Treatment of extragenital endometriosis will depend on the site. If complete excision is possible, this is the treatment of choice; when this is not possible, long-term medical treatment is necessary using the same principles of medical treatment for pelvic endometriosis (1). Appendicular endometriosis is usually treated by appendectomy. Surgical treatment of bladder endometriosis is usually in the form of excision of the lesion and primary closure of the bladder wall. Ureteral lesions may be excised after stenting the ureter; in the presence of intrinsic lesions or significant obstruction, segmental excision with end-to-end anastomosis or reimplantation may be necessary. Abdominal wall and perineal endometriosis is usually treated by complete excision of the nodule (1).
Clinical Examination In many women with endometriosis, no abnormality is detected during the clinical examination. However, the vulva, vagina, and cervix should be inspected for any signs of endometriosis, although the occurrence of endometriosis in these areas is rare (e.g., episiotomy scar). The presence of a narrow pinpoint cervical ostium can be a risk factor for endometriosis (23). Other signs of possible endometriosis include uterosacral or cul-desac nodularity, lateral or cervical displacement caused by uterosacral scarring, painful swelling of the rectovaginal septum, and unilateral ovarian cystic enlargement (198). In more advanced disease, the uterus is often in fixed retroversion, and the mobility of the ovaries and fallopian tubes is reduced. Evidence of deeply infiltrative endometriosis (deeper than 5 mm under the peritoneum) in the rectovaginal septum with cul-de-sac obliteration or cystic ovarian endometriosis should be suspected when there is clinical documentation of uterosacral nodularities during menses, especially if CA125 serum levels are higher than 35 IU/mL (199–201). In these cases, black-blue colored lesions can sometimes be observed in the vagina during speculum examination.
The clinical examination may have false-negative results. The diagnosis of endometriosis should be confirmed by visual inspection during laparoscopy and by histological confirmation of endometriosis in biopsied lesions.
Ultrasound Peritoneal endometriosis cannot be reliably visualized by imaging techniques. Compared to laparoscopy, transvaginal ultrasound has no value in diagnosing peritoneal endometriosis, but it is useful in making or excluding the diagnosis of an ovarian endometrioma (1,202). Either transvaginal or transrectal ultrasonography can be used with high sensitivity and specificity for the diagnosis of ovarian endometrioma (202–204). The typical ultrasound features of an endometriotic ovarian cyst in premenopausal women were described as “ground glass echogenicity of the cyst ﬂuid, one to four locules and no solid parts” (205). Transvaginal ultrasound may have a role in the diagnosis of endometriosis nodules with a diameter of 1 cm involving the bladder or rectum, but this is dependent on the interest and experience of the ultrasonographer and the quality and resolution of the ultrasound equipment.
Local guidelines for the management of suspected ovarian malignancy should be followed in cases of ovarian endometrioma (1). Ultrasound scanning with or without serum CA125 testing is usually used to try to identify rare instances of ovarian cancer; however, CA125 levels are frequently elevated in the presence of endometriomas, so this approach is often not useful (1).
Other Imaging Other imaging techniques, including computed tomography (CT) and MRI, can be used to provide additional and confirmatory information, but they cannot be used for primary diagnosis (1,206). These techniques are more costly than ultrasonography, and their added value is unclear.