Imaging anatomy of the lateral pelvic compartment applied to endometriosis.

Endometriosis impacts millions of women globally, making precise assessment essential for effective surgical planning and clinical management. Despite advances in transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) for diagnosis and staging, many radiologists still overlook the evaluation of lateral pelvic anatomical structures. Understanding the lateral compartment's involvement is vital for accurate disease staging and achieving optimal surgical outcomes. This pictorial review provides a thorough examination of the lateral pelvic compartment anatomy using TVUS and MRI, complemented by surgical correlations. It offers detailed discussions on pelvic ligaments, parametrium, and adjacent structures, such as nerves, vessels, and ureters. The review provides practical guidance for identifying critical anatomical structures in imaging exams and emphasizes the importance of standardized terminology. Enhancing imaging precision and diagnostic accuracy for lateral compartment endometriosis is crucial for optimal surgical planning and improved patient outcomes.

Radiology State-of-the-art Review: Endometriosis Imaging Interpretation and Reporting.

Endometriosis is a common condition impacting approximately 190 million individuals and up to 50% of women with infertility globally. The disease is characterized by endometrial-like tissue located outside of the uterine corpus, which causes cyclical hemorrhage, inflammation, and fibrosis. Based on clinical suspicion or findings at routine transvaginal pelvic US or other prior imaging, dedicated imaging for endometriosis may be warranted with MRI or advanced transvaginal US. Deep endometriosis (DE) in the pelvis includes evaluation for stromal and fibrotic components and architectural distortion resulting from fibrosis and tethering. It is a disease requiring a compartment-based, pattern-recognition approach. MRI has the benefit of global assessment of the pelvis and is effective in assessing for features of malignancy and for evaluating extrapelvic locations. Transvaginal US has the advantage of dynamic maneuvers to assess for adhesions and may achieve higher spatial resolution for assessing the depth of bowel wall invasion. T1-weighted MRI evaluation increases the specificity of diagnosis by identifying hemorrhagic components, but the presence of T1 signal hyperintensity is not essential for diagnosing DE. Endometriosis is a disease with a broad spectrum; understanding the mild through advanced manifestations, including malignancy evaluation, is within the scope and breadth of radiologists' interpretation.

Social media for radiologists: opportunities and challenges.

The use of social media in medicine offers unprecedented opportunities for social interaction. Activity on platforms such as X (formerly Twitter), Instagram, Facebook, and LinkedIn plays crucial roles in various medical services, particularly regarding patients' access to information and healthcare services, medical education, and professional networking. However, the integration of social media into healthcare is not challenge-free and has certain pitfalls. In this article, we address several critical issues that compromise the reliability and effectiveness of social media as a professional healthcare resource, particularly in the field of radiology. We discuss possible solutions and tips and tricks to facilitate the use of this valuable tool to our advantage and in a reliable manner.

Society of Radiologists in Ultrasound Consensus on Routine Pelvic US for Endometriosis.

Endometriosis is a prevalent and potentially debilitating condition that mostly affects individuals of reproductive age, and often has a substantial diagnostic delay. US is usually the first-line imaging modality used when patients report chronic pelvic pain or have issues of infertility, both common symptoms of endometriosis. Other than the visualization of an endometrioma, sonologists frequently do not appreciate endometriosis on routine transvaginal US images. Given a substantial body of literature describing techniques to depict endometriosis at US, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts to make recommendations aimed at improving the screening process for endometriosis. The panel was composed of experts in the imaging and management of endometriosis, including radiologists, sonographers, gynecologists, reproductive endocrinologists, and minimally invasive gynecologic surgeons. A comprehensive literature review combined with a modified Delphi technique achieved a consensus. This statement defines the targeted screening population, describes techniques for augmenting pelvic US, establishes direct and indirect observations for endometriosis at US, creates an observational grading and reporting system, and makes recommendations for additional imaging and patient management. The panel recommends transvaginal US of the posterior compartment, observation of the relative positioning of the uterus and ovaries, and the uterine sliding sign maneuver to improve the detection of endometriosis. These additional techniques can be performed in 5 minutes or less and could ultimately decrease the delay of an endometriosis diagnosis in at-risk patients.

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.

Imaging of Urinary Bladder and Ureteral Endometriosis with Emphasis on Diagnosis and Technique.

Endometriosis is a chronic inflammatory gynecological condition affecting 10-15% of women in the reproductive age group. The urinary tract is the second most common extragenital organ system affected by endometriosis, and the urinary bladder and ureter are the two most common sites involved. Involvement of the urinary bladder can cause chronic debilitating symptoms, whereas ureteral involvement may lead to asymptomatic loss of renal function. Both conditions are frequently unsuspected, leading to a delay in diagnosis. Therefore, it is important to recognize this entity early, for which knowledge of imaging appearances and techniques is helpful. In this review article, we describe (a) endometriosis background, pathogenesis, definitions and clinical symptoms, (b) imaging appearance, with emphasis on ultrasound and MRI findings of urinary bladder and ureteric endometriosis, (c) ultrasound technique and MRI sequences useful for making the correct diagnosis, (d) overview of the treatment options and key imaging findings that are important to the surgeon for surgical planning, and (e) a structured reporting template useful for multidisciplinary patient management.

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.

Performance of imaging interpretation, intra- and inter-reader agreement for diagnosis of pelvic endometriosis: comparison between an abbreviated and full MRI protocol.

PURPOSE: To compare the performance of imaging interpretation, intra- and inter-reader agreement between an abbreviated (aMRI) and full (fMRI) MRI protocol for diagnosis of pelvic endometriosis. METHODS: Seventy consecutive fMRI exams performed under suspicion of pelvic endometriosis were selected. Four radiologists (Rd) (1-10 years experience) independently evaluated presence/absence of endometriosis at 9 anatomic sites (AS). The readers evaluated aMRI (coronal T2 TSE volumetric images and axial T1 GRE fat-sat without contrast, extracted from fMRI) and fMRI protocols randomly, with at least 4 weeks interval between readings. The degree of confidence for diagnosis at each AS was evaluated with a 1-3 Likert Scale (1: low; 3: high). Intra- and inter-reader agreement between protocols were evaluated by kappa statistics and took reading experience into account. The gold standard for assessing the performance of imaging interpretation (sensitivity, specificity and accuracy) used a consensus reading of two other Rd (> 15 years experience). RESULTS: There was no significant difference in the accuracy of imaging interpretation between the abbreviated (0.83-0.86) and full (0.83-0.87) protocols (p = 0.15). Intra-reader agreement between protocols ranged from substantial to almost perfect (0.74-0.96). A substantial inter-reader agreement was found for both protocols for readers with similar levels of experience (0.67-0.69) and in the global analysis (0.66 for both protocols). No difference was found in terms of degree of confidence between protocols, for all readers. CONCLUSION: An abbreviated MRI protocol for pelvic endometriosis provided an accuracy of interpretation comparable to that of a complete protocol, with similar degrees of confidence and reproducibility, regardless the level of experience.

Recommendations for MRI technique in the evaluation of pelvic endometriosis: consensus statement from the Society of Abdominal Radiology endometriosis disease-focused panel.

Endometriosis is a common entity causing chronic pain and infertility in women. The gold standard method for diagnosis is diagnostic laparoscopy, which is invasive and costly. MRI has shown promise in its ability to diagnose endometriosis and its efficacy for preoperative planning. The Society of Abdominal Radiology established a Disease-Focused Panel (DFP) to improve patient care for patients with endometriosis. In this article, the DFP performs a literature review and uses its own experience to provide technical recommendations on optimizing MRI Pelvis for the evaluation of endometriosis.

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.

Endometriosis MRI lexicon: consensus statement from the society of abdominal radiology endometriosis disease-focused panel.

Endometriosis is a common gynecologic disorder characterized by the presence of ectopic endometrial tissue outside the endometrial cavity. Magnetic Resonance Imaging (MRI) has become a mainstay for diagnosis and staging of this disease. In the literature, significant heterogeneity exists in the descriptions of imaging findings and anatomic sites of involvement. The Society of Abdominal Radiology's Endometriosis Disease-Focused Panel presents this consensus document to establish an MRI lexicon for endometriosis MRI evaluation and anatomic localization.

Ultrasound evaluation of deeply infiltrative endometriosis: technique and interpretation.

Endometriosis is a common benign gynecological condition defined as the presence of endometrial tissue located outside the uterus and frequently associated with chronic pelvic pain and infertility. It is a polymorphic disease that can be presented as superficial implants, endometriomas and deep lesions that infiltrate the peritoneal surface associated with fibrosis and inflammatory reaction. Diagnosis of deep endometriosis is difficult and delayed, frequently missed in a routine ultrasound. Transvaginal ultrasound is the first-line imaging modality to investigate endometriosis and when performed by an expert in female pelvic imaging can provide a reliable mapping of the affected sites. Bowel preparation can be used to improve the detection of bowel lesions as well as the other sites affected by eliminating artifacts. Surgery has been the mainstay to treat symptomatic endometriosis and preoperative imaging mapping is crucial for better results and to reduce residual disease. The goals of surgery include radical removal of all lesions and the restoration of normal pelvic anatomy. The author describes technical aspects and imaging interpretation of the transvaginal sonography to investigate deeply infiltrative endometriosis.

Pelvic hemorrhagic lesions in women: MRI findings and differential diagnosis.

A large spectrum of pathologic pelvic conditions can present with hemorrhage in structures or organs. These may present acutely, subacutely, chronically or as incidental findings. Clinical history and MRI characteristics can often narrow the differential diagnosis and guide management. The purpose of this article is to showcase a wide array of pelvic lesions, in which the presence of blood is a key imaging feature, and their differential diagnosis.

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.

Findings of pelvic endometriosis at transvaginal US, MR imaging, and laparoscopy.

Endometriosis is a common multifocal gynecologic disease that manifests during the reproductive years, often causing chronic pelvic pain and infertility. It may occur as invasive peritoneal fibrotic nodules and adhesions or as ovarian cysts with hemorrhagic content. Although findings at physical examination may be suggestive, imaging is necessary for definitive diagnosis, patient counseling, and treatment planning. The imaging techniques that are most useful for preoperative disease mapping are transvaginal ultrasonography (US) after bowel preparation, and magnetic resonance (MR) imaging. Initial transvaginal US is a reliable technique for detecting rectosigmoid endometriotic lesions. MR imaging is indicated as a complementary examination in complex cases of endometriosis with extensive adhesions and ureteral involvement. Peritoneal endometriotic implants are typically hypoechoic on transvaginal US images and demonstrate low signal intensity on T2-weighted MR images. Endometriotic implants most commonly are found in retrocervical and rectosigmoid sites, followed by the vagina, bladder, and ureters. Cysts with low-level internal echoes and echogenic peripheral foci at transvaginal US are suggestive of endometriomas. MR imaging has high specificity for identifying endometriomas, which are characterized by high signal intensity on T1-weighted images and low signal intensity on T2-weighted images. Correlation of the radiologic imaging features of endometriotic lesions with their laparoscopic appearances may help improve individual proficiency in the radiologic diagnosis of endometriosis.

Transvaginal US after bowel preparation for deeply infiltrating endometriosis: protocol, imaging appearances, and laparoscopic correlation.

Deeply infiltrating endometriosis (DIE) is a common gynecologic disease that is characterized by a difficult and delayed diagnosis. Radiologic mapping of the DIE lesion sites is crucial for case management, patient counseling, and surgical planning. Transvaginal ultrasonography (US) is the initial imaging modality for investigating DIE and has been the focus of several recent studies. DIE typically manifests at imaging as hypoechogenic nodules throughout the affected sites and thickening of the intestinal wall, with some lesions showing a mixed pattern due to cystic areas. Transvaginal US performed after bowel preparation improves the ability to diagnose intestinal lesions and provides invaluable details, including which layers of the intestine are affected and the distance between the lesion and the anal border. It is vital that radiologists be familiar with the technical aspects of this modality and with the US manifestations of DIE lesions. Transvaginal US performed after bowel preparation should be the first-line imaging modality for the evaluation of women with suspected endometriosis.

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.