Rectovaginal examination, transvaginal ultrasonography, and Magnetic Resonance Imaging as diagnostic tools for identifying deep infiltrating endometriosis nodules
Creators: name: Wirawan, Florencia
name: M. Luky Satria Marwali
name: Refni Muslim
name: Silalahi, Eva R.
name: Harjo S. Bayuaji
name: Anindita, Astri
Publisher: name: F1000Research
Year: 2017

description: INTRODUCTION<br>Deep Infiltrating Endometriosis (DIE) was a benign disease marked by the ectopic presence of endometrium deeper than 5 mm beneath the peritoneal surface, that infiltrated different pelvic location whether anteriorly or posteriorly.<sup>1</sup> It could be located anywhere including uterosacral ligaments, vagina, intestine, bladder or even ureter.  As the DIE nodules were a major contribution to pain symptom for deep infiltrating endometriosis patients, radical surgical resection was the mainstay of treatment for this form of endometriosis. A proper diagnostic tools should be used in order to map the exact location of DIE nodule, so in the time any surgical procedures occurred, all remaining nodules could be resected and complication could be avoided.<br> <br>Magnetic resonance imaging (MRI) and Transvaginal sonography (TVS) had been recommended for diagnosing and locating DIE. Bazot , et al<sup>1-3</sup> found that MRI provided a more reliable map of DIE than physical examination or TVS, but TVS and physical examination should remain the first-line technique examination, although normal finding did not rule out the diagnosis. In this study, we wanted to compare these three modalities in diagnosing DIE in various location including their strength and weakness as a consideration of their usage.<br> <br>DESIGN, MATERIAL AND METHODS<br>Prospective longitudinal study was done on tertiary gynecology unit. Study was done by involving 31 women referred for surgical management of DIE between November 2015 until October 2016. All women underwent RVT and TVUS with/without additional MRI examination. Diagnostic criteria for RVT was identification of endometriotic nodules on palpation, whereas for both TVUS and MRI was based on visualization of hypointense/hypoechoic areas in specific location. Calculation of sensitivity, specificity, positive predictive value (PPV) , negative predictive value (NPV), and accuracy of RVT, TVUS and MRI for DIE on various sites were then recorded, with surgical/histological finding as the golden standard.<br> <br>Statical Analysis<br>For each four location including uterosacral ligaments, rectovaginal, rectosigmoid and bladder-ureter were evaluated by comparing them with the standard reference (surgical/histological finding). The sensitivity, specificity, positive - negative predictive values, and accuracy of every modality were then recorded.<br><br>DISCUSSION<br>This study shows that RVT, TVUS and MRI had their own roles in diagnosing Deep Infiltrating Endometriosis. RVT was a very simple examination that could be done easily in everyday practice. With high score of Positive Predictive Value, shows that if the nodule was palpable during RVT examination, the chance Deep Infiltrating Endometriosis mass was high, but on the other hand RVT shows a very low Negative Predictive Value, which means that if there was no nodule palpated at RVT examination doesn’t mean that there will be no Deep Infiltrating Endometriosis. Moreover RVT can only access around vaginal and rectum part, so diagnosing Deep Infiltrating Endometriosis located at urological sites was nearly impossible. Patient with typical symptoms such as, severe dysmenorrhea, dysuria, dyschezia and dyspareunia, further examination using other diagnostic methods could be considered.<br> <br>Transvaginal Ultrasonography (TVUS) was a good modality available for diagnosing deep infiltrating endometriosis as it gave a wide exposure of gynecological anatomy.<sup>7,8,9</sup> This study showed that for overall accuracy, TVUS still the best diagnostic methods. But as study went deeper, it show that TVUS was great at diagnosing DIE nodules located at uterosacral ligaments and rectovaginal, but lack of strength at diagnosing rectosigmoid  and bladder-ureter DIE. But still TVUS gave better perception of DIE than RVT itself.<br> <br>As stated on the previous line, Magnetic Resonance Imaging (MRI) provided better diagnostic rates on bowel and urological endometriosis. Bowel endometriosis was one of the most severe forms of DIE<sup>1</sup>. With accurate preoperative diagnosis, mapping of the nodule could be done, and best procedure could be performed. It was also crucial for informing women on the specific risks of surgery for example colorectal resection<sup>11</sup>. Various features of colorectal endometriosis can influence surgical management, such as the degree of rectal wall infiltration, the size of the rectal lesion, the distance from the anal margin and the possible association with other endometriotic lesions<sup>11</sup>. Although urological endometriosis cases were rare, only for about 1-2% of all endometriosis cases, the side effects occurred were devastating. Silent hydronephrosis or even silent loss of kidney secondary to urological endometriosis could happen whether in a form of blocking mass or ureter stricture mimicry <sup>10,11</sup>. MRI gave better mapping on both sites, providing better prognosis for bowel and urological DIE patients.<br> <br>Early diagnosis of pelvic endometriosis, and especially DIE, even though was a major challenge, but it could help to avoid mutilating surgery, improved quality of life, and enhanced fertility<sup>12</sup>. RVT should be done in daily examination on endometriosis patient but weak in diagnosing anterior DIE. TVUS gave a better diagnosis rates on DIE located at sacrouterine ligaments and rectovaginal area whereas MRI did better on bowel DIE (rectosigmoid-colon area) and urological DIE (bladder-ureteral area)