Presentation
Pelvic pain.
Patient Data
Bulky uterus with grossly heterogeneous myometrial textures, multiple T2 /T1 hyperintense foci are seen within anteriorly, ill-defined endo-myometrial interphase with widened junctional zone, no fibroid.
Homogenous endometrium measuring <5 mm, no polyp.
An irregular enhancing mass-like focal thickening of the left posterolateral bladder wall measuring (30x27x13) mm, replace the normal signal of detrusor muscle with lobulated inner aspect, predominantly hypointense on T2 and contains small intermingled T1 hyperintense foci that indicate bloody content, it extends to/ partially obliterate the inferior aspect of the vesicouterine recess,
Noticeable smooth bladder thickening at the left VUJ, however, no convincing peri-ureteral stranding or adventitial wall thickening, no proximal ureteric dilation to suggest ureteric involvement.
Partial obliteration of the retro-cervical recess with hypointense spiculated thickening and stranding extends to the anterior rectal wall causing focal parietal thickening, no stricture or proximal bowel obstruction. No apparent uterosacral, round ligament, or anterior abdominal wall involvement
Both ovaries are of normal size with a sub-centimetric hemorrhagic cyst on the right, the left ovary looks tethered to the posterior uterine wall with thickened mesovarium suggesting infiltration, small endometriotic deposit can’t be ruled out.
No visible suspicious pelvic lymph nodes, unremarkable neurovascular structure.
Case Discussion
A constellation of findings suggests diffuse adenomyosis, deep pelvic endometriosis at the vesicouterine pouch infiltrates the bladder muscular layer and manifests as mural masses that project into the lumen (intrinsic involvement), and posterior compartment endometriotic implants at the retro-cervical recess involving the anterior rectal wall, no feature of the urinary tract or bowel obstruction.