ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are...

49
ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN M.Basta Nikolić, S. Stojanović, O. Nikolić, T. Mrđanin, D. Donat, V. Žigić Center for Radiology, Clinical Center of Vojvodina Novi Sad

Transcript of ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are...

Page 1: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN

M.Basta Nikolić, S. Stojanović, O. Nikolić, T. Mrđanin, D. Donat, V. Žigić

Center for Radiology, Clinical Center of VojvodinaNovi Sad

Page 2: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

Chronic pelvic pain (CPP)

• Presence of pain >6m localized to the anatomic pelvis

• Severe enough to cause functional disability and require medical or surgical treatment

• Cause of ~40% laparoscopies and 10-15% hysterectomies

Page 3: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

CAUSE OF CPP

1. Gyn and Obs

2. Urologic

3. GI

4. Vascular

5. MS

6. Neuro

7. Psychological

1/3 endometriosis

1/3 adhesions

Neis KJ,Neis F. Chronic pelvic pain: cause, diagnosis and therapy from a gynaecologist’s and an endoscopist’s point of view. Gynecol Endocrinol.2009;25(11):757-761.

Page 4: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

ENDOMETRIOSIS

-presence of functional endometrial glands and stroma outside the uterine cavity

Page 5: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

• Infertility• pelvic pain

• Unusual symptoms• gastrointestinal involvement: catamenial diarrhoea,

rectal bleeding and constipation• vesical involvement: urgency, frequency, haematuria• thoracic involvement: pleuritic chest pain,

pneumothorax, pleural effusions or cyclic haemoptysis• asymptomatic: especially if disease is isolated to the

peritoneum

SYMPTOMS

Page 6: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

AETHIOPATHOGENETIC MECHANISMS OF ENDOMETRIOSIS-ASSOCIATED CPP

• Nociceptive

• Inflammatory

• Neuropathic mechanisms

Page 7: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

• metastatic theory

• metaplastic theory

• induction theory

PATHOGENESIS

radiopedia.org

Page 8: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

PREVALENCE

• 1 in 10 women

• Strongly linked to infertility

• 25-50% of infertile women have endometriosis

• 30-50% of women with endometriosis is infertile

Page 9: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus
Page 10: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

• OVARIAN

• SUPERFICIAL

• DEEP

LOCATION

Page 11: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

SUPERFICIAL ENDOMETRIOSIS

• superficial plaques scattered across the peritoneum, ovaries and uterine ligaments

DEEP PELVIC ENDOMETROSIS

• subperitoneal invasion by endometriotic lesions that exceeds 5 mm in depth and comprises nodules, cysts and secondary scarring

Antônio Coutinho, et al. MR Imaging in Deep Pelvic Endometriosis: A Pictorial EssayRadioGraphics 2011 31:2, 549-567

Page 12: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

• Most common: ovaries, pelvis, peritoneum

• Less common: C section scar, deep subperitoneal tissue, GI tract, bladder, chest, subcutaneous tissue

• Most common sites of pelvic involvement: Douglas pouch, uterosacral ligaments and torus uterinus

LOCATION

Page 13: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

• ULTRASOUND

TRANSABDOMINAL

TRANSVAGINAL

TRANSRECTAL

• MRI

• CT

• CLASSIC RADIOLOGICAL METHODS

COLONOGRAPHY, ENTEROCLISIS, CHEST X RAY...

IMAGING

Page 14: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

ENDOMETRIOSIS

TRANSVAGINAL US TRANSRECTAL US

• OVARIES

• URINARY BLADDER

• RECTOVAGINAL

• UTEROSACRAL

• RECTOSYGMOID

BAZOT M ET AL.; DEEP PELVIC ENDOMETRIOSIS: MR IMAGING FOR DIAGNOSIS AND

PREDICTION OF EXTENSION OF DISEASE; RADIOLOGY 2004.

Page 15: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

ULTRASONOGRAPHY

• Good for endometriomas

• Homogenous hypoechoic lesion

• No Doppler signal

• Unilocular

• May be multiple

• Poor for peritoneal implants

Page 16: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

ENDOMETRIOMA

“CHOCOLATE” CYST

TRANSVAGINAL US MACROSCOPICALLY

Page 17: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

THICK SEPTATIONS

TRANSVAGINAL US MACROSCOPICALLY

Page 18: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

MRI

radiopaedia.org

• T1

– hyperintense

– high SI T1 FS

• T2

– hypointense -shading sign

– T2 dark spot sign

• DWI

– variable restricted diffusion

• T1C+

– may have wall enhancement

– the presence of an enhancing mural nodule is suggestive of malignant transformation

METHOD OF CHOICE!

Page 19: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus
Page 20: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

• haemorrhagic “powder burn” lesions appear bright on T1 fat saturated sequences

• small solid deep lesions– may be hyperintense on T1 and hypointense on T2

• adhesions and fibrosis

MRI CHARACTERISTICS OF ENDOMETRIOSIS

Page 21: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

uterosacral involvement

• irregular margins

• asymmetry

• nodularity and thickening

• altered T2 signal: isointense (50%), hypointense (40%) or hyperintense (10%) cf. myometrium

vaginal involvement

• loss of hypointense signal of posterior vaginal wall on T2WI

• thickening, nodules and/or masses

Page 22: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

M Bazot et al. Accuracy of magnetic resonance imaging and rectal endoscopic sonography for the prediction of location of deep pelvic endometriosis. Human reproduction , 2007; 22:. 1457-63.

Page 23: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

BLEEDING FOCI IN VAGINA

Page 24: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

Pouch of Douglas

– partial to complete obliteration

– suspended or lateralisedfluid collections

Rectovaginal septum

– nodules or masses that passed through the lower border of the posterior lip of the cervix

Page 25: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus
Page 26: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

Gastrointestinal tract

rectal wall thickening

anterior displacement of the rectum

abnormal angulation

loss of fat plane between uterus and bowel

inflammatory response due to repeated haemorrhage can lead to adhesions, strictures and bowel obstruction

Urinary tract

– bladder

• localised or diffuse bladder wall thickening

• signal intensity abnormality, nodules or masses usually located at the level of the vesicouterine pouch

• involvement of bladder mucosa is rare

Page 27: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus
Page 28: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus
Page 29: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

KISSING OVARIES

Page 30: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus
Page 31: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

• chest

– catamenial pneumothorax

– haemothorax

– lung nodules

• cutaneous tissues

– nodules

• malignant transformation

– solid enhancing components

Page 32: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

PULMONARY ENDOMETRIOSIS- CATAMENIAL SY

CHEST X RAY THORACIC CT

Page 33: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

ENDOMETRIOSIS OF ANTERIOR ABDOMINAL

WALL

US CONTRAST CT

Page 34: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus
Page 35: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus
Page 36: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

Hematosalpinx

Page 37: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

Hydrosalpinx

Page 38: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

SENSITIVITY SPECIFICITY

UTEROSACRAL LIGAMENT 86 % 77 %

VAGINA 80 % 93%

RECTOVAGINAL SEPTUM 80 % 97 %

BOWEL 88 % 98 %

ENDOMETRIOSIS

ACCURACY OF MRI IN DIFFERENT LOCALIZATIONS 1

1. BAZOT M ET AL.; DEEP PELVIC ENDOMETRIOSIS: MR IMAGING FOR DIAGNOSIS AND

PREDICTION OF EXTENSION OF DISEASE; RADIOLOGY 2004.

Page 39: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

• VISUALIZATION OF SMALL PERITONEAL IMPLANTS

• VISUALIZATION OF ADHESIONS

1. DIRECT – PRESENCE OF FLUID ON BOTH SIDES

2. INDIRECT

-ANGULATION OF BOWEL LOOPS

-ELEVATION OF POSTERIOR VAGINAL FORNIX

-CHANGE OF UTERUS AND OVARIES POSITION

-TRIANGULAR PULLING OF ANTERIOR RECTAL WALL

LIMITATIONS OF MRI EXAMINATION

Page 40: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

LAPAROSCOPY-GOLDEN STRANDARD!

Page 41: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

12/7/2017 41

� Total rate of recurrence of endometriosis after operative

treatment is:

30-40%

� Paolo Vercellini Surgery for endometriosis-Associated infertility: a pragmatic approach. Human Reproduction, Vol.24, No.2 pp. 254–269, 2009.

Page 42: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

Up to 10 years for diagnosis!!!

Every woman who has endometriosis knows another one with the same problem.

Every doctor has different opinion

and advice. However, satisfactory

treatment is still a distant dream

for many patients!

PROBLEMS

Page 43: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

What to say?Sometimes difficult to

diagnose

Right choice of therapy-does it exist?

„Find a way to send them to someone else“

„Remember one among all colleagues who you do not like“

Page 44: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

• ADDITIONAL SEQUENCES

1. FAT SUPPRESSED

2. GRADIENT ECHO

3. SUSCEPTIBILITY WEIGHTED 1 : 93 % SENSITIVITY

100 % SPECIFICITY

• INTRAVAGINALLY - US GELLY

• INTRARECTAL - CONTRAST OR WATER

• INTRAMUSCULAR – ANTIPERISTALTIC AGENS

ENHANCEMENT OF MRI EXAMINATION

1. TAKEUCHI ET AL.; SUSCEPTIBILITY WEIGHTED MRI OF ENDOMETRIOMA: PRELIMINARY RESULTS; AJR 2008.

Page 45: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

1. Multiple T1- Hyperintense adnexal cysts are specific for endometriomas

2. Female pelvis MR imaging protocols should include T1-weighted Fat-suppressed sequences

3. Low SI of adnexal masses on STIR MR images is not specific for mature cystic teratoma and does not exclude endometrioma

Ten Imaging Pearls

MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675–1691

Page 46: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

4. Benign endometriomas show restricted diffusion

5. Hematosalpinx should be considered specific for pelvic endometriosis

6. Obstruction of antegrade menstrual flow increases the risk for endometriosis

7. Decidualized endometriosis may mimic ovarian malignancy in pregnant women

MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675–1691

Page 47: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

8. Endometriomas can transform into clear cell or endometrioid epithelial ovarian carcinomas

9. Solid fibrotic masses of endometriosis are common and easily overlooked

10. Solid invasive endometriosis of the posterior uterus can mimic posterior segmental adenomyosis

MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675–1691

Page 48: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

CONCLUSION

• Consider endometriosis

in the presence of gynecological symptoms such as dysmenorrhoea,pelvic pain, dispareunia, infertility and fatigue in the presence of any of the above

Or in women of reproductive age with non-gynecological cyclical symptoms (dyschezia,dysuria, haematuria, rectal bleeding, shoulder pain)

• MR is the imaging method of choice

• Laparoscopy is the golden standard of both diagnosis and treatment

G.A.J. Dunselman et al. ESHRE guideline: management of women with endometriosis , Human Reproduction, 2014; 29 (3): 400–412.

Page 49: ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN · 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus

Atypical endometriosis

Atypical endometriosis

Developing Novel Treatments for Fibrotic Diseases

Developing Novel Treatments for Fibrotic Diseases

endometriosis therapi

endometriosis therapi

Endometriosis 1

Endometriosis 1

Extragenital endometriosis

Extragenital endometriosis

Endometriosis - Mount Sinai Hospital · The third form is deep (or solid infiltrating) pelvic endometriosis, which is defined by the invasion of endometrial glands and stroma at least

Endometriosis - Mount Sinai Hospital · The third form is deep (or solid infiltrating) pelvic endometriosis, which is defined by the invasion of endometrial glands and stroma at least

111 Endometriosis

111 Endometriosis

Endometriosis (Complete)

Endometriosis (Complete)

Endometriosis Diet

Endometriosis Diet

Fibrotic Bronchiolitis

Fibrotic Bronchiolitis

Endometriosis, analogos de gnrh, dinogest, tratamiento endometriosis

Endometriosis, analogos de gnrh, dinogest, tratamiento endometriosis

Efficacy of treatment with corticosteroids for fibrotic ...

Efficacy of treatment with corticosteroids for fibrotic ...

Endometriosis: diagnosis and management · 2019. 7. 9. · Specialist endometriosis services (endometriosis centres) 1.1.4 Specialist endometriosis services (endometriosis centres)

Endometriosis: diagnosis and management · 2019. 7. 9. · Specialist endometriosis services (endometriosis centres) 1.1.4 Specialist endometriosis services (endometriosis centres)

Endometriosis Cedip

Endometriosis Cedip

Endometriosis · Endometriosis Definition ... Clear (“Atypical”) Endometriosis May Be Associated with Peritoneal Windows . Treatment: Overall Approach Recognize Goals: – Pain

Endometriosis · Endometriosis Definition ... Clear (“Atypical”) Endometriosis May Be Associated with Peritoneal Windows . Treatment: Overall Approach Recognize Goals: – Pain

Endometriosis 2

Endometriosis 2

Asbestos Exposure Frans Naude. Pneumoconioses Fibrotic Silicosis, coal worker pneumoconiosis, asbestosis, berylliosis, talcosis Non fibrotic Siderosis.

Asbestos Exposure Frans Naude. Pneumoconioses Fibrotic Silicosis, coal worker pneumoconiosis, asbestosis, berylliosis, talcosis Non fibrotic Siderosis.

Endometriosis & Adenomyosis

Endometriosis & Adenomyosis

Cellular and molecular basis for endometriosis-associated ... · Keywords Endometriosis.Infertility.Ovary.Oocytesand embryos.Endometrium Endometriosis Endometriosis is a gynecological

Cellular and molecular basis for endometriosis-associated ... · Keywords Endometriosis.Infertility.Ovary.Oocytesand embryos.Endometrium Endometriosis Endometriosis is a gynecological

Endometriosis moodle

Endometriosis moodle