Hum. Reprod. Advance Access originally published online on August 9, 2008
Human Reproduction 2008 23(10):2386; doi:10.1093/humrep/den304
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Letters to the Editor |
Diagnosis of rectovaginal endometriosis
1 São Paulo University, São Paulo, Brazil 2 DIGIMAGEM, São Paulo, Brazil
3 Correspondence address. E-mail: msabrao{at}mac.com
The study entitled ‘Does transvaginal ultrasonography combined with water-contrast in the rectum (RWC-TVS) aid in the diagnosis of rectovaginal endometriosis infiltrating the bowel?’, published by Valenzano Menada et al. (2008)
presented a coherent analysis of the diagnosis of rectovaginal endometriosis infiltrating the bowel. This condition represents a significant concern for the specialist faced with a case of endometriosis involving the bowel, since the decision regarding the choice of treatment should be made preoperatively. The decision regarding whether to resect a nodule of endometriosis affecting the bowel wall or to resect the affected bowel segment should be made with caution to avoid both persistence of the disease and excessive surgery. We recently published a paper showing that in cases of deep endometriotic lesions affecting the rectum beyond the inner muscularis layer, >40% of the circumference of the rectum is found to be affected by the disease, emphasizing the importance of this preoperative diagnosis (Abrao et al., 2008). In the study carried out by Valenzano Menada et al. (2008), the authors showed that RWC-TVS determines the presence of rectovaginal nodules infiltrating the rectal muscularis propria more accurately than transvaginal ultrasonography (TVS), the sensitivity of TVS for the diagnosis of rectovaginal endometriosis being 92.2% compared with 97.8% with RWT-TVS. For the diagnosis of bowel disease infiltrating at least the muscular layer of the rectal wall, the sensitivity of TVS was 56.5%, whereas the sensitivity of RWC-TVS was 95.7%, and for nodules infiltrating the rectal wall, sensitivity was 62% and 86.2% for TVS and RWC-TVS, respectively. In our study in which we compared TVS with bowel preparation and magnetic resonance imaging (Abrao et al., 2007), TVS was found to have a sensitivity of 98% and 95% for rectosigmoid and retrocervical endometriosis, respectively. In that study, all patients were submitted to a simple rectal enema 
1 h prior to the exam to eliminate fecal residue and any gases present in the rectosigmoid. The negative aspects of the protocol suggested by Valenzano, which make this method difficult to reproduce in routine clinical practice, include the severe pain reported by 25.6% of the women when the liquid medium is introduced rectally and the fact that the test was carried out following complete preparation of the colon for colorectal surgery. Concerning sensitivity and specificity for detection of bowel lesions, there was no improvement in the results compared with TVS with no rectum distention with water (Bazot et al., 2003; Abrao et al., 2007). In our protocol, we aimed to use a form of bowel preparation that would be feasible for general application and that could be carried out prior to the patient's hospitalization, allowing the surgeon to discuss the best surgical strategy with the patient and to assemble a multidisciplinary team.
References
Abrao MS, Gonçalves MO, Dias JA Jr, Podgaec S, Chamie LP, Blasbalg R. Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis. Hum Reprod (2007) 22:3092–3097.
Abrao MS, Podgaec S, Dias JA Jr, Averbach M, Silva LF, Marino de Carvalho F. Endometriosis lesions that compromise the rectum deeper than the inner muscularis layer have more than 40% of the circumference of the rectum affected by the disease. J Minim Invasive Gynecol (2008) 15:280–285.[CrossRef][Web of Science][Medline]
Bazot M, Detchev R, Cortez A, Amouyal P, Uzan S, Darai E. Transvaginal sonography and rectal endoscopic sonography for the assessment of pelvic endometriosis: a preliminary comparison. Hum Reprod (2003) 18:1686–1692.
Valenzano Menada M, Remorgida V, Abbamonte LH, Nicoletti A, Ragni N, Ferrero S. Does transvaginal ultrasonography combined with water-contrast in the rectum aid in the diagnosis of rectovaginal endometriosis infiltrating the bowel? Hum Reprod (2008) 23:1069–1075.
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