1.
Diagnosis of Endometriosis
Current Techniques and New Technologies
TEVFİK YOLDEMİR MD. BSc. MA. PhD.
tyoldemir
profdrdryoldemir

2.
Primary locations of endometriosis, their
prevalence in patients with endometriosis
supine position (entry position feet first). In patients who show
a dilatation of the excretory system, the urographic phase is
acquired in the prone position. In claustrophobic patients,
necessary to detect endometriotic lesions of the intestinal
wall, rectal distension may be useful to evaluate the degree
of bowel stenosis.
Table 1 Primary locations of endometriosis, their prevalence in patients with endometriosis, clinical features and differential diagnosis [3, 10, 11]
Locations % Clinical features MR differential diagnosis
Bladder 6.4–20 dysuria, hematuria, urinary storage symptoms,
suprapubic pain
urachal remnant, epithelial and mesenchymal
tumours
Ureters 0.01–1 dysmenorrhea, dyspareunia, flank pain
(hydronephrosis)
obstruction by cervical cancer
Ovaries 20–40 nonspecific pelvic pain dermoids, hemorrhagic cysts, endometrioid
and clear cell tumours
Round ligaments 0.3–14 painful inguinal mass, nonspecific pelvic pain
Retrocervical region,
uterosacral ligaments
69.2 painful symptoms, dyspareunia peritoneal metastases
Vagina 14.5 dysmenorrhea, dyspareunia, postcoital spotting cervical and vaginal carcinoma
Rectosigmoid colon 9.9–37 dyschezia, cyclic pain, rectal bleeding colorectal cancer, metastatic implants
Insights into Imaging (2018) 9:149–172

3.
Four basic sonographic steps for examining women with
clinical suspicion of deep infiltrating endometriosis (DIE)
endometrioma should be described using the International
Ovarian Tumor Analysis terminology21
. An atypical
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
Dynamicultrasonography
Figure 1 Four basic sonographic steps for examining women with
clinical suspicion of deep infiltrating endometriosis (DIE) or known
tubal course and occ
endometriotic foci or
occur. As a consequen
these reasons, hydrosa
cysts should be search
The third step is
using the real-time T
to assess the sliding
(Figure 2a), gentle pr
using the transvagina
anterior rectum glide
of the cervix (retrocer
wall. If the anterior re
considered positive fo
examiner then places
anterior abdominal w
between the palpating
(which is held in the
anterior bowel glides f
upper uterus/fundus.
Ultrasound Obstet Gynecol 2016; 48: 318–332

4.
Agreement between Observers A and B
Observer agreement on TVS 739
Table 1 Agreement between Observers A and B, and between each observer and laparoscopy, for the diagnosis by transvaginal sonography
(TVS) of deep infiltrating endometriosis (DIE) in different pelvic locations
Gwet’s AC1 (95% CI)
Agreement between
DIE location
Prevalence*
(n (%))
Observers A and B
on TVS
Observer A on TVS
and laparoscopy
Observer B on TVS
and laparoscopy
Observers A and B
on TVS (%)
Vagina 11 (17) 0.93 (0.86–1.00) 0.82 (0.70–0.95) 0.89 (0.77–0.99) 95.4
Bladder 4 (6) 1.00 (1.00–1.00) 0.95 (0.89–1.00) 0.95 (0.89–1.00) 100
USL 17 (26) 0.84 (0.72–0.97) 0.72 (0.56–0.89) 0.69 (0.51–0.86) 89.2
Adnexa 18 (28) 0.95 (0.87–1.00) 0.76 (0.60–0.92) 0.76 (0.60–0.92) 97.0
RVS 8 (12) 0.95 (0.89–1.00) 0.83 (0.71–0.95) 0.82 (0.70–0.94) 95.4
Rectosigmoid 16 (25) 0.98 (0.93–1.00) 0.93 (0.84–1.00) 0.95 (0.88–1.00) 98.5
*Prevalence determined by histopathological findings at laparoscopy. RVS, rectovaginal septum; USL, uterosacral ligament.
Table 2 Diagnostic performance and accuracy of diagnosis by transvaginal sonography of deep infiltrating endometriosis (DIE) by
Observers A and B, with respect to findings on laparoscopy
DIE location Observer
Sensitivity
(% (95% CI))
Specificity
(% (95% CI))
PPV
(% (95% CI))
NPV
(% (95% CI))
LR+
(95% CI)
LR–
(95% CI)
Accuracy
(%)
Vagina A 62 94 73 91 10.7 0.4 88
(35–88) (88–100) (46–99) (83–98) (3.3–35.0) (0.20–0.81)
Ultrasound Obstet Gynecol 2015; 46: 737–740

5.
Diagnostic performance and accuracy of diagnosis by
transvaginal sonography of deep infiltrating endometriosis
USL 17 (26) 0.84 (0.72–0.97) 0.72 (0.56–0.89) 0.69 (0.51–0.86) 89.2
Adnexa 18 (28) 0.95 (0.87–1.00) 0.76 (0.60–0.92) 0.76 (0.60–0.92) 97.0
RVS 8 (12) 0.95 (0.89–1.00) 0.83 (0.71–0.95) 0.82 (0.70–0.94) 95.4
Rectosigmoid 16 (25) 0.98 (0.93–1.00) 0.93 (0.84–1.00) 0.95 (0.88–1.00) 98.5
*Prevalence determined by histopathological findings at laparoscopy. RVS, rectovaginal septum; USL, uterosacral ligament.
Table 2 Diagnostic performance and accuracy of diagnosis by transvaginal sonography of deep infiltrating endometriosis (DIE) by
Observers A and B, with respect to findings on laparoscopy
DIE location Observer
Sensitivity
(% (95% CI))
Specificity
(% (95% CI))
PPV
(% (95% CI))
NPV
(% (95% CI))
LR+
(95% CI)
LR–
(95% CI)
Accuracy
(%)
Vagina A 62 94 73 91 10.7 0.4 88
(35–88) (88–100) (46–99) (83–98) (3.3–35.0) (0.20–0.81)
B 82 94 75 96 14.7 0.2 92
(56–100) (88–100) (51–100) (91–100) (4.7–45.8) (0.05–0.68)
Bladder A 67 97 50 98 20.7 0.34 95
(13–100) (92–100) (1.0–99) (95–100) (4.3–100.2) (0.01–1.7)
B 67 97 50 98 20.7 0.34 95
(13–100) (92–100) (1.0–99) (95–100) (4.3–100.2) (0.01–1.7)
USL A 73 83 47 94 4.4 0.3 82
(46–99) (73–93) (23–71) (87–100) (2.2–8.8) (0.12–0.89)
B 53 90 64 84 5.1 0.5 80
(29–77) (81–98) (39–89) (74–94) (2.0–13.1) (0.31–0.88)
Adnexa A 71 93 83 87 10.5 0.3 86
(52–91) (86–100) (66–100) (78–97) (3.4–32.3) (0.16–0.61)
B 71 93 83 87 10.5 0.31 86
(52–91) (86–100) (66–100) (78–97) (3.4–32.3) (0.16–0.61)
RVS A 40 90 25 95 4.0 0.7 86
(3.0–83) (82–98) (3.2–65) (89–100) (1.1–14.9) (0.30–1.4)
B 33 87 11 96 2.6 0.8 85
(20–87) (79–95) (9–32) (92–100) (0.5–14.5) (0.34–1.71)
Rectosigmoid A 93 96 88 98 23.3 0.1 95
(81–100) (91–100) (71–100) (94–100) (6.0–91.3) (0.01–0.5)
B 94 98 94 98 45.9 0.1 97
(82–100) (94–100) (82–100) (94–100) (6.5–321.0) (0.01–0.43)
LR+, positive likelihood ratio; LR–, negative likelihood ratio; NPV, negative predictive value; PPV, positive predictive value; RVS,
rectovaginal septum; USL, uterosacral ligament.
Ultrasound Obstet Gynecol 2015; 46: 737–740

6.
US / Doppler
ultrasound appearance of an ovarian endometrioma: a unilocular cyst with ground glass echogenicity, internal
no vascularisation in the papillary projection. This is not a true papillations but hyperechoic tissue consisting of
brin lying adjacent to the cyst wall.
C. Exacoustos et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 655–681
Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 655–681
a unilocular cyst with ground glass echogenicity,
internal papillation and no vascularisation in the
papillary projection.
This is not a true papillations but hyperechoic tissue
consisting of blood clots or fibrin lying adjacent to
the cyst wall.

7.
US / Doppler
major contributory factor to incorrect diagnosis in pregnant women [21]. Most decidualised endo-
metriomas (82%) were described as manifesting vascularised rounded papillary projections with a
smooth contour in an ovarian cyst with one or more cyst locules and ground glass, or low level
echogenicity of the cyst fluid [22].
Fig. 3. Three-dimensional ultrasound and power-Doppler image of an endometrioid borderline tumour. Note the irregular papil-
lations and the vascularisation in the papillary projections. These are true papillations composed of borderline malignant solid
tissue.
Three-dimensional ultrasound and power-
Doppler image of an endometrioid borderline
tumour.
Note the irregular papillations and the
vascularisation in the papillary projections.
These are true papillations composed of
borderline malignant solid tissue.
Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 655–681

8.
frequency of different intestinal deep endometriosis
lesions according to Piketty’s et al. studyA.Massein et al.
distin-
riton-
esions
riosis.
pelvic
g for
of the
pelvic
hronic
with-
rhagia
a fre- Diagnostic and Interventional Imaging (2013) 94, 281—291
suspected clinically but imaging is the procedure that con-
firms it and maps the lesions. Laparoscopy should not be
performed for diagnostic purposes because it is not without
risk and can ignore some deep lesions or those masked by
adhesions.
Sites of deep endometriosis
Lesions of the uterosacral ligaments are the most common
(Fig.1).They are associated with involvement of the torus
uterinus, which is a small transverse thickening on the pos-
terior surface of the cervix, between the insertions of the
two uterosacral ligaments.
Intestinal and urinary tract locations are the most severe
forms of deep endometriosis (Fig.2).The multiple intestinal
Figure 1. Table showing the frequency of deep pelvic endometriosis according to Chapron’s surgical serie [3].
locations.
The usefulness of pre-treatment
Different therapeutic strategies
Hormonal treatment of endometriosis can b
the painful symptoms but does not improve fe
first-line drug to patients with pain and no de
pregnant. Surgical treatment is offered to
pain is not sufficiently improved by medical
also to patients who wish to become pregn
IVF failures.Surgical treatment does indeed
quality of life and fertility, provided that t
completely removed [4].

9.
the ‘sliding sign’ in an anteverted uterus (a)
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
IDEA consensus opinion 321
(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
examination to eliminate fecal residue and gas in the
rectosigmoid34–37. However, this is not mandatory, and
Ultrasound Obstet Gynecol 2016; 48: 318–332

10.
the ‘sliding sign’ in an anteverted uterus (a).
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
A consensus opinion 321
(a) (b)
2 Schematic drawings demonstrating how to elicit the ‘sliding sign’ in an anteverted uterus (a) and a retroverted uterus (b).
TVS it is demonstrated that either the anterior examination to eliminate fecal residue and gas in the
34–37
Ultrasound Obstet Gynecol 2016; 48: 318–332

11.
the ‘sliding sign’ in a retroverted uterus (b).321
(b)
the ‘sliding sign’ in an anteverted uterus (a) and a retroverted uterus (b).
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
Ultrasound Obstet Gynecol 2016; 48: 318–332

12.
the ‘sliding sign’ in a retroverted uterus (b).
321
(b)
he ‘sliding sign’ in an anteverted uterus (a) and a retroverted uterus (b).
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
Ultrasound Obstet Gynecol 2016; 48: 318–332

13.
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
Ultrasound Obstet Gynecol 2016; 48: 318–332

14.
proposed ultrasound definition of the
rectovaginal septum (RVS)
IDEA consensus opinion 323
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
Ultrasound Obstet Gynecol 2016; 48: 318–332

15.
Isolated deep infiltrating endometriosis in the
rectovaginal
septum
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.
Ultrasound Obstet Gynecol 2016; 48: 318–332

16.
deep infiltrating endometriosis in the posterior vaginal
wall with extension into the rectovaginal septum
324 Guerriero and Condous et al.
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.
Ultrasound Obstet Gynecol 2016; 48: 318–332

17.
deep infiltrating endometriosis in the anterior rectal
wall with extension into the rectovaginal septum
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.
Ultrasound Obstet Gynecol 2016; 48: 318–332

18.
rectovaginal septal deep infiltrating endometriosis extending
into both anterior rectal wall and posterior 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,
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
Ultrasound Obstet Gynecol 2016; 48: 318–332

19.
ultrasound images of bowel deep infiltrating
endometriosis (DIE)consensus opinion 325
(a)
Transverse
section
Bowel
Uterus
(b)
(c)
Ultrasound Obstet Gynecol 2016; 48: 318–332
(a) DIE nodule with a regular outline (absence
of ‘spikes’).
(b) DIE nodule with progressive narrowing, like
a ‘tail’, also known as ‘comet’ sign.

20.
ultrasound images of bowel deep infiltrating
endometriosis (DIE)
Ultrasound Obstet Gynecol 2016; 48: 318–332
(c) DIE nodule with prominent spikes towards the bowel lumen,
also known as ‘Indian headdress’ or ‘moose antler’ sign.
Uterus
Bowel
Bowel
Bowel
Bowel
(c)
(d) (e)

21.
ultrasound images of bowel deep infiltrating
endometriosis (DIE)
Bowel
Bowel
Bowel
Bowel
(d)
(f)
(e)
(f)
Ultrasound Obstet Gynecol 2016; 48: 318–332
(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)

22.
ultrasound images of bowel deep infiltrating
endometriosis (DIE) Bowel
Bowel
(f) (f)
hematic drawings and corresponding ultrasound images of bowel deep infiltrating endometriosis (DIE). (a) DIE nodule with
line (absence of ‘spikes’). (b) DIE nodule with progressive narrowing, like a ‘tail’, also known as ‘comet’ sign. (c) DIE nodule
spikes towards the bowel lumen, also known as ‘Indian headdress’ or ‘moose antler’ sign. (d) DIE nodule with both promine
ards the bowel lumen (Indian headdress/moose antler sign) and progressive narrowing like a tail (comet sign). (e) DIE nodule
nent spikes towards the bowel lumen (Indian headdress/moose antler sign) and extrinsic retraction (and visible mucosal foldUltrasound Obstet Gynecol 2016; 48: 318–332
(f) DIE nodule and extrinsic retraction
(pulling sleeve sign).

23.
Rectum, rectosigmoid junction and sigmoidGuerriero and Condous et al.
oechoic
within
may be
ng into
e thick-
nsverse
ix pro-
y from
he DIE
terinus
ning of
SL DIE
nes.
rectum,
f which
nstrates
upper
of an
lesions
multiple
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).
lower (or retroperitoneal) anterior rectum (1);
upper (visible at laparoscopy) anterior rectum (2);
rectosigmoid junction (3);
and anterior sigmoid (4).
Ultrasound Obstet Gynecol 2016; 48: 318–332

24.
measurement of a nodule of deep infiltrating
endometriosis in the bowel wall.IDEA consensus opinion 327
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.
Ultrasound Obstet Gynecol 2016; 48: 318–332

25.
multifocal lesions of deep infiltrating endometriosis
total length of the bowel segment involved (caudal to cephalic)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), and the lesion (Figure S15). It is possible to measure
Ultrasound Obstet Gynecol 2016; 48: 318–332

26.
Schematic drawings giving overview of anterior
compartmental locations of deep infiltrating endometriosis
Guerriero and Condous et al.
Ultrasound Obstet Gynecol 2016; 48: 318–332

27.
Schematic drawings giving overview of posterior
compartmental locations of deep infiltrating endometriosis
Ultrasound Obstet Gynecol 2016; 48: 318–332

28.
Schematic drawings giving overview of posterior
compartmental locations of deep infiltrating endometriosis
Ultrasound Obstet Gynecol 2016; 48: 318–332

29.
Sonovaginography
o evaluate the anatomy of the uterus and the adnexa, both in the sagittal and horizontal
gentle probe movements to assess the presence of adhesion between them. Transvaginal
c examination is based on a detailed evaluation of organ and tissues dividing the pelvis in
r and posterior compartment according to the DIE classification by Chapron et al. [51].
ginography: visualisation of the vagina with transvaginal probe positioned in the rectum. The vagina is filled with
through a Foley catheter with its balloon placed in the lower part of the vagina; note the wall of the vaginal posterior
vix in the vagina, the recto-vaginal septum, and the retrocervical nodule of deep infiltrating endometriosis not
agina but infiltrating the lower part of the rectal wall and the left uterosacral sacral ligament.
Visualisation of the vagina with
transvaginal probe positioned in the
rectum.
The vagina is filled with saline solution
through a Foley catheter with its
balloon placed in the lower part of the
vagina
Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 655–681

30.
a dilated ureter seen by transvaginal ultrasound
and recto-sigmoid junction. Rectal sigmoid nodules are visualised as an irregular hypoechoic
netrating into the intestinal wall distorting its normal structure At transvaginal sonography,
asound image of a dilated ureter seen by transvaginal ultrasound in a transverse section of the pelvis, as tubular anechoic
arrows) in the parametrial tissue laterally to the uterine cervix.
In a transverse section of the pelvis,
seen as tubular anechoic structure
(arrows) in the parametrial tissue
laterally to the uterine cervix.
Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 655–681

31.
Water-contrast in the rectum during
transvaginal sonography
svaginal sonography findings, a barium enema could help decide whether segmental resection
ssary.
Water-contrast in the rectum during transvaginal sonography is performed by injecting saline solution into the rectal lumen
ansvaginal ultrasound examination. Note the presence of the deep infiltrating endometriosis nodule bulging into the bowel
Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 655–681
injecting saline solution
into the rectal lumen
during transvaginal
ultrasound examination

32.
Water enema CT A. Massein et al.
Water enema CT showing typical retrocervical involvement: nodule (arrow) of the anterior wall of the upper rectum adhering
us uterinus. a: axial slice. b: sagittal slice.
Typical retrocervical involvement:
nodule (arrow) of the anterior wall
of the upper rectum adhering to
the torus uterinus.
a: axial slice. b: sagittal slice.
Diagnostic and Interventional Imaging (2013) 94, 281—291

33.
Water enema CT
e 9. Water enema CT showing parietal thickening of the sigmoid colon (arrow) contiguous with a left ovarian lesion (star). a: axial
b: sagittal oblique reconstruction.
Diagnostic and Interventional Imaging (2013) 94, 281—291
parietal thickening of the sigmoid
colon (arrow) contiguous with a left
ovarian lesion (star).
a: axial slice. b: sagittal oblique
reconstruction.

34.
Water enema CTmaging of intestinal involvement in endometriosis 289
a: nodular thickening of the torus uterinus adhering to the anterior surface of the
upper rectum.
b, c: Thickening of the wall of the sigmoid colon (arrow) in axial (b) and oblique
sagittal (c) slices adhering to the torus uterinus and the left ovary (site of several
endometrioma detected by ultrasound).
Diagnostic and Interventional Imaging (2013) 94, 281—291

35.
Water enema CT
e: rounded nodule in the wall of the final loop of the ileum (arrow) in
axial (d) and coronal (e) slices. f: parietal thickening of an ileal loop
(arrow) in contact with the right ovary which is also involved.
Figure 10. Water enema CT showing four sites of intestinal endometriosis in the same patient. a:nodular thickening of the torus uterinu
adhering to the anterior surface of the upper rectum. b, c: Thickening of the wall of the sigmoid colon (arrow) in axial (b) and obliqu
sagittal (c) slices adhering to the torus uterinus and the left ovary (site of several endometrioma detected by ultrasound). d, e: rounde
nodule in the wall of the final loop of the ileum (arrow) in axial (d) and coronal (e) slices. f: parietal thickening of an ileal loop (arrow) i
contact with the right ovary which is also involved.
Diagnostic and Interventional Imaging (2013) 94, 281—291

36.
Muscularis involvement at the rectosigmoid junctionFigure 11. Rectal ES - axial section. Nodular hypoechoic thick-
ening of the muscularis (arrow). Submucosa (thin, hyperechoic
appearance [arrowhead]) spared. Normal appearance (hypoechoic
and fine) of the muscularis (star).
Figure 12. Muscularis involvement at the rectosigmoid junction, with correlation in transvaginal ultrasound (a), MRI (b), Enema CT (c),
rectal ES (d). a:sagittal slice showing hypoechoic nodular thickening of the muscularis (arrow). b:T2-weighted axial slice showing an arcuate
hypointense thickening of the uterosacral ligaments. On the right, this thickening is adhering to an intestinal parietal nodule. c: oblique
transvaginal ultrasound (a),
MRI (b),
Enema CT (c),
rectal ES (d)
Diagnostic and Interventional Imaging (2013) 94, 281—291

37.
MR imaging
• The state-of-the-art MR imaging protocol for the diagnosis of
endometriosis includes T2- and fat suppressed T1-weighted
sequences.
• T2-weighted sequences without fat-suppression are the best
sequences for detecting pelvic endometriosis, in particular for
the evaluation of fibrotic lesions.
• Fat-suppressed T1-weighted 3D gradient-echo LAVA sequence.
This pulse sequence improves the sensitivity of MR imaging in
the detection of small lesions. It is the most sensitive for the
detection of bloody foci and peritoneal endometriosis
Insights into Imaging (2018) 9:149–172

38.
MR imaging
• Contrast-enhanced fat-suppressed T1-weighted 3D gradient-
echo LAVA sequence is useful in the following conditions:
• detection of enhancing mural nodules within adnexal masses, when
atypical features on US or T2-weighted MR sequences suggest potential
malignancy
• the major benefit of intravenous gadolinium is ureter visualization
Insights into Imaging (2018) 9:149–172

39.
MRI Protocol Technique
• Examinations are scheduled in the first 12 days after the
beginning of the menstrual cycle.
• During this phase of the menstrual cycle, the hyperintense
signal of endometriotic blood is maximal in the T1 weighted
images and the small haemorrhagic foci can be detected.
• Furthermore, the signal intensity of blood is crucial for the
differentiation of the endometrioma from other ovarian
lesions, like simple or haemorrhagic cysts; the endometrioma
is characteristically hyperintense on T1 weighted images and
hypo- intense in the T2 weighted images (T2 shading effect).
Insights into Imaging (2018) 9:149–172

40.
Deep infiltrating endometriosisTable 3 Summary of study results: imaging of rectal or recto-sigmoid involvement in deep infiltrating endometriosis
Study Pre-test
probabilitya
(n)
Sensitivity%
(95% CI)
Specificity%
(95% CI)
LR+
(95% CI)
LR−
(95% CI)
Post-test probability
for study population:
positive test (%)
Post-test probability
for study population:
negative test (%)
Transvaginal Ultrasound
Abrao [10] 52% (54/104) 98 (95,100) 100 (100,100) ∞ 0.02 (0.00, 0.1) >99 2
Menada [17] TVS 83% (75/90) 56.5 92.5 7.57 0.47 97 60
Menada [17] RWC-TVSb,c
83% (75/90) 95.7 100.0 ∞ 0.04 >99 15
Guerriero [15] 44% (39/88) 67 (55,73) 92 (84, 100) 8.2 (3.1,21.4) 0.4 (0.2,0.6) 87 22
Bazot [11] 67% (54/81) 93 (86,100) 100 (100,100) ∞ 0.07 (0.03,0.2) >99 12
Hudelist [16] 24% (48/200) 96 (90,100) 98 (96, 100) 48.6 (15.8,149.1) 0.04 (0.01,0.2) 94 1
Piketty [18] 56% (75/134) 91 (84,97) 97 (92,100) 26.3 (6.7, 102.8) 0.1 (0.05, 0.2) 97 11
Bazot [19] 68% (63/92) 94 (88,100) 100 (100,100) ∞ 0.06 (0.02, 0.2) >99 11
Trans-rectal ultrasound
Chapron [13] 42% (34/81) 97 (91,100) 89 (81,98) 9.1 (4.0,20.9) 0.03 (0.00, 0.2) 87 2
Delpy [14] 40% (12/40) 92 (76,100) 67 (45,88) 2.8 (1.4,5.0) 0.1 (0.02,0.8) 65 8
Bazot [11] 67% (54/81) 89 (81,97) 93 (83,100) 12.0 (3.2,45.7) 0.1 (0.06,0.3) 96 20
Piketty [18] 56% (75/134) 96 (92,100) 100 (100,100) ∞ 0.04 (0.01,0.1) >99 5
Bazot [19] 68% (63.92) 89 (81,97) 93 (84,100) 12.9 (3.4,49.2) 0.1 (0.06,0.2) 96 20
Magnetic Resonance Imaging (MRI)
Chapron [13] 42% (34/81) 76 (62,91) 98 (94,100) 35.9 (5.1,252.1) 0.2 (0.1,0.4) 98 15
Abrao [10] 52% (54/104) 83 (73,93) 98 (94,100) 41.7 (6.0,291.1) 0.2 (0.09, 0.3) 98 16
Chamie [12] 54% (50/92) 86 (76,96) 93 (85,100) 12.0 (4.0,36.0) 0.2 (0.08, 0.3) 93 15
Bazot [19] 68% (63.92) 87 (79,96) 93 (84,100) 12.7 (3.3,48.4) 0,1 (0.07,0.3) 96 23
a
Pre-test probability is the prevalence of deep infiltrating endometriosis involving the rectum or rectosigmoid colon.
b
Figures published in the paper given, no data were available to construct a 2×2 table in order to calculate 95% confidence intervals
c
RWC-TVS, water contrast in the rectum combined with TVS
414
Gynecol Surg (2010) 7:407–415

41.
2 × 2 Table for diagnostic test studies
good at correctly identifying diseased patients but not so
good at correctly identifying true-negative patients.
give you the post-test probability for an individual patient.
Figure 1 summarises the interpretation of LRs in relation to
the usefulness of the test to confirm or exclude disease and
the approximate change in pre-test probability of disease
[4]. The easiest way to calculate the post-test probability is
to use a likelihood nomogram (Fig. 2). From Fig. 2, you
will see that the disease prevalence (pre-test probability) is
50%. So for patients who have not had any tests, but
present with the typical signs of a given disease that has a
50% prevalence, they have a 50% chance of having the
disease. The positive LR for our test is 35. If you follow the
line, you will see that this results in a post-test probability
of 95%. This means that following a positive test result, our
patient, has a 95% chance of having the disease. Her
chances have increased from 50% to 95%. Similarly, if the
negative likelihood for our test is 0.1 and our patient had a
negative test result, her chances of not having the disease
have gone from 50% (the prevalence) to just 9%.
You can access an interactive nomogram and 2×2 calculator
that will calculate sensitivity, specificity and likelihood ratios
with their 95% confidence intervals from diagnostic test study
Table 1 2×2 Table for diagnostic test studies
Target disorder
Present Absent
Diagnostic
test result
Positive True
positive a
False
positive b
Negative False
negative c
True
negative d
Sensitivity a/(a+c)
Specificity d/(b+d)
Positive predictive value a/(a+b)
Negative predictive value d/(c+d)
Prevalence (pre-test probability) (a+c)/(a+b+c+d)
Positive likelihood ratio (LR+) sensitivity/(1-specificity)
Negative likelihood ratio (LR−) (1–sensitivity)/specificity
Gynecol Surg (2010) 7:407–415
results online through the Centre for Evidence Based Medicine
www.cebm.net. Without the nomogram, the post-test proba-
bility of disease can be calculated in the following way:
study are accurate. The following points should be consid-
ered when reading studies of diagnostic test accuracy that
relate to our clinical scenario:
Likelihood Ratio
1 2 5 100.20.1 0.50 ∞
Excludes disease Confirms disease
0 +30%+15% +45%-15%-30%-45%
Approximate % change to pre-test probabilityFig. 1 Interpretation of likeli-
hood ratios [3, 4]
Gynecol Surg (2010) 7:407–415 409

42.
Likelihood nomogram
(adaptedfromCentreforEvidenceBasedMedicinewww.cebm.net)
Critical appraisal of diagnostic test studies
When critically appraising diagnostic studies, there are a
number of criteria that determine whether or not there is a risk
of bias affecting the results of the study [5, 6]. With a
significant risk of bias, it is unlikely that the results of the
recruitment of people to a diagnostic study is either
done consecutively or randomly so that there is no bias
in the sample. In our clinical scenario, if patients are
recruited only on the basis of a high suspicion of deep
infiltrating disease, the tests (MRI, TVS, TRS) are not
being rigorously examined. Moreover, the number of
negative test results (both true and false negative) will
be very low, leading to wide confidence intervals and
imprecise results which are difficult to interpret.
& Did all participants receive both the tests being studied
(MRI, TVS, TRS) and the gold standard test which the
study tests are being compared to? For our clinical
scenario, we would want the gold standard test to be
surgical diagnosis with histology.
& If, as often happens when the gold standard test is
surgical, a significant proportion of patients do not have
a laparoscopy to confirm the presence or absence of
endometriosis, the true negatives in the MRI, TVS and
TRS will be overestimated and the false negatives will
be underestimated.
& Were the investigators who performed the study test
blinded to the clinical information? In our clinical
scenario, if the investigator became aware that a patient
had all the typical signs of deep endometriosis, s/he
might be more vigilant in looking for evidence of
disease when carrying out the MRI/TVS/TRS.
& Was there independent blind comparison between the
study test results and the gold standard? In our clinical
scenario, if the surgeon was aware of the results of the
MRI/TVS/TRS, s/he might be more or less vigilant in
looking for evidence of the disease.
& Was the sample size sufficiently large enough to
produce precise estimates of the sensitivity, specificity
X
A
B
Fig. 2 Likelihood nomogram (adapted from Centre for Evidence Based
results online through the Centre for Evidence Based Medicine
www.cebm.net. Without the nomogram, the post-test proba-
bility of disease can be calculated in the following way:
Pre À test odds ¼ pre À test probability= 1 À pre À test probabilityð Þ
Post À test odds ¼ pre À test odds»LR
Post À test probability ¼ pre À test odds= post À test odds þ 1ð Þ
ð1Þ
Critical appraisal of diagnostic test studies
When critically appraising diagnostic studies, there are a
number of criteria that determine whether or not there is a risk
of bias affecting the results of the study [5, 6]. With a
significant risk of bias, it is unlikely that the results of the
study are
ered whe
relate to o
& Were
on all
infiltr
select
recrui
done
in the
recrui
infiltr
being
negati
be ve
impre
& Did a
(MRI,
study
scenar
0.20.1 00
Excludes disease
AGynecol Surg (2010) 7:407–415

43.
diagnostic performance of TVS vs MRI for detection of DIE
588 Guerriero et al.
Table 1 Characteristics of studies comparing diagnostic performance of transvaginal sonography (TVS) and magnetic resonance imaging
(MRI) for detection of deep infiltrating endometriosis (DIE) included in our meta-analysis, according to PICOS (Patients, Intervention,
Comparator, Outcomes, Study design) criteria
Reference
Geographical
area Setting n
Study
design
TVS
technique
MRI
technique
Observers
(n)
Reference
standard
Cases with
DIE (n)
Abrao
(2007)29
South
America
Single
center
104 Prosp Non-enhanced 1.5 T +
contrast
Single Surgery and
histopathology
RS (54), RVS (41)
Bazot
(2009)30
Europe Single
center
92 Prosp Non-enhanced 1.5 T +
contrast
Single Surgery and
histopathology
following
Bazot’s criteria
RS (63), RVS (11),
USL (83)
Vimercati
(2012)31
Europe Single
center
90 Prosp Non-enhanced 1.5 T +
contrast
Single Surgery and
histopathology
RS (18), RVS (18),
USL (112)*
Saccardi
(2012)32
Europe Single
center
54 Prosp Enhanced
(saline
contrast SVG)
1.5 T +
contrast
Single Surgery and
histopathology
RS (6), RVS (36),
USL (9)
Saba
(2012)33
Europe Single
center
59 Prosp Non-enhanced 1.5 T +
contrast
Single Surgery and
histopathology
following
Bazot’s criteria
RS (30)
Gauche
Cazalis
(2012)34
Europe Single
center
25 Retro 1.5 T +
contrast
Single Surgery and
histopathology
RS (19), RVS (19),
USL (18)
Only first author of each study is given. *Vimercati et al.31 reported separately findings in each USL. Prosp, prospective; Retro, retrospective;
RS, rectosigmoid; RVS, rectovaginal septum; SVG, sonovaginography; T, Tesla; USL, uterosacral ligaments.
format includes four domains: (1) patient selection; (2) Records identified through database
Ultrasound Obstet Gynecol 2018; 51: 586–595

44.
diagnostic performance of TVS vs MRI for detection of DIE
594 Guerriero et al.
Table 2 Comparison of published meta-analyses on diagnostic
accuracy of transvaginal sonography (TVS) and/or magnetic
resonance imaging (MRI) for deep infiltrating endometriosis (DIE)
in rectosigmoid, rectovaginal septum and uterosacral ligaments
Reference (according
to DIE location/test
method)
Pooled sensitivity
(95% CI) (%)
Pooled specificity
(95% CI) (%)
Rectosigmoid
TVS
Nisenblat (2016)19
0.90 (0.82–0.97) 0.96 (0.94–0.99)
Guerriero (2016)36
0.91 (0.85–0.94) 0.97 (0.95–0.98)
Noventa (2015)20
0.85 (0.83–0.87) 0.89 (0.87–0.90)
Current study 0.85 (0.68–0.94) 0.96 (0.85–0.99)
MRI
Medeiros (2015)21
0.83 (0.78–0.87) 0.88 (0.84–0.92)
Nisenblat (2016)19
0.92 (0.86–0.99) 0.96 (0.93–0.98)
Current study 0.85 (0.78–0.90) 0.95 (0.83–0.99)
Rectovaginal septum
TVS
Nisenblat (2016)19 0.88 (0.82–0.94) 1.00 (0.98–1.00)
Guerriero (2015)35 0.49 (0.36–0.62) 0.98 (0.95–0.99)
Noventa (2015)20 0.60 (0.55–0.64) 0.88 (0.84–0.91)
Current study 0.59 (0.26–0.86) 0.97 (0.94–0.99)
MRI
Medeiros (2015)21 0.77 (0.69–0.83) 0.95 (0.92–0.96)
Nisenblat (2016)19
0.81 (0.70–0.93) 0.86 (0.78–0.95)
Current study 0.66 (0.51–0.79) 0.97 (0.89–0.99)
Uterosacral ligaments
TVS
that those authors did not perform a direct head-to-head
comparison of TVS and MRI. That is because for
rectosigmoid, RVS and USL sites they included only two,
two and one study, respectively, preventing them from
making such a comparison. In contrast, we included six,
five and four studies, respectively, thereby allowing us to
perform a direct comparison, albeit with a small number
of cases.
With respect to the diagnostic performance of TVS and
MRI for the detection of DIE involving the rectosigmoid,
the pooled sensitivity, specificity, LR+ and LR– of
the two techniques were similar, with 85% sensitivity
for both MRI and TVS and specificity of 95% and
96%, respectively. Comparing with the other published
meta-analyses19–21,35,36, we observed lower sensitivities
than did Nisenblat et al.19 for both methods (90% for TVS
and 92% for MRI) and Guerriero et al.36
for TVS (91%),
while our overall sensitivity was similar to that of Noventa
et al.20
for TVS (85%) and similar to that of Medeiros
et al.21
for MRI21
(83%) (Table 2). Heterogeneity for
TVS was high for both sensitivity and specificity, while
for MRI it was moderate for sensitivity and high for
specificity. Meta-regression to assess covariates that might
explain this heterogeneity showed that none could explain
it. The data confirm that identification of endometriosis
involving the rectosigmoid is very good using both TVS
Guerriero (2016)36
0.91 (0.85–0.94) 0.97 (0.95–0.98)
Noventa (2015)20
0.85 (0.83–0.87) 0.89 (0.87–0.90)
Current study 0.85 (0.68–0.94) 0.96 (0.85–0.99)
MRI
Medeiros (2015)21
0.83 (0.78–0.87) 0.88 (0.84–0.92)
Nisenblat (2016)19
0.92 (0.86–0.99) 0.96 (0.93–0.98)
Current study 0.85 (0.78–0.90) 0.95 (0.83–0.99)
Rectovaginal septum
TVS
Nisenblat (2016)19 0.88 (0.82–0.94) 1.00 (0.98–1.00)
Guerriero (2015)35 0.49 (0.36–0.62) 0.98 (0.95–0.99)
Noventa (2015)20 0.60 (0.55–0.64) 0.88 (0.84–0.91)
Current study 0.59 (0.26–0.86) 0.97 (0.94–0.99)
MRI
Medeiros (2015)21 0.77 (0.69–0.83) 0.95 (0.92–0.96)
Nisenblat (2016)19
0.81 (0.70–0.93) 0.86 (0.78–0.95)
Current study 0.66 (0.51–0.79) 0.97 (0.89–0.99)
Uterosacral ligaments
TVS
Nisenblat (2016)19
0.64 (0.50–0.79) 0.97 (0.93–1.00)
Guerriero (2015)35
0.53 (0.35–0.70) 0.93 (0.83–0.97)
Noventa (2015)20
0.50 (0.46–0.53) 0.69 (0.65–0.73)
Current study 0.67 (0.55–0.77) 0.86 (0.73–0.93)
MRI
Medeiros (2015)21 0.85 (0.82–0.88) 0.80 (0.76–0.84)
Nisenblat (2016)19 0.86 (0.80–0.92) 0.84 (0.68–1.00)
Current study 0.70 (0.55–0.82) 0.93 (0.87–0.97)
Only first author of each study is given.
5-year period, from December 2007 to November 2012,
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Nisenblat (2016)19
0.90 (0.82–0.97) 0.96 (0.94–0.99)
Guerriero (2016)36
0.91 (0.85–0.94) 0.97 (0.95–0.98)
Noventa (2015)20
0.85 (0.83–0.87) 0.89 (0.87–0.90)
Current study 0.85 (0.68–0.94) 0.96 (0.85–0.99)
MRI
Medeiros (2015)21
0.83 (0.78–0.87) 0.88 (0.84–0.92)
Nisenblat (2016)19
0.92 (0.86–0.99) 0.96 (0.93–0.98)
Current study 0.85 (0.78–0.90) 0.95 (0.83–0.99)
Rectovaginal septum
TVS
Nisenblat (2016)19 0.88 (0.82–0.94) 1.00 (0.98–1.00)
Guerriero (2015)35 0.49 (0.36–0.62) 0.98 (0.95–0.99)
Noventa (2015)20 0.60 (0.55–0.64) 0.88 (0.84–0.91)
Current study 0.59 (0.26–0.86) 0.97 (0.94–0.99)
MRI
Medeiros (2015)21 0.77 (0.69–0.83) 0.95 (0.92–0.96)
Nisenblat (2016)19
0.81 (0.70–0.93) 0.86 (0.78–0.95)
Current study 0.66 (0.51–0.79) 0.97 (0.89–0.99)
Uterosacral ligaments
TVS
Nisenblat (2016)19
0.64 (0.50–0.79) 0.97 (0.93–1.00)
Guerriero (2015)35
0.53 (0.35–0.70) 0.93 (0.83–0.97)
Noventa (2015)20
0.50 (0.46–0.53) 0.69 (0.65–0.73)
Current study 0.67 (0.55–0.77) 0.86 (0.73–0.93)
MRI
Medeiros (2015)21 0.85 (0.82–0.88) 0.80 (0.76–0.84)
Nisenblat (2016)19 0.86 (0.80–0.92) 0.84 (0.68–1.00)
Current study 0.70 (0.55–0.82) 0.93 (0.87–0.97)
Only first author of each study is given.
5-year period, from December 2007 to November 2012,
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leUltrasound Obstet Gynecol 2018; 51: 586–595

45.
www.slideshare.net/dryoldemir
TEVFİK YOLDEMİR MD. BSc. MA. PhD.
tyoldemir
profdrdryoldemir