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Menstrual and Uterine Disorders
Few ultrasound studies have focused specifically on the detection Conclusions
of deep retroperitoneal endometriosis. On ultrasonography, One of the major challenges facing clinicians is the inability to readily
these endometriotic nodules can appear as solid hypoechogenic diagnose endometriosis because a definitive diagnosis of the disease
lesions that range from 0.5 to 4cm in size and adhere to the can be obtained only via laparoscopy or laparotomy. This poses a
anterior rectal wall. Characteristically, these lesions are more particular problem when investigating the presence of early stages of
painful when examined during menstruation. Rectal endoscopic the disease, since the detection of endometriosis is critical in stage I–II
sonography has been used to evaluate the thickness of the in infertile women in whom the laparoscopic treatment of the lesions
uterosacral ligaments and the presence of rectal infiltration in has been reported to almost double the rate of a spontaneous
patients with deep endometriosis.
57
pregnancy.
61
Indeed, at present physical examination may be helpful
only in the diagnosis of deeply infiltrative endometriosis of the cul-de-
Chapron et al.
58
recently described in detail the MRI appearances of sac and rectovaginal septum
62
and, while there is good evidence to
rectovaginal endometriotic nodules that varied between 2 and support the use of TVU for the diagnosis of endometrioma, it has been
2.5cm in size in eight affected patients. The nodules have an shown to be less accurate in non-ovarian endometriosis. Studies
irregular contour and are indistinguishable from the uterovaginal combining TVU with other soft markers such as medical history,
structures. In some cases a hyper-signal-intensity transition zone symptom reporting and pelvic examination have also been
can be identified between the rectum and the nodule, which has unsuccessful in identifying non-ovarian endometriosis.
63
On the other
been termed the ‘safety margin’. In other cases, this safety margin hand, reliable serum markers of the disease are currently lacking:
is not seen, and thickening of the rectum wall is noticed. The safety serum concentration of CA-125, the most extensively studied and used
margin is likely to represent interposing fat tissue. The retraction serum marker of endometriosis, has a limited diagnostic performance,
among the torus uterinum, the endometriotic nodule and the and the most promising newly proposed markers (urocortin, sICAM-1)
rectum results in obliteration of the pouch of Douglas. This have yet to prove their clinical efficacy in large clinical trials. ■
occurrence can give a false impression of the lesion being located
below the pouch and of radiated infiltration of the perirectal space
Pasquale Florio is a Research Associate in Obstetrics
with thickening and stiffness of the rectum wall.
59
and Gynaecology and a Lecturer in ‘Statistics for
experimental and technological research’ and ‘Medical
Nodular bladder endometriosis is not easily palpable at vaginal
therapy for male and female sterility’ in the Department
of Paediatrics, Obstetrics and Reproductive Medicine at
examination. Typically, it is found in patients with dysmenorrhoea
the University of Siena. He is also a Professor in the
with associated urinary symptoms, such as micturition frequency. PhD programme on ‘Medical biotechnologies in
TVU may reveal a solid nodule within the posterior bladder wall if
obstetrics and gynaecology’ and in the School of
Specialisation in Obstetrics and Gynaecology of the
the bladder is slightly filled. Colour Doppler studies may detect low
University of Siena. Professor Florio has authored more than 150 publications in peer-
to moderate vascularity, and mild pressure with the vaginal probe reviewed journals, and is a member of 11 scientific societies, an ad hoc peer reviewer
often elicits focal pain. In a series of 12 patients with nodular
for 15 journals and Deputy Editor of the Journal of Endometriosis. His research
interests include the identification and clinical validation of new markers of
bladder endometriosis that varied between 10 and 31mm in
endometriosis, the study of endometrial endocrinology and mechanisms leading to
diameter, TVU was normal in four patients. In contrast, MRI using a implantation and the identification of markers of foetal brain damage in pregnancy.
body coil enabled visualisation of the lesions in all patients.
60
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12 EUROPEAN OBSTETRICS & GYNAECOLOGY
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