Rectouterine pouch obliteration
The rectouterine pouch is a potential space at the most inferior aspect of the pelvis. Technically, a normal rectouterine pouch is present when the peritoneum between the USLs (laterally) and the cervix and rectum (anterior-posterior) is visible at time of surgery. This potential space can become obliterated in the context of severe adhesions due to endometriosis. There is a strong link between rectouterine pouch obliteration and bowel endometriosis.15,34
Presence of an obliterated rectouterine pouch has major surgical implications.3 As such, it must be evaluated for on ultrasound using the sliding sign technique described by Reid et al.15 and reinforced by the IDEA consensus.14 Ultrasound operators will sometimes need to use both hands to perform this dynamic, real-time technique; in the case of an anteverted uterus, we recommend holding the ultrasound probe still in the anterior vaginal fornix with one hand and with the other, applying pressure to the patient’s lower abdomen to move the uterus up and down. Occasionally, this will not elicit the sliding sign sufficiently and applying pressure to the uterus (either with the probe in the anterior vaginal fornix or with the probe up against the external cervical os) will be necessary. The test is considered positive when the uterus and cervix move independently (i.e. slide) along the PVF, anterior rectum and sigmoid (See Video 13. Conversely, if the uterus and cervix move in unison with the structures posteriorly, the test is negative and the pouch is thought to be obliterated (See Video 14).
In a retroverted uterus, only the hand holding the probe needs to move. The probe should be in the PVF and with pressure, the operator should be able to push the uterine fundus cephalad, allowing it to slide against the PVF and rectum (See Video 15). A small, often fluid-filled, space should become apparent between the cervix/mid-uterine body and PVF. In an obliterated rectouterine pouch, the fundus will not move independently from the PVF and/or the rectum (See Video 16). There is unlikely to be any fluid collection in the case of obliteration, though partial states of obliteration (e.g. the right side of the uterus does not slide against the structures posteriorly, but the left does) may exist. In the case of partial obliteration, the degree and location of obliteration should be described.
Thus far, SE has been an elusive target for noninvasive diagnosis. Studies that have attempted to demonstrate SE have done so with poor results.35-37 Recently, by developing the novel ultrasound technique called saline-infusion sonoPODography (SPG), we are one step closer to visualizing SE.38 Essentially, this procedure involves introduction of normal saline into the rectouterine pouch through the uterus and Fallopian tubes (when patent) via an intrauterine catheter, at which point, the contours of the peritoneal surfaces in the lower pelvis are inspected. In brief, we define the appearance of SE (all relative to a peritoneal surface) on TVS as follows: 1) hyperechoic projections ( See Figure 17), 2) hypoechoic areas (See Figures 17 and 18 online), 3) cystic areas (See Figure 19 online), 4) filmy adhesions (See Video 17) and 5) peritoneal pockets as demonstrated by incomplete septations and “entrapped” fluid (See Video 17). We are currently performing a prospective study to investigate the diagnostic accuracy of this technique more thoroughly.
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