Endovaginal ultrasound-assisted pain mapping in endometriosis and chronic pelvic pain

Pain with orgasm in endometriosis: potential etiologic factors and clinical correlates

BACKGROUND

Pelvic pain worsened by orgasm is a poorly understood symptom in patients with endometriosis.

AIM

To assess the prevalence of pelvic pain worsened by orgasm in patients with endometriosis and explore its association with potential etiologic factors, including pelvic floor myalgia, uterine tenderness and adenomyosis, and central nervous system sensitization.

METHODS

An analysis was done of a prospective data registry based at a tertiary referral center for endometriosis. Eligible participants were patients aged 18 to 50 years who were referred between January 1, 2018, and December 31, 2019, diagnosed with endometriosis, and subsequently underwent surgery at the center. Clinical features were compared between participants reporting worsening pelvic pain with orgasm and those without worsening pain with orgasm, including patient-reported variables, physical examination findings, and anatomic phenotyping at the time of surgery. Pelvic floor myalgia and uterine tenderness were assessed by palpation on pelvic examination, adenomyosis by ultrasound, and central nervous system sensitization via the Central Sensitization Inventory (range, 0-100).

OUTCOMES

Outcomes included pelvic or lower abdominal pain in the last 3 months that worsened with orgasm (yes/no).

RESULTS

Among 358 participants with endometriosis, 14% (49/358) reported pain worsened by orgasm while 86% (309/358) did not. Pain with orgasm was significantly associated with pelvic floor myalgia (55% [27/49] vs 35% [109/309]; Cohen's h = 0.40, P = .01) and higher scores on the Central Sensitization Inventory (mean ± SD, 53.3 ± 17.0 vs 42.7 ± 18.2; Cohen's d = 0.60, P < .001) but not with uterine tenderness or adenomyosis. Other clinical features associated with pain with orgasm were poorer sexual health (higher scores: deep dyspareunia, Cohen's h = 0.60; superficial dyspareunia, Cohen's h = 0.34; and Female Sexual Distress Scale-Revised, Cohen's d = 0.68; all P < .05) and poorer mental health (higher scores: Patient Health Questionnaire-9, 12.9 ± 6.7 vs 9.1 ± 6.3, Cohen's d = 0.59, P < .001; Generalized Anxiety Disorder-7, 9.4 ± 5.6 vs 6.8 ± 5.5, Cohen's d = 0.48, P = .002). Anatomic findings at the time of surgery did not significantly differ between the groups.

CLINICAL IMPLICATIONS

Interventions targeting pelvic floor myalgia and central nervous system sensitization may help alleviate pain worsened by orgasm in patients with endometriosis.

STRENGTHS AND LIMITATIONS

A strength is that pain worsened by orgasm was differentiated from dyspareunia. However, pain with orgasm was assessed by only a binary question (yes/no). Also, the study is limited to a single center, and there were limited data on sexual function.

CONCLUSION

Pelvic pain exacerbated by orgasm in people with endometriosis may be related to concurrent pelvic floor myalgia and central sensitization.

World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project: V. Physical examination standards in endometriosis research

OBJECTIVE

The World Endometriosis Research Foundation established the Endometriosis Phenome and Biobanking Harmonisation Project (EPHect) to create standardized documentation tools (with common data elements) to facilitate the comparison and combination of data across different research sites and studies. In 2014, 4 data research standards were published: clinician-reported surgical data, patient-reported clinical data, and fluid and tissue biospecimen collection. Our current objective is to create an EPHect standard for the clinician-reported physical examination (EPHect-PE) for research studies.

DESIGN

An international consortium involving 26 clinical and academic experts and patient partners from 11 countries representing 25 institutions and organizations. Two virtual workshops, followed by the development of the physical examination standards underwent multiple rounds of iterations and revisions.

SUBJECTS

N/A MAIN OUTCOME MEASURE(S): N/A RESULT(S): The EPHect-PE tool provides standardized assessment of physical examination characteristics and pain phenotyping. Data elements involve examination of back and pelvic girdle; abdomen including allodynia and trigger points; vulva including provoked vestibulodynia; pelvic floor muscle tone and tenderness; tenderness on unidigital pelvic examination; presence of pelvic nodularity; uterine size and mobility; presence of adnexal masses; presence of incisional masses; speculum examination; tenderness and allodynia at an extra-pelvic site (e.g., forearm); and recording of anthropometrics.

CONCLUSION(S)

The EPHect-PE standards will facilitate the standardized documentation of the physical examination, including the assessment and documentation of examination phenotyping of endometriosis-associated pelvic pain.

Superficial Endometriosis at Ultrasound Examination-A Diagnostic Criteria Proposal

The actual prevalence of superficial endometriosis is not known. However, it is considered the most common subtype of endometriosis. The diagnosis of superficial endometriosis remains difficult. In fact, little is known about the ultrasound features of superficial endometriotic lesions. In this study, we aimed to describe the appearance of superficial endometriosis lesions at ultrasound examination, with laparoscopic and/or histologic correlation. This is a prospective study on a series of 52 women with clinical suspicion of pelvic endometriosis who underwent preoperative transvaginal ultrasound and received a confirmed diagnosis of superficial endometriosis via laparoscopy. Women with ultrasound or laparoscopic findings of deep endometriosis were not included. We observed that superficial endometriotic lesions may appear as a solitary lesions, multiple separate lesions, and cluster lesions. The lesions may exhibit the presence of hypoechogenic associated tissue, hyperechoic foci, and/or velamentous (filmy) adhesions. The lesion may be convex, protruding from the peritoneal surface, or it may appear as a concave defect in the peritoneum. Most lesions exhibited several features. We conclude that transvaginal ultrasound may be useful for diagnosing superficial endometriosis, as these lesions may exhibit different ultrasound features.

Strengths and limitations of diagnostic tools for endometriosis and relevance in diagnostic test accuracy research

Endometriosis is a chronic systemic disease that can cause pain, infertility and reduced quality of life. Diagnosing endometriosis remains challenging, which yields diagnostic delays for patients. Research on diagnostic test accuracy in endometriosis can be difficult due to verification bias, as not all patients with endometriosis undergo definitive diagnostic testing. The purpose of this State-of-the-Art Review is to provide a comprehensive update on the strengths and limitations of the diagnostic modalities used in endometriosis and discuss the relevance of diagnostic test accuracy research pertaining to each. We performed a comprehensive literature review of the following methods: clinical assessment including history and physical examination, biomarkers, diagnostic imaging, surgical diagnosis and histopathology. Our review suggests that, although non-invasive diagnostic methods, such as clinical assessment, ultrasound and magnetic resonance imaging, do not yet qualify formally as replacement tests for surgery in diagnosing all subtypes of endometriosis, they are likely to be appropriate for advanced stages of endometriosis. We also demonstrate in our review that all methods have strengths and limitations, leading to our conclusion that there should not be a single gold-standard diagnostic method for endometriosis, but rather, multiple accepted diagnostic methods appropriate for different circumstances. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Machine Learning Revealed New Correlates of Chronic Pelvic Pain in Women

Chronic pelvic pain affects one in seven women worldwide, and there is an urgent need to reduce its associated significant costs and to improve women's health. There are many correlated factors associated with chronic pelvic pain (CPP), and analyzing them simultaneously can be complex and involves many challenges. A newly developed interaction ensemble, referred to as INTENSE, was implemented to investigate this research gap. When applied, INTENSE aggregates three machine learning (ML) methods, which are unsupervised, as follows: interaction principal component analysis (IPCA), hierarchical cluster analysis (HCA), and centroid-based clustering (CBC). For our proposed research, we used INTENSE to uncover novel knowledge, which revealed new interactions in a sample of 656 patients among 25 factors: age, parity, ethnicity, body mass index, endometriosis, irritable bowel syndrome, painful bladder syndrome, pelvic floor tenderness, abdominal wall pain, depression score, anxiety score, Pain Catastrophizing Scale, family history of chronic pain, new or re-referral, age when first experienced pain, pain duration, surgery helpful for pain, infertility, smoking, alcohol use, trauma, dysmenorrhea, deep dyspareunia, CPP, and the Endometriosis Health Profile for functional quality of life. INTENSE indicates that CPP and the Endometriosis Health Profile are correlated with depression score, anxiety score, and the Pain Catastrophizing Scale. Other insights derived from these ML methods include the finding that higher body mass index was clustered with smoking and a history of life trauma. As well, sexual pain (deep dyspareunia) was found to be associated with musculoskeletal pain contributors (abdominal wall pain and pelvic floor tenderness). Therefore, INTENSE provided expert-like reasoning without training any model or prior knowledge of CPP. ML has the potential to identify novel relationships in the etiology of CPP, and thus can drive innovative future research.

Prevalence of Deep Endometriosis and Rectouterine Pouch Obliteration in the Presence of Normal Ovaries

OBJECTIVE

It is well-established that there is a strong association between ovarian endometriomas (OE) and deep endometriosis (DE) and rectouterine pouch (RP) obliteration. We aimed to determine the prevalence of DE and RP obliteration in the presence of normal ovaries.

METHODS

We conducted a multicentre retrospective cohort study from January 2009 to December 2017 using a prospective multicentre data registry. Participants included patients with signs and/or symptoms of endometriosis who underwent excisional laparoscopic surgery at one of eight hospitals. The primary outcome was the prevalence of DE and RP obliteration, which was compared between women with normal ovaries (i.e., no OE) and women with ovaries containing OE. Secondary outcomes evaluated included rates of DE by anatomic site between women with and without OE.

RESULTS

The ovaries did not contain an OE in 319 of 410 patients (77.8%). The prevalence of DE and RP obliteration in this cohort was 25.4% and 9.7% (81 and 31 patients), respectively; whereas, in patients with OE, DE and RP obliteration prevalence was 68.1% and 60.4% (62 and 55 patients), respectively (P < 0.001 for both DE and RP obliteration). The uterosacral ligaments were the most common site for DE (right: 47/319 [14.7%]; left: 42/319 [13.2%]).

CONCLUSIONS

In patients who visited a tertiary care centre with endometriosis without ovarian involvement, 1 in 4 had DE and 1 in 10 had RP obliteration. These prevalence rates should encourage knowledge and skills dissemination to improve non-invasive imaging diagnosis overall. In patients with symptoms or signs suggestive of endometriosis, a basic pelvic ultrasound that ends at evaluation for OE should not be regarded as reassuring.

Characterization and Prevalence of Female Pelvic Pain in a General Outpatient Urology Population

OBJECTIVE

To assess the character and prevalence of female pelvic pain in a general urology population presenting for evaluation of unrelated non-painful complaints.

METHODS

This is an IRB-approved, prospective, cross-sectional survey-based assessment of pelvic pain in a general cohort of female patients presenting to a urology clinic over a 10-month period (7/2018-5/2019). Patients presenting specifically for acute painful complaints (eg, kidney stones) were excluded. Participating patients completed an original 22-item survey with questions pertaining to pelvic pain. Specific focus was placed on pain characteristics, including location, quality, frequency, exacerbating factors, and severity. Descriptive analysis, pain mapping, and plotting analyses were performed to assess pain patterns.

RESULTS

A total of 181 women (mean age 56 years) completed the survey. Overall, 75 (41%) women reported pelvic pain. Two-thirds reported experiencing pain "often" to "always" over the preceding month. Patients described a significant variety of pain locations and qualities. The most common sites of pain were lower back (73%) and bladder (72%), while "dull/aching" was the most common pain quality. A majority (84%) of patients had multiple concurrent pain locations, with 40 unique pain location combinations being reported. Similarly, 13 and 10 unique combinations were seen with pain quality and eliciting activity, respectively.

CONCLUSION

A significant percentage of women presenting to a general urology clinic experience pelvic pain. There was wide variety of pain characteristics and unique patterns. Further research is needed to comprehensively assess pain characteristics and develop related diagnostic pathways.

Clinical Conundrum: A 33-Year-Old With Pain Post-Orgasm and a History of Endometriosis

A 33-year-old with a history of endometriosis presented with pain post-orgasm, accompanied by breakthrough bleeding, nausea, sweatiness, and exhaustion. History and examination suggested a gynaecologic component, likely related to the uterus itself. After several therapeutic trials, a clinical response was obtained with the use of a gonadotropin-releasing hormone antagonist, elagolix. The case is discussed with respect to dysorgasmia and post-orgasm illness syndrome. Post-orgasm pain in women has not been well studied, and it is recommended that such periorgasm phenomena be the topic of future research.

Clinical management of endometriosis

Endometriosis is a disease of reproductive age women that is commonly characterized by symptoms that often negatively impact quality of life. The clinical management of endometriosis remains highly variable and mostly influenced by geographic location, practice patterns, and breadth of clinician experience. This variability in treatment has inspired a trend towards multidisciplinary and specialized care of patients suffering from this disease. Surgical sampling, followed by histologic confirmation of endometrial-like tissue, remains the standard for the definitive diagnosis of endometriosis. However, the high sensitivity and specificity of MRI and ultrasound has shed light on the path towards non-surgical diagnosis of deep infiltrating endometriosis. Molecular variability and intricacy of this disease has limited the development of biologic markers to target for non-invasive diagnosis and pharmacologic therapies. Surgical management of advanced-stage endometriosis can be difficult, mostly secondary to the invasive nature of the disease, and anatomical distortion requiring advanced surgical skills to manage. The high prevalence of chronic pelvic pain and other complex pain syndromes in patients with endometriosis also requires knowledge in the management of these types of issues in order to provide comprehensive care. Menopausal endometriosis, extrapelvic presentation, and potential malignant transformation of lesions are infrequent, requiring a high index of suspicion for timely diagnosis and treatment.

Phenotyping Sexual Pain in Endometriosis Using the Central Sensitization Inventory

INTRODUCTION

Deep dyspareunia, a common symptom in endometriosis, has previously been associated with bladder and/or pelvic floor tenderness (BPFT), which suggests a role for central nervous system sensitization. The Central Sensitization Inventory (CSI, 0-100) is a validated self-reported scale for patients with central sensitization.

AIM

The objective of this study was to phenotype deep dyspareunia using BPFT and the CSI.

METHODS

The methods included cross-sectional analysis from a prospective registry from January 2018 to June 2018 at a tertiary center for endometriosis (ClinicalTrials.gov #NCT02911090). Included were women aged 18-50 years with endometriosis (previously surgically diagnosed, current visualized endometrioma on ultrasound, or current palpable or visualized nodule on ultrasound), who were newly or re-referred to the center. Severity of deep dyspareunia was self-reported using an 11-point numeric rating scale (0 = no pain; 10 = worst pain imaginable), categorized as no or low deep dyspareunia (0-4) and high deep dyspareunia (5-10). We identified the subgroup with high deep dyspareunia and presence of BPFT, where we hypothesized a central component of the sexual pain. This subgroup was compared with 2 other subgroups: no or low deep dyspareunia and high deep dyspareunia but no BPFT. The CSI was compared between the groups using analysis of variance, followed by post hoc testing (P < .05).

MAIN OUTCOME MEASURE

The main outcome measure was the CSI score ranging from 0 to 100.

RESULTS

Data from 163 women with endometriosis were analyzed. The mean age of this cohort was 36.4 ± 6.8 years, and the mean CSI score was 41.0 ± 18.6. 37 percent (61/163) had high deep dyspareunia and BPFT; 29% (47/163) had high deep dyspareunia and no BPFT; and 34% (55/163) had no or low deep dyspareunia. The CSI significantly differed between the 3 groups (analysis of variance: F = 22.4, P < .001). In post hoc testing, the CSI was higher in women with high deep dyspareunia and BPFT (51.3 ± 16.9), compared with women with no or low deep dyspareunia (30.9 ± 15.4, P < .001) and compared with women with high deep dyspareunia but no BPFT (39.4 ± 17.2, P = .001).

CLINICAL IMPLICATIONS

The CSI could be used to classify and phenotype patients with endometriosis-associated sexual pain.

STRENGTH & LIMITATIONS

Strengths include a prospective registry with integrated pain scores, validated questionnaires, and physical examination findings. Limitations include the lack of quantitative sensory testing for central sensitization.

CONCLUSIONS

In women with endometriosis, the subgroup with high deep dyspareunia and bladder and/or pelvic floor tenderness had a significantly higher score on the CSI than other subgroups, suggesting that this group may have a central component to their sexual pain. Orr NL, Wahl KJ,Noga H, et al. Phenotyping Sexual Pain in Endometriosis Using the Central Sensitization Inventory. J Sex Med 2020;17:761-770.

An Interdisciplinary Approach to Endometriosis-associated Persistent Pelvic Pain

Endometriosis-associated pelvic pain is a common and often challenging problem. For certain patients, pain persists or recurs despite adequate medical or surgical therapy targeted to endometriosis. In this patient population, there is often the presence of coexisting pain conditions such as irritable bowel syndrome, painful bladder syndrome and myofascial pain as well central sensitisation. An interdisciplinary approach where both peripheral pain triggers and central sensitization are addressed is likely to lead to improved pain and quality of life. The approach to the evaluation and treatment of the patients with persistent/chronic pelvic pain and endometriosis is outlined in this article.

Anatomic Sites and Associated Clinical Factors for Deep Dyspareunia

Introduction

Deep dyspareunia negatively affects women’s sexual function. There is a known association between deep dyspareunia and endometriosis of the cul-de-sac or uterosacral ligaments in reproductive-age women; however, other factors are less clear in this population.

Aim

To identify anatomic sites and associated clinical factors for deep dyspareunia in reproductive-age women at a referral center.

Methods

This study involved the analysis of cross-sectional baseline data from a prospective database of 548 women (87% consent rate) recruited from December 2013 through April 2015 at a tertiary referral center for endometriosis and/or pelvic pain. Exclusion criteria included menopausal status, age at least 50 years, previous hysterectomy or oophorectomy, and not sexually active. We performed a standardized endovaginal ultrasound-assisted pelvic examination to palpate anatomic structures for tenderness and reproduce deep dyspareunia. Multivariable regression was used to determine which tender anatomic structures were independently associated with deep dyspareunia severity and to identify clinical factors independently associated with each tender anatomic site.

Main Outcome Measure

Severity of deep dyspareunia on a numeric pain rating scale of 0 to 10.

Results

Severity of deep dyspareunia (scale = 0–10) was independently associated with tenderness of the bladder (b = 0.88, P = .018), pelvic floor (levator ani) (b = 0.66, P = .038), cervix and uterus (b = 0.88, P = .008), and cul-de-sac or uterosacral ligaments (b = 1.39, P < .001), but not with the adnexa (b = −0.16, P = 0.87). The number of tender anatomic sites was significantly correlated with more severe deep dyspareunia (Spearman r = 0.34, P < .001). For associated clinical factors, greater depression symptom severity was specifically associated with tenderness of the bladder (b = 1.05, P = .008) and pelvic floor (b = 1.07, P < .001). A history of miscarriage was specifically associated with tenderness of the cervix and uterus (b = 2.24, P = .001). Endometriosis was specifically associated with tenderness of the cul-de-sac or uterosacral ligaments (b = 3.54, P < .001).

Conclusions

In reproductive-age women at a tertiary referral center, deep dyspareunia was independently associated not only with tenderness of the cul-de-sac and uterosacral ligaments but also with tenderness of the bladder, pelvic floor, and cervix and uterus.

Yong PJ, Williams C, Yosef A, et al. Anatomic Sites and Associated Clinical Factors for Deep Dyspareunia. Sex Med 2017;5:e184–e195.

Multifactorial contributors to the severity of chronic pelvic pain in women

BACKGROUND

Chronic pelvic pain affects ∼15% of women, and is associated with significant societal cost and impact on women's health. Identifying factors involved in chronic pelvic pain is challenging due to its multifactorial nature and confounding between potential factors. For example, while some women with endometriosis have chronic pelvic pain, there may be comorbid conditions that are implicated in the chronic pelvic pain rather than the endometriosis itself.

OBJECTIVE

We sought to explore multifactorial variables independently associated with the severity of chronic pelvic pain in women.

STUDY DESIGN

We used baseline cross-sectional data from an ongoing prospective cohort, collected from patient online questionnaires, physical examination, and physician review of medical records. Participants were recruited from a tertiary referral center for endometriosis and chronic pelvic pain in Vancouver, British Columbia, Canada, from December 2013 through April 2015. Exclusion criteria included menopausal status or age >50 years. Primary outcome was self-reported severity of chronic pelvic pain in the last 3 months (0-10 numeric rating scale). Potential associated factors ranged from known pain conditions assessed by standard diagnostic criteria, validated psychological questionnaires, musculoskeletal physical exam findings, as well as pain-related, reproductive, medical/surgical, familial, demographic, and behavioral characteristics. Mann-Whitney, Kruskal-Wallis, or Spearman test were used to identify variables with an association with the primary outcome (P < .05), followed by multivariable linear regression to control for confounding and to identify independent associations with the primary outcome (P < .05).

RESULTS

Overall, 656 women were included (87% consent rate), of whom 55% were diagnosed with endometriosis. The following factors were independently associated with higher severity of chronic pelvic pain: abdominal wall pain (P = .005), pelvic floor tenderness (P = .004), painful bladder syndrome (P = .019), higher score on Pain Catastrophizing Scale (P < .001), adult sexual assault (P = .043), higher body mass index (P = .023), current smoking (P = .049), and family history of chronic pain (P = .038). Severity of chronic pelvic pain was similar between women with and without endometriosis.

CONCLUSION

Multifactorial variables independently associated with severity of chronic pelvic pain were identified, ranging from myofascial/musculoskeletal, urological, family history, and psycho-social factors. Continued research is required to validate these factors and to determine whether any are potentially modifiable for the management of chronic pelvic pain.

Combination of the non-invasive tests for the diagnosis of endometriosis

BACKGROUND

About 10% of women of reproductive age suffer from endometriosis, a costly chronic disease causing pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but is expensive and carries surgical risks. Currently, there are no non-invasive tests available in clinical practice to accurately diagnose endometriosis. This review assessed the diagnostic accuracy of combinations of different non-invasive testing modalities for endometriosis and provided a summary of all the reviews in the non-invasive tests for endometriosis series.

OBJECTIVES

To estimate the diagnostic accuracy of any combination of non-invasive tests for the diagnosis of pelvic endometriosis (peritoneal and/or ovarian or deep infiltrating) compared to surgical diagnosis as a reference standard. The combined tests were evaluated as replacement tests for diagnostic surgery and triage tests to assist decision-making to undertake diagnostic surgery for endometriosis.

SEARCH METHODS

We did not restrict the searches to particular study designs, language or publication dates. We searched CENTRAL to July 2015, MEDLINE and EMBASE to May 2015, as well as the following databases to April 2015: CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, DARE and PubMed.

SELECTION CRITERIA

We considered published, peer-reviewed, randomised controlled or cross-sectional studies of any size, including prospectively collected samples from any population of women of reproductive age suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of a combination of several testing modalities with the findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Three review authors independently collected and performed a quality assessment of the data from each study by using the QUADAS-2 tool. For each test, the data were classified as positive or negative for the surgical detection of endometriosis and sensitivity and specificity estimates were calculated. The bivariate model was planned to obtain pooled estimates of sensitivity and specificity whenever sufficient data were available. The predetermined criteria for a clinically useful test to replace diagnostic surgery were a sensitivity of 0.94 and a specificity of 0.79 to detect endometriosis. We set the criteria for triage tests at a sensitivity of 0.95 and above and a specificity of 0.50 and above, which 'rules out' the diagnosis with high accuracy if there is a negative test result (SnOUT test), or a sensitivity of 0.50 and above and a specificity of 0.95 and above, which 'rules in' the diagnosis with high accuracy if there is a positive result (SpIN test).

MAIN RESULTS

Eleven eligible studies included 1339 participants. All the studies were of poor methodological quality. Seven studies evaluated pelvic endometriosis, one study considered DIE and/or ovarian endometrioma, two studies differentiated endometrioma from other ovarian cysts and one study addressed mapping DIE at specific anatomical sites. Fifteen different diagnostic combinations were assessed, including blood, urinary or endometrial biomarkers, transvaginal ultrasound (TVUS) and clinical history or examination. We did not pool estimates of sensitivity and specificity, as each study analysed independent combinations of the non-invasive tests.Tests that met the criteria for a replacement test were: a combination of serum IL-6 (cut-off >15.4 pg/ml) and endometrial PGP 9.5 for pelvic endometriosis (sensitivity 1.00 (95% confidence interval (CI) 0.91 to 1.00), specificity 0.93 (95% CI, 0.80, 0.98) and the combination of vaginal examination and transvaginal ultrasound (TVUS) for rectal endometriosis (sensitivity 0.96 (95% CI 0.86 to 0.99), specificity 0.98 (95% CI 0.94 to 1.00)). Tests that met the criteria for SpIN triage tests for pelvic endometriosis were: 1. a multiplication of urine vitamin-D-binding protein (VDBP) and serum CA-125 (cut-off >2755) (sensitivity 0.74 (95% CI 0.60 to 0.84), specificity 0.97 (95% CI 0.86 to 1.00)) and 2. a combination of history (length of menses), serum CA-125 (cut-off >35 U/ml) and endometrial leukocytes (sensitivity 0.61 (95% CI 0.54 to 0.69), specificity 0.95 (95% CI 0.91 to 0.98)). For endometrioma, the following combinations qualified as SpIN test: 1. TVUS and either serum CA-125 (cut-off ≥25 U/ml) or CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.79 (95% CI 0.64 to 0.91), specificity 0.97 (95% CI 0.91 to 1.00)); 2. TVUS and serum CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.54 (95% CI 0.37 to 0.70), specificity 0.97 (95% CI 0.91 to 1.0)); 3-4. TVUS and serum CA-125 (cut-off ≥20 U/ml or cut-off ≥25 U/ml) (sensitivity 0.69 (95% CI 0.49 to 0.85), specificity 0.96 (95% CI 0.88 to 0.99)); 5. TVUS and serum CA-125 (cut-off ≥35 U/ml) (sensitivity 0.52 (95% CI 0.33 to 0.71), specificity 0.97 (95% CI 0.90 to 1.00)). A combination of vaginal examination and TVUS reached the threshold for a SpIN test for obliterated pouch of Douglas (sensitivity 0.87 (95% CI 0.69 to 0.96), specificity 0.98 (95% CI 0.95 to 1.00)), vaginal wall endometriosis (sensitivity 0.82 (95% CI 0.60 to 0.95), specificity 0.99 (95% CI 0.97 to 1.0)) and rectovaginal septum endometriosis (sensitivity 0.88 (95% CI 0.47 to 1.00), specificity 0.99 (95% CI 0.96 to 1.00)).All the tests were evaluated in individual studies and displayed wide CIs. Due to the heterogeneity and high risk of bias of the included studies, the clinical utility of the studied combination diagnostic tests for endometriosis remains unclear.

AUTHORS' CONCLUSIONS

None of the biomarkers evaluated in this review could be evaluated in a meaningful way and there was insufficient or poor-quality evidence. Laparoscopy remains the gold standard for the diagnosis of endometriosis and using any non-invasive tests should only be undertaken in a research setting.

Imaging modalities for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field.

OBJECTIVES

• To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis.

SEARCH METHODS

We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH).

SELECTION CRITERIA

We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology).

MAIN RESULTS

We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rectosigmoid endometriosis. Transrectal ultrasonography (TRUS) might qualify as a SpPin triage test for rectosigmoid involvement but could not be adequately assessed for other anatomical sites because heterogeneous data were scant. Multi-detector computerised tomography enema (MDCT-e) displayed the highest diagnostic performance for rectosigmoid and other bowel endometriosis and met the criteria for both SpPin and SnNout triage tests, but studies were too few to provide meaningful results.Diagnostic accuracies were higher for TVUS with bowel preparation (TVUS-BP) and rectal water contrast (RWC-TVS) and for 3.0TMRI than for conventional methods, although the paucity of studies precluded statistical evaluation.

AUTHORS' CONCLUSIONS

None of the evaluated imaging modalities were able to detect overall pelvic endometriosis with enough accuracy that they would be suggested to replace surgery. Specifically for endometrioma, TVUS qualified as a SpPin triage test. MRI displayed sufficient accuracy to suggest utility as a replacement test, but the data were too scant to permit meaningful conclusions. TVUS could be used clinically to identify additional anatomical sites of DIE compared with MRI, thus facilitating preoperative planning. Rectosigmoid endometriosis was the only site that could be accurately mapped by using TVUS, TRUS, MRI or MDCT-e. Studies evaluating recent advances in imaging modalities such as TVUS-BP, RWC-TVS, 3.0TMRI and MDCT-e were observed to have high diagnostic accuracies but were too few to allow prudent evaluation of their diagnostic role. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Future well-designed diagnostic studies undertaken to compare imaging tests for diagnostic test accuracy and costs are recommended.

Turn-amplitude analysis as a diagnostic test for myofascial syndrome in patients with chronic pelvic pain

Myofascial pain syndrome of the pelvic floor is a common cause of chronic pelvic pain. The etiology of this neuromuscular pain disorder is unknown and symptoms can vary widely. Research attempting to identify an appropriate diagnostic test has, to date, not been fruitful. This study aimed to investigate the utility of turns-amplitude analysis, which involves analyzing electromyography data of the levator ani and anal sphincter muscles, as a diagnostic tool.

BACKGROUND:

Myofascial pain syndrome of the pelvic floor (MPSPF) is a common disease in the context of chronic pelvic pain (CPP); however, there is currently no gold-standard test to diagnose it.

OBJECTIVE:

To validate the turns-amplitude analysis (TAA) as a diagnostic test for MPSPF in patients with CPP.

METHODS:

A case-control study was performed, and patients were consecutively sampled within a specified period of time. A total of 128 patients were included: 64 patients with CPP (32 men and 32 women) and 64 control patients (32 men and 32 women). The same operator conducted all tests. Electromyography of the TAA is based on the collection of motor unit potentials that measure the number of changes in the signal and the mean amplitude of the changes. The electromyogram transfers the data to a graphical point cloud, which enables the patient’s results to be compared with the results of the healthy subjects.

RESULTS:

In patients and control subjects, the sensitivity and specificity of the proposed diagnostic test showed a marked clinical significance: the sensitivity was 83%, and the specificity was 100%. A positive predictive value of 1 (95% CI 1 to 1) and a negative predictive value of 0.85 (95% CI 0.77 to 0.93) were observed.

CONCLUSION:

TAA is a reliable diagnostic test to detect MPSPF. Further studies are needed to reproduce these results.