume was less than 35 to 40 ml. Between 35 and 100 ml there was a clear image of accumulated fluid in the cul-de-sac with good correlation between volume and image, whereas with larger amounts no clear correlation between the amount of fluid introduced and size of fluid area visualized by ultrasonography was possible. Transvaginal ultrasonography may enable quantitative evaluation of certain volumes of pelvic fluid, although amounts less than 35 ml cannot be visualized.

Detection of the fetus in the cul-de-sac by transabdominal and transvaginal ultrasound. A case report

The most common reason for a fetus in the cul-de-sac is ectopic pregnancy, such as rupture of tubal pregnancy, ovarian pregnancy, and intraabdominal pregnancy (1-3). A case of the fetus in the cul-de-sac complicated by uterine perforation was imaged transabdominally and transvaginally on September 13, 1990.

[Diagnosis of early extrauterine pregnancy by serum and Douglas pouch fluid hCG level]

In 44 patients with assumed ectopic pregnancy culdocentesis were carried out under transvaginosonographic control. In 23 cases, the clinical diagnosis ectopic pregnancy and in 16 cases, an early intact intrauterine pregnancy could be verified. Five patients had an early abortion. In all patients with an intact intrauterine pregnancy, the cul-de-sac liquid was serious. In 16 of the 23 cases of ectopic pregnancies, the fluid was bloody, 6 aspirates were bloody/serous and one serous. The findings in patients with an early abortion were as follows: three serous, one bloody/serous, one bloody. Further information could be gathered from the comparison of hCG-levels in simultaneously obtained serum samples and cul-de-sac liquid. All intact intrauterine pregnancies were associated with lower hCG-levels in the cul-de-sac liquid than in the serum (ratio: serum/cul-de-sac liquid greater than 1.3). In all ectopic pregnancies but one, we found an inverse constellation (ratio: serum/cul-de-sac liquid less than 0.7). In the described exceptional case the ratio was nearly 1 and when culdocentesis was repeated 5 days later, a ratio of 0.17 proved the clinically suspected ectopic pregnancy. In 3 cases of histologically confirmed intrauterine abortions, the hCG-level in the cul-de-sac liquid was lower than in the serum, in 2 cases of early abortions without histologically proved localisation the hCG-level was slightly above the level in the serum.

Malignant mesothelioma arising in the pouch of Douglas: computed tomography appearance (a case report)

An unusual case of a malignant peritoneal mesothelioma arising in the pouch of Douglas is presented. The tumor spread along the serosal surfaces of this space but invaded the bowel cephalad to it. A high degree of suspicion aids in considering this rare tumor in the differential diagnosis and early detection may lead to improved survival.

[X-ray anatomy of the recto-genital pouch in the child]

Peritoneography is a simple radio-anatomic method to get informations about the depth and the orientation of the Douglas pouch in children in relation to fixed bony landmarks in the pelvis (upper part of the pubic bone-lowest sacral segment). Measurements were recorded on patients ranging from 15 days-old to 15 years-old. The older the patient, the deeper and the more posterior seemed to be the Douglas pouch.

Shunt metastases of pineal tumors presenting as a pelvic mass

Three children with pineal area tumors and ventriculoperitoneal shunts developed pelvic masses. In two, the solid masses reflected tumor cells seeded to the Pouch of Douglas while the third developed a loculation of fluid and tumor cells at the shunt tip.