Monash Health, Women's and Children's Program, Clayton, Australia (Dr Piessens); City Imaging Ultrasound for Women, Melbourne, Australia (Dr Piessens and Dr Edwards).
City Imaging Ultrasound for Women, Melbourne, Australia (Dr Piessens and Dr Edwards); The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia (Dr Edwards).
J Minim Invasive Gynecol. 2020 Feb;27(2):265-266. doi: 10.1016/j.jmig.2019.08.027. Epub 2019 Sep 4.
To show how the evaluation for endometriosis can be included in the routine pelvic ultrasound examination.
Stepwise narrated video demonstration of the sonographic evaluation for endometriosis in routine pelvic ultrasound following the recommended sonographic approach published in the 2016 consensus paper by the International Deep Endometriosis Analysis (IDEA) group [1].
Endometriosis is a common and often debilitating gynecological disorder that affects 5-10% of women [2]. The prevalence is even higher among women with symptoms of endometriosis [2], which include chronic pelvic pain, acquired dysmenorrhea, dyspareunia, dyschezia, menorrhagia, abnormal bleeding, and infertility. Approximately 80% of women who have endometriosis have superficial lesions, whereas 20% have deep infiltrating endometriosis (DIE; [3]). Laparoscopy is the gold standard for diagnosing endometriosis, because it allows the diagnosis of all forms of endometriosis and often immediate removal of superficial endometriosis. The removal of DIE is considerably more complicated and usually cannot be completed unless it was diagnosed preoperatively. The technique to diagnose DIE with transvaginal ultrasound (TVUS) was first described in detail in 2009 [4]. Since then, the accuracy of TVUS for the prediction of DIE has been well established in the literature [5-7]. TVUS is widely used as a first-line investigation for women with gynecological symptoms. The inclusion of an assessment for endometriosis in the routine pelvic ultrasound allows earlier diagnosis and better surgical outcomes for all women with DIE.
The evaluation for endometriosis in routine pelvic ultrasound based on the IDEA consensus promotes a 4-step dynamic ultrasound approach [1]: (1) routine evaluation of uterus and adnexa with particular attention for sonographic signs of adenomyosis and the presence or absence of endometriomas; (2) evaluation of transvaginal sonographic 'soft markers' such as site-specific tenderness and ovarian mobility; (3) assessment of status of pouch of Douglas using the real-time ultrasound-based "sliding sign;" and (4) assessment of DIE nodules in the anterior and posterior compartments, which involves assessment of the bladder, vaginal vault, uterosacral ligaments, and bowel, including rectum, rectosigmoid junction, and sigmoid colon. Because 5-10% of women with DIE also have ureteric endometriosis, it is useful to assess the kidneys. Silent hydronephrosis is easily identified in 50-60% of patients with ureteric involvement. Although it is possible to identify DIE involving the ureters more directly, this requires more advanced skills, and further studies are still needed to better define the accuracy of ureteric DIE detection by TVUS [8-10].
Traditionally, only pathologies of the uterus and ovaries are assessed during a routine pelvic ultrasound. Here we demonstrate that the routine ultrasound examination can easily be extended beyond the uterus and ovaries into the posterior and anterior pelvic compartments to evaluate structural mobility and to look for deep infiltrating endometriotic nodules, wherewith women suffering from DIE can benefit from a preoperative diagnosis and subsequently, a single, well-planned procedure in the hands of a well-prepared team.
展示如何将子宫内膜异位症的评估纳入常规盆腔超声检查中。
按照 2016 年国际深部子宫内膜异位症分析 (IDEA) 小组 [1] 发表的推荐超声方法，逐步叙述性视频演示常规盆腔超声检查中子宫内膜异位症的超声评估。
子宫内膜异位症是一种常见且常使人虚弱的妇科疾病，影响 5-10%的女性 [2]。在有子宫内膜异位症症状的女性中，患病率甚至更高，这些症状包括慢性盆腔疼痛、获得性痛经、性交困难、排便困难、月经过多、异常出血和不孕。大约 80%的患有子宫内膜异位症的女性有浅表病变，而 20%的女性患有深部浸润性子宫内膜异位症 (DIE；[3])。腹腔镜检查是诊断子宫内膜异位症的金标准，因为它可以诊断所有形式的子宫内膜异位症，并经常可以立即切除浅表子宫内膜异位症。DIE 的切除要复杂得多，除非术前诊断，否则通常无法完成。经阴道超声 (TVUS) 诊断 DIE 的技术于 2009 年首次详细描述 [4]。此后，TVUS 对 DIE 的预测准确性已在文献中得到很好的证实 [5-7]。TVUS 广泛用作有妇科症状的女性的一线检查。在常规盆腔超声中纳入子宫内膜异位症评估，可以更早地诊断并为所有患有 DIE 的女性带来更好的手术效果。
基于 IDEA 共识的常规盆腔超声子宫内膜异位症评估采用 4 步动态超声方法 [1]：(1) 常规评估子宫和附件，特别注意子宫腺肌病的超声征象和是否存在卵巢囊肿；(2) 评估经阴道超声“软标记”，如特定部位压痛和卵巢活动度；(3) 使用实时超声“滑动征”评估Douglas 窝的情况；(4) 评估前、后盆腔 DIE 结节，包括评估膀胱、阴道穹窿、子宫骶韧带和肠道，包括直肠、直肠乙状结肠交界处和乙状结肠。因为 5-10%的 DIE 女性也有输尿管子宫内膜异位症，所以评估肾脏是有用的。在 50-60%有输尿管受累的患者中，很容易识别出无症状性肾盂积水。虽然可以更直接地识别输尿管 DIE，但这需要更先进的技能，还需要进一步的研究来更好地定义 TVUS 检测输尿管 DIE 的准确性 [8-10]。
传统上，仅在常规盆腔超声检查中评估子宫和卵巢的病变。在这里，我们证明常规超声检查可以很容易地从子宫和卵巢扩展到后盆腔和前盆腔，以评估结构的活动性，并寻找深部浸润性子宫内膜异位症结节，患有 DIE 的女性可以从术前诊断中受益，随后在准备充分的团队中进行单次、精心计划的手术。
