Page 15 - Diagnostic delay of endometriosis

with other conditions. These include cyclical urinary or intestinal complaints (dysuria, dyschezia, periodic bloating, diarrhea or constipation), excessive or irregular menstrual bleeding, fatigue, referred pain in the back or legs and many more.4, 24, 29, 30 Dysmenorrhea appears to be the leading presenting complaint, present in up to 62% of women with endometriosis, followed by chronic pelvic pain (57%), deep dyspareunia (55%), cyclical intestinal complaints (48%), subfertility (40%) and cyclical urinary complaints (12%).31 However, these numbers vary between different studies, and the predictive value of any symptom or combination of symptoms remains uncertain as they can have other causes, and a significant proportion of affected women is asymptomatic.24, 32, 33 Nevertheless, performing a detailed history in women with abdominal symptoms will help in identifying those with an increased risk of endometriosis in a timely matter.
Physical examination
Clinical examination is aimed at facilitating timely diagnosis and treatment of endometriosis. It includes inspection and palpation of the abdomen and a pelvic examination including visualization of the cervix, posterior fornix and vaginal wall using a speculum, and bimanual palpation of the internal genital organs and rectovaginal septum. A well-performed clinical examination can attribute to the suspicion of deep endometriosis or adnexal mass and direct further diagnostic strategy, but it does not rule out the presence of endometriosis if no abnormalities are found. The positive and negative predictive values of clinical examination for identifying various types of deep endometriosis in experienced hands are 43-100% and 84-98% respectively.34 Clinical examination has the benefits of being easily available at low cost but has some disadvantages as well. There are occasions that vaginal examination is considered inappropriate, for instance in adolescent girls and women with a history of sexual abuse or certain religious beliefs. Furthermore, the pelvic examination can be very painful for some women and should always be performed with caution.
Imaging techniques and biomarkers
In addition to the clinical examination, imaging techniques can be applied to explain underlying symptoms and assess the size and location of specific lesions. Transvaginal ultrasound (with or without bowel preparation) is used as a first line imaging tool for mapping of disease localizations in different compartments of the pelvis, preferably using a systematic approach.35 Diagnostic accuracy of transvaginal ultrasound with regard to the detection
General introduction | 13