4 Practical approach for endometriosis diagnosis by TVS
Pelvic endometriosis evaluation by TVS starts with the basic sonographic examination
as usual (“basic TVS”) [17 ]
[18 ]. All non-endometriotic findings should be described and proceed following the given
standards. The comprehensive evaluation for endometriosis is directly connected to
the basic examination. The examiners should strictly follow a well-developed examination
protocol ([Table 2 ]). The presented concept shows the suggested sequence for working through the compartments
and structures ([Table 1 ], [2 ]
[Video 4 ]). We propose the application of five compartments in the pelvis ([Table 1, ]
[Video 4 ]), defined by the WSL, containing a total of 35 relevant sliding qualities, structures,
and organs ([Table 2 ]), as described in IDEA 2016 [8 ] and its extensions. Our proposal provides direct preparation for classifying the
endometriotic findings with #ENZIAN [16 ] ([Fig. 6 ]).
Table 1
Compartment Definition.
Compartments
Definitions
Content
Leading structure
“White Sliding Line” (WSL)
WSL, VVS, RVS
Anterior
Ventral to WSL
Sliding, bladder, ureters
Central
Enclosed by WSL
Tent sign, uterus, vagina, POD
Posterior
Posterior to WSL
RVS, rectum
Lateral right/left
Lateral to WSL
(lateral to uterus/vagina)
Sliding, omega sign, ovaries, tubes, uterus, bowel, ligaments
WSL: White Sliding Line; VVS: vesicovaginal septum; RVS: rectovaginal septum; POD:
pouch of Douglas
Table 2
Checklist.
Checklist Endometriosis evaluation
Procedure
Examination sequence
Definition, mobility, and organs/structures
#ENZIAN classification
Findings
DOC[* ]
Preparation
1
Routine transvaginal sonography (TVS) including biometry and description of any other
pathology than endometriosis or adenomyosis (polyps, myomas, congenital anomalies,
adnexal tumors, etc.)
2
Expose the complete sagittal White Sliding Line (WSL )
Compartment evaluation
Anterior
Definition: ventral to WSL
Sliding (impaired? block sign ?)
3
Vesicouterine region (VUR)
Fb
4
Bladder dome
Fb
Lesion (DE?)
5
Bladder wall[** ] (trigonum, base, dome, extraperitoneal)
Fb
6
Vesicovaginal septum (VVS)
Fb
7
Ureter right
Fu
8
Ureter left
Fu
Central
Definition: enclosed by WSL
Sliding (impaired? block sign ?)
9
Uterine serosa (WSL )
T2,3
10
Tent sign (entire dorsal uterine serosa), transverse
T2,3
11
Pouch of Douglas (POD)
T2/3
Lesion (DE? superficial?)
12
Adenomyosis
Fa
13
Vaginal wall anterior
A
14
Vaginal fornix anterior
A
15
Vaginal fornix posterior
A
16
Vaginal wall posterior
A
Posterior
Definition: posterior to WSL
Lesion (DE? superficial?)
17
Rectovaginal septum (RVS)
A
18
Rectal wall anterior (< 16 cm to anal verge)[** ]
C
19
Intestinal wall anterior (> 16 cm to anal verge)[** ]
Fi
Lateral
Definition: lateral to WSL
Right
Right
Sliding (impaired? block sign ?)
20
Right tail sign
T1,2,3
21
Between ovaries, tubes, uterus, bowel, ligaments
T1,2,3
Lesion (DE? superficial?)
22
Broad ligament (dorsal sheath)
B
23
Pelvic sidewall
B
24
Cardinal ligament (CAL)
B
25
Sacrouterine ligament (SUL)
B
26
Endometrioma(s)
O
27
Tube[*** ]
T
Left
Left
Left/right
Sliding (impaired? Block Sign ?)
28
Left tail sign
T1,2,3
T /
29
Between ovaries, tubes, uterus, bowel, ligaments
T1,2,3
T /
Lesion (DE? superficial?)
30
Broad ligament
B
B /
31
Pelvic sidewall
B
B /
32
Cardinal ligament (CAL)
B
B /
33
Sacrouterine ligament (SUL)
B
B /
34
Endometrioma(s)
O
O /
35
Tube[*** ]
T
T /
Forms of impaired sliding: free, reduced, fixed; DE lesion: definition by #ENZIAN
≥ 5 mm from the surface, measured in three dimensions; in bowel nodule: measure distance
from anal verge to lowest end of lesions, indicate with or without internal obstruction.
* documentation (photos, movies, drawings).
** Definition of partial or full thickness defect by IDEA affecting bowel and bladder:
in full thickness defect the nodule affects the complete muscular layer, in partial
thickness defect only parts of it are affected.
*** if visible.
Download available on www.sgumgg.ch
Fig. 6 Compartmentation and #ENZIAN classification. TVS: transvaginal sonography.
The term nodule is suitable for describing the palpable findings of a hard nodular
resistance in the pelvis. In contrast, on TVS, endometriotic lesions typically appear
as discrete, blurred, hypoechoic changes in the tissue of varying size and shape in
favored locations. They often do not resemble a nodule and are hard to detect. Therefore,
the term lesion should be preferred for TVS.
IDEA 2016 and #ENZIAN [8 ]
[16 ] define only lesions at a sub-peritoneal depth of 5 mm or more as DE . All thinner lesions are counted as superficial. For hollow organs such as bowels,
bladder, and ureters, DE partial thickness defects reach the muscular layer, and DE full thickness defects involve the complete muscular layer. They may reach or even penetrate the submucosal
layer. The infiltrated layers should be documented (adventitia/peritoneal border,
muscularis, submucosa, mucosa/urothelium).
Conscious navigation through the pelvis, exposing the region of interest as best possible,
is mandatory to avoid missing relevant pathologies while taking the patient’s comfort
into account at the same time. The examiner’s free hand rests on the suprapubic region
and gently applies pressure toward the true pelvis, supporting the exposure of dedicated
structures and sliding between them. We use the following self-explaining terminology
to describe the movements of the ultrasound probe : up, down, right, left, push, pull, and rotate . It is important to note that the pen-like ultrasound probe used for TVS pivots around an intravaginal center point close to the introitus, and the terminology describes the movements of the probe tip . In contrast, the probe guiding hand must move automatically in the opposite direction
for the pivoting motions, which are up, down, right, and left.
The proper machine settings, mainly the optimal magnification scale, allow the inspection
of the investigated structure/organ (region of interest) in detail at a glance.
4.1 Anterior compartment
4.1.1 Definition
The anterior compartment is defined by organs and structures ventral to the WSL , principally represented by the bladder and the ureters (“urologic compartment ”) ([Fig. 8, ]
[Video 7 ], [Table 2 ]).
Fig. 7 a QR code for #ENZIAN-App in App store (Apple iOS); b QR code for #ENZIAN-App in Google Play store (Android).
Fig. 8 Anterior compartment. Image on the right: adapted from Schünke M, Schulte E, Schumacher U, Voll M, Wesker
K. 6.23 Schnittbildanatomie des weiblichen Beckens. In: Schünke M, Schulte E, Schumacher
U, Voll M, Wesker K, Hrsg. Prometheus LernAtlas – Innere Organe. 5. Auflage. Stuttgart:
Thieme; 2018. doi:10.1055/b-006–149 645.
Video 7 Anterior compartment
Sliding should be observable along the WSL on the ventral uterine serosa, at the bladder dome, and in the subperitoneal vesicouterine
region, corresponding to the adventitia ([Fig. 3 ]), but not at the VVS. Impaired sliding mainly occurs at the surface of the bladder
dome ([Fig. 9 ]) due to adhesions to the bowel or at the bladder base. DE in this compartment appears
preferably in the median part of the bladder at the bladder base ([Video 8 ]) or dome and at the ureters at the undercrossing of the uterine vessel complex (UVC,
containing the uterine artery) [22 ]
[23 ]. Lesions may affect all layers of the bladder and ureters, single or multiple.
Fig. 9 Bladder regions. The trigonal zone (purple) is a smooth triangular region bounded
by the two ureteral openings and the internal urethral opening. The bladder base (green)
is directed posteriorly and borders the vagina and the supravaginal portion of the
uterine cervix. The bladder dome (red) is located above the base and is intraperitoneal.
The extraperitoneal area (blue) of the bladder is located anteriorly or opposite the
bladder dome.
Endometriotic lesions affecting the bladder area are reported as #ENZIAN FB, and lesions
affecting the ureters as #ENZIAN FU ([Fig. 7a ]) [16 ].
Video 8 Bladder wall lesion after hysterectomy. DE nodule at the bladder base (red circle),
full thickness defect. #ENZIAN: FB.
4.1.2 Assessment
A lightly or moderately filled bladder is advantageous. It may be necessary to postpone
the examination of this compartment to the end of the workup if the bladder is empty.
The probe is placed in the center of the anterior vaginal fornix sagittally , also in retroflexed uteri. The proper settings, mainly the optimal magnification
scale, allow the inspection of the entire bladder circumference in one plane at a
glance.
4.1.3 Vesicouterine region (VUR)
The vesicouterine region is a typical site for reduced or absent sliding mobility
due to endometriotic adhesions or prior surgery, commonly seen after cesarean sections
([Video 9 ]), but also for DE lesions ([Video 8 ]), with or without the bladder wall being affected [24 ].
Video 9 Sliding in the vesicouterine region (VUR).
4.1.4 Bladder
DE of the bladder belongs to the most common sites (number 4 of the top 5, 6 %) [15 ]. Lesions may be discovered by consciously steering the probe in a sagittal plane from right to left and then switching to the transverse plane, moving from cranial to caudal for scanning the entire bladder wall in all
four zones ([Fig. 9 ]) [8 ].
4.1.5 Vesicovaginal septum (VVS)
With correct sagittal exposure on TVS, the VVS appears as a thin white line, running from the pelvic floor to the cervix behind
the vagina, representing its adventitia. The VVS is the ventral part of the WSL . No physiological sliding is visible at the VVS between the bladder wall or urethra
and the vagina ([Video 10 ]). These structures may only be stretched, accompanied by remarkable bladder and
vaginal wall thinning and displacement. DE lesions are rarely observed at this site.
Video 10 Vesico-vaginal septum (VVS). Dynamic investigation.
4.1.6 Right and left ureters
To assess the hypoechoic tubular right and left ureters, the internal urethral meatus should first be identified sagittally ([Video 11, 12 ]). The probe is then gently moved right or left towards the investigated side, whereby
the investigator’s guiding hand may come close to the patient’s contralateral thigh
and rotated slightly outward (about 30 degrees clockwise for the right side and 30
degrees counterclockwise for the left side). Identifying the intramural part of the
ureter is facilitated by a lightly or moderately filled bladder. Waiting for peristalsis,
occurring approximately 1 to 4 times per minute, also called vermiculation , is particularly helpful as it confirms kidney function and ureter patency. Using
CD, a high-flow urine jet into the bladder can often be documented, occasionally presenting
color flow in the prevesical ureter ([Video 13 ]). Visualization up to the under-crossing of the UVC is usually successful ([Video 14 ]). Beyond the pelvis, the ureters and the kidneys should be assessed by TAS for hydronephrosis.
A urethral inner diameter of more than 5 mm is suspicious for urethral obstruction
[16 ]
DE lesions at the dorsolateral cervix, potentially obstructing the ureters, represent
a common location (number 5 of the top 5, 2 %) [15 ].
Video 11 Right distal ureter presentation
Video 12 Left distal ureter presentation
Video 13 Ureter jet sign. The jet sign occurs approximately 1 to 4 times per minute.
Video 14 Ureter course. AUT: uterine artery; AII: iliacal internal artery; AIE: iliacal external
artery
4.2 Central compartment
4.2.1 Definition
The central compartment is defined by organs and structures encircled by the WSL , principally represented by the uterus and vagina (“gynecologic compartment ”) ([Table 2 ]).
Sliding should be seen along the WSL on the entire free peritoneal surface, represented by the uterine serosa ([Fig. 10 ], [Video 15 ]). Impaired or absent sliding may be seen on all parts of the serosa and should be
carefully worked out dynamically ([Video 16 ]). DE lesions in this compartment are common, occurring preferably at the lower POD
(levels II and III, [Fig. 11 ]) and the vaginal fornices, also affecting the vaginal wall [15 ]. Furthermore, the uterus is checked in detail for signs of adenomyosis [6 ].
Fig. 10 Central compartment. Image on the right: adapted from Schünke M, Schulte E, Schumacher U, Voll M, Wesker
K. 6.23 Schnittbildanatomie des weiblichen Beckens. In: Schünke M, Schulte E, Schumacher
U, Voll M, Wesker K, Hrsg. Prometheus LernAtlas – Innere Organe. 5. Auflage. Stuttgart:
Thieme; 2018. doi:10.1055/b-006–149 645.
Video 15 Central compartment
Video 16 Free uterus sliding
4.2.2 Assessment
The anteflexed uterus should be visualized first sagittally with the tip of the TVS probe in the anterior vaginal fornix and the retroflexed
uterus in the posterior vaginal fornix [17 ].
The uterus’ surface is checked for endometriotic lesions along the WSL in sagittal and parasagittal planes and transverse planes (tent sign), including a profound assessment of the POD by a highly dynamic investigation.
The anterior vaginal wall with the anterior fornix is inspected separately by pulling
the TVS probe backward to the introitus while stretching the vaginal wall simultaneously,
followed by examining the posterior vaginal wall the same way. These lesions are often
smaller than 5 mm, so they do not fulfill the criteria of real DE. Therefore, we call
them endometriotic lesions or simply lesions .
4.2.3 Pouch of Douglas (POD)
The POD is defined as the entire space between the posterior uterus and the anterior
rectum [8 ]. We follow the suggestion of IDEA 2016 of splitting the POD into three levels but
propose the following division ([Fig. 11 ]): The first level covers the area behind the uterine corpus from the fundus to the
SULs. The SULs represent the narrow second level. The area behind the cervix from
the SULs to the bottom of the pocket counts as the third level.
Fig. 11 Sonographic approach to the pouch of Douglas. SUL: sacrouterine ligament; AUT: uterine
artery. Image on the left: adapted from Schünke M, Schulte E, Schumacher U, Voll M,
Wesker K. 6.23 Schnittbildanatomie des weiblichen Beckens. In: Schünke M, Schulte
E, Schumacher U, Voll M, Wesker K, Hrsg. Prometheus LernAtlas – Innere Organe. 5.
Auflage. Stuttgart: Thieme; 2018. doi:10.1055/b-006–149 645.
Physiologically, the uterus freely slides within its serosa in the surrounding area
(free sliding) ([Video 17 ]). Impaired sliding typically occurs on the backside of the uterus along the WSL ([Video 18 ]). With a specificity of 91–100 % and a sensitivity of 93–100 % for detecting local
adhesions, it is a strong indicator of adhesions in the POD [19 ]
[20 ]. Sliding may be judged as free, reduced, or absent ([Video 19 ]), indicating the origin and end of a suspected adhesion, as well as the POD level
(I, II, III) they affect. Occasionally, the uterus is found already in a forced position
with the fundus leaning backward, leaving the cavity in the shape of a question mark
(question mark sign ) ([Video 20 ]). This indicates significant adhesions pulling the uterine fundus or corpus backward
to the bowel or the posterior pelvic wall.
A specific search should be conducted for adhesions and DE in the POD between the
uterus and other structures, such as the bowel and ovaries. Levels II (SUL) and III
(retrocervical) are most frequently affected. Adhesions in the POD are classified
as #ENZIAN T2 or T3 ([Fig. 7 ]) [16 ].
Video 17 Free POD sliding. POD: pouch of Douglas, definition by IDEA 2016: the space behind
the uterus.
Video 18 Impaired POD sliding. #ENZIAN: T 3/0.
Video 19 Sliding mobility – terminology
Video 20 Question mark sign
4.2.4 Adenomyosis
The examiners should describe morphologic findings, especially all indicators of adenomyosis
of the uterus, and assess them following the revised MUSA criteria [6 ]. Direct signs indicate the presence of an ectopic endometrium in the myometrium
(cystic inclusions, hyperechoic islands, echogenic sub-endometrial lines, and buds)
([Video 21 ]). Indirect signs may result from myometrium remodeling (globular uterus, asymmetric
myometrial thickening, trans-lesional vascularity, fan-shaped acoustic shadows, irregular
or disrupted junctional zone). Direct signs are diagnostic for adenomyosis, whereas
indirect signs only serve as indicators. Adenomyosis is reported as #ENZIAN FA ([Fig. 7 ]) [16 ].
Video 21 Adenomyosis. CYS: cystic inclusions; ISL: hyperechoic islands, LIN: echogenic sub-endometrial
lines: BUD: buds
4.2.5 Vaginal wall
The vaginal walls belong to the three most common locations of endometriosis (number
3 of the top 5, 16 %) [15 ]. They should be examined by palpation for single or multiple hard pinheads with
a diameter of a few millimeters and then by ultrasound. The probe should be moved
deliberately slowly from right to left over the anterior and posterior vaginal wall,
including the fornices ([Video 22 ]). Inhomogeneities, cysts, and small nodules in the vaginal wall are the typical
findings ([Video 23 ]). They tend to rush away (slip off sign ). In our experience, the tip of the probe may stretch the healthy vaginal wall to
a thickness of less than 3 mm ([Video 24 ]). Local enlargements in the stretched vaginal wall exceeding 3 mm could be the sole
ultrasound representation of palpable, firm nodules. Furthermore, examiners should
always search for the involvement of deeper structures: in the first layer, the VVS
(anterior compartment) or the RVS (posterior compartment); in the second layer, the
bladder wall anteriorly or the rectum wall posteriorly; and to the sides, the sacrouterine
ligaments (SUL), the cardinal ligaments (CAL), and the ovaries (lateral compartments).
Lesions in the vaginal wall are classified as #ENZIAN A1 for largest diameter < 1 cm,
A2 for 1 to 3 cm, and A3 for > 3 cm ([Fig. 7 ]) [16 ].
Video 22 Normal vaginal wall. Normal vaginal wall may be stretched to < 3 mm thickness (dotted
line).
Video 23 Thickened vaginal wall. Palpation reveals a hard line of tiny nodules, 2 × 0.5 cm,
6 h, cranio-caudal in dorsal fornix. In TVS, the VW presents an increased thickness
> 3 mm (dotted red line) and inhomogeneous, small cystic irregularity. #ENZIAN: A2.
Video 24 Vaginal wall lesion – slip off sign. Palpation of a hard nodule of 20 × 5 mm in the
right dorsal fornix. In TVS, no proper nodule is visible. The vaginal wall (VW) only
presents an increased thickness > 3 mm (dotted red line) and inhomogeneous, small
cystic irregularity, which tends to slip off. #ENZIAN: A2.
4.2.6 Vaginal fornices
Suspicion of fornical endometriosis most frequently arises when a lesion occurs behind
the cervix or when the posterior vaginal fornix appears thickened. Other possible
involvement should be clarified (vagina, SUL, CAL, ureter, ovary, bowel). Rectovaginal
lesions, which simultaneously involve the posterior fornix and the anterior rectal
wall, are also referred to as “diabolo-like lesions ” due to their typical angular hourglass-shaped appearance ([Fig. 12 ]) [25 ]. These often-large lesions (with an average size of 3 cm) pass from the posterior
fornix to the anterior rectal wall. They may be located below the peritoneum of the
POD, rendering them poorly visible during laparoscopy [26 ]. Lesions in the vaginal fornices are classified as #ENZIAN A1 for largest diameter
< 1 cm, A2 for 1 to 3 cm, and A3 for > 3 cm ([Fig. 7 ]) [16 ].
Fig. 12 Diabolo-like lesion. Left: Native DE lesion. Right: Marked DE lesion (blue).
4.3 Posterior compartment
4.3.1 Definition
The posterior compartment is defined by organs and structures dorsal to the WSL , principally represented by the rectum/intestine (“bowel compartment ”) ([Table 2 ]).
Sliding mobility should be observable along the anterior rectal/intestinal serosa
but not at the RVS ([Fig. 13 ], [Video 25 ]). DE lesions in this compartment occur preferably in the upper RVS and the anterior
rectal wall.
Fig. 13 Posterior compartment. Image on the right: adapted from Schünke M, Schulte E, Schumacher U, Voll M, Wesker
K. 6.23 Schnittbildanatomie des weiblichen Beckens. In: Schünke M, Schulte E, Schumacher
U, Voll M, Wesker K, Hrsg. Prometheus LernAtlas – Innere Organe. 5. Auflage. Stuttgart:
Thieme; 2018. doi:10.1055/b-006–149 645.
Video 25 Posterior compartment
4.3.2 Assessment
Examination of the rectum/intestine may be compromised by excessively meandering bowel
loops with steep curves and the view obscuring faces. Nevertheless, the anterior wall
of the rectum/intestine is usually visible up to the pelvic brim. Keeping the probe
close to the target is crucial for appropriate image quality and judgment ([Fig. 14 ]). Isolated DE lesions affecting the intestine are some of the most challenging lesions
to detect.
Fig. 14 Sonoanatomy of visceral organs.
We propose starting with RVS and bowel examination at the anal verge, proceeding from
caudal to cranial in sagittal and parasagittal planes for RVS evaluation and then checking the anterior rectum/intestine
from the posterior fornix following its center line ([Video 25 ]). The bowel in the true pelvis, at least the anterior wall, may be visualized by
TVS (8). Measuring rectal length is feasible [27 ].
At the deepest point of the peritoneal cavity, the RVS divides into an anterior branch,
corresponding to the cervical serosa (WSL), and a posterior branch, corresponding
to the rectal serosa ([Video 26 ]). This division is a topographic TVS landmark that represents the cranial end of
the RVS and the beginning of the intra-abdominal free bowel.
Video 26 Rectovaginal septum (RVS) “splitting”. Blue circle: upper end of RVS
4.3.3 Rectovaginal septum (RVS) and bowel
In the case of reduced or absent sliding, examiners should describe the degree of
suspicion for adhesions ([Video 19 ]) and which organs are involved. DE lesions are judged to be either retrocervical,
in the vaginal (fornix) wall, in the RVS (#ENZIAN A), or purely affecting the rectum
(#ENZIAN C) ([Fig. 7 ]) [16 ]. The largest diameter in a sagittal midline plane along the axis of the rectum is
measured, and severity is assigned regarding the size: < 1 cm (A1 or C1, respectively),
1–3 cm (A2 or C2), > 3 cm (A3 or C3). The distance to the anal verge should be measured
using the ultrasound probe as a measuring tool [27 ]. Lesions above 16 cm cranial to the anal verge are described as intestinal lesions
(#ENZIAN FI) ([Fig. 7 ]) [16 ].
DE lesions of the bowel belong to the most common sites (number 2 of the top 5, 23 %)
[15 ]. Rectal DE lesions may be associated with a second intestinal lesion in more than
50 % of cases [8 ]. Typically, bowel endometriosis appears as irregular, hypoechogenic lesions affecting
the bowel wall ([Video 27 ]). These lesions may present a regular elliptic shape but often exhibit an asymmetric,
irregular shape, sometimes with spikes or tails. Working out the affected layers ([Fig. 14 ]) is crucial since this has significant implications for surgical treatment. Retractions
inside the anterior rectal wall may be visible if a bowel lesion is fixed to the uterus
or cervix. This phenomenon has been described as the Indian headdress sign or moose antler sign ([Video 28 ]). Lesions with progressive narrowing, like a tail, have been described as the comet sign
[8 ].
Video 27 Intestinal DE lesion. Mushroom-shaped lesion. Full thickness defect. #ENZIAN: FI.
Video 28 Rectal DE lesion. Indian headdress sign or moose antler sign. Full thickness defect.
#ENZIAN: C2.
4.4 Lateral compartments
4.4.1 Definition
The right and left lateral compartments are defined by organs and structures lateral
to the WSL (“adnexal compartment”) : ([Fig. 15 ], [Video 29 ], [Table 2 ]). The upper border of this compartment corresponds to the cranial border of the
external and common iliac artery.
Fig. 15 Lateral compartments. Image on the right: adapted from Schünke M, Schulte E, Schumacher U, Voll M, Wesker
K. 6.23 Schnittbildanatomie des weiblichen Beckens. In: Schünke M, Schulte E, Schumacher
U, Voll M, Wesker K, Hrsg. Prometheus LernAtlas – Innere Organe. 5. Auflage. Stuttgart:
Thieme; 2018. doi:10.1055/b-006–149 645.
Video 29 Lateral compartment
4.4.2 Assessment
The lateral compartments are generally investigated starting in the ipsilateral fornix
using a transverse plane.
Sliding mobility should be verifiable along all peritoneal surfaces, except at the
broad ligament, where only the dorsal sheet is accessible ([Video 30, 31 ]). The guiding sliding line is the transversally (horizontally) running omega sign ([Video 5 ]), presentable on the backside of the uterus and broad ligaments.
Video 30 Right tail sign
Video 31 Left tail sign
Whenever one or more tiny, hard nodules are palpated on the lateral posterior vaginal
fornix, TVS should assign the nodule to the vaginal wall, SUL, or components and organs
in the peritoneal cavity, such as the ovary and bowel. Several of them may appear
stuck together, and move as a block (block sign , [Video 32 ]), which can also be recognized by the lack of physiological distance between them
when the probe is withdrawn quickly.
Video 32 Block sign. «Moving block» involving vaginal wall, SUL, ovary, bowel. #ENZIAN: A2
B3/0 T3/0.
4.4.3 Ovaries
Endometriomas represent a proper entity of endometriosis manifestation [5 ]. They affect only the ovaries, are typically asymptomatic, and are found in > 10 %
of women with subfertility [28 ]. They appear as one of the typical four elementary benign adnexal tumors [29 ]. In about 50 % of cases, endometriomas present a uniform pattern of a smooth-walled
unilocular cyst of homogeneous ground glass echogenicity, containing no acoustic streaming
[5 ]. Endometriomas are rarely isolated findings [30 ]. They often occur with other potentially painful endometriotic lesions, such as
adhesions in > 70 % of cases and DE in > 50 % [28 ]
[31 ]. The most common differential diagnosis is the self-limiting hemorrhagic cyst, typically
presenting a spider-web-like, retracting clot and resolving over time. Endometriomas
should be documented in number, three perpendicular measurements each, and the type
appearance (typical or atypical) [5 ]. The sum of all endometrioma diameters should be calculated for each ovary (side-separated)
and classified by #ENZIAN; O1 (sum of diameters < 3 cm), O2 (3–7 cm) or O3 (> 7 cm)
([Video 33 ], [Fig. 7 ]) [16 ].
Video 33 Endometrioma. «Moving block» involving vaginal wall, SUL, ovary, bowel. #ENZIAN:
A2 B3/0 T3/0.
In a situs with one or more endometriomas, a careful and comprehensive evaluation
should include the search for impaired sliding as an indication of adhesions and DE.
Mobility terminology is not yet uniform ([Video 19 ]). The ovaries are slightly pushed cranially by gently applying axial or paraxial
pressure ([Video 34 ]). If the ovaries do not slide against the pelvic sidewall, the broad ligament, or
the surrounding bowels, lateral adhesions must be considered (#ENZIAN T1) ([Video 35 ]). In our experience, it is less challenging to demonstrate free or impaired sliding
against the medial structures (uterus, vagina). The tubal-ovarian complex with the
indication of adhesions to the uterus is classified as #ENZIAN T2. Additional adhesions
to the bowel or SULs are classified as #ENZIAN T3, leading to a moving block (block sign ) ([Video 32 ], [Fig. 7 ]) [16 ].
Video 34 Completely free ovarian sliding
Video 35 Impaired ovarian sliding
The kissing ovaries sign describes both ovaries (with or without endometriomas) fixed together behind the
uterus in the POD ([Video 36 ]). Pushing the probe between them does not separate them but probably causes pain,
leading to the conclusion of a high probability of adhesions corresponding to #ENZIAN
T3. This is particularly important for preoperative planning [32 ] since intestinal involvement is more likely in patients with kissing ovaries than in those with other endometriosis manifestations [32 ].
Video 36 Kissing ovaries sign. Fixed ovaries in “kissing position” behind the uterus, the
so-called “kissing ovaries sign”, an example of the “block sign”
4.4.4 Fallopian tubes
The Fallopian tubes are only visible on TVS if contrasted from inside or outside by
a physiological or pathological collection of liquid. Endometriosis may cause hemato-
or hydrosalpinges [17 ] ([Video 37 ]) and peritoneal cysts [8 ], sometimes showing typical swashing sails ([Video 38 ]). Chronic sactosalpinx carries the pathognomonic signs of incomplete septa or the cogwheel sign
[33 ].
Video 37 Chronic sactosalpinx
Video 38 Swashing pseudoperitoneal cyst
4.4.5 Broad ligaments and pelvic sidewall
Dynamic investigation of the adnexal region, provoking sliding of bowels and ovaries
along the omega sign, should demonstrate the free sliding between these organs, to the dorsal sheet of
the broad ligaments, and the pelvic sidewalls ([Video 30, 31 ]). Investigators should notice reduced or absent sliding, which can be classified
for each side as #ENZIAN T1 (adhesions of adnexa to pelvic sidewall), T2 (T1 and adhesions
to uterus), or T3 (T2 and adhesions to SULs or bowel). DE lesions appear mainly near
the cervix (#ENZIAN B) ([Fig. 7 ]) [16 ].
4.4.6 Cardinal ligaments (CAL)
On TVS, the CALs become visible under an appropriate push as the echogenic, longish
structure several centimeters in length at the caudal end of the broad ligament, containing the UVC with the uterine artery and many veins ([Video 39–41 ]). They may be conveniently found when looking for the tail sign (dorsal sheet of
the broad ligament) from the lateral fornix in a transverse plane running nearly horizontally
through the right or left lateral compartment at the lower uterine corpus ([Video 41 ]). They run from the lower lateral corpus, cervix, and vaginal fornix to the pelvic
sidewall, whereby both borders fade into the neighboring structures. At the caudal
end, the CALs connect directly to the SULs.
The ureters are the second leading structures in the CALs. They cross the CALs by passing under
the UVC in a more or less straight course laterodorsally ([Video 42 ]).
Video 39 Right CAL presentation. CAL: cardinal ligament
Video 40 Left CAL presentation. CAL: cardinal ligament
Video 41 CAL and SUL presentation. CAL: cardinal ligament; POD: pouch of Douglas; SUL: sacrouterine
ligament; UTA: uterine artery; UVC: uterovascular complex. Image top right: adapted
from Schünke M, Schulte E, Schumacher U, Voll M, Wesker K. 6.23 Schnittbildanatomie
des weiblichen Beckens. In: Schünke M, Schulte E, Schumacher U, Voll M, Wesker K,
Hrsg. Prometheus LernAtlas – Innere Organe. 5. Auflage. Stuttgart: Thieme; 2018. doi:10.1055/b-006–149 645
Video 42 CAL, ureter, UVC. CAL: cardinal ligament; UTA: uterine artery; UVC: utero-vascular
complex
Lesions in this area should also be measured in their maximum lateral extent and assigned
to #ENZIAN B separately for left and right (B1: < 1 cm, B2: 1–2 cm, B3: > 3 cm) ([Fig. 7 ]) [16 ].
4.4.7 Sacrouterine ligaments (SULs)
The SULs are preferably found topographically and not morphologically [14 ]. In a transverse plane, they directly connect caudally to the CALs as a bright, echogenic stripe in
the dorsal peritoneum that extends laterally from the cervix. The probe should be
rotated outwardly and downwardly to follow the SULs towards the pelvic sidewall ([Video 43, 44 ]). If correctly exposed, the SULs will wrap around the tip of the TVS probe.
Video 43 Right SUL presentation. CAL: cardinal ligament, SUL: sacrouterine ligament
Video 44 Left SUL presentation. CAL: cardinal ligament, SUL: sacrouterine ligament
The SULs are the favored site of DE and harbor 53 % of DE lesions [15 ]. They should be considered affected if the retrocervical sliding mobility is impaired,
a hypoechogenic thickening interrupts its hyperechoic presentation, or a substantial
DE lesion affects one or both SULs or the torus in-between ([Video 45 ]). Lesions may be isolated or multiple, affecting the vaginal wall, the ovaries,
the bowel, the ureters, or some combination thereof ([Video 32 ]) [8 ]. An advantage of using the transverse plane is the comparability of the right and left SULs and the inspection of the torus
at a glance ([Video 45 ]).
Video 45 SUL DE lesion. #ENZIAN: B 0/2. DE: deep endometriosis; SUL: sacrouterine ligament
As with CAL lesions, SUL lesions are measured in the largest diameter and subsequently
classified as side-separated according to #ENZIAN B (left/right). Note that central
lesions on the torus, affecting the retrocervical area, have to be assigned to #ENZIAN
A ([Fig. 7 ]) [16 ].
