Gastrointestinal Symptoms as a Predictor of Deep Infiltrating Endometriosis of the Posterior Compartment of the Pelvis on MRI Imaging

Abstract

Study Objective To determine if gastrointestinal symptoms can predict deep infiltrating endometriosis (DIE) of the posterior compartment of the pelvis on magnetic resonance imaging (MRI). Design Retrospective cohort study. Presenting gastrointestinal symptoms were collected from the modified International Pelvic Pain Society Pelvic Pain Assessment Form (mIPPS-PPAF). MRI reports and interdisciplinary conference notes were reviewed to identify DIE of the posterior compartment (rectosigmoid, uterosacral ligaments, posterior cul de sac, and pelvic side walls). Associations between symptoms and DIE were evaluated using logistic regression. Setting Academic tertiary care center. Patients or Participants Patients with suspected endometriosis undergoing an endometriosis protocol MRI with interdisciplinary conference review between 9/1/2015 and 7/31/2018 were identified from a clinical database. Patients with a pre-treatment mIPPS-PPAF were included. Interventions N/A Measurements and Main Results 104 patients met inclusion criteria; 89 (85.6%) presented with at least one gastrointestinal symptom. DIE of the posterior compartment was identified on MRI in 47 patients (45.2%). A bowel movement resulting in pain relief was the gastrointestinal symptom that most strongly predicted DIE (OR 3.36, 95%CI 1.31-8.61, p=0.012). For this symptom, sensitivity, specificity, positive and negative predictive values were 0.42, 0.82, 0.67, and 0.63, respectively. Other gastrointestinal symptoms such as nausea, emesis, rectal bleeding, and increased pain with change in frequency of bowel movements did not have a statistically significant association with DIE; a trend towards significance was seen for bowel movements making pain worse (OR 2.33, 95%CI 0.97-5.58, p=0.059). Of the 15 patients with no gastrointestinal symptoms, 5 were found to have DIE of the posterior compartment. Conclusion In patients with suspected endometriosis, those who noted that bowel movements relieved their pain had more than 3 times the odds of having DIE of the posterior compartment on an endometriosis protocol MRI. Preoperative evaluation with MRI may be of value in these patients; however, lack of gastrointestinal symptoms does not exclude the possibility of posterior compartment DIE.