Is Pouch of Douglas Obliteration a Marker of Bowel Endometriosis?

Monozygotic twins with endometriosis in matching locations at time of laparoscopy: A case report

Endometriosis is a common benign gynaecological disorder, which has an increased prevalence amongst twins and first degree relatives of affected individuals. Here we describe a case of remarkable resemblance in the distribution of deep infiltrating endometriosis related to the bowel in a monozygotic twin pair. We provide a literature review of studies of endometriosis in twins. We propose that genetic factors influence the nature and distribution of the disease, while environmental factors may affect the severity.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effectiveness of ultrasound for endometriosis diagnosis

PURPOSE OF REVIEW

Endometriosis is a chronic benign gynaecological condition characterized by pelvic pain, subfertility and delay in diagnosis. There is an emerging philosophical shift from gold standard histopathological diagnosis through laparoscopy to establishing diagnosis through noninvasive imaging.

RECENT FINDINGS

The ENZIAN classification system was updated in 2021 to be suitable for both diagnostic imaging and laparoscopy. The accuracy of transvaginal ultrasound (TVUS) in diagnosing endometriosis varies depending on location of the lesion. A recent international pilot study found that when ultrasound is performed in accordance with the IDEA consensus, a higher detection of deep endometriosis is seen, with an overall sensitivity of 88% and specificity of 79% compared with direct surgical visualization.

SUMMARY

Although ultrasound can detect adenomyosis, deep endometriosis and endometriomas, it is not possible to reliably detect superficial endometriosis. In the instance of a negative ultrasound with persistence of symptoms despite medical therapy, laparoscopy should be considered for diagnosis and treatment.

MRI in the Diagnosis of Endometriosis and Related Diseases

Endometriosis, a common chronic inflammatory disease in female of reproductive age, is closely related to patient symptoms and fertility. Because of its high contrast resolution and objectivity, MRI can contribute to the early and accurate diagnosis of ovarian endometriotic cysts and deeply infiltrating endometriosis without the need for any invasive procedure or radiation exposure. The ovaries, which are the most frequent site of endometriosis, can be afflicted by multiple related conditions and diseases. For the diagnosis of deeply infiltrating endometriosis and secondary adhesions among pelvic organs, fibrosis around the ectopic endometrial gland is usually found as a T2 hypointense lesion. This review summarizes the MRI findings obtained for ovarian endometriotic cysts and their physiologically and pathologically related conditions. This article also includes the key imaging findings of deeply infiltrating endometriosis.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Fresh Frozen Cadaveric Study of Direct Pouch of Douglas Laparoscopic and Robotic Trocar Insertion for Vaginal Natural Orifice Transluminal Endoscopic Surgery

STUDY OBJECTIVE

To determine the distances and angles that assure a safe entry into the pouch of Douglas (POD) during blind laparoscopic and robotic trocar entry.

DESIGN

Trocars were inserted into the POD of 4 intact fresh frozen female pelves. Cadaveric dissection was performed, and the distance from the POD to the sacrum at rest and with maximal pressure to POD with the trocar was measured. In addition, the optimal angle for trocar insertion and entry was evaluated.

SETTING

Inova Advanced Simulation and Technology Evaluation Center.

PATIENTS

Fresh frozen cadavers with intact reproductive organs.

INTERVENTIONS

Vaginal POD trocar insertion.

MEASUREMENTS AND MAIN RESULTS

Measurements were recorded from the sacrum to the POD at rest and from the sacrum to the hymen with trocar pressure. The dissection demonstrated correct trocar placement in the POD of human cadaveric specimens. The mean distances from the sacrum to the hymen, the sacrum to the POD, and the sacrum to the POD with pressure were 18.75 cm, 9.75 cm, and 7.25 cm, respectively. After the deployment of the trocar, the tip was observed to be 2 cm below the cervix in the POD. The mean trocar angle to clear the sacral promontory and the neurovascular structures without injury to the uterus was 25° to 40° from the horizontal plane and 15° to 30° from the coronal plane.

CONCLUSION

A direct trocar entry into the POD has been found to be feasible in fresh frozen cadaveric specimens. This study provided valuable information for the angle of entry into the POD to facilitate vaginal and robotic trocar entry for minimally invasive gynecologic procedures.

Postoperative imaging findings after laparoscopic surgery for deeply infiltrating endometriosis

Deeply infiltrative endometriosis (DIE) is a common gynecologic disease affecting women of reproductive age and often causing chronic pelvic pain and infertility. Clinical treatment options and preventive actions are ineffective due to the lack of knowledge about the etiology of DIE. Surgical treatment is currently the only alternative to eradicate the disease. Diagnostic imaging plays a crucial role for surgical planning and postoperative evaluation. Transvaginal sonography (TVS) with a dedicated protocol and magnetic resonance imaging (MRI) can be used to evaluate recurrent disease. Extensive pelvic surgery may cause anatomical changes and a variable spectrum of postoperative findings. Residual disease and complications can be also evaluated and are of great importance to estimate pain relief and fertility prognosis. The most common imaging findings following radical surgery for DIE are fibrotic scars in the retrocervical space and bowel anastomosis, absence of the posterior vaginal fornix and loculated fluid in the pararectal spaces. Ovaries are the most frequent site of early recurrence. Complications include infection, hemorrhage, urinary/evacuatory voiding dysfunctions as well as bowel and ureteral stenosis. The purpose of this article is to review the surgical techniques currently used to treat endometriosis in the retrocervical space, vagina, bladder, bowel, ureters, and ovaries and to describe the most common imaging findings including normal aspects, residual disease, complications, and recurrence.

Transvaginal US of Endometriosis: Looking Beyond the Endometrioma with a Dedicated Protocol

Transvaginal sonography (TVS) is a valuable primary imaging tool for the initial evaluation and management of endometriosis, a complex multifocal disease process with a varied spectrum of clinical and morphologic features that can substantially affect quality of life. The high accuracy of TVS for the detailed mapping of disease extent, an essential process for guiding treatment strategies, is well documented. The dynamic nature of US provides added value, revealing information that is not easily addressed with other imaging modalities. As recognized by the International Deep Endometriosis Analysis Consensus Group, a dedicated standardized protocol that is used by experienced and knowledgeable operators is necessary for a complete evaluation. The four components of a dedicated TVS protocol for evaluation of pelvic endometriosis are (a) evaluation of the uterus and adnexa, (b) dedicated search for deep infiltrating endometriosis, (c) assessment of the sliding sign, and (d) detection of sonographic soft markers. These components are described, and the multiple locations and US findings of endometriosis within the pelvis are reviewed, with emphasis on the unique features of US as an extension of the physical examination. In addition to enabling evaluation of the static findings of adenomyosis, endometrioma, hydrosalpinx, hematosalpinx, and hypoechoic nodules of deep infiltrating endometriosis, dynamic TVS enables assessment of pouch of Douglas obliteration, organ mobility, and site-specific tenderness, as well as tenderness-guided imaging. The benefits of implementing a dedicated TVS protocol in terms of improved patient care are also discussed. Online supplemental material is available for this article. ^©RSNA, 2019.

Transvaginal sonography in the diagnosis of deep infiltrating endometriosis: A review

This review summarizes the current evidence regarding the diagnostic accuracy of sonography (US) in women with deep infiltrating endometriosis (DIE). It is well known that transvaginal ultrasound (TVUS) can detect ovarian endometriomas with a high degree of sensitivity. In recent years, US has also been used to detect DIE. In the hands of an experienced sonologist, the sensitivity and specificity of TVUS in the detection of DIE is comparable to those of MRI. TVUS can eliminate the need for an MRI in the majority of patients and reduce the need for diagnostic laparoscopy, proving to be an important tool in preoperative planning. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:313-318, 2017.

Performance of ultrasound-based endometriosis staging system (UBESS) for predicting level of complexity of laparoscopic surgery for endometriosis

OBJECTIVE

To develop and assess the performance of a preoperative ultrasound-based endometriosis staging system (UBESS) to predict the level of complexity of laparoscopic surgery for endometriosis.

METHODS

This was a multicenter prospective and retrospective cohort study on consecutive women with suspected endometriosis who underwent laparoscopy between June 2009 and July 2013. Each woman underwent a systematic transvaginal ultrasound evaluation to assess the pelvis for different phenotypes of endometriosis, and the diagnostic performance of ultrasound for these different phenotypes was evaluated relative to the gold standard, laparoscopy. A three-stage preoperative UBESS was developed to assess the severity of pelvic endometriosis, based on the histological phenotypes of endometriosis, the anatomical locations of deep infiltrating endometriosis and their sonographic markers of local invasiveness. The three stages of UBESS (I-III) were then correlated with the three levels of complexity of laparoscopic surgery for endometriosis described by the Royal College of Obstetricians and Gynaecologists (Levels 1-3). The end-points were the diagnostic performance of UBESS to predict the level of complexity of laparoscopic surgery for endometriosis, i.e. UBESS stage I to predict Level-1 laparoscopic surgery, UBESS stage II to predict Level-2 laparoscopic surgery and UBESS stage III to predict Level-3 laparoscopic surgery.

RESULTS

The analysis included 192 women, with a mean ± SD age at diagnosis of endometriosis of 23.7 ± 9.3 years and a mean duration of symptoms prior to presentation of 42 months. Predominant reported locations of pelvic pain were left iliac fossa (32%), right iliac fossa (29.5%) and lower abdomen (61%) and predominant symptoms included dyspareunia (57.5%), dysmenorrhea (58.5%) and dyschezia (41.5%). The accuracy, sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios of UBESS I for predicting a requirement for Level-1 laparoscopic surgery were: 87.5%, 83.3%, 91.7%, 90.9%, 84.6%, 10 and 0.182; those of UBESS II for predicting Level-2 surgery were: 87.0%, 73.7%, 90.3%, 65.1%, 93.3%, 7.6 and 0.292; and those of UBESS III for predicting Level-3 surgery were: 95.3%, 94.8%, 95.5%, 90.2%, 97.7%, 21.2 and 0.054, respectively.

CONCLUSION

UBESS could be utilized to predict the level of complexity of laparoscopic surgery for endometriosis. It has the potential to facilitate the triage of women with suspected endometriosis to the most appropriate surgical expertise required for laparoscopic endometriosis surgery. UBESS needs to be validated externally in multiple centers to assess its general applicability. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Systematic evaluation of women with suspected endometriosis using a 5-domain sonographically based approach

In recent years, knowledge has evolved regarding the role of transvaginal sonography in the assessment of the pouch of Douglas status and the preoperative prediction of extraovarian endometriosis in specific locations. Despite these advances in transvaginal sonography, the challenge of developing a comprehensive, cost-effective, and reproducible preoperative classification system for endometriosis remains. Critical to this classification system should be a sonographically based evaluation protocol that is systematic, evidence based, and reproducible with clearly defined end points. To date, no structured evaluation protocol exists for the assessment of the pelvis in women with suspected endometriosis. In this article, we propose a domain-based evaluation protocol for the assessment of women with suspected endometriosis using transvaginal sonography.

Current strategies for endometriosis management

Endometriosis is a common gynecologic disorder that persists throughout the reproductive years. Although endometriosis is a surgical diagnosis, medical management with ovarian suppression remains the mainstay of long-term management with superimposed surgical intervention when needed. The goal of surgery should be excision or ablation of all visible disease to minimize risk of recurrence and need for repeat surgeries. When infertility is the presenting symptom, surgical therapy in addition to assisted reproductive technology can improve chances of conception; however, the treatment approach depends on stage of disease and other patient characteristics that affect fecundity.

Endometriosis: Survey of Current Diagnostic and Therapeutic Options and Latest Research Work

Endometriosis is one of the most frequent benign diseases in women of child-bearing age. The main symptoms are chronic upper abdominal pain and infertility. However, the aetiology and pathogenesis of endometriosis are as yet insufficiently clarified. Thus, therapy is mainly symptomatic with laparoscopic surgery being the gold standard. The aim of drug therapy is to achieve a hypo-oestrogenic condition. In cases of severe endometriosis and a desire to have children there is often an indication for assisted reproduction. The present article illustrates almost all current aspects on the diagnosis of and therapy of endometriosis. From the clinical viewpoint, emphasis is placed on the rare cases of deeply infiltrating endometriosis that are, however, accompanied with a high morbidity. Current therapeutic options in cases of infertility are also presented in more detail. Furthermore, special attention is paid to the latest research results from both clinical and basic research fields in order to demonstrate our current knowledge on the pathogenesis and, where possible, potentially related therapeutic options.

Extended transvaginal sonography in deep infiltrating endometriosis: use of bowel preparation and an acoustic window with intravaginal gel: preliminary results

OBJECTIVES

The purpose of this study was to assess the diagnostic performance of extended transvaginal sonography for diagnosing deep infiltrating endometriosis.

METHODS

A prospective study was conducted comprising 51 women (mean age, 32.9 years; range, 23-43 years) with suspected deep infiltrating endometriosis based on clinical symptoms. All women underwent extended transvaginal sonography, which included assessment of 2 pelvic compartments (anterior compartment: bladder and distal ureters; and posterior compartment: posterior vaginal fornix, retrocervical area, pouch of Douglas, and rectosigmoid). The sliding sign for detecting pouch of Douglas obliteration was also assessed. All patients received bowel preparation before sonographic examinations. A single examiner performed all examinations. All women underwent laparoscopic surgery, and histologic confirmation of endometriosis was done. The sensitivity, specificity, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were calculated.

RESULTS

Some women had more than 1 lesion, giving a total of 55 histologically confirmed lesions (rectosigmoid, n = 13; vagina, n = 5; retrocervical, n = 32; bladder, n = 5). The sensitivity, specificity, and LR+ for rectosigmoid involvement were 100%, 93%, and 14.0, respectively. The sensitivity, specificity, LR+, and LR- for vaginal involvement were 60%, 98%, 30.0, and 0.41. The sensitivity, specificity, LR+, and LR- for retrocervical involvement were 84%, 96%, 19.4, and 0.16. The sensitivity, specificity, and LR- for bladder involvement were 20%, 100%, and 0.80. The sensitivity, specificity, LR+, and LR- of the sliding sign for diagnosing pouch of Douglas obliteration were 89%, 92%, 10.7, and 0.12.

CONCLUSIONS

Except for bladder involvement, extended transvaginal sonography has good diagnostic performance for deep infiltrating endometriosis.

The 'sliding sign' in conjunction with sonovaginography: is this the optimal approach for the diagnosis of Pouch of Douglas obliteration and posterior compartment deep infiltrating endometriosis?

Introduction: Endometriosis is a chronic peritoneal disease that may progress as a deep infiltrating lesion involving the posterior compartment of the pelvis. Efforts to improve pre-operative knowledge of the location and extent of these lesions have resulted in the development of Transvaginal ultrasound (TVS) as the first-line imaging modality for extra-ovarian endometriosis. However, various techniques of TVS have been described in the literature for this purpose. Methods: In this review we will detail the evolution of TVS as the primary imaging modality in the pre-operative diagnosis of posterior compartment deep infiltrating endometriosis (DIE). We will also discuss the potential of an emerging new real-time diagnostic ultrasound-based technique known as the 'sliding sign' in combination with office gel sonovaginography for the pre-operative diagnosis of Pouch of Douglas obliteration and posterior compartment DIE. Conclusion: Implementation of the new real-time dynamic, reproducible and simple 'sliding sign' in conjunction with SVG has the potential to challenge the current concept that traditional laparoscopy is the 'gold standard' modality for the diagnosis of women with posterior compartment DIE.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Four subtypes of adenomyosis assessed by magnetic resonance imaging and their specification

OBJECTIVE

The aim of the present study was to differentiate and specify the subtypes of adenomyosis.

STUDY DESIGN

Surgically treated adenomyosis (n = 152) was subcategorized retrospectively into 4 subtypes on the basis of magnetic resonance imaging geography. Subtype I (n = 59) consisted of adenomyosis that occurs in the uterine inner layer without affecting the outer structures. Subtype II (n = 51) consisted of adenomyosis that occurs in the uterine outer layer without affecting the inner structures. Subtype III (n = 22) consisted of adenomyosis that occurs solitarily without relationship to structural components. Adenomyosis that did not satisfy these criteria composed subtype IV (n = 20). Stepwise logistic regression analysis was used for specification of the subtypes.

RESULTS

Subtypes I-III were suggested as a product of direct endometrial invasion, endometriotic invasion from the outside, and de novo metaplasia, respectively. Subtype IV was a heterogeneous mixture of far advanced disease.

CONCLUSION

Adenomyosis appears to consist of 3 distinct subtypes of different causes and an additional subtype of indeterminate cause.

Gonadotrophin-releasing hormone analogues and endometriosis: current strategies and new insights

BACKGROUND

Endometriosis is an estrogen-dependent chronic inflammatory disease affecting 5% to 10% of women in reproductive age and has been reported also in adolescents. Its main clinical presentations are chronic pelvic pain and infertility.

OBJECTIVE

To provide a comprehensive review of the recently published data concerning the mechanism of action of gonadotrophin-releasing hormone analogues (GnRHas) as well as to analyze their role in the management of endometriosis-associated pain and infertility in addition to its value in adolescent cases. Furthermore, to provide practical recommendations and new insights based on the best available information.

METHODS

Systematic search was performed of the Cochrane Library and Medical Literature Analysis and Retrieval System Online database looking for the different trials, reviews and various guidelines relating to GnRHas usage in the management of endometriosis-associated pain, infertility and in adolescent cases.

RESULTS

From a pathophysiological perspective, there is a growing scientific evidence that GnRHas exert its therapeutic effects by their classical pituitary downregulation and via a direct effect on the endometrial cells themselves. Accordingly, they represent an important medical option for the management of different aspects of this enigmatic disease.

CONCLUSION

GnRHas have a valuable strategic role in treatment of endometriosis-associated pain and infertility as well as in adolescents above 16 years.

Sonovaginography: redefining the concept of a "normal pelvis" on transvaginal ultrasound pre-laparoscopic intervention for suspected endometriosis

Office sonovaginography (SVG) challenges the concept of the "normal" pelvic ultrasound in women with chronic pelvic pain and suspected endometriosis. When positive for posterior compartment deep infiltrating endometriosis, with or without Pouch of Douglas obliteration, office SVG allows for triaging of women to the appropriately trained advanced laparoscopic gynaecological and colorectal surgical team. We advocate that all women with suspected endometriosis undergo office SVG prior to laparoscopy to ensure an accurate pre-operative mapping of endometriosis disease location and extension.