Endometriosis is a debilitating condition affecting about one in 10 reproductive-aged women, with symptoms that may impair fertility and quality of life. Once detected, management may include medication or surgery for endometriosis.
Before advancements in ultrasound, endometriosis was largely hidden from detection, with physicians using laparoscopy to diagnose and treat the condition. Today, ultrasound screening has made detecting complex endometriosis easier and less invasive, providing high-quality imaging to visualize ovarian endometriomas and deep infiltrating endometriosis when evaluating the pelvic region. Beyond screening, the strategic use of ultrasound imaging allows careful planning of multidisciplinary surgical interventions to enhance patient health and well-being.
The full session can be viewed HERE.
Preoperative Assessment
Endometriosis is a disease defined by its complexity, often affecting multiple organ systems. Helpfully, tests performed during the ultrasound exam may reveal the extent of the disease and thus inform the surgical approach in ways that weren't widely understood until recently.
During a recent interactive session on the use of ultrasound in planning multidisciplinary endometriosis surgery, Professor George Condous says he had historically witnessed a vast mismatch between pre-op ultrasound imaging versus the complexity of the disease discovered in surgery.
Describing a pivotal example from more than a decade ago, he recalls, "We were scanning a patient who had symptoms suggestive of endometriosis, and it was a real light bulb, Eureka moment, where we saw for the first time a rectal lesion," he notes. "And what I realized, during my surgical fellowship, is that we were looking at the rectovaginal septum, which is almost always normal. So this first rectal nodule we saw was above the level of the cervix." With that in mind, according to Dr. Condous, they began their journey into endometriosis imaging.
Dr. Condous suggests a preoperative assessment ahead of surgery for endometriosis that includes a scan of the rectum, uterus, ovaries, anterior compartment, bladder, ureters, vagina, uterosacral ligaments, and torus. The sliding sign test can reveal obliteration of the rectouterine pouch, also known as the pouch of Douglas, a common late-stage complication of endometriosis. Transvaginal ultrasound is typically the first choice for this assessment, but he notes that transrectal ultrasound is also an effective option for patients uncomfortable with the transvaginal probe.
Planning for Endometriosis Surgery
Ultrasound investigation offers insight into the extent of the disease, allowing for multidisciplinary planning ahead of surgery. As a surgical planning tool, ultrasound can predict the endometriosis stage, guided by standards from the American Society for Reproductive Medicine (ASRM). Ultrasound offers insight on the potential length and complexity of surgery for endometriosis, informing the decision to enlist the expertise of colorectal or urological surgeons when bowel or bladder endometriosis is discovered postoperatively.
Dr. Condous routinely works with a multidisciplinary team. They gather monthly to review cases and plan surgical approaches based on ultrasound findings. Given the complexity of many endometriosis cases, he believes that consultative planning ensures that surgeons with the necessary skill are present to handle these cases.
The following three examples illustrate the team's approach to ultrasound assessment and surgery for endometriosis.
Case One: Abnormal Anatomy
The patient was a 46-year-old woman with a history of one cesarean section and surgery for rectal endometriosis. Her symptoms included heavy menstrual bleeding, rectal bleeding, dysmenorrhea, chronic pelvic pain, noncyclical dyspareunia, and cyclical dyskinesia, but no dysuria. She was scheduled for a colonoscopy, laparoscopic hysterectomy, cystoscopy, insertion of ureteric catheters, bilateral ureterolysis, appendectomy, adhesiolysis, and rectal segmental resection.
The presurgery ultrasound showed some adenomyosis features, such as myometrial echotexture, irregular junctional zone, and hyper-echogenic buds. Her ovaries appeared fixed to the uterus, and the pouch of Douglas appeared obliterated. A dynamic evaluation of the sliding sign revealed a rectal lesion measuring 3.3 millimeters long in the muscularis propria of the anterior rectal wall. An examination of the anterior compartment, bladder, ureters, vagina, uterus, uterosacral ligaments, and torus suggested possible multifocal rectal disease, uterosacral disease, torus disease, and a lesion in the pouch of the upper rectovaginal septum. However, the vagina and anterior compartment appeared normal.
She was prepped with ureteric catheters for surgery, as Dr. Condous has seen improvements in injury rates in complicated cases with the use of catheters. Using ultrasound during surgery, the team measured the rectal lesion in three planes, as per the consensus statement, says Dr. Condous. Ultrasound revealed abnormal anatomy, with the rectum fixed to the back of the uterus, with adherence between the rectum and the back of the cervix, in the region of the torus uterus.
"So the principle is to normalize the anatomy first in those cases where there's disordered anatomy, and then we perform the surgery," he notes. The team proceeded to open up the two pararectal spaces, move laterally to medially, and then freed the bowel before removing the diseased tissue.
The multidisciplinary team included a bowel surgeon, who performed an intraoperative colonoscopy to rule out coexisting pathology, and a flexible sigmoidoscopy at the end of surgery to confirm that the bowel was free of any bleeding.
Case Two: Findings From a Presurgical Sliding Scale Test
The second case involved a 40-year-old woman experiencing heavy menstrual bleeding, dysmenorrhea, dyskinesia, and dyspareunia. Along with a 10-year history of subfertility, she'd had three laparotomies and an appendectomy for endometriosis in the past. The surgical plan included a cystoscopy and hysterectomy.
An ultrasound and sliding scale test performed prior to surgery showed that the uterus was axial, ovaries were fixed, and the rectouterine pouch was partially obliterated. The ultrasound also showed the presence of multifocal disease, with more than two lesions appearing in the same segment of the bowel, along with uterosacral ligament endometriosis. Research suggests that the uterosacral ligament is where most endometrial lesions are found.
In this case, Dr. Condous says color Doppler proved instrumental, helping to differentiate between vessels running through the uterosacral ligament and the lesions. He adds that the case is a prime example of how insight gathered in the preoperative ultrasound assessment can positively inform treatment planning.
Dr. Condous notes that the patient had only been booked for a hysterectomy. If they hadn't scanned this patient, he points out, the surgeon could have potentially left residual disease and symptoms if they had only performed a hysterectomy. Dr. Condous suggests this scenario is becoming increasingly common among patients who have had hysterectomies alone to treat endometriosis, leaving patients with continuing symptoms.
Case Three: Chronic Pelvic Pain and Endometrioma
In the third case, a 37-year-old woman with no previous abdominal surgeries had been experiencing chronic pelvic pain, dysmenorrhea, severe dyschezia, and periodic rectal bleeding. An ultrasound revealed an anteverted uterus without abnormalities, fixed ovaries, and complete obliteration of the pouch of Douglas. The scan showed rectal disease, torus disease, and uterosacral ligament endometriosis, with a large lesion suggesting unifocal disease with endometrioma, says Dr. Condous.
A patient with "endometrioma is very, very highly likely to have underlying uterosacral disease as well," he notes. "So always go looking for deep endometriosis when you've got an endometrioma present."
Given the ultrasound findings, the team established a surgical treatment plan including laparoscopic resection of endometriosis, rectal segmental resection, ovarian cystectomy, and adhesiolysis.
Ultrasound as a Preoperative Assessment Tool for Endometriosis Cases
Today, ultrasound imaging facilitates multidisciplinary surgical planning, providing welcome relief to patients with this debilitating condition. As these three cases show, preoperative ultrasound assessment can shed critical light on a patient's condition and significantly alter diagnosis, as well as the plan for treatment.
