Extensive deep pelvic endometriosis

Case contributed by Mostafa El-Feky


Abdominal pain, bleeding per rectum

Patient Data

Age: 40 years
Gender: Female

MRI pelvis


Marked bilateral hemato/hydrosalpinges reaching 4 cm in caliber, showing foci of blood signal as well as marked diffusion restriction.

Multiple islands of deep invasive uterine endometriosis, involving the outer myometrium and showing low T2 signal, the largest of which is 5 cm and shows internal microcysts of blood signal. The uterus is retroverted, with normal endometrial and junctional zone thickness.

A T2 hypointense plaque measuring 12 mm involves the colonic wall at the level of recto-sigmoid junction (which may explain the bleeding per rectum).

Minimal free pelvic fluid.

Case Discussion

This case represents some features of extensive deep pelvic endometriosis with bilateral marked hemato/hydrosalpinges, pelvic endometriotic implants, invasive uterine endometriosis and involvement of the rectosigmoid junction.

This case presented with bleeding per rectum which is unusual and rare presentation of pelvic endometriosis that resulted from invasion of endometriotic lesion to the recto-sigmoid junction.

The marked hemato/hydrosalpinges in the setting of endometriosis is a result of pelvic adhesions and Fallopian tubes strictures. No post contrast enhancement of the walls of the dilated Fallopian tubes though diffusion restriction, hypointense T1 fat sat with parts of hyperintensity and T2 hyperintensity of the contents mostly representing low hemorrhagic contents. The lack of enhancement as well as the clinical presentation differentiated this appearance from tubo-ovarian abscess and hydrosalpinx of pelvic inflammatory disease. 

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