Now you see me: Sonovaginography and Magnetic Resonance as allies in endometriosis diagnosis
Type:Educational Electronic Presentation
Authors: Mafalda Machado, Carla Bahia, Pedro Alves, Rodrigo Monteiro, André Teixeira Gomes, Carolina Carneiro, Fernanda Vilela, Ana Sofia L. Moreira
Keywords:endometriosis; sonovaginography; MRI; ultrasound
Educational objective


- To review the female anatomy and main locations of peritoneal implants.


- To describe sonovaginography (SVG) technique, used in the study of women with suspected endometriosis.


- To describe and illustrate the findings of deep infiltrating endometriosis on SVG, and correlation with the magnetic resonance imaging (MRI) appearance.

Topic Review


Endometriosis is a chronic gynecological disease characterized by the growth of functional ectopic endometrial glands outside the uterus. It can be clinically silent or present with chronic pelvic pain and infertility.


Endometriosis can be divided in three groups:


- Ovarian endometrioma

- Superficial peritoneal implants: endometriotic foci are located at the peritoneal surface or less than 5 mm from it;

- Deep infiltrating endometriosis (DIE): endometriotic nodules are located more than 5 mm away from the peritoneal surface, and may extend to the retroperitoneal space and wall of adjacent organs.




Figure 1: Representation of the female pelvis and most common sites of pelvic endometriosis. (a) Sagittal T2-weighted image on MRI; (b) Schematic representation of the pelvic organs TVS. Subtitles: Stars (anterior to posterior): bladder, vaginal walls, torus uterinus, rectovaginal area, rectum/sigmoid colon. Delineated in purple: peritoneal reflexions; Black line: rectosigmoid transition.
Figure 2: 37 year old, female patient, followed in Gynecology consultation for infertility, performed a TVS that allowed the identification of bilateral ovarian ground glass cystic lesions, suggesting endometriomas (delineated in a and b), confirmed by the T2 shading in T2-weighted images (c) and the high signal intensity in T1-weighted images (d) on MRI study. Ovaries were located in a posterior disposition, close to each other though not touching (b, c and d). TVS also demonstrated a isoechoic mass located posterolateraly to the cervix (yellow arrow in e), measuring 25 x 11 mm, corresponding on MRI to the thickened left uterosacral ligament (white arrow in f). Subtitle: c) axial T2-weighted image, d) axial T1-weighted image, f) coronal T2-weighted image. C – cervix, LO – left ovary, RO- right ovary, Sa – sacrum.



TVS is many times the first imaging modality in women with pelvic chronic pain or suspected endometriosis. A significant proportion of women with a “normal” TVS, who have chronic pelvic pain, will have subsequent abnormal findings on laparoscopy, emphasising the need for every radiologist to be familiar with some of endometriosis sonographic features.


We want to highlight the importance of searching specific signs of endometriosis when performing a TVS in women with chronic pelvic pain, infertility or clinically suspected endometriosis, such as the sliding sign and search for DIE nodules in the anterior and posterior compartments.


SVG has an important role in cases in which findings of endometriosis have already been found, in order to evaluate its extent with a dedicated protocol, once it enables a... more

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