Transvaginal Sonography and Clinical Exam for Preop Pelvic Endometriosis Dx
Transvaginal Sonography and Clinical Exam for Preop Pelvic Endometriosis Dx
Background: The aim of the present study was to evaluate the accuracy of routine clinical examination (per vaginam, PV) combined with transvaginal sonography (TVS) for presurgical, non-invasive diagnosis of endometriosis.
Methods: Two-hundred women with symptoms suggestive of endometriosis were prospectively assessed by PV and TVS prior to laparoscopy and radical resection of disease and histological confirmation.
Results: Prevalence of endometriosis on the right/left (r/l) ovary, r/l uterosacral ligament (USL), pouch of Douglas (POD), vagina, bladder, rectovaginal space (RVS) and rectum was 12%, 13%, 12%, 22%, 15%, 11%, 2%, 4% and 24%. Sensitivities, specificities, positive and negative predictive values and positive and negative likelihood ratios for combined use of TVS and PV resulted in 96/100%, 100/99%, 100/93%, 93/100% and —;0.04/87.0;— for the r/l ovarian endometriosis; 67/84%, 97/86%, 73/62%, 96/95% and 19.56;0.35/5.97;0.19 for the r/l USL disease; 87%, 98%, 90%, 98% and 49.11;0.14 for involvement of the POD; 82%, 99%, 95%, 98% and 145.64;0.18 for vaginal endometriosis; 88%, 99%, 78%, 99% and 84.0;0.13 for endometriosis of the RVS; 75%, 98%, 50%, 99% and 49.0;0.25 for bladder involvement and 96%, 98%, 94%, 99% and 48.56;0.04 for rectal endometriosis.
Conclusions: The combination of PV and TVS accurately predicts the presence of endometriosis affecting the ovaries, vagina, rectum, USL, RVS and POD in patients with suspected endometriosis. We suggest the routine combination of PV and TVS as an essential part of the standard primary assessment of pelvic pain patients with suspected endometriosis.
Endometriosis is one of the most challenging gynaecological disorders affecting 10–15% of women in their reproductive years (Melis et al., 1994). Symptoms such as dysmenorrhoea, dyspareunia, dyschezia and infertility are caused by infiltrative growth of endometriotic implants involving the ovaries or uterosacral ligaments (USLs), but may also affect the vagina, the rectovaginal space (RVS) or the rectosigmoid in cases of deep infiltrating disease defined as subperitoneal endometriotic infiltration of tissues >5 mm (Cornillie et al., 1990; Brosens et al., 2004). Considerable diagnostic delay of up to 8 years from presenting symptoms often confers a heavy economic and social price (Ballard et al., 2006). One cause for this phenomenon is that the primary assessment of patients with pelvic pain and suspected endometriosis is suboptimal since it is often limited to the patient's past gynaecological history and clinical assessment of the patient, i.e. speculum and bimanual pelvic (per vaginam, PV) examination. Although bimanual examination may be helpful in detecting deep infiltrating endometriosis (DIE) of the pouch of Douglas (POD), the vagina, the RVS or the USLs (Nezhat et al., 1994; Cheewadhanaraks et al., 2004; Abrao et al., 2007), data on its value in detecting deep infiltrating disease of the bladder and the rectosigmoid are limited.
Over the past years, additional diagnostic tools such as transvaginal sonography (TVS) and/or MRI have been recommended as appropriate investigative techniques to diagnose ovarian endometriomas or adenomyosis. Several lines of recent evidence strongly suggest that the use of TVS also has an important role in detecting DIE of the pelvis not only involving the ovaries but also structures such as the vagina, the RVS, the USLs, the bladder or the rectal wall (Bazot et al., 2003, 2004b; Dessole et al., 2003; Abrao et al., 2007). It is therefore conceivable that digital bimanual-vaginal examination (PV) in combination with TVS in patients with suspected endometriosis might further increase the rate of preoperative diagnosis of DIE, especially if performed by the same examiner. At present, assessment of the pelvis at laparoscopy and histological confirmation of disease is considered the gold standard of diagnosis. The aim of the present study was to investigate the diagnostic value of PV examination and combined use of PV with TVS for non-surgical diagnosis of endometriosis of the pelvis in patients with pelvic pain and associated symptoms.
Abstract and Introduction
Abstract
Background: The aim of the present study was to evaluate the accuracy of routine clinical examination (per vaginam, PV) combined with transvaginal sonography (TVS) for presurgical, non-invasive diagnosis of endometriosis.
Methods: Two-hundred women with symptoms suggestive of endometriosis were prospectively assessed by PV and TVS prior to laparoscopy and radical resection of disease and histological confirmation.
Results: Prevalence of endometriosis on the right/left (r/l) ovary, r/l uterosacral ligament (USL), pouch of Douglas (POD), vagina, bladder, rectovaginal space (RVS) and rectum was 12%, 13%, 12%, 22%, 15%, 11%, 2%, 4% and 24%. Sensitivities, specificities, positive and negative predictive values and positive and negative likelihood ratios for combined use of TVS and PV resulted in 96/100%, 100/99%, 100/93%, 93/100% and —;0.04/87.0;— for the r/l ovarian endometriosis; 67/84%, 97/86%, 73/62%, 96/95% and 19.56;0.35/5.97;0.19 for the r/l USL disease; 87%, 98%, 90%, 98% and 49.11;0.14 for involvement of the POD; 82%, 99%, 95%, 98% and 145.64;0.18 for vaginal endometriosis; 88%, 99%, 78%, 99% and 84.0;0.13 for endometriosis of the RVS; 75%, 98%, 50%, 99% and 49.0;0.25 for bladder involvement and 96%, 98%, 94%, 99% and 48.56;0.04 for rectal endometriosis.
Conclusions: The combination of PV and TVS accurately predicts the presence of endometriosis affecting the ovaries, vagina, rectum, USL, RVS and POD in patients with suspected endometriosis. We suggest the routine combination of PV and TVS as an essential part of the standard primary assessment of pelvic pain patients with suspected endometriosis.
Introduction
Endometriosis is one of the most challenging gynaecological disorders affecting 10–15% of women in their reproductive years (Melis et al., 1994). Symptoms such as dysmenorrhoea, dyspareunia, dyschezia and infertility are caused by infiltrative growth of endometriotic implants involving the ovaries or uterosacral ligaments (USLs), but may also affect the vagina, the rectovaginal space (RVS) or the rectosigmoid in cases of deep infiltrating disease defined as subperitoneal endometriotic infiltration of tissues >5 mm (Cornillie et al., 1990; Brosens et al., 2004). Considerable diagnostic delay of up to 8 years from presenting symptoms often confers a heavy economic and social price (Ballard et al., 2006). One cause for this phenomenon is that the primary assessment of patients with pelvic pain and suspected endometriosis is suboptimal since it is often limited to the patient's past gynaecological history and clinical assessment of the patient, i.e. speculum and bimanual pelvic (per vaginam, PV) examination. Although bimanual examination may be helpful in detecting deep infiltrating endometriosis (DIE) of the pouch of Douglas (POD), the vagina, the RVS or the USLs (Nezhat et al., 1994; Cheewadhanaraks et al., 2004; Abrao et al., 2007), data on its value in detecting deep infiltrating disease of the bladder and the rectosigmoid are limited.
Over the past years, additional diagnostic tools such as transvaginal sonography (TVS) and/or MRI have been recommended as appropriate investigative techniques to diagnose ovarian endometriomas or adenomyosis. Several lines of recent evidence strongly suggest that the use of TVS also has an important role in detecting DIE of the pelvis not only involving the ovaries but also structures such as the vagina, the RVS, the USLs, the bladder or the rectal wall (Bazot et al., 2003, 2004b; Dessole et al., 2003; Abrao et al., 2007). It is therefore conceivable that digital bimanual-vaginal examination (PV) in combination with TVS in patients with suspected endometriosis might further increase the rate of preoperative diagnosis of DIE, especially if performed by the same examiner. At present, assessment of the pelvis at laparoscopy and histological confirmation of disease is considered the gold standard of diagnosis. The aim of the present study was to investigate the diagnostic value of PV examination and combined use of PV with TVS for non-surgical diagnosis of endometriosis of the pelvis in patients with pelvic pain and associated symptoms.
Source...