Fact-sheet: External endometriosis


Updated on 08/25/2020 at 4:44 PM

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Definition

  • Implantation of endometrial tissue (glands and stroma) outside the uterine cavity.
  • Frequency: 10% of the female population.
  • Peak age: between 25 and 40 years
  • Condition whose diagnosis is often difficult and delayed (5 to 10 years depending on the form).
  • The MRI/ultrasound combination should precede diagnostic laparoscopy.
  • 3 forms, often associated: Ovarian endometrioma.
  • Deep infiltrating subperitoneal endometriosis.
  • Superficial endometriosis.

Clinical features

• Dyspareunia (deep, thrusting, positional)
• Dysmenorrhea, catamenial pain.
• Chronic pelvic pain.
• Infertility

Symptomatology varies with the cycle.
Symptomatology varies with the location (pleural, diaphragmatic).

Ultrasound

First-line examination:

Ovarian form (endometrioma):

  • Ovoid cystic lesion
  • Fine ground-glass appearance
  • Regular contours.
  • Thin wall in young endometriomas and thick wall greater than 3 mm in older lesions, related to repeated hemorrhage.
  • Homogeneous, finely echogenic content (seen in 80%).
  • Dependent, adherent hyperechoic clots.
  • Doppler: often avascular on Doppler; some endometriomas show predominantly arterial vascularization
  • Bilaterality in 42%.
  • Kissing ovaries: ovaries adherent to the digestive tract and to the posterior aspect of the uterus: suggestive sign

Deep infiltrating endometriosis

  • Heterogeneous hypoechoic masses, nodular or with irregular contours.
  • to be searched for in cases of uterine retroversion
  • Vascularization varies according to the age of the lesions.
  • A normal ultrasound does not rule out the diagnosis.

The rectosigmoid junction is the site of predilection:

  • Severe form.
  • Hypoechoic or hypointense mass of variable size adherent to the posterior uterine wall and the anterior rectal wall.

Kidney evaluation: assessment for pyelocaliceal dilation.

MRI

Reference examination, allows precise mapping of subperitoneal lesions. Look for implants with T1 hyperintensity and variable T2 signal, often T2 hypointense.

Ovarian form (endometrioma):

  • T1: hyperintense (greater than subcutaneous fat)
  • T1 Fat-Sat: persistent hyperintensity
  • T2: look for shading, i.e., T2 hypointensity of part of the cyst, signal drop.
  • After gadolinium injection: no wall enhancement.

Suggestive but nonspecific appearance; all T1 and T2 signal patterns are possible. Differential diagnosis with dermoid cyst.

Deep infiltrating endometriosis: signal varies according to the type of lesion.

  • T1 and T2 hypointense appearance: fibrous, containing foci
  • T1 hyperintensity (persistent on fat saturation): hemorrhage.
  • T2 hyperintensity: cystic.
  • Vaginal opacification with ultrasound gel facilitates detection of vaginal wall lesions

The rectosigmoid junction is the site of predilection: severe form. Loss of the hypointense signal of the digestive wall muscularis, confirmed by absence of enhancement after gadolinium injection. Assess the level relative to the levator ani muscles, the depth of the lesion within the digestive wall, its circumference, and multifocality. Look for signs of adhesions: uterine retroflexion, attraction of bowel loops, peritoneal effusion above the uterine fundus...

Involvement of the uterosacral ligaments:

  • Irregular or asymmetric nodular thickening > 9mm
  • Involvement of the torus produces a retractile, stellate appearance.
  • Cervicovaginal involvement, less common: vaginal involvement often cystic, to be differentiated from Nabothian cysts. Failure of the posterior vaginal fornix to unfold is suggestive.

The vagina: involvement of the posterior vaginal fornix and the rectovaginal septum. Look for surgical history: cesarean section. These lesions are most often located opposite the vesicovaginal septum. Endovaginal ultrasound may miss bladder lesions.

Bladder involvement: this is a lesion of the vesicouterine pouch, oblong, 2 to 3 cm in size, with obtuse angles at its junction with the bladder. This lesion is T1 and T2 hypointense, containing cystic components. This mass is outlined against the bladder by a highly echogenic line not found in cancers.

Ureteral endometriosis: this involvement may be extrinsic or intrinsic. The pelvic ureter is the segment most commonly affected. Ureterohydronephrosis in a young woman should raise suspicion of endometriosis.

Management

  • Multidisciplinary management
  • Medical treatment
  • Surgical treatment
  • Psychosocial management

Differential diagnosis

  • Hemorrhagic functional cyst
  • Dermoid cyst
  • Abscess
  • Serous tumors of the ovary (including benign serous cystadenoma)