Transperineal ultrasound in women with rectal endometriosis: could sonographic parameters be correlated with bowel symptoms?

STUDY OBJECTIVE: to compare levator hiatal area and anorectal angle at rest and after maximal contraction, at transperineal 2D/3D/4D ultrasound between patients with rectal endometriosis and asymptomatic healthy women and, secondly, to find any association between sonographic findings and bowel symptoms. PATIENTS: 96 nulliparous patients with symptomatic rectal endometriosis scheduled for laparoscopic surgery (study group) were compared to 88 nulliparous asymptomatic healthy women (control group). Patients had never undergone surgery for deep endometriosis and had not assumed hormonal therapy before the enrollment. INTERVENTIONS: transperineal ultrasound for evaluation of levator hiatal area and anorectal angle was performed in all patients at rest. Data were analyzed offline with a dedicated software by an investigator blinded to clinical data. Bowel symptoms were collected using a validated questionnaire (Knowles-Eccersley-Scott-Symptom Questionnaire). Comparisons of mean values between controls and cases were performed. Correlations between sonographic parameters and KESS questionnaire’s items were analyzed using Spearman’s correlation. MEASUREMENTS AND MAIN RESULTS: Compared to the control group, patients with rectal endometriosis show a significantly narrower levator hiatal area at rest and after maximal contraction; patient with rectal endometriosis show a narrower anorectal angle at rest (109.8±10.8 grade versus 113.7±13.0 grade, p=0.03). In the study group we found a significant association between severity of dyschezia at KESS questionnaire and dimension of anorectal angle (p < 0.001). In the study group, Patients with constipation had a narrower anorectal angle compared to endometriotic patients without constipation . CONCLUSION: women with rectal endometriosis had a significantly narrower levator hiatal area and anorectal angle than healthy controls, suggesting pelvic floor hypertone. Pelvic floor dysfunctions in women with rectal endometriosis seem to be associated to bowel complaints, particularly dyschezia and constipation. Transperineal ultrasound may be a useful, inexpensive and non-invasive tool to detect pelvic floor dysfunctions in sympomatic patients affected by deep endometriosis.