The UOG Journal Club for June 2013 features two papers on the detection of obliteration of the pouch of Douglas and rectal involvement in DIE using a ‘uterine sliding sign’ on TVS: Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound technique: the sliding sign S. Reid, C. Lu, I. Casikar, G. Reid, J. Abbott, G. Cario, D. Chou, D. Kowalski, M. Cooper, and G. Condous Volume 41, Issue 6, Date: June 2013, pages 685–691 http://onlinelibrary.wiley.com/doi/10.1002/uog.12305/abstract Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating endometriosis of the rectum G. Hudelist, N. Fritzer, S. Staettner, A. Tammaa, A. Tinelli, R. Sparic, and J. Keckstein Volume 41, Issue 6, Date: June 2013, pages 692–695 http://onlinelibrary.wiley.com/doi/10.1002/uog.12431/abstract

1. UOG Journal Club: June 2013
Prediction of pouch of Douglas obliteration in women with suspected
endometriosis using a new real-time dynamic transvaginal ultrasound
technique: the sliding sign
S. Reid, C. Lu, I. Casikar, G. Reid, J. Abbott, G. Cario, D. Chou, D. Kowalski, M.
Cooper, G. Condous
Volume 41, Issue 6, Date: June 2013, pages 685–691
Uterine sliding sign: a simple sonographic predictor for presence of deep
infiltrating endometriosis of the rectum
G. Hudelist, N. Fritzer, S. Staettner, A. Tammaa, A. Tinelli, R. Sparic, J.
Keckstein
Volume 41, Issue 6, Date: June 2013, pages 692–695
Journal Club slides prepared by Dr Tommaso Bignardi
(UOG Editor for Trainees)

2. UOG Journal Club: June 2013
Prediction of pouch of Douglas obliteration in women with suspected
endometriosis using a new real-time dynamic transvaginal ultrasound
technique: the sliding sign
S. Reid, C. Lu, I. Casikar, G. Reid, J. Abbott, G. Cario, D. Chou, D. Kowalski, M.
Cooper, G. Condous
Volume 41, Issue 6, Date: June 2013, pages 685–691

3. To evaluate whether real-time dynamic transvaginal
sonography (TVS) can predict pouch of Douglas (POD)
obliteration.
Prediction of pouch of Douglas obliteration in women with suspected endometriosis
using a new real-time dynamic transvaginal ultrasound technique: the sliding sign
Reid et al., UOG 2013
Objective

4. Patients and Methods
• Multicenter prospective observational study
• 100 consecutive women with symptoms suggestive of endometriosis scheduled
for laparoscopy
Presence of sliding was evaluated at TVS in two locations: over the posterior
cervix/posterior vaginal wall and at the upper uterus/fundus
Final diagnosis of endometriosis was based on surgical resection with
histological confirmation
Prediction of pouch of Douglas obliteration in women with suspected endometriosis
using a new real-time dynamic transvaginal ultrasound technique: the sliding sign
Reid et al., UOG 2013

5. Predicted POD obliteration
(sliding sign negative)
True POD obliteration
Yes No
Yes 25 2 PPV = 92.6%
No 5 68 NPV = 93.2%
Sensitivity = 83.3% Specificity = 97.1% (P = 1.8E−16)
True pouch of Douglas (POD) obliteration vs predicted POD obliteration
PPV, positive predictive value; NPV, negative predictive value
Prediction of pouch of Douglas obliteration in women with suspected endometriosis
using a new real-time dynamic transvaginal ultrasound technique: the sliding sign
Reid et al., UOG 2013
Results

6. DIE nodule location Sensitivity Specificity PPV NPV
Rectosigmoid/ anterior
rectum nodule
17/20 (85.0) 73/80 (91.3) 17/24 (70.8) 73/76 (96.1)
Uterosacral ligament
nodule
4/10 (40.0) 86/90 (95.6) 4/8 (50.0) 86/92 (93.5)
Rectovaginal
septum/vaginal nodule*
2/8 (25.0) 92/92 (100.0) 2/2 (100.0) 92/98 (93.9)
Results
Data are given as n/n (%). *7/8 (87.5%) of the nodules invading the rectovaginal
septum/vagina were contiguous with an anterior rectal nodule.
NPV, negative predictive value; PPV, positive predictive value
Prediction of pouch of Douglas obliteration in women with suspected endometriosis
using a new real-time dynamic transvaginal ultrasound technique: the sliding sign
Reid et al., UOG 2013
Prediction of deep infiltrating endometriosis (DIE) location

7. Comparison of DIE location according to pouch of Douglas (POD) obliteration
transvaginal sonography
Data are given as n (%)
*More than one DIE nodule was visualized in some patients
†Sliding sign negative. ‡Sliding sign positive.
Prediction of pouch of Douglas obliteration in women with suspected endometriosis
using a new real-time dynamic transvaginal ultrasound technique: the sliding sign
Reid et al., UOG 2013
DIE nodule location* POD obliteration†
(n=27)
POD non-obliteration‡
(n = 73)
Anterior rectum 10 (37%) 0 (0%)
Rectosigmoid 11 (41%) 3 (4%)
Uterosacral ligament 5 (19%) 3 (4%)
Rectovaginal septum/vagina 0 (0%) 2 (35)
DIE absent 1 (4%) 66 (90%)
Results

8. • The sliding sign may give important additional information for planning
laparoscopic surgery
• High NPV of this simple technique means that one can confidently
expect the POD to be non-obliterated when the sliding sign is positive
Discussion
Prediction of pouch of Douglas obliteration in women with suspected endometriosis
using a new real-time dynamic transvaginal ultrasound technique: the sliding sign
Reid et al., UOG 2013

9. • Surgical exploration with histological confirmation in all women included
in the study
Strengths of the study
Weaknesses
• Surgeons who performed the surgeries were not blinded to the
preoperative TVS results
• A large proportion of women had a previous history of endometriosis
confirmed at laparoscopy
• All TVS performed by an experienced sonologist
Prediction of pouch of Douglas obliteration in women with suspected endometriosis
using a new real-time dynamic transvaginal ultrasound technique: the sliding sign
Reid et al., UOG 2013

10. Conclusions
• TVS with the sliding sign technique may be useful in the identification of
women at increased risk for bowel endometriosis
• Preoperative use of the sliding sign may ensure appropriate referral of
women to an advanced laparoscopic surgeon if appropriate
Prediction of pouch of Douglas obliteration in women with suspected endometriosis
using a new real-time dynamic transvaginal ultrasound technique: the sliding sign
Reid et al., UOG 2013

11. UOG Journal Club: June 2013
Uterine sliding sign: a simple sonographic predictor for presence
of deep infiltrating endometriosis of the rectum
G. Hudelist, N. Fritzer, S. Staettner, A. Tammaa, A. Tinelli, R. Sparic, J.
Keckstein
Volume 41, Issue 6, Date: June 2013, pages 692–695

12. • Several imaging techniques based on transvaginal sonography
(TVS) or magnetic resonance imaging have been used to investigate
deep infiltrating endometriosis (DIE) prior to laparoscopy.
• In women with DIE, obliteration of the pouch of Douglas may
predict difficult surgery.
• There are limited data on the use of preoperative TVS as a simple
test to predict obliteration of the pouch of Douglas in women with
suspected endometriosis.
Background

13. To evaluate if uterine sliding sign on transvaginal sonography
(TVS) can predict deep infiltrating endometriosis (DIE) of the
rectum.
Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating
endometriosis of the rectum
Hudelist et al., UOG 2013
Objective

14. • The transducer is introduced in the posterior vaginal fornix, then withdrawn to
assess the movement of the rectum against the posterior vaginal fornix and the
posterior uterine wall, in a midsagittal plane
• Examiner’s left hand is placed on the patient’s abdomen to apply pressure on
the uterus
Sliding sign positive:
sliding of the rectum against the posterior uterine wall
Sliding sign negative:
immobility of the rectum against the uterus
Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating
endometriosis of the rectum
Hudelist et al., UOG 2013
Assessment of the uterine sliding sign

15. Patients and Methods
• 117 consecutive women with symptoms suggestive of endometriosis who
underwent laparoscopic surgery
• Presence of positive or negative uterine sliding was evaluated at TVS by one
examiner prior to surgery
Final diagnosis of endometriosis was based on surgical resection with histological
confirmation
Sensitivity, specificity, PPV and NPV, respectively, test accuracy and LR+ and LR–, were calculated for
the presence or absence of uterine sliding in relation to the presence of DIE affecting the rectosigmoid
Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating
endometriosis of the rectum
Hudelist et al., UOG 2013

16. Site of disease n/total (%)
Primary locations
Pelvic peritoneum 62/117 (53)
Ovaries 13/117 (11)
DIE of the rectum 34/117 (29)
Other locations
Uterosacral ligaments 34/117 (29)
Pouch of Douglas 20/117 (17)
Vagina 15/117 (13)
Rectovaginal space 21/117 (18)
Urinary bladder 10/117 (9)
Results: surgical findings
Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating
endometriosis of the rectum
Hudelist et al., UOG 2013

17. n/total (%) or ratio 95% CI
Prevalence of rectal/sigmoidal
endometriosis
34/117 (29)
Negative sliding sign 32/117 (27)
Sensitivity 29/34 (85) 73–97
Specificity 80/83 (96) 92–100
PPV 29/32 (91) 81–100
NPV 80/85 (94) 89–99
Accuracy 109/117 (93)
LR + 23.6 7.7–72.3
LR – 0.15 0.07–0.34
LR+, positive likelihood ratio; LR–, negative likelihood ratio; NPV, negative predictive value; PPV, positive predictive value.
Results: diagnostic performance of a negative uterine sliding sign
Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating
endometriosis of the rectum
Hudelist et al., UOG 2013

18. • A negative uterine sliding sign could be an easy method for prediction
of DIE involving the rectum
• This sign could be a valuable ‘red flag’ sign for triaging women to
specialized clinics for detailed investigation
Discussion
Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating
endometriosis of the rectum
Hudelist et al., UOG 2013

19. • Surgical exploration with histological confirmation in all women included
in the study
Strengths of the study
Weaknesses
• TVS was performed by a highly experienced sonographer in a tertiary
referral center, this may not reflect a primary care setting
• No data on intra/inter-observer reproducibility
Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating
endometriosis of the rectum
Hudelist et al., UOG 2013

20. Discussion points
Uterine sliding sign: a simple sonographic
predictor for presence of deep infiltrating
endometriosis of the rectum
Hudelist et al., UOG 2013
Prediction of pouch of Douglas
obliteration in women with suspected
endometriosis using a new real-time
dynamic transvaginal ultrasound
technique: the sliding sign
Reid et al., UOG 2013
• Do we need a simple test for diagnosing deep infiltrating endometriosis
in the primary care setting?
• What are the surgical implications of a positive sliding test?
• Is the ‘sliding sign’ also a reliable method in less experienced hands?
• Should evaluation of the posterior pelvis always be included in the
routine transvaginal scan?