ultrasound_based endometriosis scoring system

All thankfulness, and deep respects to Obstetrics and gynecology department, faculty of medicine, Benha university, where this study was done.

Obst. &Gyn. dep.

I'd like to express my sincere thanks to my family_my father, my sisters and my kids for their love, support and understanding.

A special thanks to my husband, who is always there for me.

Family

At last bot not least, I wish my mother was alive now so, I dedicate this work to her pure soul.

At last

Incidence

Incidence

Incidence is difficult to quantify, as women with the disease are often asymptomatic.

• In those asymptomatic women the prevalence of E is 6-11%
• In infertile women ..20-50%
• In those with pelvic pain..40-50%
• In 2/3 of adolescents with CPP.

Pathogenesis

Pathogenesis

The definitive cause of E remains unknown, but theories have been proposed.

• Retrograde menstruation through the fallopian tubes (Gordts et al. 2017).
• The stem cell theory
• Aberrent lymphatic or vascular spread of endometrial tissues
• coelomic metaplasia
• Mullerian remenats differentiation

Examination

Examination

• Physical examination

visual cues are often lacking

• Speculum examination

powder_burn lesions may be seen on the Cx or post. vag. fornix

• Bimanual examination

can detect Adenexal masses, USL nodularity, anatomical distortion and organ fixation

• Rectal examination

may reveal RVS nodularity

Lap investigations

Lap Investigations

• To date, there is no single biomarker or biomarker panel that seems to be useful in the clinical setting

• Usually undertaken to exclude other causes of CPP

• CA125 is elevated in severe stage of E, but has poor sensetivity in detecting mild stages

• TVS is the intial imaging tool in women presenting with CPP and it is accurate in detecting Endometriomas,aids exclusion of other causes of CPP, and has a suitable accuracy in assessment of DIE

• MRI help in clarifying anatomy, and better resolution for soft tissues so, can assist in preoperative planning for DIE

• CT plays a limited role in the evaluation of Endometriosis

Diagnostic imaging

• To date, Laparoscopy is the primary method for confirming diagnosis of Endometriosis

• Current guidlines do not require biopsy and histologic evaluation for diagnosis of Endometriosis

Diagnostic laparoscopy

• Most commonly used worldwide

• Surgically_based

• Evaluate 2 categories:-

-lesions (location & extent)

-adhesions (severity & extent)

• It reflected by point scores, and has 4 stages

• Addition point scores for partial or complete POD obliteration

rASRM classification

• Was popular in the past

• surgically_based

• It has 4 stages

EEC

• Morphological-topographical classification

• Complement to rASRM classification to encompass all lesions specially DIE

• The pelvis is divided into 3 compartments

-A..RVS & vagina

-B..USLs lig. , cardinal lig. , lateral pelvic side walls and extrinsic ureteric involvement

-C..Rectum & rectosegmoid

• It has 3 grades of severity 1,2 & 3

ENZIAN classification

• Developed by Menakaya et al. 2016 to predict the level of complexity of laparoscopic surgery for endometriosis, aiming to help in triage of women with endometriosis to a surgeon with appropriate skill level for optimal & best ttt of E in one & the first surgical set
• It is pre_operative US_based approach
• It has 3 stages

UBESS

Setting :-

Obs. & Gyn. dep., faculty of medicine, Benha university

Inclusion criteria :-

reproductive_aged women W CPP and/or endometriosis and infertility

Exclusion criteria :-

-menopause -pregnancy

-malignancy

-adnexal lesions other than endometrioma

setting

• after h/o taking and physical ex was completed, a TVS evaluation was done using Voluson 730 pro equipment after taking the pt. consent
• The bladder should be empty, but not routine bowel preparation
• patient was examined in lithotomy position with knee support and told that " let your knees go floppy "
• A detailed specialized TVS was done using the 5-domain ultrasound_based approach that described by Menakaya and consists of ....

Methods

5-domains

low fixed ovary

Hydrosalpinx

normal sliding sign

abnormal sliding sign

Torus &USL

Bowel DIE

correlating data

distribution of 100 cases according to UBESS/RANZCOG

Agreement of UBESS W RANZCOGW Kappa test

diagnostic Performance of TVS for E phenotypes

Agreement for UBESS

• Future studies should focus on incorporating ultrasound markers, which potentially can overcome the documented deficiencies of the current UBESS.
• Further studies to determine whether preoperative ultrasonography mapping can lead to a decrease in the number of surgical procedures needed, in a change of the surgical procedure planned, and reduction of both recurrences surgical complications.
• Further studies on large geographical scale and on larger sample size to emphasize our conclusion

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