The risk factors for endometriosis are thought to be related to increased exposure to menstruation. These include early age of menarche, short menstrual cycle, long duration of menstrual flow, nulliparity, and positive family history. In postmenopausal women, exogenous estrogen replacement therapy is hypothesized to be a causative factor, however cases without exogenous estrogen exposure are also described. Other symptoms depend on location of endometriosis and organs involved; however, symptoms do not necessarily correlate with extent or severity of disease.
Radiologist familiarity with the various imaging appearances of endometriosis may permit earlier diagnosis, reduce treatment delays, and minimize the financial impact of the disease.
Multiple theories regarding the pathogenesis of endometriosis have been proposed. Currently, the most widely accepted is the retrograde menstruation theory which hypothesizes that retrograde menstruation allows endometrial tissue to reflux through the fallopian tubes and implant on peritoneal surfaces or pelvic organs where it can continue to grow with hormonal cycles.
Alternatively, the metaplastic theory suggests that existing peritoneal cells differentiate into functioning endometrial cells and is based on embryological development since both peritoneal and endometrial tissue are derived from coelomic wall epithelium. Finally, the induction theory suggests a combination of the two above mentioned theories, proposing that shed endometrium releases substances that allow undifferentiated mesenchyme to differentiate into endometriotic tissue.
A dedicated MRI protocol is essential for identification of disease and surgical planning. MRI imaging at 3 Tesla is preferred due to superior resolution. Specific sequences with and without fat saturation are helpful in differentiating cystic teratomas from endometriomas. Diffusion-weighted sequences can be helpful in identifying endometriotic deposits that restrict diffusion secondary to blood products, and can be used for the assessment of malignant transformation.
Sagittal T1- and T2-weighted imaging are very helpful for identifying disease in the anterior and posterior cul-de-sacs, which may be overlooked on axial or coronal imaging. Administration of intravenous contrast is important, as areas of mural nodularity or solid components may exist within an ovarian lesion, and is essential to differentiate endometriomas from other cystic neoplasms.
Subtraction of pre- and postcontrast T1-weighted images is also often helpful, as the intrinsic T1-weighted hyperintensity within the endometrioma can make it difficult to visually assess for contrast enhancement. Anti-peristaltic agents help reduce motion artifacts on the studies and improve visualization of bowel lesions. Rectal and vaginal gel help optimize visualization of endometriosis deposits on the vaginal and rectal wall.
At Mayo Clinic we routinely use vaginal gel and rectal gel for troubleshooting or for patients who are suspected of having rectosigmoid involvement. Table 1 details the endometriosis imaging protocol used at Mayo Clinic. Endometriosis can be intraperitoneal or extraperitoneal.
In the pelvis, endometriosis commonly involves the peritoneum anterior and posterior cul-de-sacs, pelvic side walls and ovarian fossa , uterosacral ligaments, ovaries, fallopian tubes, and uterus.
Other structures less commonly involved include the rectovaginal septum, rectum, sigmoid colon, appendix, ureters, and bladder. Additional extra-pelvic endometriosis is uncommon but can involve the diaphragm, cecum, small and large bowel, abdominal wall, and other abdominal organs.
There are three forms of intraperitoneal pelvic endometriosis. Superficial peritoneal implants are hemorrhagic and nonhemorrhagic deposits on the surface of pelvic organs or the peritoneum, favoring the cul-de-sacs and adnexae.
They can grow with monthly bleeding and generate plaque-like reactive fibrosis. Small nonhemorrhagic foci of superficial endometriosis are often not detectable with MRI or ultrasound due to their small size, whereas they are easily identified at laparoscopy.
They may appear as plaque-like reactive fibrosis. Superficial endometriosis is often not detectable with MRI or ultrasound. Background Endometriosis is a chronic gynaecological condition affecting women of reproductive age and may cause pelvic pain and infertility. Conclusion Owing to the possibility to perform a complete assessment of all pelvic compartments at one time, MRI represents the best imaging technique for preoperative staging of endometriosis, in order to choose the more appropriate surgical approach and to plan a multidisciplinary team work.
Keywords: Endometriosis, Magnetic resonance imaging, Endometrioma, Deep infiltrating endometriosis, Pelvis, Pelvic pain.
Introduction Endometriosis is a chronic multifocal gynecologic disease that affects women of reproductive age and may cause pelvic pain and infertility. Locations and clinical features The primary locations of endometriosis are in the pelvis: on the ovaries, uterus, fallopian tubes, uterosacral ligaments USL , broad ligaments, round ligaments, cul-de-sac, rectosigmoid colon, bladder, ureters, and rectovaginal septum RVS Fig.
Open in a separate window. Table 1 Primary locations of endometriosis, their prevalence in patients with endometriosis, clinical features and differential diagnosis [ 3 , 10 , 11 ].
Table 2 MRI protocol. Types of endometriotic lesions: MR imaging appearance with pathologic correlation The main different types of endometriotic lesions are as follows: endometrial ovarian cysts endometriomas ; small superficial peritoneal implants; adhesions; deep infiltrating endometriosis—solid deep lesions involving round ligaments, parametrium, retrocervical region, USL; deep infiltrating endometriosis—visceral solid endometriosis involving the bladder and rectal wall. MR imaging findings Because of the multifocal nature of the disease, often foci of endometriosis are simultaneously observed at different sites.
Ovarian endometriosis may show the following patterns [ 37 ]: superficial implants associated with fibrous adhesions; micro intra-ovarian endometriomas; deep implants with repeated cyclic haemorrhage resulting in endometriotic cysts endometriomas. Uterine serosa, round ligaments, broad ligaments, fallopian tube The vesicouterine pouch or anterior cul-de-sac is a common site of endometriotic involvement [ 2 ]. Retrocervical region, uterosacral ligaments The retrocervical area is a virtual extraperitoneal space behind the cervix, located above the rectovaginal septum [ 2 ].
Rectovaginal space The rectovaginal space is the anatomical region located between the posterior vaginal wall and the anterior rectal wall.
Vagina Vaginal endometriosis is usually associated with implants in other pelvic locations, mostly retrocervical and rectal lesions; seldom isolated involvement of the vagina may occur.
Rectosigmoid colon Among the bowel segments the rectosigmoid is the most commonly involved by endometriosis Table 3 Different laparoscopic bowel resection techniques depending on the degree of invasion [ 51 ].
Diaphragmatic endometriosis Diaphragmatic endometriosis is thought to be rare, accounting for about 1. Conclusions Endometriosis is a chronic condition affecting women during the reproductive lifespan. References 1. Eur Radiol. MR imaging in deep pelvic endometriosis: a pictorial essay. Findings of pelvic endometriosis at transvaginal US, MR imaging, and laparoscopy. Creating solutions in endometriosis: global collaboration through the world endometriosis research foundation.
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Hum Reprod. Review of anatomy, clinical characteristics, and MR imaging features. Abdom Imaging. Deep retroperitoneal pelvic endometriosis: MR imaging appearance with laparoscopic correlation. The importance of pelvic nerve fibers in endometriosis. Womens Health Lond ; 11 5 — Diagnosis and treatment of bladder endometriosis: state of the art.
Urol Int. Polypoid endometriosis of post vaginal fornix: utility of MRI imaging of pelvis with diffusion weighted imaging for diagnosis. Med J Malaysia. Deep infiltrating endometriosis of the bowel: MR imaging as a method to predict muscular invasion. Redwine DB. Diaphragmatic endometriosis: diagnosis, surgical management, and long-term results of treatment. MR diagnosis of diaphragmatic endometriosis. JSLS 18 3. Cyclical sciatica: endometriosis of the sciatic nerve.
J Bone Joint Surg Br. Magnetic resonance neurography for the diagnosis of extrapelvic sciatic endometriosis. Possover M, Chiantera V. Isolated infiltrative endometriosis of the sciatic nerve: a report of three patients. Endoscopic rendezvous procedure for ureteral iatrogenic detachment: report of a case series with long-term outcomes. J Endourol. Susceptibility-weighted MRI of endometrioma: preliminary results. Pelvic endometriosis: MR imaging spectrum with laparoscopic correlation and diagnostic pitfalls.
Radiol Med. MR imaging of endometriosis: ten imaging pearls. Deep infiltrating endometriosis affecting the urinary tract-surgical treatment and fertility outcomes in Gynecol Surg. Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series.
Bladder endometriosis: a systematic review of pathogenesis, diagnosis, treatment, impact on fertility, and risk of malignant transformation. Eur Urol. Bladder endometriosis: characterization by magnetic resonance imaging and the value of documenting ureteral involvement.
Ureteral endometriosis: a complication of rectovaginal endometriotic adenomyotic nodules. Laparoscopic management of ureteral endometriosis: the Stanford University hospital experience with 96 consecutive cases. J Urol. Different patterns of pelvic ureteral endometriosis.
What is the best treatment? Results of a retrospective analysis. Arch Ital Urol Androl. Importance of retroperitoneal ureteric evaluation in cases of deep infiltrating endometriosis. J Minim Invasive Gynecol. MR imaging of ovarian masses: classification and differential diagnosis. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev. The utility of diffusion-weighted magnetic resonance imaging in differentiation of endometriomas from hemorrhagic ovarian cysts.
Clin Imaging. Diffusion-weighted magnetic resonance imaging in the differentiation of endometriomas from hemorrhagic cysts in the ovary. Acta Radiol. Surgery for endometriosis: beyond medical therapies. Non-neoplastic diseases of the fallopian tube: MR imaging with emphasis on diffusion-weighted imaging. Accuracy of magnetic resonance in deeply infiltrating endometriosis: a systematic review and meta-analysis.
Arch Gynecol Obstet. Role of diffusion-weighted imaging in the diagnosis of gynecological diseases. Value of thin-section oblique axial T2-weighted magnetic resonance images to assess uterosacral ligament endometriosis. Urinary complications after surgery for posterior deep infiltrating endometriosis are related to the extent of dissection and to uterosacral ligaments resection. Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized, controlled trial.
The feasibility of laparoscopic bowel resection performed by a gynaecologist to treat endometriosis. Curr Opin Obstet Gynecol. Bowel resection for deep endometriosis: a systematic review. Evaluation of MR diffusion-weighted imaging in differentiating endometriosis infiltrating the bowel from colorectal carcinoma.
Neural involvement in endometriosis: review of anatomic distribution and mechanisms. Clin Anat. Endometriotic lesions of the lower troncular nerves. Gynecol Obstet Fertil. Biomarkers of pelvic endometriosis. Rev Bras Ginecol Obstet. Reducing low-value care in endometriosis between limited evidence and unresolved issues: a proposal. Articles from Insights into Imaging are provided here courtesy of Springer.
Support Center Support Center. External link. Please review our privacy policy. Case 2: in anterior abdominal wall Case 2: in anterior abdominal wall. Figure 3: endometriosis distribution Figure 3: endometriosis distribution. Case 3: scar endometriosis Case 3: scar endometriosis. Case 4 Case 4. Case 5 Case 5. Case 6 Case 6. Case 7: scar endometriosis Case 7: scar endometriosis. Case 9: involving bladder Case 9: involving bladder. Case 8: rectovaginal septal nodule Case 8: rectovaginal septal nodule.
Case scar endometriosis : rectus abdominis muscle Case scar endometriosis : rectus abdominis muscle. Case involving right ovary Case involving right ovary. Case 12 Case Case deep infiltration involving spinal nerves Case deep infiltration involving spinal nerves. Case involving abdominal wall Case involving abdominal wall. Case causing recurrent small bowel obstruction Case causing recurrent small bowel obstruction.
Case rectosigmoid endometriosis Case rectosigmoid endometriosis. Case deep infiltrating, rectovaginal Case deep infiltrating, rectovaginal. Case endometrioma, omental endometriosis Case endometrioma, omental endometriosis. Case bilateral Fallopian tubes endometriosis Case bilateral Fallopian tubes endometriosis. Loading more images Close Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys.
Swallowing Swallowing disorders update. Temporal Bone Anatomy 1. Tinnitus Pulsatile and non-pulsatile tinnitus. Bone Tumors Bone tumors in alphabetical order Differential diagnosis of bone tumors Osteolytic - ill defined Osteolytic - well defined Sclerotic tumors. Diabetic foot MRI examination. Hip Arthroplasty.
Knee Meniscal pathology Non-Meniscal pathology Meniscus special cases. Muscle MRI traumatic changes Non-traumatic changes. Stress fractures Stress fractures. Ultrasound US-guided injection of joints. Wrist Carpal instability Fractures. Anatomy Anatomy. Brain Tumor Systematic Approach. Epilepsy Role of MRI. Normal values. Hip pathology in Children.
Normal values Normal Values in Ultrasound. Radiology Assistant Information. Apps Radiology Assistant 2. How to make videos and illustrations How to make illustrations in Keynote How to make videos in Quicktime Player. CT Protocols CT contrast injection and protocols. Click on image for enlarged view. The illustration shows the typical localizations of endometriosis: ovarian endometrioma retrocervical endometriosis deep bowel endometriosis bladder endometriosis abdominal wall endometriosis.
MRI-protocol If the only reason for performing MRI is to determine the presence or extent of endometriosis, the sequences listed in the table on the left are sufficient. Small superficial endometriotic plaque at laparoscopy. Coronal T2 and T1-Fatsat images: superficial serosal implants of endometriosis. Sagittal T2-weighted images demonstrating endometriosis infiltrating the rectum and endometriosis infiltrating the bladder.
Endometriosis in the posterior cul-de-sac with infiltration of the rectal wall. Cul-de-sac localization The cul-de-sac is the most common site of pelvic involvement. Uterus The torus uterinus - where the sacrouterine ligaments attach - and posterior fornix are common localizations of endometriosis. Endometriosis involving the torus uterinus. T2-images of endometriosis involving the torus uterinus.
Retrocervical endometriosis. Endometriosis with involvement of the left sacrouterine ligament. T2-weighted images demonstrating involvement of the left sacrouterine ligament. Rectal endometriosis. Rectal stenosis due to endometriosis.
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