DOI: 10.1148/rg.266065048
Deep Retroperitoneal Pelvic Endometriosis: MR Imaging Appearance with Laparoscopic Correlation1
Chiara Del Frate, MD,
Rossano Girometti, MD,
Marco Pittino, MD,
Giovanni Del Frate, MD,
Massimo Bazzocchi, MD and
Chiara Zuiani, MD
1 From the Department of Radiology, University of Udine, Via Colugna 50, 33100 Udine, Italy (C.D.F., R.G., M.B., C.Z.); and the Department of Gynaecology and Obstetrics, Hospital of San Daniele del Friuli, Udine, Italy (M.P., G.D.F.). Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received March 30, 2006; revision requested May 1; final revision received August 14; accepted August 23. All authors have no financial relationships to disclose.
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Figure 1a. Axial (a) and sagittal (b) T2-weighted fast spin-echo images (repetition time msec/echo time msec = 5000/118) show the most frequent sites of involvement with peritoneal endometrial implants ( ), such as the surface of the ovaries, uterus, bowel, and pouch of Douglas. The red dashed lines indicate the typical locations of deep implants, which occur along uterovesical and rectovaginal septa across peritoneal reflections in the pelvis.
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Figure 1b. Axial (a) and sagittal (b) T2-weighted fast spin-echo images (repetition time msec/echo time msec = 5000/118) show the most frequent sites of involvement with peritoneal endometrial implants (), such as the surface of the ovaries, uterus, bowel, and pouch of Douglas. The red dashed lines indicate the typical locations of deep implants, which occur along uterovesical and rectovaginal septa across peritoneal reflections in the pelvis.
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Figure 2. Classification of endometrial implants of the rectovaginal septum. Red spot = deep implant, yellow line = visceral peritoneum. Left: Rectovaginal septum lesions, seen in 10% of cases, are located in the rectovaginal septum between the posterior wall of the vagina (V) and the anterior wall of the rectal muscularis. Metaplasia of müllerian remnants has been hypothesized to explain their origin. F = posterior vaginal fornix, R = rectum, U = uterus. Center: The most frequent type of lesion (65% of cases) occurs in the posterior wall of the vaginal fornix. Such implants develop from the posterior fornix toward the rectovaginal septum, without extension to the septum itself or the rectal wall. Right: Hourglass-shaped lesions are found in 25% of cases and are due to posterior extension of a posterior forniceal lesion toward the anterior rectal muscularis.
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Figure 3a. Hemorrhagic endometrial implants of the rectovaginal septum in a 26-year-old woman with dyspareunia and dysmenorrhea who presented with a palpable nodule in the posterior vaginal fornix. (a) Axial T1-weighted fast spin-echo fat-suppressed image (852/12) shows multiple round, hyperintense hemorrhagic foci (arrow) in the retrocervical space and pouch of Douglas. (b) Sagittal T1-weighted fast spin-echo fat-suppressed image (852/12) shows an endometrial implant in the posterior fornix (arrow), a finding consistent with the palpable nodule. (c) Photograph obtained during laparoscopy (same orientation as in a) shows adhesions (*) and multiple red endometrial implants (arrow) on the surface of the uterus and rectum and in the pouch of Douglas. (d) Photograph obtained after initial lysis of the adhesions (near the tip of the laparoscope) shows that the forniceal implant remains hidden.
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Figure 3b. Hemorrhagic endometrial implants of the rectovaginal septum in a 26-year-old woman with dyspareunia and dysmenorrhea who presented with a palpable nodule in the posterior vaginal fornix. (a) Axial T1-weighted fast spin-echo fat-suppressed image (852/12) shows multiple round, hyperintense hemorrhagic foci (arrow) in the retrocervical space and pouch of Douglas. (b) Sagittal T1-weighted fast spin-echo fat-suppressed image (852/12) shows an endometrial implant in the posterior fornix (arrow), a finding consistent with the palpable nodule. (c) Photograph obtained during laparoscopy (same orientation as in a) shows adhesions (*) and multiple red endometrial implants (arrow) on the surface of the uterus and rectum and in the pouch of Douglas. (d) Photograph obtained after initial lysis of the adhesions (near the tip of the laparoscope) shows that the forniceal implant remains hidden.
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Figure 3c. Hemorrhagic endometrial implants of the rectovaginal septum in a 26-year-old woman with dyspareunia and dysmenorrhea who presented with a palpable nodule in the posterior vaginal fornix. (a) Axial T1-weighted fast spin-echo fat-suppressed image (852/12) shows multiple round, hyperintense hemorrhagic foci (arrow) in the retrocervical space and pouch of Douglas. (b) Sagittal T1-weighted fast spin-echo fat-suppressed image (852/12) shows an endometrial implant in the posterior fornix (arrow), a finding consistent with the palpable nodule. (c) Photograph obtained during laparoscopy (same orientation as in a) shows adhesions (*) and multiple red endometrial implants (arrow) on the surface of the uterus and rectum and in the pouch of Douglas. (d) Photograph obtained after initial lysis of the adhesions (near the tip of the laparoscope) shows that the forniceal implant remains hidden.
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Figure 3d. Hemorrhagic endometrial implants of the rectovaginal septum in a 26-year-old woman with dyspareunia and dysmenorrhea who presented with a palpable nodule in the posterior vaginal fornix. (a) Axial T1-weighted fast spin-echo fat-suppressed image (852/12) shows multiple round, hyperintense hemorrhagic foci (arrow) in the retrocervical space and pouch of Douglas. (b) Sagittal T1-weighted fast spin-echo fat-suppressed image (852/12) shows an endometrial implant in the posterior fornix (arrow), a finding consistent with the palpable nodule. (c) Photograph obtained during laparoscopy (same orientation as in a) shows adhesions (*) and multiple red endometrial implants (arrow) on the surface of the uterus and rectum and in the pouch of Douglas. (d) Photograph obtained after initial lysis of the adhesions (near the tip of the laparoscope) shows that the forniceal implant remains hidden.
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Figure 4a. Endometrial implant of the uterovesical septum in a 36-year-old woman with dysmenorrhea and dysuria. (a) Sagittal T1-weighted fast spin-echo fat-saturated image (852/12) shows a hyperintense hemorrhagic nodule (arrow) in the uterovesical septum. (b) Photograph obtained during laparoscopy (cranial view) shows the region of the uterovesical cul-de-sac after raising of the uterus. The endometriotic nodule (arrow) is attached to the posterior surface of the bladder.
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Figure 4b. Endometrial implant of the uterovesical septum in a 36-year-old woman with dysmenorrhea and dysuria. (a) Sagittal T1-weighted fast spin-echo fat-saturated image (852/12) shows a hyperintense hemorrhagic nodule (arrow) in the uterovesical septum. (b) Photograph obtained during laparoscopy (cranial view) shows the region of the uterovesical cul-de-sac after raising of the uterus. The endometriotic nodule (arrow) is attached to the posterior surface of the bladder.
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Figure 5a. Fibrotic obliteration of the pouch of Douglas in a 27-year-old patient with dyspareunia and pain in the posterior vaginal fornix at clinical examination. (a, b) Axial T1-weighted (865/11) (a) and T2-weighted (5000/118) (b) fast spin-echo images show a low-signal-intensity area of tissue retraction (arrow), which extends from the posterior upper cervix to the pouch of Douglas. (c) Sagittal fat-saturated T1-weighted fast spin-echo image (852/12) shows hyperintense foci (arrow) in the same region as the area of tissue retraction in a and b, a finding consistent with hemorrhagic content. (d) Photograph obtained during laparoscopy (same orientation as in a and b) shows only the super-ficial part of the endometriotic nodule, which appears as an area of tissue distortion with red hemorrhagic spots (arrow). (e) Photograph from the same examination shows a detail of the deep lesion (near the tip of the laparoscope), which was excised laparoscopically by using a finger placed through the vagina for guidance.
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Figure 5b. Fibrotic obliteration of the pouch of Douglas in a 27-year-old patient with dyspareunia and pain in the posterior vaginal fornix at clinical examination. (a, b) Axial T1-weighted (865/11) (a) and T2-weighted (5000/118) (b) fast spin-echo images show a low-signal-intensity area of tissue retraction (arrow), which extends from the posterior upper cervix to the pouch of Douglas. (c) Sagittal fat-saturated T1-weighted fast spin-echo image (852/12) shows hyperintense foci (arrow) in the same region as the area of tissue retraction in a and b, a finding consistent with hemorrhagic content. (d) Photograph obtained during laparoscopy (same orientation as in a and b) shows only the super-ficial part of the endometriotic nodule, which appears as an area of tissue distortion with red hemorrhagic spots (arrow). (e) Photograph from the same examination shows a detail of the deep lesion (near the tip of the laparoscope), which was excised laparoscopically by using a finger placed through the vagina for guidance.
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Figure 5c. Fibrotic obliteration of the pouch of Douglas in a 27-year-old patient with dyspareunia and pain in the posterior vaginal fornix at clinical examination. (a, b) Axial T1-weighted (865/11) (a) and T2-weighted (5000/118) (b) fast spin-echo images show a low-signal-intensity area of tissue retraction (arrow), which extends from the posterior upper cervix to the pouch of Douglas. (c) Sagittal fat-saturated T1-weighted fast spin-echo image (852/12) shows hyperintense foci (arrow) in the same region as the area of tissue retraction in a and b, a finding consistent with hemorrhagic content. (d) Photograph obtained during laparoscopy (same orientation as in a and b) shows only the super-ficial part of the endometriotic nodule, which appears as an area of tissue distortion with red hemorrhagic spots (arrow). (e) Photograph from the same examination shows a detail of the deep lesion (near the tip of the laparoscope), which was excised laparoscopically by using a finger placed through the vagina for guidance.
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Figure 5d. Fibrotic obliteration of the pouch of Douglas in a 27-year-old patient with dyspareunia and pain in the posterior vaginal fornix at clinical examination. (a, b) Axial T1-weighted (865/11) (a) and T2-weighted (5000/118) (b) fast spin-echo images show a low-signal-intensity area of tissue retraction (arrow), which extends from the posterior upper cervix to the pouch of Douglas. (c) Sagittal fat-saturated T1-weighted fast spin-echo image (852/12) shows hyperintense foci (arrow) in the same region as the area of tissue retraction in a and b, a finding consistent with hemorrhagic content. (d) Photograph obtained during laparoscopy (same orientation as in a and b) shows only the super-ficial part of the endometriotic nodule, which appears as an area of tissue distortion with red hemorrhagic spots (arrow). (e) Photograph from the same examination shows a detail of the deep lesion (near the tip of the laparoscope), which was excised laparoscopically by using a finger placed through the vagina for guidance.
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Figure 5e. Fibrotic obliteration of the pouch of Douglas in a 27-year-old patient with dyspareunia and pain in the posterior vaginal fornix at clinical examination. (a, b) Axial T1-weighted (865/11) (a) and T2-weighted (5000/118) (b) fast spin-echo images show a low-signal-intensity area of tissue retraction (arrow), which extends from the posterior upper cervix to the pouch of Douglas. (c) Sagittal fat-saturated T1-weighted fast spin-echo image (852/12) shows hyperintense foci (arrow) in the same region as the area of tissue retraction in a and b, a finding consistent with hemorrhagic content. (d) Photograph obtained during laparoscopy (same orientation as in a and b) shows only the super-ficial part of the endometriotic nodule, which appears as an area of tissue distortion with red hemorrhagic spots (arrow). (e) Photograph from the same examination shows a detail of the deep lesion (near the tip of the laparoscope), which was excised laparoscopically by using a finger placed through the vagina for guidance.
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Figure 6a. Small endometrioma and endometrial implant of the uterosacral ligament in a 28-year-old woman with pelvic pain and infertility. (a) Axial fat-suppressed T1-weighted fast spin-echo image (852/12) shows a small endometrioma in the left ovary. (The endometrioma was histologically proved.) (b, c) Axial fat-suppressed T1-weighted fast spin-echo images (852/12), obtained at contiguous levels, show linear, hyperintense, hemorrhagic endometrial implants (arrow in b) on the surface of the uterus, with a more definite nodular spot in the anterior extremity. (d) Photograph obtained during laparoscopy shows the region of the implants seen in b and c. The hemorrhagic spot in c correlates with a red implant on the left uterosacral ligament (arrow), which is stretched by uterine laterodeviation. Left oophorectomy was performed (*).
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Figure 6b. Small endometrioma and endometrial implant of the uterosacral ligament in a 28-year-old woman with pelvic pain and infertility. (a) Axial fat-suppressed T1-weighted fast spin-echo image (852/12) shows a small endometrioma in the left ovary. (The endometrioma was histologically proved.) (b, c) Axial fat-suppressed T1-weighted fast spin-echo images (852/12), obtained at contiguous levels, show linear, hyperintense, hemorrhagic endometrial implants (arrow in b) on the surface of the uterus, with a more definite nodular spot in the anterior extremity. (d) Photograph obtained during laparoscopy shows the region of the implants seen in b and c. The hemorrhagic spot in c correlates with a red implant on the left uterosacral ligament (arrow), which is stretched by uterine laterodeviation. Left oophorectomy was performed (*).
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Figure 6c. Small endometrioma and endometrial implant of the uterosacral ligament in a 28-year-old woman with pelvic pain and infertility. (a) Axial fat-suppressed T1-weighted fast spin-echo image (852/12) shows a small endometrioma in the left ovary. (The endometrioma was histologically proved.) (b, c) Axial fat-suppressed T1-weighted fast spin-echo images (852/12), obtained at contiguous levels, show linear, hyperintense, hemorrhagic endometrial implants (arrow in b) on the surface of the uterus, with a more definite nodular spot in the anterior extremity. (d) Photograph obtained during laparoscopy shows the region of the implants seen in b and c. The hemorrhagic spot in c correlates with a red implant on the left uterosacral ligament (arrow), which is stretched by uterine laterodeviation. Left oophorectomy was performed (*).
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Figure 6d. Small endometrioma and endometrial implant of the uterosacral ligament in a 28-year-old woman with pelvic pain and infertility. (a) Axial fat-suppressed T1-weighted fast spin-echo image (852/12) shows a small endometrioma in the left ovary. (The endometrioma was histologically proved.) (b, c) Axial fat-suppressed T1-weighted fast spin-echo images (852/12), obtained at contiguous levels, show linear, hyperintense, hemorrhagic endometrial implants (arrow in b) on the surface of the uterus, with a more definite nodular spot in the anterior extremity. (d) Photograph obtained during laparoscopy shows the region of the implants seen in b and c. The hemorrhagic spot in c correlates with a red implant on the left uterosacral ligament (arrow), which is stretched by uterine laterodeviation. Left oophorectomy was performed (*).
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Figure 7a. Deep endometriosis of the bladder wall in a 30-year-old patient with dysuria and infertility. (a) Axial T2-weighted fast spin-echo image (5000/118) shows a solid, nodular hypointense mass in the posterior bladder wall. (b) Sagittal T1-weighted fast spin-echo image (865/11) shows multiple hemorrhagic foci in the lesion (arrow) and better demonstrates its craniocaudal extension along the bladder wall. (c) Photograph obtained during laparoscopy shows the vesicouterine cul-de-sac, with the bladder distended before the uterus by a Foley catheter. Linear tight adhesions (arrows) are evident between the bladder and uterus. (d) Photograph from the same examination shows the region depicted in c after lysis of the adhesions (white rectangles). (e) Close-up photograph of the region of the dashed white rectangle in d shows multiple small, black endometrial implants on the surface of the bladder in the zone of the lysed adhesion. (f ) Close-up photograph of the region of the solid white rectangle in d shows the deep endometriotic nodule as tumescence of the bladder surface (arrow) under the lysed adhesion. On the basis of the MR imaging and laparoscopic findings, an open laparotomy was performed to excise the extended bladder lesion, which was confirmed to be a deep endometriotic lesion at pathologic analysis.
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Figure 7b. Deep endometriosis of the bladder wall in a 30-year-old patient with dysuria and infertility. (a) Axial T2-weighted fast spin-echo image (5000/118) shows a solid, nodular hypointense mass in the posterior bladder wall. (b) Sagittal T1-weighted fast spin-echo image (865/11) shows multiple hemorrhagic foci in the lesion (arrow) and better demonstrates its craniocaudal extension along the bladder wall. (c) Photograph obtained during laparoscopy shows the vesicouterine cul-de-sac, with the bladder distended before the uterus by a Foley catheter. Linear tight adhesions (arrows) are evident between the bladder and uterus. (d) Photograph from the same examination shows the region depicted in c after lysis of the adhesions (white rectangles). (e) Close-up photograph of the region of the dashed white rectangle in d shows multiple small, black endometrial implants on the surface of the bladder in the zone of the lysed adhesion. (f ) Close-up photograph of the region of the solid white rectangle in d shows the deep endometriotic nodule as tumescence of the bladder surface (arrow) under the lysed adhesion. On the basis of the MR imaging and laparoscopic findings, an open laparotomy was performed to excise the extended bladder lesion, which was confirmed to be a deep endometriotic lesion at pathologic analysis.
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Figure 7c. Deep endometriosis of the bladder wall in a 30-year-old patient with dysuria and infertility. (a) Axial T2-weighted fast spin-echo image (5000/118) shows a solid, nodular hypointense mass in the posterior bladder wall. (b) Sagittal T1-weighted fast spin-echo image (865/11) shows multiple hemorrhagic foci in the lesion (arrow) and better demonstrates its craniocaudal extension along the bladder wall. (c) Photograph obtained during laparoscopy shows the vesicouterine cul-de-sac, with the bladder distended before the uterus by a Foley catheter. Linear tight adhesions (arrows) are evident between the bladder and uterus. (d) Photograph from the same examination shows the region depicted in c after lysis of the adhesions (white rectangles). (e) Close-up photograph of the region of the dashed white rectangle in d shows multiple small, black endometrial implants on the surface of the bladder in the zone of the lysed adhesion. (f ) Close-up photograph of the region of the solid white rectangle in d shows the deep endometriotic nodule as tumescence of the bladder surface (arrow) under the lysed adhesion. On the basis of the MR imaging and laparoscopic findings, an open laparotomy was performed to excise the extended bladder lesion, which was confirmed to be a deep endometriotic lesion at pathologic analysis.
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Figure 7d. Deep endometriosis of the bladder wall in a 30-year-old patient with dysuria and infertility. (a) Axial T2-weighted fast spin-echo image (5000/118) shows a solid, nodular hypointense mass in the posterior bladder wall. (b) Sagittal T1-weighted fast spin-echo image (865/11) shows multiple hemorrhagic foci in the lesion (arrow) and better demonstrates its craniocaudal extension along the bladder wall. (c) Photograph obtained during laparoscopy shows the vesicouterine cul-de-sac, with the bladder distended before the uterus by a Foley catheter. Linear tight adhesions (arrows) are evident between the bladder and uterus. (d) Photograph from the same examination shows the region depicted in c after lysis of the adhesions (white rectangles). (e) Close-up photograph of the region of the dashed white rectangle in d shows multiple small, black endometrial implants on the surface of the bladder in the zone of the lysed adhesion. (f ) Close-up photograph of the region of the solid white rectangle in d shows the deep endometriotic nodule as tumescence of the bladder surface (arrow) under the lysed adhesion. On the basis of the MR imaging and laparoscopic findings, an open laparotomy was performed to excise the extended bladder lesion, which was confirmed to be a deep endometriotic lesion at pathologic analysis.
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Figure 7e. Deep endometriosis of the bladder wall in a 30-year-old patient with dysuria and infertility. (a) Axial T2-weighted fast spin-echo image (5000/118) shows a solid, nodular hypointense mass in the posterior bladder wall. (b) Sagittal T1-weighted fast spin-echo image (865/11) shows multiple hemorrhagic foci in the lesion (arrow) and better demonstrates its craniocaudal extension along the bladder wall. (c) Photograph obtained during laparoscopy shows the vesicouterine cul-de-sac, with the bladder distended before the uterus by a Foley catheter. Linear tight adhesions (arrows) are evident between the bladder and uterus. (d) Photograph from the same examination shows the region depicted in c after lysis of the adhesions (white rectangles). (e) Close-up photograph of the region of the dashed white rectangle in d shows multiple small, black endometrial implants on the surface of the bladder in the zone of the lysed adhesion. (f ) Close-up photograph of the region of the solid white rectangle in d shows the deep endometriotic nodule as tumescence of the bladder surface (arrow) under the lysed adhesion. On the basis of the MR imaging and laparoscopic findings, an open laparotomy was performed to excise the extended bladder lesion, which was confirmed to be a deep endometriotic lesion at pathologic analysis.
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Figure 7f. Deep endometriosis of the bladder wall in a 30-year-old patient with dysuria and infertility. (a) Axial T2-weighted fast spin-echo image (5000/118) shows a solid, nodular hypointense mass in the posterior bladder wall. (b) Sagittal T1-weighted fast spin-echo image (865/11) shows multiple hemorrhagic foci in the lesion (arrow) and better demonstrates its craniocaudal extension along the bladder wall. (c) Photograph obtained during laparoscopy shows the vesicouterine cul-de-sac, with the bladder distended before the uterus by a Foley catheter. Linear tight adhesions (arrows) are evident between the bladder and uterus. (d) Photograph from the same examination shows the region depicted in c after lysis of the adhesions (white rectangles). (e) Close-up photograph of the region of the dashed white rectangle in d shows multiple small, black endometrial implants on the surface of the bladder in the zone of the lysed adhesion. (f ) Close-up photograph of the region of the solid white rectangle in d shows the deep endometriotic nodule as tumescence of the bladder surface (arrow) under the lysed adhesion. On the basis of the MR imaging and laparoscopic findings, an open laparotomy was performed to excise the extended bladder lesion, which was confirmed to be a deep endometriotic lesion at pathologic analysis.
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Figure 8a. Rectal hemorrhagic endometrial implants and right-sided dermoid cyst in a 26-year-old woman with infertility and severe pelvic pain. The patient also had a left-sided endometriotic cyst (not shown). (a) Axial T1-weighted fast spin-echo image (865/11) shows a small hyperintense lesion (arrow) of the rectal wall, which represents an endometrial implant. A high-signal-intensity mass is seen in the right ovary. (b) Axial fat-suppressed T1-weighted fast spin-echo image (852/12) shows the rectal endometrial implant more clearly and also shows other small hyperin-tense foci in the same region (arrow). The signal intensity of the adnexal mass is markedly decreased, an appearance consistent with a dermoid cyst. (c) Photograph obtained during laparoscopy shows the pouch of Douglas, with the tip of the instrument moving apart the rectum. Multiple red endometrial implants are present, including one on the rectal wall (arrow). (d) Photograph from the same examination shows the dermoid cyst between the tips of the laparoscope, with a red endometrial implant on its surface.
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Figure 8b. Rectal hemorrhagic endometrial implants and right-sided dermoid cyst in a 26-year-old woman with infertility and severe pelvic pain. The patient also had a left-sided endometriotic cyst (not shown). (a) Axial T1-weighted fast spin-echo image (865/11) shows a small hyperintense lesion (arrow) of the rectal wall, which represents an endometrial implant. A high-signal-intensity mass is seen in the right ovary. (b) Axial fat-suppressed T1-weighted fast spin-echo image (852/12) shows the rectal endometrial implant more clearly and also shows other small hyperin-tense foci in the same region (arrow). The signal intensity of the adnexal mass is markedly decreased, an appearance consistent with a dermoid cyst. (c) Photograph obtained during laparoscopy shows the pouch of Douglas, with the tip of the instrument moving apart the rectum. Multiple red endometrial implants are present, including one on the rectal wall (arrow). (d) Photograph from the same examination shows the dermoid cyst between the tips of the laparoscope, with a red endometrial implant on its surface.
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Figure 8c. Rectal hemorrhagic endometrial implants and right-sided dermoid cyst in a 26-year-old woman with infertility and severe pelvic pain. The patient also had a left-sided endometriotic cyst (not shown). (a) Axial T1-weighted fast spin-echo image (865/11) shows a small hyperintense lesion (arrow) of the rectal wall, which represents an endometrial implant. A high-signal-intensity mass is seen in the right ovary. (b) Axial fat-suppressed T1-weighted fast spin-echo image (852/12) shows the rectal endometrial implant more clearly and also shows other small hyperin-tense foci in the same region (arrow). The signal intensity of the adnexal mass is markedly decreased, an appearance consistent with a dermoid cyst. (c) Photograph obtained during laparoscopy shows the pouch of Douglas, with the tip of the instrument moving apart the rectum. Multiple red endometrial implants are present, including one on the rectal wall (arrow). (d) Photograph from the same examination shows the dermoid cyst between the tips of the laparoscope, with a red endometrial implant on its surface.
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Figure 8d. Rectal hemorrhagic endometrial implants and right-sided dermoid cyst in a 26-year-old woman with infertility and severe pelvic pain. The patient also had a left-sided endometriotic cyst (not shown). (a) Axial T1-weighted fast spin-echo image (865/11) shows a small hyperintense lesion (arrow) of the rectal wall, which represents an endometrial implant. A high-signal-intensity mass is seen in the right ovary. (b) Axial fat-suppressed T1-weighted fast spin-echo image (852/12) shows the rectal endometrial implant more clearly and also shows other small hyperin-tense foci in the same region (arrow). The signal intensity of the adnexal mass is markedly decreased, an appearance consistent with a dermoid cyst. (c) Photograph obtained during laparoscopy shows the pouch of Douglas, with the tip of the instrument moving apart the rectum. Multiple red endometrial implants are present, including one on the rectal wall (arrow). (d) Photograph from the same examination shows the dermoid cyst between the tips of the laparoscope, with a red endometrial implant on its surface.
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Figure 9a. Deep fibrotic endometriosis of the pouch of Douglas in a 33-year-old woman with dyspareunia and a palpable nodule in the rectovaginal septum. (a) Axial T2-weighted fast spin-echo image (5000/118) shows a nodular region of hypointense tissue (arrow) between the anterior rectal wall and cervix, with some degree of surrounding soft-tissue distortion. (b) Axial fat-suppressed T1-weighted fast spin-echo image (852/12) shows that the nodule (arrow) is isointense relative to surrounding tissues with no hemorrhagic content, an appearance indicative of its fibrotic nature. (c) Photograph obtained during laparoscopy (same orientation as in a and b) shows the pouch of Douglas during the procedure of nodule excision, which was performed by using a finger placed through the vagina for guidance. The tip of the instrument (near the top of the image) is moving apart the posterior vaginal fornix. The fibrotic endometriotic lesion without hemorrhagic content (arrow) is seen in the rectovaginal septum.
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Figure 9b. Deep fibrotic endometriosis of the pouch of Douglas in a 33-year-old woman with dyspareunia and a palpable nodule in the rectovaginal septum. (a) Axial T2-weighted fast spin-echo image (5000/118) shows a nodular region of hypointense tissue (arrow) between the anterior rectal wall and cervix, with some degree of surrounding soft-tissue distortion. (b) Axial fat-suppressed T1-weighted fast spin-echo image (852/12) shows that the nodule (arrow) is isointense relative to surrounding tissues with no hemorrhagic content, an appearance indicative of its fibrotic nature. (c) Photograph obtained during laparoscopy (same orientation as in a and b) shows the pouch of Douglas during the procedure of nodule excision, which was performed by using a finger placed through the vagina for guidance. The tip of the instrument (near the top of the image) is moving apart the posterior vaginal fornix. The fibrotic endometriotic lesion without hemorrhagic content (arrow) is seen in the rectovaginal septum.
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Figure 9c. Deep fibrotic endometriosis of the pouch of Douglas in a 33-year-old woman with dyspareunia and a palpable nodule in the rectovaginal septum. (a) Axial T2-weighted fast spin-echo image (5000/118) shows a nodular region of hypointense tissue (arrow) between the anterior rectal wall and cervix, with some degree of surrounding soft-tissue distortion. (b) Axial fat-suppressed T1-weighted fast spin-echo image (852/12) shows that the nodule (arrow) is isointense relative to surrounding tissues with no hemorrhagic content, an appearance indicative of its fibrotic nature. (c) Photograph obtained during laparoscopy (same orientation as in a and b) shows the pouch of Douglas during the procedure of nodule excision, which was performed by using a finger placed through the vagina for guidance. The tip of the instrument (near the top of the image) is moving apart the posterior vaginal fornix. The fibrotic endometriotic lesion without hemorrhagic content (arrow) is seen in the rectovaginal septum.
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Figure 10a. Bowel adhesions due to endometriosis in a 37-year-old patient with dysmenorrhea and infertility. (a) Axial T2-weighted fast spin-echo image (5000/118) shows tight contact between a large hypointense mass of the left ovary and a bowel loop (arrow). (b) Axial contrast-enhanced fat-suppressed T1-weighted fast spin-echo image (852/12) shows that the mass has high signal intensity, a finding indicative of hemorrhagic contents. There is absence of the fat plane between the endometrioma and the bowel loop (arrow), which demonstrates increased angulation. (c) Photograph obtained during laparoscopy shows the tight adhesions between the endometriotic cyst and the bowel loop, which was shown to be the sigmoid colon.
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Figure 10b. Bowel adhesions due to endometriosis in a 37-year-old patient with dysmenorrhea and infertility. (a) Axial T2-weighted fast spin-echo image (5000/118) shows tight contact between a large hypointense mass of the left ovary and a bowel loop (arrow). (b) Axial contrast-enhanced fat-suppressed T1-weighted fast spin-echo image (852/12) shows that the mass has high signal intensity, a finding indicative of hemorrhagic contents. There is absence of the fat plane between the endometrioma and the bowel loop (arrow), which demonstrates increased angulation. (c) Photograph obtained during laparoscopy shows the tight adhesions between the endometriotic cyst and the bowel loop, which was shown to be the sigmoid colon.
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Figure 10c. Bowel adhesions due to endometriosis in a 37-year-old patient with dysmenorrhea and infertility. (a) Axial T2-weighted fast spin-echo image (5000/118) shows tight contact between a large hypointense mass of the left ovary and a bowel loop (arrow). (b) Axial contrast-enhanced fat-suppressed T1-weighted fast spin-echo image (852/12) shows that the mass has high signal intensity, a finding indicative of hemorrhagic contents. There is absence of the fat plane between the endometrioma and the bowel loop (arrow), which demonstrates increased angulation. (c) Photograph obtained during laparoscopy shows the tight adhesions between the endometriotic cyst and the bowel loop, which was shown to be the sigmoid colon.
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Copyright © 2006 by the Radiological Society of North America.
