Comparisons of Clinical Examination, Transvaginal Sonography and MRI
Comparisons of Clinical Examination, Transvaginal Sonography and MRI
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%.
Conculsions: 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.
Endometriosis is one of the most prevalent conditions in gynecology today and in recent years has been one of the most studied (Giudice and Kao, 2004). Following recognition of the importance of the degree of infiltration of the endometriotic lesions (Koninckx and Martin, 1992), various studies have emphasized the relevance of this topic for the adequate treatment of the disease (Brosens and Brosens, 2000). Endometriosis is considered to be infiltrative when lesions reach a depth of >5 mm into the peritoneum, and may be situated in the Douglas pouch, in the vesicouterine pouch and in other regions of the pelvis (Cornillie et al., 1990). It should be emphasized that the retrouterine, infiltrative form of the disease may be retrocervical if the primary area affected lies between the lower third of the vagina and the rectum (Martin and Batt, 2001).
Clinically, patients may complain of dysmenorrhea, deep dyspareunia, chronic pelvic pain (acyclic) and/or infertility. Depending on the site of the lesions, particularly when the bowel and the bladder are affected, patients may also experience pain during micturition and evacuation. Diagnosing endometriosis remains a dilemma in view of the non-specific nature of the symptoms, and laparoscopy continues to be the gold standard for evaluation. Although digital vaginal examination may be successful in detecting painful nodules in the posterior cul-de-sac or along the uterosacral ligaments (Cheewadhanaraks et al., 2004), for many patients the physical examination may not reveal abnormalities.
Several imaging methods, such as transvaginal ultrasonography (TVUS), transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI) have been used in an attempt to improve the non-invasive diagnosis of endometriosis (Chapron et al., 1998; Fedele et al., 1998; Balleyguier et al., 2002; Abrão et al., 2004). These methods are important for establishing the site of the lesions and for assessing their dimensions, which may be useful information for determining the choice of surgical technique to be used when surgery is indicated. (Chapron and Dubuisson, 1996).
TVUS is the most accessible imaging method for the diagnosis of pelvic endometriosis, and is the method of choice for differentiating endometriomas from other ovarian cysts (Mais et al., 1993; Guerriero et al. 1995). In recent years, some studies have emphasized the use of this method for evaluating deep endometriosis (Bazot et al., 2003; Koga et al., 2003), and have reported promising results in view of the broad availability and good tolerability of the method.
The use of MRI for the diagnosis of endometriosis underwent a major milestone following the publication of a study carried out by Nishimura et al. (1987), who demonstrated the value of this method in the diagnosis of ovarian endometriosis. Although this diagnostic tool has been shown to be effective for evaluating the ovary, TVUS remains the diagnostic method of choice in these situations, generally reserving MRI as a tool for resolving cases in which there is some doubt. The use of MRI for the evaluation of deep endometriosis was first proposed by Siegelman et al. (1994), who studied its role in analysing solid pelvic masses. However, the promising results of this method for the specific evaluation of deep endometriosis have been reported by other investigators (Kinkel et al., 1999; Bazot et al., 2004).
In view of the conflicting data in the literature with respect to the methods available for the diagnosis of deep endometriosis, the objective of this study was to compare the degree of accuracy between clinical examination, TVUS and MRI in patients with a clinical suspicion of endometriosis in the rectosigmoid and/or retrocervical regions.
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%.
Conculsions: 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.
Endometriosis is one of the most prevalent conditions in gynecology today and in recent years has been one of the most studied (Giudice and Kao, 2004). Following recognition of the importance of the degree of infiltration of the endometriotic lesions (Koninckx and Martin, 1992), various studies have emphasized the relevance of this topic for the adequate treatment of the disease (Brosens and Brosens, 2000). Endometriosis is considered to be infiltrative when lesions reach a depth of >5 mm into the peritoneum, and may be situated in the Douglas pouch, in the vesicouterine pouch and in other regions of the pelvis (Cornillie et al., 1990). It should be emphasized that the retrouterine, infiltrative form of the disease may be retrocervical if the primary area affected lies between the lower third of the vagina and the rectum (Martin and Batt, 2001).
Clinically, patients may complain of dysmenorrhea, deep dyspareunia, chronic pelvic pain (acyclic) and/or infertility. Depending on the site of the lesions, particularly when the bowel and the bladder are affected, patients may also experience pain during micturition and evacuation. Diagnosing endometriosis remains a dilemma in view of the non-specific nature of the symptoms, and laparoscopy continues to be the gold standard for evaluation. Although digital vaginal examination may be successful in detecting painful nodules in the posterior cul-de-sac or along the uterosacral ligaments (Cheewadhanaraks et al., 2004), for many patients the physical examination may not reveal abnormalities.
Several imaging methods, such as transvaginal ultrasonography (TVUS), transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI) have been used in an attempt to improve the non-invasive diagnosis of endometriosis (Chapron et al., 1998; Fedele et al., 1998; Balleyguier et al., 2002; Abrão et al., 2004). These methods are important for establishing the site of the lesions and for assessing their dimensions, which may be useful information for determining the choice of surgical technique to be used when surgery is indicated. (Chapron and Dubuisson, 1996).
TVUS is the most accessible imaging method for the diagnosis of pelvic endometriosis, and is the method of choice for differentiating endometriomas from other ovarian cysts (Mais et al., 1993; Guerriero et al. 1995). In recent years, some studies have emphasized the use of this method for evaluating deep endometriosis (Bazot et al., 2003; Koga et al., 2003), and have reported promising results in view of the broad availability and good tolerability of the method.
The use of MRI for the diagnosis of endometriosis underwent a major milestone following the publication of a study carried out by Nishimura et al. (1987), who demonstrated the value of this method in the diagnosis of ovarian endometriosis. Although this diagnostic tool has been shown to be effective for evaluating the ovary, TVUS remains the diagnostic method of choice in these situations, generally reserving MRI as a tool for resolving cases in which there is some doubt. The use of MRI for the evaluation of deep endometriosis was first proposed by Siegelman et al. (1994), who studied its role in analysing solid pelvic masses. However, the promising results of this method for the specific evaluation of deep endometriosis have been reported by other investigators (Kinkel et al., 1999; Bazot et al., 2004).
In view of the conflicting data in the literature with respect to the methods available for the diagnosis of deep endometriosis, the objective of this study was to compare the degree of accuracy between clinical examination, TVUS and MRI in patients with a clinical suspicion of endometriosis in the rectosigmoid and/or retrocervical regions.
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