Endometriotic lesions of the lower troncular nerves

MRI Features of Pelvic Nerve Involvement in Endometriosis

Endometriosis is a common condition that mostly affects people assigned as female at birth. The most common clinical symptom of endometriosis is pain. Although the mechanism for this pain is poorly understood, in some cases, the nerves are directly involved in endometriosis. Endometriosis is a multifocal disease, and the pelvis is the most common location involved. Nerves in the pelvis can become entrapped and involved in endometriosis. Pelvic nerves are visible at pelvic MRI, especially when imaging planes and sequences are tailored for neural evaluation. In particular, high-spatial-resolution anatomic imaging including three-dimensional isotropic imaging and contrast-enhanced three-dimensional short inversion time inversion-recovery (STIR) fast spin-echo sequences are useful for nerve imaging. The most commonly involved nerves are the sciatic, obturator, femoral, pudendal, and inferior hypogastric nerves and the inferior hypogastric and lumbosacral plexuses. Although it is thought to be rare, the true incidence of nerve involvement in endometriosis is not known. Symptoms of neural involvement include pain, weakness, numbness, incontinence, and paraplegia and may be constant or cyclic (catamenial). Early diagnosis of neural involvement in endometriosis is important to prevent irreversible nerve damage and chronic sensorimotor neuropathy. Evidence of irreversible damage can also be seen at MRI, and radiologists should evaluate pelvic nerves that are commonly involved in endometriosis in their search pattern and report template to ensure that this information is incorporated into treatment planning.

Extragenital Endometriosis in the Differential Diagnosis of Non- Gynecological Diseases

BACKGROUND

Endometriosis is a chronic, benign disease that affects approximately 10% of women of childbearing age. Its characteristic clinical features are dysmenorrhea, dyschezia, dysuria, dyspareunia, and infertility. The manifestations of extragenital endometriosis (EE) are a diagnostic challenge, as this disease can mimic other diseases due to its unusual location with infiltration of various organs and corresponding symptoms.

METHODS

This review is based on publications retrieved by a selective search of the literature on the commonest extragenital sites of endometriosis, including the relevant current guideline.

RESULTS

Current evidence on the treatment of extragenital endometriosis consists largely of cohort studies and cross-sectional studies. The treatment is either surgical and/or conservative (e.g., hormonal therapy). Gastrointestinal endometriosis is the most common form of EE, affecting the rectum and sigmoid colon in nearly 90% of cases and typically presenting with dyschezia. Urogenital endometriosis is the second most common form of EE. It affects the bladder in more than 85% of cases and may present with dysuria, hematuria, or irritable bladder syndrome. The diaphragm is the most common site of thoracic endometri - osis, potentially presenting with period-associated shoulder pain or catamenial pneumothorax. Endometriosis affecting a nerve often presents with sciatica. In abdominal wall endometriosis, painful nodules arise in scars from prior abdominal surgery.

CONCLUSION

There is, as yet, no causally directed treatment for chronic endometriosis. The treatment is decided upon individually in discussion with the patient, in consideration of risk factors and after assessment of the benefits and risks. Timely diagnosis is essential.

Surgical Neuropelveology: Lateral Femoral Cutaneous Nerve Endometriosis. Laparoscopic Resection and Nerve Transplantation

STUDY OBJECTIVE

To demonstrate the application of surgical neuroanatomic principles for the diagnosis and treatment of deep infiltrating endometriosis involving the lateral femoral cutaneous nerve.

DESIGN

Video demonstration of laparoscopic lateral femoral cutaneous endometriosis resection with nerve transplant.

SETTING

Endometriosis infiltrating somatic nerves is a poorly known condition, which can cause severe neuropathic symptoms [1] and is often unrecognized with a subsequent treatment delay [1]. Intimate knowledge of pelvic neuroanatomy and expertise in minimally invasive surgery are essential to manage this challenging surgical scenario [2-4].

INTERVENTIONS

Thirty-six years old patient with primary infertility and chronic pelvic pain associated with dysmenorrhea, dyspareunia, dysuria, and dyschezia. Preoperative magnetic resonance imaging detected a 3-cm parauterine and a 2-cm retrocervical endometriosis nodule. Magnetic resonance imaging did not demonstrate pelvic nerve involvement. Preoperative neuropelveologic assessment demonstrated a significant hypoesthesia of the corresponding lateral femoral cutaneous nerve dermatome, representing the primary complaint. A swab test showed spotting areas of allodynia. These findings prompted us to investigate for a right lateral femoral cutaneous entrapment. Laparoscopy showed an endometriosis nodule infiltrating the right lateral femoral cutaneous nerve. A resection of the nerve was necessary, and a subsequent reconstruction with a collagen bovine neuro-guide was carried out. The operative time was 300 minutes, and the estimated blood loss was 150 mL. Hospital stay was 3 days. After 3 months, the patient showed a clinical improvement in the pain and hypoesthesia on the reconstructed nerve dermatome.

CONCLUSION

Neuropelvic anatomic assessment should be considered during the preoperative evaluation for patients with endometriosis who have pelvic pain and neuropathy as part of the diagnostic process [5]. This unique case demonstrates that nerve resection and transplantation can be used in specific situations for neuropathy related to deep infiltrative endometriosis of pelvic nerves.

Renal Endometriosis Mimicking Cystic Renal Tumor: Case Report and Literature Review

Background: Endometriosis mainly affects female pelvic tissues and organs, and the presence of endometriosis in the kidney is extremely rare.

Case Presentation: We report a case of a 48-year-old woman who presented with intermittent hematuria. She was found to have a cystic mass on renal ultrasonography, and contrast-enhanced computed tomography (CT) showed slight enhancement of the cystic wall and septa. These findings were indicative of cystic renal tumor. The patient subsequently underwent partial right nephrectomy. Histopathology revealed endometriosis of the right renal parenchyma. The patient recovered well and had no evidence of a recurrent renal mass at the 3 months' follow up.

Conclusion: The possibility of renal endometriosis should be considered in a female patient with a cystic renal mass and clinical symptoms related to the menstrual cycle.

Sciatic endometriosis: A narrative review of an unusual neurogynecologic condition

Endometriosis is a condition in which there is an ectopic growth of endometrial tissue. Sciatic endometriosis, otherwise known as catamenial sciatica, is a rare but exceedingly significant presentation of endometriosis. Symptoms include cyclic sciatic pain that peaks during the menstrual period; additionally, paresthesia, paresis, and areflexia may occur with this condition. Sciatic endometriosis can be presumptively diagnosed in response to empiric treatment (e.g. gonadotropin-releasing hormone analogs) or imaging studies, but a definitive diagnosis of sciatic endometriosis may occur from examining tissue obtained during surgery. Surgical removal of endometriosis from the sciatic nerve root can potentially eliminate symptoms while maintaining normal reproductive function, though poses particular surgical risks. Familiarity with this rare condition is paramount to making this diagnosis and the initiation of earlier treatment.

Peritoneal Retraction Pocket Defects and Their Important Relationship with Pelvic Pain and Endometriosis

OBJECTIVE

The objective of this video is to demonstrate different clinical presentations of peritoneal defects (peritoneal retraction pockets) and their anatomic relationships with the pelvic innervation, justifying the occurrence of some neurologic symptoms in association with these diseases.

DESIGN

Surgical demonstration of complete excision of different types of peritoneal retraction pockets and a comparison with a laparoscopic retroperitoneal cadaveric dissection of the pelvic innervation.

SETTING

Private hospital in Curitiba, Paraná, Brazil.

INTERVENTIONS

A pelvic peritoneal pocket is a retraction defect in the surface of the peritoneum of variable size and shapes [1]. The origin of defects in the pelvic peritoneum is still unknown [2]. It has been postulated that it is the result of peritoneal irritation or invasion by endometriosis, with resultant scarring and retraction of the peritoneum [3,4]. It has also been suggested that a retraction pocket may be a cause of endometriosis, where the disease presumably settles in a previously altered peritoneal surface [5]. These defects are shown in many studies to be associated with pelvic pain, dyspareunia, and secondary dysmenorrhea [1-4]. Some studies have shown that the excision of these peritoneal defect improves pain symptoms and quality of life [5]. It is important to recognize peritoneal pockets as a potential manifestation of endometriosis because in some cases, the only evidence of endometriosis may be the presence of these peritoneal defects [6]. In this video, we demonstrate different types of peritoneal pockets and their close relationship with pelvic anatomic structures. Case 1 is a 29-year-old woman, gravida 0, with severe dysmenorrhea and catamenial bowel symptoms (bowel distension and diarrhea/constipation) that were unresponsive to medical treatment. Imaging studies were reported as normal, and a laparoscopy showed a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the lateral border of the rectum. Case 2 is a cadaveric dissection of a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the pelvic sidewall. After dissection of the obturator fossa, we can observe that the pocket is close to the sacrospinous ligament, pudendal nerve, and some sacral roots. Case 3 is a 31-year-old woman, gravida 1, para 1, with severe dysmenorrhea that was unresponsive to medical treatment and catamenial bowel symptoms (catamenial bowel distention and diarrhea). Imaging studies were reported as normal and a laparoscopy showed left uterosacral peritoneal pocket infiltrating the pararectal fossa in close proximity to the rectal wall. Case 4 is a cadaveric dissection of the ovarian fossa and the obturator fossa showing the proximity between these structures. Case 5 is a 35-year-old woman, gravida 0, with severe dysmenorrhea that was unresponsive to medical treatment, referring difficulty, and pain when walking only during menstruation. A neurologic physical examination revealed weakness in thigh adduction, and the magnetic resonance imaging showed no signs of endometriosis. During laparoscopy, we found a peritoneal pocket infiltrating the ovarian fossa, with involvement in the area between the umbilical ligament and the uterine artery. This type of pocket can easily reach the obturator nerve. Because the obturator nerve and its branches supply the muscle and skin of the medial thigh [7,8], patients may present with thigh adduction weakness or difficulty ambulating [9,10]. Case 6 is a cadaveric dissection of the sacrospinous ligament and the pudendal nerve from a medial approach, between the umbilical artery and the iliac vessels. Case 7 is a 34-year-old woman, gravida 1, para 1, with severe dysmenorrhea and catamenial bowel symptoms as well as deep dyspareunia. The transvaginal ultrasound showed focal adenomyosis and a 2-cm nodule, 9-cm apart from the anal verge, affecting 30% of the bowel circumference. In the laparoscopy, we found a posterior cul-de-sac retraction pocket associated with a large deep endometriosis nodule affecting the vagina and the rectum. In all cases, endometriosis was confirmed by histopathology, and in a 6-month follow-up, all patients showed improvement of bowel, pain, and neurologic symptoms.

CONCLUSION

Peritoneal pockets can have different clinical presentations. Depending on the topography and deepness of infiltration, they can be the cause of some neurologic symptoms associated with endometriosis pain. With this video, we try to encourage surgeons to totally excise these lesions and raise awareness about the adjacent key anatomic structures that can be affected.

Atypical Sites of Deeply Infiltrative Endometriosis: Clinical Characteristics and Imaging Findings

Endometriosis is defined as the presence of endometrial tissue that is located outside the uterine cavity and associated with fibrosis and inflammatory reaction. It is a polymorphic and multifocal disease with no known cure or preventive mechanisms. Patients may be asymptomatic or may experience chronic pelvic pain, dysmenorrhea, dyspareunia, or infertility. The pelvic cavity is the most common location for endometriotic implants, which usually affect the retrocervical space, ovaries, vagina, rectosigmoid colon, bladder dome, and round ligaments. Atypical endometriosis is rare and difficult to diagnose. The most common atypical locations are the gastrointestinal tract, urinary tract, lung, umbilicus, inguinal area, breast, and pelvic nerves, as well as abdominal surgical scars. Gastrointestinal lesions are the most common extragenital manifestation, and the diaphragm is the most frequent extrapelvic site. The catamenial nature of the symptoms (occurring between 24 hours before and 72 hours after the onset of menstruation) may help suggest the diagnosis, but imaging by specialists is fundamental to evaluation. Depending on the area affected, radiography, ultrasonography, thin-section computed tomography, or magnetic resonance imaging can be used to assess suspected lesions. Because isolated extragenital endometriosis is rare, concomitant evaluation of the pelvic cavity is mandatory. Surgical excision is the only therapeutic option for definitive treatment, and comprehensive disease mapping is necessary to avoid residual disease. The authors review atypical locations for endometriosis and emphasize the most appropriate imaging protocols for investigation of various clinical manifestations. Online supplemental material is available for this article. ^©RSNA, 2018.

Endometriosis: clinical features, MR imaging findings and pathologic correlation

Objective

We illustrate the magnetic resonance imaging (MRI) features of endometriosis.

Background

Endometriosis is a chronic gynaecological condition affecting women of reproductive age and may cause pelvic pain and infertility. It is characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus and includes three different manifestations: ovarian endometriomas, peritoneal implants, deep pelvic endometriosis. The primary locations are in the pelvis; extrapelvic endometriosis may rarely occur. Diagnosis requires a combination of clinical history, invasive and non-invasive techniques. The definitive diagnosis is based on laparoscopy with histological confirmation. Diagnostic imaging is necessary for treatment planning. MRI is as a second-line technique after ultrasound. The MRI appearance of endometriotic lesions is variable and depends on the quantity and age of haemorrhage, the amount of endometrial cells, stroma, smooth muscle proliferation and fibrosis. The purpose of surgery is to achieve complete resection of all endometriotic lesions in the same operation.

Conclusion

Owing to the possibility to perform a complete assessment of all pelvic compartments at one time, MRI represents the best imaging technique for preoperative staging of endometriosis, in order to choose the more appropriate surgical approach and to plan a multidisciplinary team work.

Teaching Points

• Endometriosis includes ovarian endometriomas, peritoneal implants and deep pelvic endometriosis.

• MRI is a second-line imaging technique after US.

• Deep pelvic endometriosis is associated with chronic pelvic pain and infertility.

• Endometriosis is characterized by considerable diagnostic delay.

• MRI is the best imaging technique for preoperative staging of endometriosis.

Shining light in a dark landscape: MRI evaluation of unusual localization of endometriosis

Endometriosis is a disease distinguished by the presence of endometrial tissue outside the uterine cavity with intralesional recurrent bleeding and resulting fibrosis. The most common locations for endometriosis are the ovaries, pelvic peritoneum, uterosacral ligaments, and torus uterinus. Typical symptoms are secondary dysmenorrhea and cyclic or chronic pelvic pain. Unusual sites of endometriosis may be associated with specific symptoms depending on the localization. Atypical pelvic endometriosis localizations can occur in the cervix, vagina, round ligaments, ureter, and nerves. Moreover, rare extrapelvic endometriosis implants can be localized in the upper abdomen, subphrenic fold, or in the abdominal wall. Magnetic resonance imaging (MRI) represents a problem-solving tool among other imaging modalities. MRI is an advantageous technique, because of its multiplanarity, high contrast resolution, and lack of ionizing radiation. Our purpose is to remind the radiologists the possibility of atypical pelvic and extrapelvic endometriosis localizations and to illustrate the specific MRI findings. Endometriotic tissue with hemorrhagic content can be distinguished from adherences and fibrosis on MRI imaging. Radiologists should keep in mind these atypical localizations in patients with suspected endometriosis, in order to achieve the diagnosis and to help the clinicians in planning a correct and complete treatment strategy.