ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN M.Basta Nikoli, S. - PowerPoint PPT Presentation

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 Vojvodina Novi 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 1/3 endometriosis 2. Urologic 3. GI 4. Vascular 1/3 adhesions 5. MS 6. Neuro 7. Psychological 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

SYMPTOMS • 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

AETHIOPATHOGENETIC MECHANISMS OF ENDOMETRIOSIS-ASSOCIATED CPP • Nociceptive • Inflammatory • Neuropathic mechanisms

PATHOGENESIS • metastatic theory • metaplastic theory • induction theory 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

LOCATION • OVARIAN • SUPERFICIAL • DEEP

SUPERFICIAL ENDOMETRIOSIS DEEP PELVIC ENDOMETROSIS • superficial plaques • subperitoneal invasion by scattered across the endometriotic lesions that peritoneum, ovaries and exceeds 5 mm in depth and uterine ligaments comprises nodules, cysts and secondary scarring Antônio Coutinho, et al. MR Imaging in Deep Pelvic Endometriosis: A Pictorial Essay RadioGraphics 2011 31:2, 549-567

LOCATION • 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

IMAGING • U LTRASOUND TRANSABDOMINAL TRANSVAGINAL TRANSRECTAL • MRI • CT • C LASSIC RADIOLOGICAL METHODS COLONOGRAPHY , ENTEROCLISIS , CHEST X RAY ...

E NDOMETRIOSIS T RANSVAGINAL US T RANSRECTAL US • RECTOVAGINAL • OVARIES • UTEROSACRAL • U RINARY BLADDER • RECTOSYGMOID B AZOT M ET AL .; D EEP PELVIC ENDOMETRIOSIS : MR IMAGING FOR DIAGNOSIS AND PREDICTION OF EXTENSION OF DISEASE ; R ADIOLOGY 2004.

ULTRASONOGRAPHY • Good for endometriomas • Homogenous hypoechoic lesion • No Doppler signal • Unilocular • May be multiple • Poor for peritoneal implants

E NDOMETRIOMA “ CHOCOLATE ” CYST T RANSVAGINAL US MACROSCOPICALLY

T HICK SEPTATIONS T RANSVAGINAL US MACROSCOPICALLY

MRI METHOD OF CHOICE! • T1 • DWI – variable restricted diffusion – hyperintense T1C+ • – high SI T1 FS – may have wall • T2 enhancement – hypointense -shading – the presence of an sign enhancing mural nodule is – T2 dark spot sign suggestive of malignant transformation radiopaedia.org

MRI CHARACTERISTICS OF ENDOMETRIOSIS • 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

uterosacral involvement vaginal involvement • irregular margins • loss of hypointense signal of posterior vaginal wall on • asymmetry T2WI • nodularity and thickening • thickening, nodules and/or • altered T2 signal: isointense masses (50%), hypointense (40%) or hyperintense (10%) cf. myometrium

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.

B LEEDING FOCI IN VAGINA

Pouch of Douglas Rectovaginal septum – partial to complete – nodules or masses that obliteration passed through the lower border of the – suspended or lateralised posterior lip of the cervix fluid collections

Gastrointestinal tract Urinary tract rectal wall thickening – bladder • localised or diffuse anterior displacement of bladder wall thickening the rectum • signal intensity abnormal angulation abnormality, nodules or loss of fat plane masses usually located between uterus and bowel at the level of the vesicouterine pouch inflammatory response due to repeated • involvement of bladder mucosa is rare haemorrhage can lead to adhesions, strictures and bowel obstruction

KISSING OVARIES

• chest – catamenial pneumothorax – haemothorax – lung nodules • cutaneous tissues – nodules • malignant transformation – solid enhancing components

P ULMONARY ENDOMETRIOSIS - CATAMENIAL SY C HEST X RAY T HORACIC CT

E NDOMETRIOSIS OF ANTERIOR ABDOMINAL WALL US C ONTRAST CT

Hematosalpinx

Hydrosalpinx

E NDOMETRIOSIS ACCURACY OF MRI IN DIFFERENT LOCALIZATIONS 1 SENSITIVITY SPECIFICITY 86 % 77 % UTEROSACRAL LIGAMENT V AGINA 80 % 93% 80 % 97 % RECTOVAGINAL SEPTUM 88 % 98 % BOWEL 1. B AZOT M ET AL .; D EEP PELVIC ENDOMETRIOSIS : MR IMAGING FOR DIAGNOSIS AND PREDICTION OF EXTENSION OF DISEASE ; R ADIOLOGY 2004.

L IMITATIONS OF MRI EXAMINATION • V ISUALIZATION OF SMALL PERITONEAL IMPLANTS • V ISUALIZATION OF ADHESIONS 1. DIRECT – PRESENCE OF FLUID ON BOTH SIDES 2. I NDIRECT -A NGULATION OF BOWEL LOOPS -E LEVATION OF POSTERIOR VAGINAL FORNIX -C HANGE OF UTERUS AND OVARIES POSITION -T RIANGULAR PULLING OF ANTERIOR RECTAL WALL

LAPAROSCOPY-GOLDEN STRANDARD!

� 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. 12/7/2017 41

PROBLEMS 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!

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“

E NHANCEMENT OF MRI EXAMINATION • A DDITIONAL SEQUENCES 1. F AT SUPPRESSED 2. G RADIENT ECHO 3. S USCEPTIBILITY WEIGHTED 1 : 93 % SENSITIVITY 100 % SPECIFICITY • I NTRAVAGINALLY - US GELLY • I NTRARECTAL - CONTRAST OR WATER • I NTRAMUSCULAR – ANTIPERISTALTIC AGENS 1. T AKEUCHI ET AL .; S USCEPTIBILITY WEIGHTED MRI OF ENDOMETRIOMA : PRELIMINARY RESULTS ; AJR 2008.

Ten Imaging Pearls 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 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.