MRI Features of Pelvic Nerve Involvement in Endometriosis.

Endometriosis is a common condition that mostly affects people assigned as female at birth. The most common clinical symptom of endometriosis is pain. Although the mechanism for this pain is poorly understood, in some cases, the nerves are directly involved in endometriosis. Endometriosis is a multifocal disease, and the pelvis is the most common location involved. Nerves in the pelvis can become entrapped and involved in endometriosis. Pelvic nerves are visible at pelvic MRI, especially when imaging planes and sequences are tailored for neural evaluation. In particular, high-spatial-resolution anatomic imaging including three-dimensional isotropic imaging and contrast-enhanced three-dimensional short inversion time inversion-recovery (STIR) fast spin-echo sequences are useful for nerve imaging. The most commonly involved nerves are the sciatic, obturator, femoral, pudendal, and inferior hypogastric nerves and the inferior hypogastric and lumbosacral plexuses. Although it is thought to be rare, the true incidence of nerve involvement in endometriosis is not known. Symptoms of neural involvement include pain, weakness, numbness, incontinence, and paraplegia and may be constant or cyclic (catamenial). Early diagnosis of neural involvement in endometriosis is important to prevent irreversible nerve damage and chronic sensorimotor neuropathy. Evidence of irreversible damage can also be seen at MRI, and radiologists should evaluate pelvic nerves that are commonly involved in endometriosis in their search pattern and report template to ensure that this information is incorporated into treatment planning.

The Cecum Revisited: A Multimodality Imaging Case-based Review of Common and Uncommon Cecal Diseases.

A wide range of conditions involving the cecum may be found in patients undergoing imaging work-up for conditions as various as right lower pain, diarrhea, fever, and weight loss. The cecum may be the only area of involvement by a particular disease. However, it may also be affected by a more diffuse process of the gastrointestinal tract or even as part of systemic diseases. Imaging provides an excellent evaluation of the cecal region and its surrounding planes, with an impactful clinical application in multiple scenarios. While typical features in many situations allow establishing a confident diagnosis, there are also challenging entities with overlapping features, making it critical for the radiologist awareness of the whole gamut of these conditions, as well as the ability to correlate imaging findings with other clinical data. Additional challenges to the imaging evaluation include anatomical variations of the cecal position and the absence of proper colonic distention in some cases. This article aims to revisit the spectrum of cross-sectional imaging features of common and uncommon pathologies involving the cecum, ranging from inflammatory and infectious to vascular and neoplastic ones.

Postoperative imaging findings after laparoscopic surgery for deeply infiltrating endometriosis.

Deeply infiltrative endometriosis (DIE) is a common gynecologic disease affecting women of reproductive age and often causing chronic pelvic pain and infertility. Clinical treatment options and preventive actions are ineffective due to the lack of knowledge about the etiology of DIE. Surgical treatment is currently the only alternative to eradicate the disease. Diagnostic imaging plays a crucial role for surgical planning and postoperative evaluation. Transvaginal sonography (TVS) with a dedicated protocol and magnetic resonance imaging (MRI) can be used to evaluate recurrent disease. Extensive pelvic surgery may cause anatomical changes and a variable spectrum of postoperative findings. Residual disease and complications can be also evaluated and are of great importance to estimate pain relief and fertility prognosis. The most common imaging findings following radical surgery for DIE are fibrotic scars in the retrocervical space and bowel anastomosis, absence of the posterior vaginal fornix and loculated fluid in the pararectal spaces. Ovaries are the most frequent site of early recurrence. Complications include infection, hemorrhage, urinary/evacuatory voiding dysfunctions as well as bowel and ureteral stenosis. The purpose of this article is to review the surgical techniques currently used to treat endometriosis in the retrocervical space, vagina, bladder, bowel, ureters, and ovaries and to describe the most common imaging findings including normal aspects, residual disease, complications, and recurrence.

Translabial US and Dynamic MR Imaging of the Pelvic Floor: Normal Anatomy and Dysfunction.

Pelvic floor dysfunction (PFD) is a common condition that typically affects women older than 50 years and decreases the quality of life. Weakening of support structures can involve all three pelvic compartments and cause a combination of symptoms, including constipation, urinary and fecal incontinence, obstructed defecation, pelvic pain, perineal bulging, and sexual dysfunction. The causes of PFD are complex and multifactorial; however, vaginal delivery is considered a major predisposing factor. Physical examination alone is limited in the evaluation of PFD; it frequently leads to an underestimation of the involved compartments. Imaging has an important role in the clinical evaluation, yielding invaluable information for patient counseling and surgical planning. Three- and four-dimensional translabial ultrasonography (US) is a relatively new imaging modality with high accuracy in the evaluation of PFD such as urinary incontinence, pelvic organ prolapse, and puborectalis avulsion. Evaluation of mesh implants is another important indication for this modality. Dynamic magnetic resonance (MR) imaging of the pelvic floor is a well-established modality for pelvic floor evaluation, with high-resolution images yielding detailed anatomic information and dynamic sequences yielding functional data. Specific protocols and dedicated image interpretation are required with both of these imaging methods. In this article, the authors review the normal anatomy of the female pelvic floor by using a practical approach, discuss the roles of translabial US and MR imaging in the investigation of PFD, describe the most appropriate imaging protocols, and illustrate the most common imaging findings of PFD in the anterior, middle, and posterior compartments of the pelvis. Online supplemental material is available for this article. ©RSNA, 2018.

Atypical Sites of Deeply Infiltrative Endometriosis: Clinical Characteristics and Imaging Findings.

Endometriosis is defined as the presence of endometrial tissue that is located outside the uterine cavity and associated with fibrosis and inflammatory reaction. It is a polymorphic and multifocal disease with no known cure or preventive mechanisms. Patients may be asymptomatic or may experience chronic pelvic pain, dysmenorrhea, dyspareunia, or infertility. The pelvic cavity is the most common location for endometriotic implants, which usually affect the retrocervical space, ovaries, vagina, rectosigmoid colon, bladder dome, and round ligaments. Atypical endometriosis is rare and difficult to diagnose. The most common atypical locations are the gastrointestinal tract, urinary tract, lung, umbilicus, inguinal area, breast, and pelvic nerves, as well as abdominal surgical scars. Gastrointestinal lesions are the most common extragenital manifestation, and the diaphragm is the most frequent extrapelvic site. The catamenial nature of the symptoms (occurring between 24 hours before and 72 hours after the onset of menstruation) may help suggest the diagnosis, but imaging by specialists is fundamental to evaluation. Depending on the area affected, radiography, ultrasonography, thin-section computed tomography, or magnetic resonance imaging can be used to assess suspected lesions. Because isolated extragenital endometriosis is rare, concomitant evaluation of the pelvic cavity is mandatory. Surgical excision is the only therapeutic option for definitive treatment, and comprehensive disease mapping is necessary to avoid residual disease. The authors review atypical locations for endometriosis and emphasize the most appropriate imaging protocols for investigation of various clinical manifestations. Online supplemental material is available for this article. ©RSNA, 2018.

Accuracy of magnetic resonance imaging for diagnosis and preoperative assessment of deeply infiltrating endometriosis.

OBJECTIVE: To evaluate the accuracy of preoperative magnetic resonance imaging (MRI) findings relative to surgical presence of deeply infiltrating endometriosis (DIE). METHODS: This prospective study included 92 women with clinical suspicion of DIE. The MR images were compared with laparoscopy and pathology findings. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI for diagnosis of DIE were assessed. RESULTS: DIE was confirmed at histopathology in 77 of the 92 patients (83.7%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI to diagnose DIE at each of the specific sites evaluated were as follows: retrocervical space (89.4%, 92.3%, 96.7%, 77.4%, 90.2%); rectosigmoid (86.0%, 92.9%, 93.5%, 84.8%, 89.1%); bladder (23.1%, 100%, 100%, 88.8%, 89.1%); ureters (50.0%, 100%, 95.5%, 95.7%); and vagina (72.7%, 100%, 100%, 96.4%, 96.7%). CONCLUSION: MRI demonstrates high accuracy in diagnosing DIE in the retrocervical region, rectosigmoid, bladder, ureters, and vagina.

Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis.

BACKGROUND: Deeply infiltrating endometriosis affecting the retrocervical region and the rectosigmoid generally requires surgical treatment. Clinical examination, transvaginal ultrasonography (TVUS) and pelvic magnetic resonance imaging (MRI) are useful in the preoperative diagnosis of the involvement of these sites. The objective of this study was to evaluate the capacity of digital vaginal examination, TVUS and MRI to diagnose rectosigmoid and retrocervical involvement. METHODS: A total of 104 patients with clinically suspected endometriosis were submitted to clinical examination, pelvic MRI and TVUS until 3 months prior to videolaparoscopy and the findings of these methods were matched with histopathological confirmation of endometriosis. RESULTS: Endometriosis was histologically confirmed in 98 of 104 (94.2%) patients. With respect to the rectosigmoid and retrocervical sites, respectively, digital vaginal examination had a sensitivity of 72 and 68%, specificity of 54 and 46%, positive predictive value (PPV) of 63 and 45%, negative predictive value (NPV) of 64 and 69% and accuracy of 63 and 55%. For TVUS, sensitivity was 98 and 95%, specificity 100 and 98%, PPV 100 and 98%, NPV 98 and 97% and accuracy 99 and 97%. MRI had a sensitivity of 83 and 76%, specificity of 98 and 68%, PPV of 98 and 61%, NPV of 85 and 81% and accuracy of 90 and 71%. CONCLUSIONS: TVUS had better sensitivity, specificity, PPV, NPV and accuracy in cases of deep retrocervical and rectosigmoid endometriosis when compared with MRI and digital vaginal examination, confirming that it is an important preoperative examination for the definition of surgical strategies.