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Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group: IDEA consensus opinion

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The IDEA (International Deep Endometriosis Analysis group) statement is a consensus opinion on terms, definitions and measurements that may be used to describe the sonographic features of the different phenotypes of endometriosis. Currently, it is difficult to compare results between published studies because authors use different terms when describing the same structures and anatomical locations. We hope that the terms and definitions suggested herein will be adopted in centers around the world. This would result in consistent use of nomenclature when describing the ultrasound location and extent of endometriosis. We believe that the standardization of terminology will allow meaningful comparisons between future studies in women with an ultrasound diagnosis of endometriosis and should facilitate multicenter research. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Content may be subject to copyright.
Ultrasound Obstet Gynecol 2016
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.15955
Systematic approach to sonographic evaluation of the pelvis
in women with suspected endometriosis, including terms,
definitions and measurements: a consensus opinion from the
International Deep Endometriosis Analysis (IDEA) group
S. GUERRIERO1#, G. CONDOUS2#, T. VAN DEN BOSCH3, L. VALENTIN4,F.P.G.LEONE
5,
D. VAN SCHOUBROECK3,C.EXACOUSTOS
6, A. J. F. INSTALL ´
E7,W.P.MARTINS
8,
M. S. ABRAO9,G.HUDELIST
10,M.BAZOT
11, J. L. ALCAZAR12 , M. O. GONC¸ ALVES13,
M. A. PASCUAL14,S.AJOSSA
1, L. SAVELLI15,R.DUNHAM
16, S. REID17 , U. MENAKAYA18,
T. BOURNE19, S. FERRERO20 , M. LEON21,T.BIGNARDI
22, T. HOLLAND23 ,D.JURKOVIC
23,
B. BENACERRAF24,Y.OSUGA
25, E. SOMIGLIANA26 and D. TIMMERMAN3
1Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy;
2Acute Gynaecology, Early Pregnancy & Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean
Hospital, Penrith, NSW, Australia; 3Department Obstetrics and Gynecology, University Hospitals, KU Leuven, Leuven, Belgium and
Department of Obstetrics and Gynecology, Tienen Regional Hospital, Tienen, Belgium; 4Lund University, Department of Obstetrics and
Gynecology, Sk˚
ane University Hospital, Malm ¨
o, Sweden; 5Department of Obstetrics and Gynecology, Clinical Sciences Institute L. Sacco,
Milan, Italy; 6Department of Biomedicine and Prevention, Obstetrics and Gynecological Clinic, Faculty of Medicine, University of Rome
‘Tor Vergata’, Rome, Italy and Ospedale Generale S. Giovanni Calibita Fatebene Fratelli, Rome, Italy; 7KU Leuven, Department of
Electrical Engineering (ESAT), STADIUS, Center for Dynamical Systems, Signal Processing and Data Analytics, Leuven, Belgium and
iMinds Medical IT, Leuven, Belgium; 8Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo,
Sao Paulo, Brazil; 9Endometriosis Division, Obstetrics and Gynecological Department, Sao Paulo University, Sao Paulo, Brazil; 10Hospital
St John of God Johannes, Vienna, Austria; 11Department of Radiology, H ˆ
opital Tenon, Assistance Publique-H ˆ
opitaux de Paris and
Universit´
e Pierre et Marie Curie, Paris, France; 12Department of Obstetrics and Gynecology, Cl´
ınica Universidad de Navarra School of
Medicine, University of Navarra, Pamplona, Spain; 13Clinica Medicina da Mulher and RDO Medicina Diagn ´
ostica, Sao Paulo, Brazil;
14Department of Obstetrics, Gynaecology and Reproduction, Institut Universitari Dexeus, Barcelona, Spain; 15 Gynecology and Early
Pregnancy Ultrasound Unit, S. Orsola - Malpighi Hospital, University of Bologna, Bologna, Italy; 16Department of Radiology, Leeds
Teaching Hospitals NHS Trust, Leeds, UK; 17Department of Obstetrics and Gynaecology, Wollongong Hospital, Wollongong, NSW,
Australia; 18Department of Obstetrics and Gynaecology Calvary Public Hospital & JUNIC Specialist Imaging & Women’s Center,
Canberra, Australia; 19Queen Charlotte’s & Chelsea Hospital, Imperial College, London, UK; 20 Unit of Obstetrics and Gynaecology,
IRCCS AOU San Martino IST, Genova, Italy and Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and
Child Health (DiNOGMI), University of Genova, Genova, Italy; 21Ultrasound Unit, Department of Gynaecology and Obstetrics, Clinica
Indisa, Santiago, Chile; 22Department of Obstetrics and Gynecology, Azienda, Ospedaliera Niguarda Ca’ Granda, Milan, Italy; 23 Institute
for Women’s Health, University College Hospital, London, UK; 24Department of Obstetrics, Gynecology and Radiology, Brigham and
Women’s Hospital and Harvard Medical School, Boston, MA, USA; 25Department of Obstetrics and Gynecology, The University of Tokyo,
Tokyo, Japan; 26Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
KEYWORDS: anterior and posterior compartments; deep infiltrating endometriosis; endometrioma; laparoscopy; ultrasound
ABSTRACT
The IDEA (International Deep Endometriosis Analysis
group) statement is a consensus opinion on terms,
definitions and measurements that may be used to describe
the sonographic features of the different phenotypes of
endometriosis. Currently, it is difficult to compare results
between published studies because authors use different
terms when describing the same structures and anatomical
locations. We hope that the terms and definitions
Correspondence to: Prof. G. Condous, Acute Gynaecology, Early Pregnancy & Advanced Endosurgery Unit, Sydney Medical School Nepean,
University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia (e-mail: gcondous@omnigynaecare.com.au)
#S.G. and G.C. are joint first authors.
Accepted: 25 April 2016
suggested herein will be adopted in centers around the
world. This would result in consistent use of nomenclature
when describing the ultrasound location and extent of
endometriosis. We believe that the standardization of
terminology will allow meaningful comparisons between
future studies in women with an ultrasound diagnosis of
endometriosis and should facilitate multicenter research.
Copyright ©2016 ISUOG. Published by John Wiley &
Sons Ltd.
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. CONS E N S U S STATE M E N T
2Guerriero and Condous et al.
INTRODUCTION
Endometriosis is a common gynecological problem, affect-
ing approximately 5% of women1. The disease can be
found in many sites throughout the pelvis, in partic-
ular the ovaries, pelvic peritoneum, pouch of Douglas
(POD), rectum, rectosigmoid, rectovaginal septum (RVS),
uterosacral ligaments (USLs), vagina and urinary bladder.
Correct site-specific diagnosis is fundamental in defin-
ing the optimal treatment strategy for endometriosis.
Non-invasive imaging methods are required to map accu-
rately the location and extent of endometriotic lesions.
The recent consensus statement produced by the World
Endometriosis Society recommended the establishment of
centers of expertise for the management of higher-stage
disease2. This recommendation requires a reliable pre-
operative system of triage which enables immediate
understanding of the location and severity of disease.
Increasingly, endometriosis is being managed medically
and surgery can be avoided or delayed in a growing
proportion of cases. Transvaginal sonography (TVS) is
the first-line imaging technique in the diagnosis of pelvic
endometriosis and in particular for deep infiltrating
endometriosis (DIE)3. It is important to note, however,
that there is substantial heterogeneity in the reported
sensitivity and specificity of TVS with regard to detection
of DIE, irrespective of its location4,5. Adding ultrasound
examination by an experienced operator to history and
pelvic examination improves the accuracy of diagno-
sis of pelvic endometriosis6,7. In their meta-analysis,
Hudelist et al.8concluded that TVS with or without
the use of prior bowel preparation is an accurate test
for non-invasive, presurgical detection of DIE of the
rectosigmoid. Although the diagnostic performance of
ultrasound for detecting DIE reported by individual
units is excellent for certain anatomical locations911,
the lack of standardized definitions in the sonographic
classification and diagnosis of DIE is a general cause
for concern. This lack of uniformity when classifying
anatomical location and extent of disease contributes
to the considerable variation in the reported diagnostic
accuracy of TVS in the diagnosis of endometriosis.
The aim of this consensus opinion is to ensure that
the ultrasound examination of a woman with potentially
underlying endometriosis is performed in a standardized
manner, that the measurement of endometriotic lesions
is standardized and that the terminology used when
describing the location of DIE and the sonographic
features of DIE and other manifestations of endometriosis
(endometriomas, adenomyosis, pelvic adhesions) is uni-
form. This consensus opinion should be useful in clinical
practice as well as in research. We believe that careful
definition of ultrasound-detected DIE will facilitate inter-
pretation of research and lead to improved clinical care.
METHODS
This work is based on the opinion of a panel
of clinicians, gynecological sonologists, advanced
laparoscopic surgeons and radiologists (International
Deep Endometriosis Analysis (IDEA) group) with
expertise in diagnosis and management of endometriosis.
Criteria used to invite the experts to participate in
this consensus process included their having significant
peer-reviewed publications in the field of diagnosis
and management of endometriosis. An initial statement
was presented in 2011 at the ISUOG congress in
Copenhagen12, incorporating several suggestions from all
participants. A first draft was written in December 2014
by a joint effort of the two first authors (S.G. and G.C.)
and sent to all coauthors. All coauthors had the oppor-
tunity to comment within a fixed time limit. Reply was
mandatory for coauthorship. Taking all comments into
account, a revised draft was then sent to all coauthors.
In case of conflicting opinions, a consensus was proposed
after discussion between the two first authors and the last
author (D.T.). This pathway was repeated until a con-
sensus between all authors was reached. The consensus
also included ultrasound images/videos and schematic
drawings to illustrate the text. After 13 revisions, the
manuscript was deemed ready for submission.
In addition to terms, definitions and measurements
to describe the sonographic features of DIE, adhesions,
adenomyosis and endometriomas, this consensus opinion
includes recommendations regarding how to take a
history, how to perform a clinical examination, how to
perform an ultrasound examination and which ultrasound
modality to use when examining patients with suspected
or known endometriosis. DIE anatomical locations in
this consensus were modified from Chapron’s anatomical
distribution of pelvic DIE13.
HISTORY
A detailed clinical history should be taken for all
women with suspected endometriosis, with particular
emphasis on symptoms which could be attributed
to endometriosis14,15. The following should be noted
specifically: age; height; weight; ethnic origin; parity;
bleeding pattern (regular, irregular or absent); last
menstrual period; previous surgery for endometriosis
(type, effect); previous myomectomy or Cesarean delivery
(these entail increased risk of DIE in the bladder); family
history of endometriosis; previous non-surgical treatment
for endometriosis (type, duration, effect); subfertility
including duration of subfertility; treatment for infertility
and outcome of fertility treatment; pain (dysmenorrhea,
dyspareunia, dysuria, dyschezia, chronic pelvic pain);
hematochezia and/or hematuria. The onset and duration
of symptoms should be noted and, if possible, the intensity
of the pain recorded by letting the patient use a visual
analog scale or investigating it with a 010 narrative
numeric rating scale.
PELVIC EXAMINATION
A pelvic examination should be performed either before or
after the pelvic ultrasound scan, with the aim of defining
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
IDEA consensus opinion 3
the presence or absence of vaginal and/or low rectal
endometriosis7. The pelvic examination should include
speculum examination (direct visualization of vaginal or
cervical DIE) and vaginal palpation. Mobility, fixation
and/or tenderness of the uterus should be evaluated
carefully. Site-specific tenderness in the pelvis should also
be evaluated.
SONOGRAPHY OVERVIEW
The purpose of performing an ultrasound examination
in a woman with suspected endometriosis is to try to
explain underlying symptoms, map the disease location
and assess the severity of disease prior to medical
therapy or surgical intervention. Various ultrasound
approaches have been published, but to date none has
been externally validated16,17. We propose four basic
sonographic steps when examining women with suspected
or known endometriosis, as shown in Figure 1. Note that
these steps can be adopted in this or any order as long
as ALL four steps are performed to confirm/exclude the
different forms of endometriosis.
Using TVS as the first-line imaging tool, the operator
should examine the uterus and the adnexa. The mobility
of the uterus should be evaluated: normal, reduced
or fixed (‘question mark sign’)18. Sonographic signs
of adenomyosis should be searched for and described
using the terms and definitions published in the
Morphological Uterus Sonographic Assessment consensus
opinion19.
The presence or absence of endometriomas (Figure S1a),
their size, measured systematically in three orthogonal
planes (see ‘Measurement of lesions’, below), the number
of endometriomas and their ultrasound appearance
should be noted20. The sonographic characteristics of any
endometrioma should be described using the International
Ovarian Tumor Analysis terminology21.Anatypical
endometrioma (Figure S1b) is defined as a unilocular-solid
First step
Routine evaluation of uterus and adnexa
(+ sonographic signs of adenomyosis/presence or
absence of endometrioma)
Evaluation of transvaginal sonographic
‘soft markers’
(i.e. site-specific tenderness and ovarian mobility)
Assessment of status of POD using real-time
ultrasound-based ‘sliding sign’
Assessment for DIE nodules in
anterior and posterior compartments
Second step
Third step
Fourth step
Dynamic ultrasonography
Figure 1 Four basic sonographic steps for examining women with
clinical suspicion of deep infiltrating endometriosis (DIE) or known
endometriosis. All steps should be performed, but not necessarily in
this order. Note, bladder should contain small amount of urine.
Dynamic ultrasonography is when the operator performing the
ultrasound examination assesses both the pelvic organs and their
mobility in real-time. POD, pouch of Douglas.
mass with ground glass echogenicity with a papillary
projection, a color score of 1 or 2 and no flow inside the
papillary projection20.
Ovarian endometriomas are associated frequently
with other endometriotic lesions, such as adhesions
and DIE22,23. The ‘kissing’ ovaries sign (Figure S2)
suggests that there are severe pelvic adhesions; bowel
and Fallopian tube endometriosis are significantly more
frequent in women with kissing ovaries vs those without
kissing ovaries: 18.5% vs 2.5% and 92.6% vs 33%,
respectively24.
Endometriomas may undergo decidualization in preg-
nancy, in which case they can be confused with an ovarian
malignancy on ultrasound examination (Figure S3)25.
Simultaneous presence of other endometriotic lesions
may facilitate a correct diagnosis of endometrioma in
pregnancy and minimize the risk of unnecessary surgery.
The second step is to search for sonographic ‘soft
markers’, i.e. site-specific tenderness (SST) and fixed
ovaries. The presence of soft markers increases the likeli-
hood of superficial endometriosis and adhesions26,27.By
applying pressure between the uterus and ovary, one can
assess if the ovary is fixed to the uterus medially, to the
pelvic side wall laterally or to the USLs. The presence of
adhesions can also be suspected if, on palpation with the
probe and/or abdominal palpation with the free hand,
the ovaries or the uterus appear to be fixed to adjacent
structures (broad ligament, POD, bladder, rectum and/or
parietal peritoneum). If there is pelvic fluid, fine strands
of tissue (adhesions) may be seen between the ovary
(with or without endometrioma) and the uterus or the
peritoneum of the POD27 30.
If there are endometriomas or pelvic endometriosis, the
Fallopian tubes are frequently involved in the disease
process. Adhesions may distort the normal Fallopian
tubal course and occlusion of the Fallopian tube(s) by
endometriotic foci or distal tubular adhesions may also
occur. As a consequence, a sactosalpinx may develop. For
these reasons, hydrosalpinx/hematosalpinx and peritoneal
cysts should be searched for and reported.
The third step is to assess the status of the POD
using the real-time TVS-based ‘sliding sign’. In order
to assess the sliding sign when the uterus is anteverted
(Figure 2a), gentle pressure is placed against the cervix
using the transvaginal probe, to establish whether the
anterior rectum glides freely across the posterior aspect
of the cervix (retrocervical region) and posterior vaginal
wall. If the anterior rectal wall does so, the ‘sliding sign’ is
considered positive for this location (Videoclip S1a). The
examiner then places one hand over the woman’s lower
anterior abdominal wall in order to ballot the uterus
between the palpating hand and the transvaginal probe
(which is held in the other hand), to assess whether the
anterior bowel glides freely over the posterior aspect of the
upper uterus/fundus. If it does so, the sliding sign is also
considered positive in this region (Videoclip S1b). When
the sliding sign is found to be positive in both of these
anatomical regions (retrocervix and posterior uterine
fundus), the POD is recorded as being not obliterated.
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
4Guerriero and Condous et al.
(a) (b)
Figure 2 Schematic drawings demonstrating how to elicit the ‘sliding sign’ in an anteverted uterus (a) and a retroverted uterus (b).
If on TVS it is demonstrated that either the anterior
rectal wall or the anterior sigmoid wall does not glide
smoothly over the retrocervix or the posterior uterine
fundus, respectively, i.e. at least one of the locations
has a negative sliding sign, then the POD is recorded as
obliterated31,32.
Demonstrating and describing the real-time
ultrasound-based sliding sign in a retroverted uterus is
different (Figure 2b). Gentle pressure is placed against
the posterior upper uterine fundus with the transvaginal
probe, to establish whether the anterior rectum glides
freely across the posterior upper uterine fundus. If the
anterior rectum does so, the sliding sign is considered
to be positive for this location (Videoclip S2a). The
examiner then places one hand over the woman’s lower
anterior abdominal wall in order to ballot the uterus
between the palpating hand and transvaginal probe
(which is held in the other hand), to assess whether the
anterior sigmoid glides freely over the anterior lower
uterine segment. If it does so, the sliding sign is also
considered to be positive in this region (Videoclip S2b).
As long as the sliding sign is found to be positive in both
of these anatomical regions (i.e. the posterior uterine
fundus and the anterior lower uterine segment), the POD
is recorded as non-obliterated33.
The fourth step is to search for DIE nodules in
the anterior and posterior compartments. To assess the
anterior compartment, the transducer is positioned in the
anterior fornix of the vagina. If bladder endometriosis
is suspected on the basis of symptoms, patients should
be asked not to empty their bladder completely before
the ultrasound examination. A slightly filled bladder
facilitates evaluation of the walls of the bladder and
detection and description of endometriotic nodules.
Finally, the transducer is positioned in the posterior fornix
of the vagina and slowly withdrawn through the vagina
to allow visualization of the posterior compartment.
Some authors advocate the use of bowel preparation
on the evening before the pelvic scan and the use of
a rectal enema within an hour before the ultrasound
examination to eliminate fecal residue and gas in the
rectosigmoid34 37. However, this is not mandatory, and
there are no published prospective studies comparing TVS
with and without bowel preparation for the diagnosis of
bowel DIE. In a recent meta-analysis, TVS, either with or
without bowel preparation, was found to be an accurate
predictor of rectosigmoid DIE8.
COMPARTMENTAL EVALUATION
Anterior compartment
The anterior compartment includes the following anatom-
ical locations: urinary bladder, uterovesical region and
ureters.
Urinary bladder
Bladder DIE occurs more frequently in the bladder
base and bladder dome than in the extra-abdominal
bladder (Videoclip S3)38. The bladder is best scanned
if it contains a small amount of urine because this
reduces false-negative findings. Although Savelli et al.38
described two zones (bladder base and dome), we propose
dividing the bladder ultrasound assessment into four
zones (Figure 3): (i) the trigonal zone, which lies within
3 cm of the urethral opening, is a smooth triangular
region delimited by the two ureteral orifices and the
internal urethral orifice (Figure S4a); (ii) the bladder base,
which faces backward and downward and lies adjacent
to both the vagina and the supravaginal cervix (Figure
S4b); (iii) the bladder dome, which lies superior to the
base and is intra-abdominal (Figure S4c); and (iv) the
extra-abdominal bladder (Figure S4d). Figure S5 and
Videoclip S3 demonstrate the most frequent location of
endometriotic bladder nodules, i.e. the bladder base.
On two-dimensional (2D) ultrasound the appearance
of DIE in the anterior compartment can be varied,
including hypoechoic linear or spherical lesions, with
or without regular contours involving the muscularis
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
IDEA consensus opinion 5
Extra-abdominal
Bladder
Urethra
Trigone
Bladder base
Bladder dome
Figure 3 Schematic drawing illustrating the four bladder zones:
trigone, bladder base, bladder dome and extra-abdominal bladder.
The demarcation point between the base and the dome of the
bladder is the uterovesical pouch.
(most common) or (sub)mucosa of the bladder6,38 43.
The dimensions of the bladder nodule should be measured
in three orthogonal planes. Bladder DIE is diagnosed only
if the muscularis of the bladder wall is affected; lesions
involving only the serosa represent superficial disease.
Uterovesical region
Obliteration of the uterovesical region can be evaluated
using the sliding sign, i.e. the transvaginal probe is placed
in the anterior fornix and the uterus is balloted between
the probe and one hand of the operator placed over
the suprapubic region. If the posterior bladder slides
freely over the anterior uterine wall, then the sliding
sign is positive and the uterovesical region is classified as
non-obliterated (Videoclip S4). If the bladder does not
slide freely over the anterior uterine wall, then the sliding
sign is negative and the uterovesical region is classified as
obliterated44 (Figure S6). Adhesions in the anterior pelvic
compartment are present in nearly one third of women
with a previous Cesarean section and are not necessarily
a sign of pelvic endometriosis44.
Ureters
The distal ureters should be examined routinely using the
transvaginal probe. The ureters can be found by identify-
ing the urethra in the sagittal plane and moving the probe
towards the lateral pelvic wall. The intravesical segment of
the ureter is identified and its course followed to where it
leaves the bladder and then further, to the pelvic side wall
and up to the level of the bifurcation of the common iliac
vessels. It is helpful to wait for peristalsis to occur as this
confirms ureteric patency. Ureters typically appear as long
tubular hypoechoic structures, with a thick hyperechoic
mantle, extending from the lateral aspect of the bladder
base towards the common iliac vessels. Dilatation of the
ureter due to endometriosis is caused by stricture (from
either extrinsic compression or intrinsic infiltration) and
the distance from the distal ureteric orifice to the stric-
ture should be measured (Figure S7)35,45,46. Thorough
evaluation of the ureter at the time of surgery is important
in all cases in which ureteral involvement is suspected.
In all women with DIE, a transabdominal scan of
the kidney to search for ureteral stenosis is necessary,
because the prevalence of endometriotic lesions in the
urinary tract may be underestimated and women with
DIE involving the ureter may be asymptomatic47 51.The
degree of hydronephrosis should be assessed and graded
using generally accepted ultrasound criteria52.Women
with evidence of hydronephrosis should be referred for
urgent stenting of a stenosed ureter to prevent further
loss of renal function.
Posterior compartment
According to Chapron et al.53, the most common sites of
DIE in the posterior compartment are: USLs, posterior
vaginal fornix, anterior rectum/anterior rectosigmoid
junction and sigmoid colon. Sonographic assessment of
the posterior compartment should aim at identifying the
number, size and anatomical location of DIE nodules
affecting these structures. On TVS, posterior compartment
DIE lesions appear as hypoechoic thickening of the wall of
the bowel or vagina, or as hypoechoic solid nodules which
may vary in size and have smooth or irregular contours54.
Rectovaginal septum
Some studies have defined the TVS diagnosis of DIE in
the RVS as absence of the normal appearance of the
hyperechoic layer between the vagina and rectum due to
the presence of a DIE nodule55. Other researchers have
used the terms ‘RVS DIE’ and ‘rectovaginal DIE (RV
DIE)’ interchangeably to describe DIE in the RVS55,56.
The RVS is an individual anatomical structure with a
specific location, whereas RV DIE describes DIE located
in the rectovaginal area. The rectovaginal area includes
the vagina, the rectum and the RVS. Furthermore, there
is inconsistency in the definition of RV DIE in the
literature. RV DIE has been described as endometriotic
lesions which infiltrate both the rectum and the posterior
vaginal fornix with possible extension into the RVS55.
Others have used the term ‘rectovaginal endometriosis’
to describe nodules which primarily infiltrate the RVS
with possible extension into the vagina and/or rectum.
Isolated RVS endometriosis is uncommon.
We propose that involvement of the RVS should be
suspected when a DIE nodule is seen on TVS in the
rectovaginal space below the line passing along the
lower border of the posterior lip of the cervix (under
the peritoneum)39 (Figure 4). Isolated RVS DIE is rare
(Figure 5); RVS DIE is usually an extension of posterior
vaginal wall (Figure 6), anterior rectal wall (Figure 7)
or both posterior vaginal wall and anterior rectal wall
involvement57 (Figure 8). The use of sonovaginography
improves the detection of posterior vaginal and RVS
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
6Guerriero and Condous et al.
Septum
Rectum
Vagina
Cervix
(a)
Free fluid
Figure 4 Schematic drawing (a) and ultrasound image (b) demonstrating our proposed ultrasound definition of the rectovaginal septum
(RVS). (a) The RVS is denoted by the double-headed green arrow, below (anatomically) the blue line passing along the lower border of the
posterior lip of the cervix. The posterior vaginal fornix lies between the blue line and the red line (the latter passing along the caudal end of
the peritoneum of the lower margin of the rectouterine peritoneal pouch (cul-de-sac of Douglas)). (b) The upper delimitation of the RVS is
where the blue line passes along the lower border of the posterior lip of the cervix.
Free
fluid
Figure 5 Schematic drawings and ultrasound images demonstrating isolated deep infiltrating endometriosis in the rectovaginal septum
(RVS, ). The green ellipses encircle the endometriotic nodules in the RVS. , bowel wall; , vaginal wall.
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
IDEA consensus opinion 7
Figure 6 Schematic drawings and ultrasound image demonstrating deep infiltrating endometriosis in the posterior vaginal wall with
extension into the rectovaginal septum (RVS, ). The green ellipses encircle the endometriotic nodules in the RVS. , bowel wall;
, vaginal wall.
Figure 7 Schematic drawings and ultrasound image demonstrating deep infiltrating endometriosis in the anterior rectal wall with extension
into the rectovaginal septum ( ). , bowel wall; , vaginal wall.
Figure 8 Schematic drawings and ultrasound image demonstrating rectovaginal septal ( ) deep infiltrating endometriosis with extension
into both anterior rectal wall and posterior vaginal wall. , bowel wall; , vaginal wall.
DIE54,58. The dimensions of the RVS DIE nodule should
be recorded in three orthogonal planes and the distance
between the lower margin of the lesion and the anal
verge should be measured. This should be done whether
the DIE is only in the vagina or only in the rectum,
or involves the vagina, RVS and rectum. Low RVS
lesions, when managed surgically, are associated with
severe complications, including fistulae56,59 61.
Vaginal wall
We propose that involvement of the posterior vaginal
fornix and/or lateral vaginal fornix should be suspected
when a DIE nodule is seen on TVS in the rectovaginal
space below the line passing along the caudal end of
the peritoneum of the lower margin of the rectouterine
peritoneal pouch (cul-de-sac of Douglas) and above the
line passing along the lower border of the posterior lip of
the cervix (under the peritoneum) (seen in Figure 4).
Posterior vaginal fornix or forniceal endometriosis is
suspected if the posterior vaginal fornix is thickened or if
a discrete nodule is found in the hypoechoic layer of the
vaginal wall (Figure S8a). The hypoechoic nodule may be
homogeneous or inhomogeneous with or without large
cystic areas (Figure S8a) and there may or may not be
cystic areas surrounding the nodule6,39,41,42. Figure S8b
is an ultrasound image demonstrating posterior vaginal
fornix DIE. The dimensions of the vaginal wall DIE nodule
should be measured in three orthogonal planes.
Rectovaginal nodules (‘diabolo’-like nodules)
Hourglass-shaped or ‘diabolo’-like nodules occur when
DIE lesions in the posterior vaginal fornix extend into
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
8Guerriero and Condous et al.
(a)
Transverse
section
Bowel
Uterus
Bowel
Bowel
Bowel
Bowel
(b)
(c)
(d)
(f)
(e)
(f)
Figure 9 Schematic drawings and corresponding ultrasound images of bowel deep infiltrating endometriosis (DIE). (a) DIE nodule with a
regular outline (absence of ‘spikes’). (b) DIE nodule with progressive narrowing, like a ‘tail’, also known as ‘comet’ sign. (c) DIE nodule with
prominent spikes towards the bowel lumen, also known as ‘Indian headdress’ or ‘moose antler’ sign. (d) DIE nodule with both prominent
spikes towards the bowel lumen (Indian headdress/moose antler sign) and progressive narrowing like a tail (comet sign). (e) DIE nodule with
both prominent spikes towards the bowel lumen (Indian headdress/moose antler sign) and extrinsic retraction (and visible mucosal folds)
(known as ‘pulling sleeve’ sign). The sliding sign is expected to be negative. (f) DIE nodule and extrinsic retraction (pulling sleeve sign). The
sliding sign is expected to be negative. Ultrasound image shows bowel adherent to the ovary; the hypoechogenic area between the bowel
loops and the ovary to which the bowel is adherent correspond to linear endometriotic changes (containing endometriotic glands and
stroma) not involving the muscularis of the bowel wall but located between the bowel and the ovary.
the anterior rectal wall62 (Figure S9a). On ultrasound,
the part of the DIE lesion situated in the anterior
rectal wall is the same size as the part situated in
the posterior vaginal fornix (Figure S9b). There is a
small but easily visualized continuum between these two
parts of the lesion. These lesions are located below the
peritoneum of the POD and are usually large (3 cm on
average)63.
Uterosacral ligaments
Normal USLs are usually not visible on ultrasound (Figure
S10a). USL DIE lesions can be seen in the mid-sagittal view
of the uterus (Figure S10b). However, these are best seen
by placing the transvaginal probe in the posterior vagi-
nal fornix in the midline in the sagittal plane and then
sweeping the probe inferolaterally to the cervix. USLs
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
IDEA consensus opinion 9
are considered to be affected by DIE when a hypoechoic
thickening with regular or irregular margins is seen within
the peritoneal fat surrounding the USLs. The lesion may be
isolated or may be part of a larger nodule extending into
the vagina or into other surrounding structures. The thick-
ness of a ‘thickened’ USL can be measured in the transverse
plane at the insertion of the ligament on the cervix pro-
vided that the ligament can be distinguished clearly from
adjacent structures (Figure S10c). In some cases the DIE
lesion involving the USL is located at the torus uterinus
(Figure S10d). If so, it is seen as a central thickening of
the retrocervical area64. The dimensions of the USL DIE
nodule should be recorded in three orthogonal planes.
Rectum, rectosigmoid junction and sigmoid
Bowel DIE classically involves the anterior rectum,
rectosigmoid junction and/or sigmoid colon, all of which
can be visualized using TVS. Figure S11a demonstrates
a schematic drawing of a DIE lesion within the upper
anterior rectum. Bowel DIE can take the form of an
isolated lesion or can be multifocal (multiple lesions
affecting the same segment) and/or multicentric (multiple
lesions affecting several bowel segments, i.e. small bowel,
large bowel, cecum, ileocecal junction and/or appendix)65.
Although TVS can be used to visualize multifocal rectal
DIE (Figure S11b), there are no published data assessing
its performance. Computed tomographic colonography
and magnetic resonance imaging (MRI) can be used
to diagnose both multifocal and multicentric bowel
endometriosis65.
Histologically, bowel endometriosis is defined as the
presence of endometrial glands and stroma in the bowel
wall, reaching at least the muscularis propria66,where
this invariably induces smooth-muscle hyperplasia and
fibrosis. This results in thickening of the bowel wall
and some narrowing of the bowel lumen. Normal rectal
wall layers can be visualized on TVS: the anterior
rectal serosa is seen as a thin hyperechoic line; the
muscularis propria is hypoechoic, with the longitudinal
smooth muscle (outer) and circular smooth muscle (inner)
separated by a faint thin hyperechoic line; the submucosa
is hyperechogenic; and the mucosa is hypoechoic37,67
(Figure S12a). Bowel DIE usually appears on TVS as a
thickening of the hypoechoic muscularis propria or as
hypoechoic nodules, with or without hyperechoic foci
(Figure S12b) with blurred margins. The morphological
type of bowel lesion should be described according to
Figure 9. Sonographically, bowel lesions are hypoechoic
and in some cases a thinner section or a ‘tail’ is noted at
one end, resembling a ‘comet’68 (Figure 9b). The normal
appearance of the muscularis propria of the rectum
or rectosigmoid is replaced by a nodule of abnormal
tissue with possible retraction and adhesions, resulting
in the so-called ‘Indian headdress’ or ‘moose antler’ sign
(Figure 9c,e,f)42; the size of these lesions can vary.
We propose that bowel DIE lesions noted on TVS
be described according to the segment of the rectum or
sigmoid colon in which they occur, with DIE lesions
1
2
3
4
Figure 10 Schematic drawing demonstrating distinction at
ultrasound between segments of the rectum and sigmoid colon for
specifying location of deep infiltrating endometriotic lesions: lower
(or retroperitoneal) anterior rectum (1); upper (visible at
laparoscopy) anterior rectum (2); rectosigmoid junction (3); and
anterior sigmoid (4).
located below the level of the insertion of the USLs
on the cervix being denoted as lower (retroperitoneal)
anterior rectal DIE lesions, those above this level being
denoted as upper (visible at laparoscopy) anterior rectal
DIE lesions, those at the level of the uterine fundus being
denoted as rectosigmoid junction DIE lesions and those
above the level of the uterine fundus being denoted as
anterior sigmoid DIE lesions (Figure 10). The dimensions
of the rectal and/or rectosigmoid DIE nodules should
be recorded in three orthogonal planes and the distance
between the lower margin of the most caudal lesion and
the anal verge should be measured using TVS.
Because bowel DIE may affect the bowel simultaneously
at different sites, other bowel lesions should be looked for
carefully when there is a DIE lesion affecting the rectum
(Figure S12b) or rectosigmoid. Preliminary data showed
that rectal DIE lesions may be associated with a second
intestinal lesion in 54.6% of cases34.
Ultrasound diagnosis of POD obliteration31,32 has been
explained extensively earlier in this article. The oblitera-
tion can be graded as partial or complete depending on
whether one side (left or right) or both sides, respectively,
demonstrate a negative sliding sign. Furthermore, an
experienced operator can identify the level of POD oblit-
eration, i.e. specifying, in an anteverted uterus, whether
it is at the retrocervical level (lower third of the uterus),
mid-posterior uterus (middle third) and/or posterior uter-
ine fundus (upper third)69 and, in a retroverted uterus,
whether it is at the posterior uterine fundus, mid-anterior
uterus and/or lower anterior uterine wall33(Figure S13).
MEASUREMENT OF LESIONS
We propose that each endometrioma and DIE lesion
should be measured systematically in three orthogonal
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
10 Guerriero and Condous et al.
Transverse
Sagittal
Figure 11 Schematic drawing and ultrasound images demonstrating measurement of a nodule of deep infiltrating endometriosis in the bowel
wall. Three orthogonal measurements should be taken, i.e. mid-sagittal, anteroposterior and transverse.
Figure 12 In cases of multifocal lesions of deep infiltrating endometriosis in the bowel, the total length of the bowel segment involved (from
caudal to cephalic aspect) should be measured, as shown in this schematic drawing and ultrasound image.
planes, to obtain the length (mid-sagittal measurement),
thickness (anteroposterior measurement) and transverse
diameter (Figure 11). This approach of measuring
in three planes applies to DIE lesions located in
the bladder, RVS, vagina, USLs, anterior rectum and
rectosigmoid.
Additionally, in cases of endometriosis in the ureters,
it is important to measure the distance between the
distal ureteric orifice and a DIE lesion which causes a
ureteric stricture; the stricture can be caused by either
extrinsic compression or intrinsic infiltration. Once the
stricture is identified along the longitudinal course of the
ureter, one caliper should be placed at this level and
the other at the distal ureteric orifice for measurement
(Figure S7).
In cases of multifocal bowel DIE lesions the total
mid-sagittal length of the bowel segment involved, from
caudal to cephalic aspect, should be measured (Figure 12).
It is important to be aware that the retraction within
rectosigmoid DIE lesions can result in an overestimation
of the true thickness of the lesion and an underestimation
of the true length of the lesion (Figure S14). This has
been described as the ‘mushroom cap’ sign on MRI and
can also be noted on TVS70.
In cases of DIE lesions in the bowel or RVS, it is
important to measure the distance between the anal verge
and the lesion (Figure S15). It is possible to measure
the distance from the anus to the bowel lesion using
transrectal sonography. By inserting the probe into the
anus and positioning the tip of the probe up against
the endometriotic lesion71, one’s finger can be kept on the
probe at the level of the anus and a ruler used to measure
the distance from the finger on the probe to the tip of
the probe when the probe has been withdrawn. TVS can
also be used to approximate the distance from the anal
verge to the lower margin of the bowel lesion. If there
are multifocal bowel lesions, then the distance between
the anal verge and the most caudal bowel lesion is
measured.
Figure 13 gives an overview of anterior and pos-
terior compartmental locations for deep infiltrating
endometriosis.
OTHER ULTRASOUND TECHNIQUES
Color Doppler
Although well established in the evaluation of
endometrioma20, no prospective data have been reported
for the role of color Doppler in the evaluation of DIE.
Usually, endometriotic lesions in the rectosigmoid are
poorly vascularized. Color Doppler is useful in the dif-
ferential diagnosis between DIE in the bowel and rectal
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
IDEA consensus opinion 11
Figure 13 Schematic drawings giving overview of anterior and posterior compartmental locations of deep infiltrating endometriosis.
cancer (Figure S16) and we propose that color Doppler
be used as an adjunct modality in the assessment of DIE
lesions of the bowel.
Tenderness-guided ultrasound examination
Tenderness-guided ultrasound examination is performed
with or without an acoustic window between the
transvaginal probe and the surrounding vaginal struc-
tures, coupled with an ‘active’ role of the patient, who
indicates the site of any tenderness experienced during
the examination27,41.
Rectal water contrast transvaginal ultrasound
Rectal water contrast TVS requires injection, under
ultrasound guidance, of saline through a catheter into the
rectum; the procedure is well tolerated36,72 and allows
estimation of the degree of stenosis of the bowel lumen73
(Figure S17).
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
12 Guerriero and Condous et al.
Sonovaginography with saline or gel
Saline contrast sonovaginography combines TVS with
injection of saline into the vagina74. A transvaginal probe
is used with, at its base, a purpose-designed hydraulic ring
that inflates with approximately 40 mL saline solution to
prevent escape of the 60120 mL saline that is injected
into the vagina using a Foley catheter58. The solution cre-
ates an acoustic window between the transvaginal probe
and the structures surrounding the vagina and exerts pres-
sure that distends the vaginal walls. This permits more
complete visualization of the vaginal walls and anterior/
posterior vaginal fornices.
In order to perform gel contrast sonovaginography,
2050 mL ultrasound gel is inserted into the posterior
vaginal fornix, using a 20-mL plastic syringe, before
insertion of the transvaginal probe35,57.Thegelcreates
an acoustic window, allowing a ‘stand-off’ view of the
structures of the posterior compartment (Figure S18). The
gel must be loaded carefully into the syringe, ensuring
there are no or only minimal air bubbles in the gel. The
syringe is filled completely, so that the plunger comes in
direct contact with the gel, reducing the possibility of air
pockets when instilling the gel into the vagina. Great care
is taken to ensure that the syringe is inserted sufficiently
far into the vagina that the gel fills the posterior fornix
completely. In published reports, no woman required any
refilling of the posterior fornix with gel35,57.
Transrectal sonography using transvaginal probe
Transrectal sonography61,75 can be used if necessary; if
TVS is impossible or inappropriate, for example if the
woman is virgo intacta.
Three-dimensional ultrasound
Three-dimensional TVS
In one study, offline analysis of three-dimensional (3D)
volumetric datasets was useful in the diagnosis of posterior
locations of DIE without intestinal involvement, such
as DIE in the USLs, vagina or RVS10. 3D ultrasound,
however, does not permit evaluation of the mobility of
pelvic organs; nor does it allow mapping of SST.
Introital three-dimensional sonography
There are no studies demonstrating that 3D introital
ultrasound outperforms 2D ultrasound in the detection or
characterization of DIE. However, one research team
reported introital 3D sonography to be an effective
and reproducible method for detecting and describing
endometriosis in the RVS76,77 (Figure S19). Guerriero
et al.78 suggested that 3D image rendering allows analysis
of DIE nodules because 3D rendering may show irregular
shapes and borders clearly.
Three-dimensional rectosonography
There are no studies demonstrating that 3D rectosonog-
raphy outperforms 2D ultrasound in the detection or
characterization of DIE. However, in a recent study, 3D
rectosonography was found to be highly concordant with
MRI79.
Transvaginal elastography
Limited data are available on the usefulness of transvagi-
nal elastography in the diagnosis of DIE80. DIE nodules
usually demonstrate high stiffness on elastography
(Figure S20).
CONCLUSION
TVS is the first-line investigative tool in the work-up
of women with potential underlying endometriosis3.The
ability for ultrasound to detect ovarian endometriosis and
DIE (bowel and non-bowel) is well documented4,5,8,19.
Prediction of severe forms of DIE as well as POD obliter-
ation using TVS is helpful in planning a multidisciplinary
surgical approach3,16,22,27,30,31,56,81.
Some experience with gynecological ultrasound is
necessary to assess the sliding sign to predict POD obliter-
ation. Menakaya et al.82 found that trainees in obstetrics
and gynecology who have performed at least 200 prior
TVS scans outperform trainees who have performed
fewer than 200 in interpreting offline videos of the sliding
sign. They also found that interpretation of the sliding
sign at the retrocervix was better than that at the posterior
upper uterine fundus. Experienced operators who have
performed in excess of 2500 scans reach proficiency in
performing the sliding sign maneuver and detecting POD
obliteration after approximately 40 examinations83,84.
Inter- and intraobserver agreement and diagnostic
accuracy with regard to interpretation of the TVS sliding
sign to predict POD obliteration has been found to be
acceptable, with agreement ranging from substantial to
almost perfect for observers who specialize in gynecolog-
ical ultrasound85. In the same study, the agreement for all
observers was higher for interpretation of the sliding sign
in the retrocervical region compared with the posterior
upper uterine fundal region.
Similar to detection of POD obliteration, experienced
operators who have performed in excess of 2500 scans
reach proficiency in the detection of rectal DIE nodules
using TVS after approximately 40 examinations83,84.
With the exception of DIE affecting the RVS, TVS in
the hands of well-trained staff is a highly accurate and
reproducible method for non-invasive diagnosis of DIE86.
In this consensus opinion, we have described a sys-
tematic approach to examining the pelvis in women
with suspected endometriosis, and defined terms and
measurements to describe the appearance of endometrio-
sis on sonography. This consensus opinion represents
the collective opinion of clinicians, gynecological sono-
logists, advanced laparoscopic surgeons and radiolo-
gists with an interest in diagnosis and management of
endometriosis. Currently, it is difficult to compare results
between published studies, because authors use different
terms when describing the same structures and locations.
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
IDEA consensus opinion 13
We hope that the terms and definitions suggested herein
will be adopted in centers around the world. This would
result in consistent use of nomenclature when describing
the ultrasound location and extent of endometriosis. We
believe that the standardization of terminology should
allow meaningful comparisons between future studies in
women with an ultrasound diagnosis of endometriosis
and should facilitate multicenter studies.
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SUPPORTING INFORMATION ON THE INTERNET
The following supporting information may be found in the online version of this article:
Videoclip S1 Assessment of sliding sign in an anteverted uterus, in posterior uterine fundus (a) and
retrocervix (b).
Videoclip S2 Assessment of sliding sign in a retroverted uterus, in posterior uterine fundus (a) and anterior
lower uterine segment (b).
Videoclip S3 Assessment of deep infiltrating endometriotic nodules in the bladder base.
Videoclip S4 Assessment of sliding sign in the uterovesical region.
Figure S1 Transvaginal sonographic images of: (a) a typical endometrioma (unilocular cyst with rather thick
walls and ground glass echogenicity of cyst fluid); and (b) an atypical endometrioma (irregular, apparently
solid, hyperechogenic structure within the cystic lesion, with ground glass echogenicity of cyst fluid).
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
IDEA consensus opinion 15
Figure S2 Ultrasound image demonstrating ‘kissing’ ovaries sign: two ovaries containing endometriomas are
fixed to each other by adhesions in the pouch of Douglas.
Figure S3 Color Doppler ultrasound image demonstrating decidualization of endometrioma in pregnancy.
Figure S4 Schematic drawings demonstrating deep infiltrating endometriosis located in: (a) trigonal zone of
bladder; (b) base of bladder; (c) dome of bladder; (d) extra-abdominal bladder.
Figure S5 Schematic drawing and ultrasound image demonstrating most frequent location of endometriotic
bladder nodules: bladder base.
Figure S6 Schematic drawing demonstrating location of uterovesical obliteration. If the bladder does not slide
freely over the anterior uterine wall, then the ‘sliding sign’ is negative and the uterovesical region is classified
as obliterated.
Figure S7 (a) Schematic drawing demonstrating measurement of distance from ureteric orifice to level of
stricture, necessary in cases of deep infiltrating endometriosis (DIE) in the ureters. (b) Ultrasound image
showing distal ureter obstructed by DIE; proximal hydronephrosis is seen.
Figure S8 (a) Schematic drawings and ultrasound images demonstrating location and different morphological
appearances of deep infiltrating endometriosis (DIE) in posterior vaginal fornix. A normal ultrasound image is
shown for comparison. (b) Ultrasound image demonstrating forniceal lesion, characterized by increased
thickness of posterior vaginal fornix above line passing along lower border of posterior lip of cervix (under
peritoneum).
Figure S9 Schematic drawing (a) and ultrasound image (b) demonstrating ‘diabolo-like’ nodule of deep
infiltrating endometriosis in posterior vaginal fornix extending into anterior rectal wall.
Figure S10 Ultrasound images and schematic drawings demonstrating deep infiltrating endometriosis (DIE) of
the uterosacral ligaments (USL). (a) Longitudinal and transverse planes: normal USLs are usually not visible
on ultrasound. (b) Location of USL DIE in the mid-sagittal view. (c) Location of DIE in the right USL in
transverse view. (d) Location of USL DIE at the torus uterinus in a transverse view through the pelvis.
Figure S11 Schematic drawings and transvaginal ultrasound image demonstrating deep infiltrating
endometriotic (DIE) rectal lesions. (a) DIE in the upper anterior rectum. (b) Multifocal DIE in the rectum.
Figure S12 Schematic image showing histological layers of normal rectum (a), with corresponding layers
shown in ultrasound image of a bowel loop with nodule of deep infiltrating endometriosis in the bowel
wall (b).
Figure S13 (ac) Schematic drawings and corresponding ultrasound images demonstrating different levels of
obliteration of the pouch of Douglas (POD) in an anteverted uterus: (a) retrocervical level; the ‘comet’ sign is
also present; (b) mid-posterior uterus; the ‘Indian headdress’ (or ‘moose antler’) and ‘pulling sleeve’ signs are
also present; (c) posterior uterine fundus; the pulling sleeve sign is also present. (d) POD obliteration in a
retroverted uterus.
Figure S14 Schematic drawing and ultrasound image demonstrating ‘mushroom cap’ sign. Retraction within
nodule of deep infiltrating endometriosis in rectosigmoid results in overestimation of true thickness of lesion
and, in some cases, in underestimation of true length of bowel segment affected by lesion.
Figure S15 Schematic drawing and ultrasound image demonstrating measurement of distance from anal verge
to deep infiltrating endometriotic lesion of bowel.
Figure S16 Doppler images demonstrating rectal cancer with marked vascularity.
Figure S17 Ultrasound image obtained during rectal water contrast transvaginal ultrasound in a woman with
deep infiltrating endometriosis.
Figure S18 Ultrasound image obtained during gel sonovaginography in a woman without endomotriosis,
showing pouch of Douglas.
Figure S19 Multiplanar view of pelvic floor as visualized by introital ultrasound with three-dimensional
reconstruction with render mode, showing endometriotic nodule in rectovaginal septum, between rectum and
vagina.
Figure S20 Transvaginal elastogram of nodule of rectal deep infiltrating endometriosis; nodule has mainly
high stiffness, with some low-stiffness spots.
Copyright ©2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016.
... For imaging evaluation (both sonography and MRI), anatomical structures were defined according to the IDEA consensus of 2016. 13 In a study of Indrielle-Kelly et al. 14 it was shown that the IDEA consensus can be properly used for MRI as well. In case of discrepancies between diagnostic modalities, the responsible gynaecologist in the study centre determined the final cEnzian coding in the relevant compartment, taking into account the respective experience in the different diagnostic modalities. ...
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... To date, TVS represents the standard imaging technique for identifying ovarian endometriomas due to its high values in sensitivity (93%) and specificity (97%) when performed by an expert operator [21,22]. ...
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Objectives To review the diagnostic accuracy of transvaginal ultrasound (TVS) in the preoperative detection of rectosigmoid endometriosis in patients with clinical suspicion of deep infiltrating endometriosis (DIE), comparing enhanced (E-TVS) and non-enhanced approaches. Methods An extensive search was performed in MEDLINE (PubMed) and EMBASE for studies published between January 1989 and December 2014. The eligibility criterion was use of TVS for preoperative detection of rectosigmoid endometriosis in women with clinical suspicion of DIE, using surgical data as the reference standard. Study quality was assessed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Results Our extended search identified a total of 801 citations, among which 19 studies (n = 2639) were considered eligible and included in the meta-analysis. Overall pooled sensitivity, specificity, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) of TVS for detecting DIE in the rectosigmoid were 91% (95%CI, 85-94%), 97% (95%CI, 95-98%), 33.0 (95%CI, 18.6-58.6) and 0.10 (95%CI, 0.06-0.16), respectively. Significant heterogeneity was found for sensitivity (I2, 90.8%; Cochran Q, 195.2; P < 0.001) and specificity (I2, 76.8%; Cochran Q, 77.7; P < 0.001). We did not find statistical differences between non-enhanced TVS and E-TVS (P = 0.304). Conclusion Overall diagnostic performance of TVS for DIE of the rectosigmoid is good. However, further studies with improved quality in design are needed.
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Transvaginal ultrasound (TVS) has been used for preoperative detection of deep endometriosis (DIE) in uterosacral ligaments (USL), recto-vaginal septum (RVS), vagina and bladder locations. However, there is no clear evidence up to date about the overall diagnostic performance in these locations. To perform a systematic review about the diagnostic accuracy of TVS in the preoperative detection of USL, RVS, vagina and bladder endometriosis in patients with clinical suspicion of DIE. An extensive search was performed in Medline (Pubmed) and EMBASE from January 1989 to December 2014. Eligibility criteria were studies using TVS in the preoperative detection of USL, RVS, vaginal and bladder endometriosis in women with clinical suspicion of DIE using the surgical data as a reference standard. Quality was assessed using PRISMA guidelines and QUADAS-2 tool. Of the 801 citations identified, 11 studies (involving 1532 patients) were eligible and included in the meta-analysis. Regarding USL, the overall pooled sensitivity and specificity was 53% (95% CI, 35-70%) and 93% (95% CI, 83-97%), respectively. The pretest probability of USL endometriosis was 42%, and this probability increased to 85% when TVS suspicion was present. Regarding RVS endometriosis, the overall pooled sensitivity and specificity was 49% (95% CI, 36-62%) and 98% (95% CI, 95-99%), respectively. The pretest probability of RVS endometriosis was 26%, and this probability increased to 90% when TVS suspicion was present. Regarding vaginal endometriosis, the overall pooled sensitivity and specificity was 58% (95% CI, 40-74%) and 96% (95% CI, 87-99%), respectively. The pretest probability of vaginal endometriosis was 18%, and this probability increased to 77% when TVS suspicion was present. Substantial heterogeneity was found for sensitivity and specificity for all these locations. Regarding bladder endometriosis, the overall pooled sensitivity and specificity was 62% (95% CI, 40-80%) and 100% (95% CI, 97-100%), respectively. Moderate heterogeneity was found for sensitivity and specificity. The pretest probability of bladder endometriosis was 6%, and this probability increased to 93% when TVS suspicion was present. Overall diagnostic performance of TVS for detecting deep endometriosis is fair but a high specificity is present for all the locations. This article is protected by copyright. All rights reserved.
Article
To determine inter and intra-observer agreements, diagnostic accuracy and the learning curve required for interpreting 'sliding sign' and predicting Pouch of Douglas (POD) obliteration. An inter/ intra observer, diagnostic accuracy and learning curve study involving 6 observers who viewed 32 offline 'sliding sign' videos in two anatomical locations viz retro-cervix (RC) and posterior uterine fundus (PUF). Observer 1 was a medical student with no previous gynaecological ultrasound experience, observer 2 was a 2nd year obstetrics and gynaecology (O&G) trainee (50 scans), observer 3 was a 1st year sonographer trainee (50 scans), observer 4 was a 4th year O&G trainee (200 scans), observer 5 was a gynaecological ultrasound fellow (750 scans) and observer 6 was an expert sonologist (15,000 scans). Each observer interpreted the videos (Observation set 1) as positive or negative and predicted status of POD. The same observers reanalysed the same video sets albeit in a different order (Observation set 2), at least 7 days apart for intra-observer agreement. Observer 6 was reference standard for interpreting 'sliding sign' and gold standard laparoscopy was used for POD. Learning curve cumulative summation (LC-CUSUM) tests were conducted to assess if observer performances reached acceptable levels. Multiple rater agreements for interpreting 'sliding sign' was moderate (Fleiss kappa (K) = 0.499). Observers were more consistent with observation set 2 vs. set 1 (K = 0.547 vs. 0.453) and for RC vs. PUF (K = 0.556 vs. 0.346). Intra-observer correlations were moderate (Cohen's kappa (k) = 0.447 - 0.496) to almost perfect (k = 0.678 - 0.953). Accuracy, sensitivity, specificity, positive and negative predictive value for predicting status of POD ranged from 65.4 - 96.2%, 80.0 - 100%, 64.7 - 100%, 50.0 - 100% and 94.7 - 100% respectively. Using LC-CUSUM score < -2.45, observer 4 reached acceptable levels for predicting POD obliteration and interpreting 'sliding sign' at both regions (RC and PUF) at 39, 54 and 28 and observer 5 at 56, 53 and 53 respectively. A minimum number of gynaecological ultrasound experiences are relevant for interpreting the 'sliding sign'. Non-specialist observers with at least 200 prior TVS were more consistent in interpreting 'sliding sign' at RC vs. PUF regions. This article is protected by copyright. All rights reserved.