Deep and superficial endometriosis
Chronic pelvic pain.
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Irregular nodule at the rectovaginal septum with T1-weighted intermediate signal intensity and T2-weighted high signal intensity. There are areas within the nodule with high signal on the fat-suppressed T1 sequence compatible with haemorraghic foci and T2-weighted high-signal small areas probably representing dilated ectopic endometrial glands. There is no enhancement after contrast media injection and no sign of rectal invasion. These findings are compatible with deep pelvic endometriosis.
The aforementioned nodule has a retraction effect, evidenced by the proximity of both ovaries behind the uterus, almost touching one another as in the "kissing ovaries sign" on ultrasound.
Two small high-signal foci on fat-suppressed T1-weighted images on the left ovary and one on the right ovary, compatible with superficial endometriosis.
The right ovary contains a heterogeneous cyst, predominantly high signal on T2-weighted sequences with low signal lines within the cyst, and intermediate/high signal on fat-suppressed T1. Signal intensity added to the others findings above described suggest an endometrioma, although a heamorraghic cyst is the differential diagnosis.
Small volume of free blood in the posterior rectovaginal pouch.
This case is a nice example of the many patterns of presentation of endometriosis: deep pelvic and superficial endometriosis with a cyst suggestive of an endometrioma.