Diagnosis of deep endometriosis

The final diagnosis of a deep endometriosis nodule -defined as adenomyosis externa- is made during surgery. Confirmation by pathology is close to 100%. After previous surgery, however , it can be difficult to distinguish deep endometriosis from fibrosis.

Deep endometriosis should be suspected in all women with severe menstrual pain, especially severe dyschesia, mictalgia , deep dyspareunea and pain with perineal radiation.
The diagnostic accuracy of exams varies with the size and the localisation of the deep endometriosis nodule.

Clinical exam will obviously diagnose 100% of vaginally visible nodules if the clinician has experience. Otherwise, clinical exam will diagnose only 50% (1) to 90% of recto-vaginal nodules . A clinical exam cannot exclude a deep endometriosis nodule.

Although CA125 has a specificity and sensitivity of 90% when assayed during the first days after menstruation, it was not considered a useful clinical tool for the diagnosis of deep endometriosis (1).

Ultrasound is reported to have a sensitivity and specificity of 90 to over 95% for recto-vaginal and recto-sigmoid nodules. Accuracy moreover is operator dependent. Although the accuracy for small nodules is not known the accuracy obviously is less. A negative ultrasound exam therefore cannot exclude a small and/or a high situated or sigmoid nodule.

MRI has a similar sensitivity and specificity as ultrasound and is less operator dependent. Since the accuracy for small nodules and the lower detection limit has not been established a negative exam cannot exclude a deep endometriosis nodule.

Approved by

Surgeons.
Stephan Gordts, Life Expert Centre, Leuven, Belgium, Errico Zupi Prof Univ Tor vergate, Rome Italy, Anastasia Ussia Gruppo Italo Belga, Villa del Rosario Rome Italy, Consultant Università Cattolica, Rome, Italy, Michel Canis, Prof & Chairman, Univ Clermond Ferrand, France, , Roberta Corona,Barbados Fertility Centre, Barbados, Leila Adamyan, Academician Moscow state University,Moscow, Russia,Fabio Imperato, Villa del Rosario, Rome, Italy, Rodrigo Fernandes, Sao Paulo Brazil, Renato Seriaccholi, Prof and chairman Univ Bologna Italy, Jacques Donnez,em prog and chairman Catholic university of Louvain, David Soriano, President ISGE, Director of Center for Multidisciplinary Management of Endometriosis, Ron Schonman, Head of endometriosis clinic, Meir Medical Center, Kfar Saba, Israel

Therapy

Asymptomatic deep endometriosis without hydronephrosis and/or bowel sub-occlusion/occlusion does not necessitate surgery.. It is unclear whether medical therapy is useful.Before becoming pregnant however, is seems wise to remove a deep endometriosis nodule because of the associated serious although rare problems during pregnancy.

IVF with a deep recto-vaginal endometriosis nodule should not be performed. We endometriosis surgeons unanimously have the experience that in these women surgery after some cycles of IVF, becomes very difficult, often with a frozen pelvis, with severe pelvic adhesions. In addition conservative bowel surgery becomes more challenging and the risk of ureter or neural lesions increase.

Women with severe pain deserve a laparoscopy (medical therapy for a long time is not an option). If deep endometriosis is found it be removed if the surgeon has the skills and experience. If he has not it is preferable to refer the patient, and not to attempt surgery.

Deep endometriosis is often associated with adenomyosis, This has to be taken into account during diagnosis and counselling.

Preparation for surgery if deep endometriosis is suspected.

Ultrasound is important to estimate localisation and size of the endometriosis nodule.

For larger nodules it permits some prediction of difficulty and of duration of surgery : nodules bigger than 3 cm are always difficult surgery with often bowel and/or ureter involvement. In the individual patient it however the prediction is insufficient for the less experienced surgeon to know which patients should be referred.

it permits to exclude a hydronephrosis. it permits to discuss the probable extend and risk of the intervention with the patient

it does not permit to evaluate an eventual sub-occlusion of the sigmoid which can only be diagnosed with a contrast enema

it does not permit to predict invasion in the bowel wall with sufficient accuracy -although expert sonographers come close- to decide to do a bowel resection before surgery.

MRI does not give additional information, besides a suggestion of sigmoid endometriosis.

Surgery for deep endometriosis

Guidelines when to do a bowel resection and when to do conservative surgery cannot be formulated since this remains debated during meetings of deep endometriosis surgeons.

Discussion, considering  the ESHRE guidelines (2)

Diagnosis

Eshre guidelines : clinical diagnosis of deep endomatriosis

Eshre guidelines : clinical diagnosis of deep endometriosis

eshre guidelines : diagnosis of deep endometriosis by laparoscopy

Eshre guidelines : diagnosis of deep endometriosis by laparoscopy

The exact accuracy of the laparoscopic diagnosis of deep endometriosis cannot be found in the literature for several reasons. First if deep endometriosis is defined as >6mm under the peritoneum -as P. Koninckx suggested in 1994- typical lesions risk to be included. Secondly Surgery is not always based upon a laparoscopic diagnosis since some surgeons perform bowel resections based upon imaging and/or clinical exam.

The accuracy of clinical diagnosis when the nodule is vaginally visible obviously varies with the experience of the clinician but cannot be found in the literature.

The accuracy of the  diagnosis by clinical exam is not clear. We reported 20 years ago that   …  were felt by clinical exam, but this reflects the early pioneering years. Although probably  actually superior, the accuracy is unclear.

eshre guidelines . diagnosis of deep endometriosis biomarkers

Eshre guidelines : diagnosis of deep endometriosis biomarkers

Eshre guidelines : diagnosis of deep endometriosis by ultrasound

Eshre guidelines : diagnosis of deep endometriosis by ultrasound

The accuracy of the ultrasound diagnosis of deep endometriosis is very good for larger and for low situated deep nodules. It is unclear what the exact accuracy is for smaller and higher situated nodules and in women with fibrosis after surgery.  The Eshre guidelines based upon one reference only are highly biased. First, all ultrasound reports also include to some extend clinical pain symptoms and pain on exam. Second, since the accuracy for higher situated and smaller nodules is not clear, it remains unknown to what extend ultrasonography adds to the diagnosis.

eshre guidelines -deep endometriosis-mri

eshre guidelines -deep endometriosis-mri

Therapy

The existing guidelines clinically are not very useful since they do not consider to do a laparoscopy in all women with severe pain. As a consequence medical therapy is given to avoid surgery, which explains why it takes so long before a diagnosis is made. Another consequence is that no distinction is made between superficial and deep endometriosis since this often requires a laparoscopy.

If on the contrary a diagnostic laparoscopy is performed, diagnosis will be made. Superficial endometriosis will be treated. Deep endometriosis will at least be diagnosed and treated or referred according to the skills/experience of the surgeon.

ESHRE guidelines are given below for information

eshre-guidelines-counseling

eshre-guidelines-counseling

eshre-guidelines-medical-treatment

eshre-guidelines-medical-treatment

eshre-guidelines-oestro progestagens

eshre-guidelines-oestro progestagens

eshre-guidelines-progestagens

eshre-guidelines-progestagens

eshre-guidelines-gnrh agonists

eshre-guidelines-gnrh agonists

eshre-guidelines-deep endometriosis surgery

eshre-guidelines-deep endometriosis surgery

Reference List

1. Koninckx PR, Meuleman C, Oosterlynck D, Cornillie FJ. Diagnosis of deep endometriosis by clinical examination during menstruation and plasma CA-125 concentration. Fertil Steril. 1996;65:280-287.
2. Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De BB et al. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014;29:400-412.

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