Imaging Pearls ❯ OB GYN ❯ Endometriosis
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- “Endometriosis is a chronic disease characterized by the presence and growth of endometrial glands and stroma outside of the uterine cavity. The pathogenesis is unclear, but a common theory attributes the condition to retrograde menstruation into the peritoneal cavity via the fallopian tubes. Hormonal influence causes these ectopic tissues to undergo cyclical bleeding, resulting in subsequent inflammation and scar tissue formation; however, it can affect postmenopausal women. In rare instances, endometriotic lesions can obstruct the ureter and result in hydroureteronephrosis and subsequent loss of renal function. This condition presents with nonspecific symptoms and is known as an often-silent disease, resulting in challenging and delayed preoperative diagnosis.”
Deep pelvic endometriosis causing ureteral obstruction
Ryan C. Rizk, MS , Mohammad Yasrab, MD, Edmund M. Weisberg, MS, MBE, Linda C. Chu, MD, Elliot K. Fishman, MD
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 3 8 4 5 – 3 8 4 9 - Deep pelvic endometriosis is a chronic condition characterized by endometriotic implants that extend 5 mm beneath the peritoneum. These implants can involve the urinary tract, and most commonly the bladder (15%) and ureters (4.5%), accounting for only 1% of all endometriosis patients but up to 53% of patients with deep infiltrating endometriosis . As seen in our case, urinary tract involvement is often associated with extensive pelvic involvement. Ureteral endometrio- sis is defined as any instance where endometriosis causes compression or distortion of normal ureteral anatomy, with or without hydroureteronephrosis. The distal ureter is the most common part of the ureteral segment involved, along with a unilateral and left ureter predisposition . Further- more, ureteral obstruction can be an extrinsic or intrinsic disease. Extrinsic obstruction occurs due to external compression by adjacent endometriotic lesions as well as fibrosis and is four times more common. This obstructive uropathy can lead to severe hydronephrosis and acute kidney injury.
Deep pelvic endometriosis causing ureteral obstruction
Ryan C. Rizk, MS , Mohammad Yasrab, MD, Edmund M. Weisberg, MS, MBE, Linda C. Chu, MD, Elliot K. Fishman, MD
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 3 8 4 5 – 3 8 4 9 - “There is symptom overlap in conditions such as pelvic inflammatory disease, appendicitis, bowel obstruction, renal disease, malignancy, and urinary obstruction. Primarily due to this disease’s nonspecific presentations and unknown etiology, approximately 30% of patients have reduced kidney function at the time of diagnosis and 47% require nephrectomy. Differential diagnosis of ureteral en- dometriosis includes invasion by cervical cancer.”
Deep pelvic endometriosis causing ureteral obstruction
Ryan C. Rizk, MS , Mohammad Yasrab, MD, Edmund M. Weisberg, MS, MBE, Linda C. Chu, MD, Elliot K. Fishman, MD
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 3 8 4 5 – 3 8 4 9 - ‘Although CT features for deep pelvic endometriosis are poorly specific, CT is often the first-line imaging modality, can eliminate other possible diagnoses, and along with pa- tient’s relevant history, can assist with diagnosis. On contrast- enhanced CT, deep pelvic endometriosis appears as a soft- tissue density mass, often similar to diverticulitis, and malig- nant or benign neoplasms. Additionally, they are seen with characteristic bowel tethering and scarring. In our case, CT revealed severe hydronephrosis and because of the patient’s history of uterine fibroids, endometriosis was included in the differential diagnosis. Initially, the invasive/infiltrative appear- ance of the adnexal mass was suspicious for invasive cancer; however, percutaneous biopsy confirmed endometriosis."
Deep pelvic endometriosis causing ureteral obstruction
Ryan C. Rizk, MS , Mohammad Yasrab, MD, Edmund M. Weisberg, MS, MBE, Linda C. Chu, MD, Elliot K. Fishman, MD
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 3 8 4 5 – 3 8 4 9 
Deep pelvic endometriosis causing ureteral obstruction
Ryan C. Rizk, MS , Mohammad Yasrab, MD, Edmund M. Weisberg, MS, MBE, Linda C. Chu, MD, Elliot K. Fishman, MD
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 3 8 4 5 – 3 8 4 9
Deep pelvic endometriosis causing ureteral obstruction
Ryan C. Rizk, MS , Mohammad Yasrab, MD, Edmund M. Weisberg, MS, MBE, Linda C. Chu, MD, Elliot K. Fishman, MD
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 3 8 4 5 – 3 8 4 9- “Ureteral involvement from endometriosis is a rare condition, especially in postmenopausal women. High clinical suspicion of endometriosis when extrinsic obstruction of the distal ureter and hydroureteronephrosis are seen on imaging can al- low for prompt treatment intervention and lessen the probability of renal function loss.”
Deep pelvic endometriosis causing ureteral obstruction
Ryan C. Rizk, MS , Mohammad Yasrab, MD, Edmund M. Weisberg, MS, MBE, Linda C. Chu, MD, Elliot K. Fishman, MD
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 3 8 4 5 – 3 8 4 9
Emergent and unusual presentations of endometriosis: pearls and pitfalls.
Brookmeyer C, Fishman EK, Sheth S.
Emerg Radiol. 2023 Apr 1. doi: 10.1007/s10140-023-02128-7.- “Although endometriosis is a chronic condition, some women experience acute severe symptoms. Approximately 15,000 ED visits per year in the USA are for endometriosis. There is significant chronic economic burden of endometriosis, with increased emergency department costs in the few years prior to and immediately after the diagnosis of this condition. Thirty-nine percent of patients eventually diagnosed with endometriosis report ED visits for symptom relief.”
Emergent and unusual presentations of endometriosis: pearls and pitfalls.
Brookmeyer C, Fishman EK, Sheth S.
Emerg Radiol. 2023 Apr 1. doi: 10.1007/s10140-023-02128-7. - “In the emergency department setting, contrast-enhanced CT and abdominal and pelvic ultrasound are the primary imaging method to evaluate abdominopelvic pain. On CT, findings of endometriosis are often non-specific. However, occasionally, endometriosis presents with acute symptoms mimicking more common gynecological, gastrointestinal, or urinary conditions. As it may be the first imaging modality, especially in the emergency department setting, it is important to recognize CT abnormalities that would suggest the diagnosis to avoid misinterpretation of imaging findings. Important clues to the diagnosis of endometriosis on CT have been noted throughout this essay.”
Emergent and unusual presentations of endometriosis: pearls and pitfalls.
Brookmeyer C, Fishman EK, Sheth S.
Emerg Radiol. 2023 Apr 1. doi: 10.1007/s10140-023-02128-7. - “Occasionally, gynecologic endometriosis can present acutely. Rupture of endometrioma presents with acute pelvic pain mimicking more common conditions such as rupture of functional ovarian cysts or adnexal torsion. The reported incidence of rupture is 3% among women who underwent surgery due to endometriotic ovarian cysts, although the exact incidence of rupture among all women with endometriosis is not well known. Ruptured endometriotic cysts tend to be larger, multi-loculated, with thicker walls, associated loculated ascites or ascites confined to the pelvis, and significant peritoneal stranding/infiltration.”
Emergent and unusual presentations of endometriosis: pearls and pitfalls.
Brookmeyer C, Fishman EK, Sheth S.
Emerg Radiol. 2023 Apr 1. doi: 10.1007/s10140-023-02128-7. - “Thoracic endometriosis can be thought of as four distinct clinical entities: catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis, and lung nodules. The etiology of thoracic endometriosis is likely multifactorial. Lung parenchymal involvement may be from vascular or lymphatic embolization of endometrial tissue, whereas pleural or diaphragmatic involvement may be from retrograde menstruation and subsequent transdiaphragmatic migration. Thoracic endometriosis is rare, limiting exact epidemiologic data on it.”
Emergent and unusual presentations of endometriosis: pearls and pitfalls.
Brookmeyer C, Fishman EK, Sheth S.
Emerg Radiol. 2023 Apr 1. doi: 10.1007/s10140-023-02128-7. - “While the classic pelvic manifestations of endometriosis do not pose a diagnostic dilemma, unusual locations can present acutely and with clinical and imaging picture mimicking other acute genitourinary or gastrointestinal processes or intra-abdominal or abdominal wall neoplasms. Furthermore, it may present emergently prior to an established diagnosis of endometriosis; thus, it is important to consider this diagnosis in reproductive age women.”
Emergent and unusual presentations of endometriosis: pearls and pitfalls.
Brookmeyer C, Fishman EK, Sheth S.
Emerg Radiol. 2023 Apr 1. doi: 10.1007/s10140-023-02128-7.
- “Abdominal wall masses have a wide differential diagnosis, which includes endometriosis and other neoplastic and inflammatory etiologies. Abdominal wall endometriosis is commonly associated with scars related to Cesarean section, hysterectomy and other uterine surgery. However, in a substantial minority of cases, AWE does not arise in association with abdominal scarring or in the context of prior surgery. The condition may be detected incidentally on imaging or it may come to medical attention because of chronic abdominal or pelvic pain. As with the pelvic variety, malignant transformation is a rare but recognized complication. Although the diagnosis may at times be made based on clinical presentation, in many scenarios, clinical manifestations of AWE are nonspecific, and patients may complain only of vague abdominal pain, a tender mass, or they may be asymptomatic Moreover, symptoms may not occur until years after uterine surgery (reported cases range from 6 months to 20 years), and as such may not be recognized as being related to prior surgical treatment.”
Abdominal wall endometriosis: differentiation from other masses using CT features
Gail Yarmish et al.
Abdom Radiol (NY). 2017 May ; 42(5): 1517–1523 - "The literature regarding imaging features of AWE is scarce, with many authors concluding that the usefulness of imaging is limited to determining the location and extent of involvement of the lesion with respect to the surrounding tissue. Interestingly, the few studies that consider the sonographic features of abdominal wall endometriosis have described specific features, including solid lesions with ill-defined blurred outer borders and the presence of a hyperechoic ring. The latter correspond to adipose tissue that has become edematous and is filled with cells of inflammatory origin. Our findings are consistent with these results, as the “gorgon” sign may be a CT correlate to the hyperechoic rim seen on ultrasound.”
Abdominal wall endometriosis: differentiation from other masses using CT features
Gail Yarmish et al.
Abdom Radiol (NY). 2017 May ; 42(5): 1517–1523 - “Deep gastrointestinal involvement in endometriosis is characterised by fibrous, retractile thickening of the intestinal wall. The most common location is the upper rectum, in contiguity with a lesion of the torus uterinus. As part of a preoperative assessment, it is essential to establish an accurate and exhaustive map of intestinal lesions so that the surgeon can plan hisactions. Transvaginalsonography and MRI correctly analyse pelvic and rectal involvement. Given the frequency of multiple intestinal sites, particularly sigmoid and associated ileo-caecal lesions, water enema CT should be performed.”
Imaging of intestinal involvement in endometriosis
Massein A et al.
Diagnostic and Interventional Imaging Volume 94, Issue 3, March 2013, Pages 281-291 - "Endometriosis is a common chronic gynaecological disease affecting 10 to 15% of women of reproductive age. It is defined by the presence of functional ectopic endometrial tissue outside the uterus. Depending on the site of the endometrial implants, three main clinicopathological types of endometriosis can be distinguished, generally intricately linked: superficial peritoneal endometriosis, ovarian endometriosis (cystic lesions known as endometriomas) and deep pelvic endometriosis. Extrapelvic locations (abdominal, pleural) are rare.”
Imaging of intestinal involvement in endometriosis
Massein A et al.
Diagnostic and Interventional Imaging Volume 94, Issue 3, March 2013, Pages 281-291 - “Endometriosis is a common cause of pelvic pain and infertility, with as many as 30% of women with endometriosis demonstrating tubal involvement at laparoscopy. Ruptured deep pelvic endometriomas release blood products that cause adhesions and fibrosis, which may lead to findings that can mimic PID, such as the development of complex pelvic masses, nodularity of the uterosacral ligaments, and peritubal adhesions with tubal obstruction.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation
Revzin MV et al.
RadioGraphics 2016; 36:1579–1596 - “The CT appearance of endometriomas can be nonspecific, although the presence of multiple complex lesions, high-attenuation components within the mass, and hematosalpinx help to narrow the differential diagnosis. Solid invasive endometriosis, which is commonly found in the rectouterine pouch or posterior cul-de-sac, often extends to or invades the posterior myometrium and can mimic an adhesion from previous PID.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation
Revzin MV et al.
RadioGraphics 2016; 36:1579–1596 - “Ovarian vein thrombophlebitis may occur as a complication of PID. The right ovarian vein is the affected vessel in 80%–90% of cases. Contrast- enhanced CT demonstrates a distended ovarian vein with an enhancing wall and with low-attenua- tion intraluminal filling defects. Lack of enhancement of the vein will be observed if the entire vessel is occluded. Associated inflamma- tory changes may be seen in the pelvic fat, often accompanied by free fluid. If unrecognized or left untreated, ovarian vein thrombophlebitis may result in septic pulmonary emboli .”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation
Revzin MV et al.
RadioGraphics 2016; 36:1579–1596