Different ultrasound morphologies of rectosigmoid endometriosis nodules: an exploratory analysis of their prevalence and associated clinical characteristics

Objective: To investigate the prevalence of various ultrasound morphologies of rectosigmoid endometriosis (RSE) nodules according to the International Deep Endometriosis Analysis consensus, and their potential association with distinct clinical phenotypes of the disease. Design: Pilot, single-center, observational, cross-sectional study on a prospectively collected database. Subjects: Consecutive patients with a diagnosis of RSE at transvaginal ultrasound referred to our center from May 2022 to June 2023. Exposure: During the study period, 273 eligible women were included. Demographic and clinical data were collected. Characteristics of RSE were evaluated using transvaginal ultrasound. Morphologies of RSE nodules were classified as regular profile outlines, “moose antler” sign, “comet” sign, “mushroom cup” sign, or “pulling sleeve” sign. Statistical analyses included χ2 tests, Fisher's exact tests, and Kruskal–Wallis tests, with P values adjusted using Sidak's method. The significance level was set at .05. Main Outcome Measures: Primary outcome was the prevalence of each ultrasound International Deep Endometriosis Analysis morphology of RSE nodules. Secondary outcomes were the associations between each ultrasound morphology and clinical characteristics, moderate-severe pain symptoms, altered bowel habits, and coexistence of other endometriosis localizations. Results: Prevalence was: 35.9% for regular outline lesions, 28.2% for the “moose antler” sign, 24.2% for the “comet” sign lesions, 5.1% for the “pulling sleeve” sign, and 6.6% for the “mushroom cup” sign. Mean nodule diameters/volumes were significantly larger in the “moose antler,” “pulling sleeve,” and “mushroom cup” sign groups. Moderate-to-severe dysmenorrhea showed a significantly higher prevalence in “comet” sign (52.2%) and “moose antler” sign (50.0%) when compared with the prevalence in the regular outline group (22.2%). Compared with the 6.1% prevalence observed in the “comet” sign group, the rate of rectovaginal space involvement was significantly higher in the “mushroom cup” group (27.8%). Conclusion: The regular profile was the most frequent morphology of RSE nodules, followed by “moose antler” and “comet” signs, which were associated with a higher incidence of moderate-to-severe dysmenorrhea. “Moose antler” and “pulling sleeve” signs, along with the “mushroom cup” sign, were the largest RSE nodules, with the latter showing a stronger association with rectovaginal space involvement.