ADENOMYOSIS. Chronic Pelvic Pain in Women IMAGING OF CHRONIC PELVIC PAIN IN WOMEN. Chronic Pelvic Pain in Women
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1 Chronic Pelvic Pain in Women IMAGING OF CHRONIC PELVIC PAIN IN WOMEN MOSTAFA ATRI, MD, Dipl. Epid. UNIVERSITY OF TORONTO Ø Non-menstrual pain of 6 months Ø Prevalence 15%: years of age Ø 10-40% of gynecology visits Ø 35% of laparoscopies/15% of hysterectomies Ø Total cost: 39 billion/year in US Chronic Pelvic Pain in Women Ø Gynecology causes Ø Adenomyosis Ø Endometriosis Ø Chronic PID Ø Pelvic congestion Ø Ovarian remnant syndrome Ø Pelvic adhesions Ø GI causes Ø Diverticulitis Ø Urology causes (cystitis, urethral diverticulum) Ø MSK causes ADENOMYOSIS 1
2 Adenomyosis Adenomyosis: Pathology Ø Up to 70% of hysterectomy specimens Ø Clinical diagnosis correct in 48% Ø Pain starting before and continuing after period Ø Menorrhagia, metrorrhagia Ø Soft and tender uterus Ø More common dorsally Ø Endometrial glands & stroma Ø One high power field below endometrium; > 2.5 mm Ø Glandular cyst Ø Glandular proliferation in proliferative phase Ø Peri-glandular muscle hypertrophy Pathology Junctional Zone (JZ) Thickening on Ø JZ thickness < 8 mm Ø JZ thickness 8mm-12mm Reinhold et. al. Radiology
3 Junctional Zone (JZ) Thickening on Junctional Zone (JZ) Thickening on Ø JZ thickness < 8 mm Ø JZ thickness < 8 mm Ø JZ thickness 8mm-12mm Ø JZ thickness > 12mm ì ì Ø JZ thickness 8mm-12mm Ø JZ thickness > 12mm ì ì Ø Focal thickening of JZ Reinhold et. al. Radiology 1996 Junctional Zone (JZ) Thickening on Focal Abnormality (specific) Ø JZ thickness < 8 mm Ø JZ thickness > 12mm Ø JZ thickness 8mm-12mm Ø Focal thickening of JZ Ø T1W/ high signal foci Ø Endometrial gland Ø Endometrial cyst Ø Hemorrhage Ø Round/Linear nodules T1W Ø Changing thickness of JZ 3
4 Focal Abnormality (specific) Focal Abnormality (specific) Ø T1W/ high signal foci Ø Endometrial gland Ø Endometrial cyst Ø Hemorrhage Ø Round/Linear nodules ê Ø T1W/ high signal foci Ø Endometrial gland Ø Endometrial cyst Ø Hemorrhage Ø Round/Linear nodules Ø Myometrial Cyst: < 5mm ê Adenomyosis Location Sonographic Features Ø Round or elongated echogenic nodules Ø Poor definition of outer endometrium Ø Edge shadows ê Ø Sub-endometrial myometrial cysts Ø Globular configuration or asymmetrical wall Ø Heterogenous architecture Atri et. al. Radiology
5 Nodule Cyst Endo Definition Adenomyoma vs Fibroid Ø Less mass effect Ø Poor definition Ø Oval shaped Ø Similar to JZ on Ø Iso-vascular to myometrium Adenomyoma Adenomyoma Sag Tra Fibroid GE +C 5
6 Focal Adenomyosis 1 2 ENDOMETRIOSIS 3 Endometriosis Edometriotic Cyst Evidence of Chronocity Ø Endometriotic cyst Ø Endometriotic plaques ê 6
7 Lack of Vascularity Physiologic Cyst Trans-abdominal Trans-vaginal Endometriotic Cyst Edometriotic Cyst Endometriosis Common Disease Axial T1W Axial Ø General population: 7% - 10% Ø Infertile: 20% - 50% Ø 90% of women with chronic pelvic pain/ dyspareunia Ø 50% - 80% symptomatic Ø Amount of pain or other symptoms not correlated with extent but related to depth of penetration 7
8 Endometriosis Pathology Ø Glands ± hemorrhage Ø Fibro/muscular reaction Staging Ø Minimal, mild, moderate, severe Ø Location, size, extent Ø Superficial <3mm, 3-5mm, deep >5mm Ø Adhesion Ø Endometriotic cyst Locations Ø Common sites: Ø Ovary & ligaments & cul de sac Ø Anywhere on the peritoneal surface of the pelvis Ø Urethro-vaginal septum Ø Vagina/recto-vaginal septum Ø C-section scar / Abd. wall Gross Changes US & Ø Plaques Ø Gland Ø Fibromuscular reaction (active vs chronic) Ø Evidence of scar Ø Uterine flexion Ø Ovary/uterine adhesion, kissing ovaries Ø Bowel angulation Ø Hydrosalpinx/hematosalpinx Ø Adhesive bands ULTRASOUND Ø Hypoechoic plaques Ø Bright foci Ø cysts Ø ± Vascularity MRI Ø T1W: High signal foci Ø : Low to intermediate signal Ø ± Enhancement 8
9 Ovarian Endometriosis Utero-sacral Ligament Ø Most common site of endometriosis (20% 40% of cases) Ø Under-diagnosed because of microscopic size Gastro-intestinal Tract Recto-Uterine Ø Rectum and rectosigmoid junction Ø Appendix, ileum, cecum, and descending colon Ø MR less accurate than US to detect deep bowel infiltrating lesions, especially small nodules (<1.5cm) p p Goncalves et al. Human Reproduction 2010 GE +C GE +C 9
10 Recto-Vaginal Septum Recto-Cervical Ø Extensions from recto-cervical or posterior vaginal lesions Ø Bladder and rectovaginal plaques difficult to see laparoscopically GE Kissing Ovaries GE +C 10
11 Dorsal Uterine Kissing Ovaries GE Utero-Vesical Sag T1W GE 11
12 Bladder Abdominal Wall Chronic Pelvic Pain in Women Diverticulosis Ø Gynecology causes Ø Adenomyosis Ø Endometriosis Ø Chronic PID Ø Pelvic congestion Ø Ovarian remnant syndrome Ø Pelvic adhesions Ø GI causes Ø Diverticulitis Ø Urology causes (cystitis, urethral diverticulum) Ø MSK causes Diverticulum TVS TVS 12
13 Diverticulitis Take Home Points Ø Adenomyosis Ø Look for evidence of endometrial glands as well as surrounding fibromuscular reaction on imaging Ø Endometriotic cyst Ø Look for evidence of chronocity in an ovarian cyst Ø Endometriosis Ø Look for an abnormality that disturbs fatty contour of pelvic organs and fat between the organs 13
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