Endometriosis - hematosalpinx and kissing ovaries

Case contributed by Dr Eid Kakish


Severe chronic pelvic pain and dysmenorrhea. Previous c-section.

Patient Data

Age: 40 years
Gender: Female

Both ovaries appear enlarged and in close proximity, located in the rectouterine space, containing multiple irregular cystic lesions of variable sizes, most of which demonstrate a hyperintense signal on T1 fat-sat, corresponding to a heterogeneously hypointense signal on T2-weighted images "Shading sign (endometrioma)". Findings are consistent with multiple bilateral ovarian endometriomas.

Tortuous dilated fallopian tubes, measuring around 1.5 - 1.8 cm in maximal diameter, with T1 hyperintense internal contents, best seen on T1 FS, suggestive of tubal blood, which is more pronounced on the left side, in keeping with bilateral hematosalpinx.

A small amount of T1 hyperintense fluid is seen within the endometrial cavity, suggestive of hematometrium. 

Large intramural leiomyoma arising from the left side of the uterine body, resulting in moderate architectural distortion of the endometrial cavity, exhibiting considerable mass effect on the adjacent pelvic structures. 

Tortuous dilated parametrial venous structures with associated dilatation of both ovarian veins, suggestive of pelvic congestion.

Case Discussion

This case demonstrates a few manifestations of endometriosis, in the form of multiple ovarian endometriomas and hematosalpinx. 

When endometriosis affects the cul-de-sac along with bilateral ovarian involvement, deep pelvic adhesions may result in pulling of both oavries towards the midline, often seen posteriorly in the rectouterine pouch, giving rise to the Kissing ovaries sign

Around one third of women with endometriosis show tubal disease. The serosal lining of the tubes is commonly affected, resulting in tubal adhesions with secondary luminal obstruction. Less than half of the tubes affected may demonstrate high intraluminal signal on T1FS (Hematosalpinges), when endometrial implants are involving the serosa. Differentials for dilated fluid-filled fallopian tubes include simple hydrosalpinx or pyosalpinx as a result of pelvic inflammatory disease. 

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