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

▶
endometriosis as a common cause of pelvic pain
SMART_READER_LITE
LIVE PREVIEW

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

Feb 01, 2024 228 likes •733 views

ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN M.Basta Nikoli, S. Stojanovi, O. Nikoli, T. Mranin, D. Donat, V. igi Center for Radiology, Clinical Center of Vojvodina Novi Sad Chronic pelvic pain (CPP) Presence of pain >6m

slide-1
SLIDE 1

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

slide-2
SLIDE 2

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

slide-3
SLIDE 3

CAUSE OF CPP

  • 1. Gyn and Obs
  • 2. Urologic
  • 3. GI
  • 4. Vascular
  • 5. MS
  • 6. Neuro
  • 7. Psychological

1/3 endometriosis 1/3 adhesions

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.

slide-4
SLIDE 4

ENDOMETRIOSIS

  • presence of functional endometrial glands and

stroma outside the uterine cavity

slide-5
SLIDE 5
  • 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

SYMPTOMS

slide-6
SLIDE 6

AETHIOPATHOGENETIC MECHANISMS OF ENDOMETRIOSIS-ASSOCIATED CPP

  • Nociceptive
  • Inflammatory
  • Neuropathic mechanisms
slide-7
SLIDE 7
  • metastatic theory
  • metaplastic theory
  • induction theory

PATHOGENESIS

radiopedia.org

slide-8
SLIDE 8

PREVALENCE

  • 1 in 10 women
  • Strongly linked to infertility
  • 25-50% of infertile women have endometriosis
  • 30-50% of women with endometriosis is infertile
slide-9
SLIDE 9
slide-10
SLIDE 10
  • OVARIAN
  • SUPERFICIAL
  • DEEP

LOCATION

slide-11
SLIDE 11

SUPERFICIAL ENDOMETRIOSIS

  • superficial plaques

scattered across the peritoneum, ovaries and uterine ligaments DEEP PELVIC ENDOMETROSIS

  • subperitoneal invasion by

endometriotic lesions that exceeds 5 mm in depth and 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

slide-12
SLIDE 12
  • 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

LOCATION

slide-13
SLIDE 13
  • ULTRASOUND

TRANSABDOMINAL TRANSVAGINAL TRANSRECTAL

  • MRI
  • CT
  • CLASSIC RADIOLOGICAL METHODS

COLONOGRAPHY, ENTEROCLISIS, CHEST X RAY...

IMAGING

slide-14
SLIDE 14

ENDOMETRIOSIS

TRANSVAGINAL US TRANSRECTAL US

  • OVARIES
  • URINARY BLADDER
  • RECTOVAGINAL
  • UTEROSACRAL
  • RECTOSYGMOID

BAZOT M ET AL.; DEEP PELVIC ENDOMETRIOSIS: MR IMAGING FOR DIAGNOSIS AND

PREDICTION OF EXTENSION OF DISEASE; RADIOLOGY 2004.

slide-15
SLIDE 15

ULTRASONOGRAPHY

  • Good for endometriomas
  • Homogenous hypoechoic lesion
  • No Doppler signal
  • Unilocular
  • May be multiple
  • Poor for peritoneal implants
slide-16
SLIDE 16

ENDOMETRIOMA “CHOCOLATE” CYST

TRANSVAGINAL US

MACROSCOPICALLY

slide-17
SLIDE 17

THICK SEPTATIONS

TRANSVAGINAL US

MACROSCOPICALLY

slide-18
SLIDE 18

MRI

radiopaedia.org

  • T1

– hyperintense – high SI T1 FS

  • T2

– hypointense -shading sign – T2 dark spot sign

  • DWI

– variable restricted diffusion

  • T1C+

– may have wall enhancement – the presence of an enhancing mural nodule is suggestive of malignant transformation

METHOD OF CHOICE!

slide-19
SLIDE 19
slide-20
SLIDE 20
  • 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

MRI CHARACTERISTICS OF ENDOMETRIOSIS

slide-21
SLIDE 21

uterosacral involvement

  • irregular margins
  • asymmetry
  • nodularity and thickening
  • altered T2 signal: isointense

(50%), hypointense (40%) or hyperintense (10%) cf. myometrium

vaginal involvement

  • loss of hypointense signal of

posterior vaginal wall on T2WI

  • thickening, nodules and/or

masses

slide-22
SLIDE 22

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.

slide-23
SLIDE 23

BLEEDING FOCI IN VAGINA

slide-24
SLIDE 24

Pouch of Douglas

– partial to complete

  • bliteration

– suspended or lateralised fluid collections

Rectovaginal septum

– nodules or masses that passed through the lower border of the posterior lip of the cervix

slide-25
SLIDE 25
slide-26
SLIDE 26

Gastrointestinal tract

rectal wall thickening anterior displacement of the rectum abnormal angulation loss of fat plane between uterus and bowel inflammatory response due to repeated haemorrhage can lead to adhesions, strictures and bowel obstruction

Urinary tract

– bladder

  • localised or diffuse

bladder wall thickening

  • signal intensity

abnormality, nodules or masses usually located at the level of the vesicouterine pouch

  • involvement of bladder

mucosa is rare

slide-27
SLIDE 27
slide-28
SLIDE 28
slide-29
SLIDE 29

KISSING OVARIES

slide-30
SLIDE 30
slide-31
SLIDE 31
  • chest

– catamenial pneumothorax – haemothorax – lung nodules

  • cutaneous tissues

– nodules

  • malignant transformation

– solid enhancing components

slide-32
SLIDE 32

PULMONARY ENDOMETRIOSIS- CATAMENIAL SY

CHEST X RAY THORACIC CT

slide-33
SLIDE 33

ENDOMETRIOSIS OF ANTERIOR ABDOMINAL

WALL

US CONTRAST CT

slide-34
SLIDE 34
slide-35
SLIDE 35
slide-36
SLIDE 36

Hematosalpinx

slide-37
SLIDE 37

Hydrosalpinx

slide-38
SLIDE 38

SENSITIVITY SPECIFICITY UTEROSACRAL LIGAMENT

86 % 77 % VAGINA 80 % 93%

RECTOVAGINAL SEPTUM

80 % 97 %

BOWEL

88 % 98 %

ENDOMETRIOSIS

ACCURACY OF MRI IN DIFFERENT LOCALIZATIONS 1

  • 1. BAZOT M ET AL.; DEEP PELVIC ENDOMETRIOSIS: MR IMAGING FOR DIAGNOSIS AND

PREDICTION OF EXTENSION OF DISEASE; RADIOLOGY 2004.

slide-39
SLIDE 39
  • VISUALIZATION OF SMALL PERITONEAL IMPLANTS
  • VISUALIZATION OF ADHESIONS
  • 1. DIRECT – PRESENCE OF FLUID ON BOTH SIDES
  • 2. INDIRECT
  • ANGULATION OF BOWEL LOOPS
  • ELEVATION OF POSTERIOR VAGINAL FORNIX
  • CHANGE OF UTERUS AND OVARIES POSITION
  • TRIANGULAR PULLING OF ANTERIOR RECTAL WALL

LIMITATIONS OF MRI EXAMINATION

slide-40
SLIDE 40

LAPAROSCOPY-GOLDEN STRANDARD!

slide-41
SLIDE 41

12/7/2017 41

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.

slide-42
SLIDE 42

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!

PROBLEMS

slide-43
SLIDE 43

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“

slide-44
SLIDE 44
  • ADDITIONAL SEQUENCES
  • 1. FAT SUPPRESSED
  • 2. GRADIENT ECHO
  • 3. SUSCEPTIBILITY WEIGHTED 1 : 93 % SENSITIVITY

100 % SPECIFICITY

  • INTRAVAGINALLY - US GELLY
  • INTRARECTAL - CONTRAST OR WATER
  • INTRAMUSCULAR – ANTIPERISTALTIC AGENS

ENHANCEMENT OF MRI EXAMINATION

  • 1. TAKEUCHI ET AL.; SUSCEPTIBILITY WEIGHTED MRI OF ENDOMETRIOMA:

PRELIMINARY RESULTS; AJR 2008.

slide-45
SLIDE 45
  • 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

Ten Imaging Pearls

MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675–1691

slide-46
SLIDE 46
  • 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

slide-47
SLIDE 47
  • 8. Endometriomas can transform into clear cell
  • r 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

slide-48
SLIDE 48

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.

slide-49
SLIDE 49