Endometriosis differential diagnosis: Difference between revisions

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==Overview==
==Overview==
[[Endometriosis]] is a cause of [[dysmenorrhea]] and [[dyspareunia]], it must be differentiated from other conditions presenting with dyspareunia and dysmenorrhea such as [[adenomyosis]], [[pelvic inflammatory disease]], pelvic congestion syndrome and sub mucosal uterine [[fibroids]].
[[Endometriosis]] causes [[dysmenorrhea]] and [[dyspareunia]]. [[Endometriosis]] must be differentiated from other conditions presenting with [[dyspareunia]] and [[dysmenorrhea]] such as [[adenomyosis]], [[pelvic inflammatory disease]], pelvic congestion syndrome, and sub-mucosal uterine [[fibroids]].


==Differential Diagnosis==
==Differential Diagnosis==
Endometriosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.
Endometriosis is a cause of [[abnormal uterine bleeding]] and can result in [[infertility]]. There are several diseases which can result in excessive [[uterine bleeding]]. The following table is a description of the various diseases that cause [[abnormal uterine bleeding]].


==== Differentiating Endometriosis on the Basis of Abnormal Uterine Bleeding: ====
{| class="wikitable"
{| class="wikitable"
!
! style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|}}
!Clinical Features
! style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Clinical Features}}
!Physical Examination
! style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Physical Examination}}
!Diagnostic Findings
! style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Diagnostic Findings}}
|-
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|[[Endometriosis]]
|[[Endometriosis]]
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*Nodules in the [[posterior fornix]]
*Nodules in the [[posterior fornix]]
*Adnexal masses
*[[Adnexal mass causes|Adnexal masses]]
*Fixed retroverted [[uterus]]
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
*Lateral displacement of the [[cervix]]
|
|
*Increased [[CA-125|serum cancer antigen-125]] 
*Increased [[CA-125|serum cancer antigen-125]] 
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Nodules of the [[Rectovaginal fascia|recto vaginal]] septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
*[[Laparoscopy|Laparoscopic]] visualization confirms the diagnosis
|-
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099  }}</ref>
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099  }}</ref>
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*[[Abnormal uterine bleeding]]
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
*Common in women between 40 and 50
|
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
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*Mobile [[uterus]] with an irregular contour
*Mobile [[uterus]] with an irregular contour
|
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
*[[Transvaginal ultrasound]] will demonstrate the presence of [[Myoma|myomas]]
|-
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035  }}</ref>
|[[PID|Pelvic inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035  }}</ref>
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*Seen in patients with history of [[sexually transmitted disease]]
*Seen in patients with history of [[sexually transmitted disease]]
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*[[Abdominal tenderness]] 
*[[Abdominal tenderness]] 
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge 
*Visualization of [[purulent]] endocervical discharge 
|
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Positive [[Nucleic acid test|nucleic acid amplification tests]] for ''[[Chlamydia trachomatis]]'' and ''[[N. gonorrhea]]''
*Gram negative [[diplococci]] on [[gram stain]]
*[[Gram negative]] [[diplococci]] on [[gram stain]]
|-
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549  }}</ref>
|Pelvic congestion syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549  }}</ref>
|
|
*Shifting lower abdominal pain
*Shifting lower abdominal pain
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*Exacerbation of pain after prolonged standing 
*Exacerbation of pain after prolonged standing 
|
|
*Bimanual tenderness
*Bimanual [[tenderness]]
*[[Cervical motion tenderness]]
*[[Cervical motion tenderness]]
|
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow  
*Pelvic [[varicosities]] on ultrasound with reduced blood flow  
|}
|}
Endometriosis should also be differentiated from conditions that present with [[lower abdominal pain]] in young women. The following is a list of diseases that present with acute onset severe lower abdominal pain:
 
'''Differentiating Endometriosis on the Basis of Lower Abdominal Pain:'''
 
Endometriosis can also be differentiated from conditions that present with [[lower abdominal pain]] in young women. The following is a list of diseases that present with acute onset severe lower abdominal pain:
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
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| style="padding: 7px 7px; background: #DCDCDC;" | '''[[Ectopic pregnancy]]'''
| style="padding: 7px 7px; background: #DCDCDC;" | '''[[Ectopic pregnancy]]'''
| style="padding: 7px 7px; background: #F5F5F5;" | History of missed menses, positive [[pregnancy test]], [[ultrasound]] reveals an empty [[uterus]] and may show a mass in the [[fallopian tubes]].<ref name="pmid27720100">{{cite journal |vauthors=Morin L, Cargill YM, Glanc P |title=Ultrasound Evaluation of First Trimester Complications of Pregnancy |journal=J Obstet Gynaecol Can |volume=38 |issue=10 |pages=982–988 |year=2016 |pmid=27720100 |doi=10.1016/j.jogc.2016.06.001 |url=}}</ref>
| style="padding: 7px 7px; background: #F5F5F5;" | History of missed menses; positive [[pregnancy test]]; [[ultrasound]] reveals an empty [[uterus]] and may show a mass in the [[fallopian tubes]].<ref name="pmid27720100">{{cite journal |vauthors=Morin L, Cargill YM, Glanc P |title=Ultrasound Evaluation of First Trimester Complications of Pregnancy |journal=J Obstet Gynaecol Can |volume=38 |issue=10 |pages=982–988 |year=2016 |pmid=27720100 |doi=10.1016/j.jogc.2016.06.001 |url=}}</ref>
|-
|-
| style="padding: 7px 7px; background: #DCDCDC;" |'''[[Appendicitis]]'''
| style="padding: 7px 7px; background: #DCDCDC;" |'''[[Appendicitis]]'''
| style="padding: 7px 7px; background: #F5F5F5;" |Pain localized to the [[right iliac fossa]], [[vomiting]], [[Ultrasound|abdominal ultrasound]] [[Sensitivity (tests)|sensitivity]] for diagnosis of [[acute appendicitis]] is 75% to 90%.<ref name="pmid8259423">{{cite journal |vauthors=Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C |title=Acute appendicitis: CT and US correlation in 100 patients |journal=Radiology |volume=190 |issue=1 |pages=31–5 |year=1994 |pmid=8259423 |doi=10.1148/radiology.190.1.8259423 |url=}}</ref>
| style="padding: 7px 7px; background: #F5F5F5;" |Pain localized to the [[right iliac fossa]]; [[vomiting]]; [[Ultrasound|abdominal ultrasound]] [[Sensitivity (tests)|sensitivity]] for the diagnosis of [[acute appendicitis]] is 75% to 90%.<ref name="pmid8259423">{{cite journal |vauthors=Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C |title=Acute appendicitis: CT and US correlation in 100 patients |journal=Radiology |volume=190 |issue=1 |pages=31–5 |year=1994 |pmid=8259423 |doi=10.1148/radiology.190.1.8259423 |url=}}</ref>
|-
|-
| style="padding: 7px 7px; background: #DCDCDC;" | '''Ruptured[[ ovarian cyst]]'''
| style="padding: 7px 7px; background: #DCDCDC;" | '''Ruptured[[ ovarian cyst]]'''
| style="padding: 7px 7px; background: #F5F5F5;" |Usually spontaneous, can follow history of trauma, mild chronic lower abdominal discomfort may suddenly intensify, [[ultrasound]] is diagnostic.<ref name="pmid19299205">{{cite journal |vauthors=Bottomley C, Bourne T |title=Diagnosis and management of ovarian cyst accidents |journal=Best Pract Res Clin Obstet Gynaecol |volume=23 |issue=5 |pages=711–24 |year=2009 |pmid=19299205 |doi=10.1016/j.bpobgyn.2009.02.001 |url=}}</ref>
| style="padding: 7px 7px; background: #F5F5F5;" |Usually spontaneous; can follow the history of the trauma; mild chronic lower [[abdominal discomfort]] may suddenly intensify; [[ultrasound]] is diagnostic.<ref name="pmid19299205">{{cite journal |vauthors=Bottomley C, Bourne T |title=Diagnosis and management of ovarian cyst accidents |journal=Best Pract Res Clin Obstet Gynaecol |volume=23 |issue=5 |pages=711–24 |year=2009 |pmid=19299205 |doi=10.1016/j.bpobgyn.2009.02.001 |url=}}</ref>
|-
|-
| style="padding: 7px 7px; background: #DCDCDC;" | '''[[Ovarian cyst ]]torsion'''
| style="padding: 7px 7px; background: #DCDCDC;" | '''[[Ovarian cyst ]]torsion'''
| style="padding: 7px 7px; background: #F5F5F5;" |Presents with acute severe unilateral [[Lower abdominal pain|lower quadrant abdominal pain]], [[nausea and vomiting]], tender adnexal mass palpated in 90%, [[ultrasound]] is diagnostic.<ref name="pmid26760839">{{cite journal |vauthors=Bhavsar AK, Gelner EJ, Shorma T |title=Common Questions About the Evaluation of Acute Pelvic Pain |journal=Am Fam Physician |volume=93 |issue=1 |pages=41–8 |year=2016 |pmid=26760839 |doi= |url=}}</ref>
| style="padding: 7px 7px; background: #F5F5F5;" |Presents with acute severe unilateral [[Lower abdominal pain|lower quadrant abdominal pain]], [[nausea and vomiting|nausea, and vomiting]]; tender [[Adnexal mass causes|adnexal mass]] palpated in 90%; [[ultrasound]] is diagnostic.<ref name="pmid26760839">{{cite journal |vauthors=Bhavsar AK, Gelner EJ, Shorma T |title=Common Questions About the Evaluation of Acute Pelvic Pain |journal=Am Fam Physician |volume=93 |issue=1 |pages=41–8 |year=2016 |pmid=26760839 |doi= |url=}}</ref>
|-
|-
| style="padding: 7px 7px; background: #DCDCDC;" | '''Hemorrhagic [[ovarian cyst]]'''
| style="padding: 7px 7px; background: #DCDCDC;" | '''Hemorrhagic [[ovarian cyst]]'''
| style="padding: 7px 7px; background: #F5F5F5;" |Presents with [[Abdominal pain|localized abdominal pain]], [[nausea and vomiting]]. [[Hypovolemic shock]] may be present, [[abdominal tenderness]] and guarding are physical exam findings, [[ultrasound]] is diagnostic.<ref name="pmid26760839">{{cite journal |vauthors=Bhavsar AK, Gelner EJ, Shorma T |title=Common Questions About the Evaluation of Acute Pelvic Pain |journal=Am Fam Physician |volume=93 |issue=1 |pages=41–8 |year=2016 |pmid=26760839 |doi= |url=}}</ref>
| style="padding: 7px 7px; background: #F5F5F5;" |Presents with [[Abdominal pain|localized abdominal pain]], [[nausea and vomiting|nausea, and vomiting]]; [[Hypovolemic shock]] may be present; [[abdominal tenderness]] and guarding are physical exam findings; [[ultrasound]] is diagnostic.<ref name="pmid26760839">{{cite journal |vauthors=Bhavsar AK, Gelner EJ, Shorma T |title=Common Questions About the Evaluation of Acute Pelvic Pain |journal=Am Fam Physician |volume=93 |issue=1 |pages=41–8 |year=2016 |pmid=26760839 |doi= |url=}}</ref>
|-
|-
| style="padding: 7px 7px; background: #DCDCDC;" | '''[[Endometriosis]]'''
| style="padding: 7px 7px; background: #DCDCDC;" | '''[[Endometriosis]]'''
| style="padding: 7px 7px; background: #F5F5F5;" |Presents with cyclic pain that is exacerbated by onset of menses, [[dyspareunia]]. [[Laparoscopy|laparoscopic]] exploration is diagnostic.<ref name="pmid26760839">{{cite journal |vauthors=Bhavsar AK, Gelner EJ, Shorma T |title=Common Questions About the Evaluation of Acute Pelvic Pain |journal=Am Fam Physician |volume=93 |issue=1 |pages=41–8 |year=2016 |pmid=26760839 |doi= |url=}}</ref>
| style="padding: 7px 7px; background: #F5F5F5;" |Presents with cyclic pain that is exacerbated by the onset of menstruation and [[dyspareunia]]. [[Laparoscopy|Laparoscopic]] exploration is diagnostic.<ref name="pmid26760839">{{cite journal |vauthors=Bhavsar AK, Gelner EJ, Shorma T |title=Common Questions About the Evaluation of Acute Pelvic Pain |journal=Am Fam Physician |volume=93 |issue=1 |pages=41–8 |year=2016 |pmid=26760839 |doi= |url=}}</ref>
|-
|-
| style="padding: 7px 7px; background: #DCDCDC;" | '''[[Acute cystitis]]'''
| style="padding: 7px 7px; background: #DCDCDC;" | '''[[Acute cystitis]]'''

Latest revision as of 12:27, 10 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]

Overview

Endometriosis causes dysmenorrhea and dyspareunia. Endometriosis must be differentiated from other conditions presenting with dyspareunia and dysmenorrhea such as adenomyosis, pelvic inflammatory disease, pelvic congestion syndrome, and sub-mucosal uterine fibroids.

Differential Diagnosis

Endometriosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding. The following table is a description of the various diseases that cause abnormal uterine bleeding.

Differentiating Endometriosis on the Basis of Abnormal Uterine Bleeding:

Clinical Features Physical Examination Diagnostic Findings
Endometriosis
Adenomyosis[1]
  • Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of gestation
Submucous uterine leiomyomas[2]
  • Mobile uterus with an irregular contour
Pelvic inflammatory disease[3]
  • Seen in patients with history of sexually transmitted disease
  • History of multiple sexual partners 
  • Common in women younger than 25 years of age
Pelvic congestion syndrome[4]
  • Shifting lower abdominal pain
  • Deep dyspareunia
  • Post-coital pain
  • Exacerbation of pain after prolonged standing 

Differentiating Endometriosis on the Basis of Lower Abdominal Pain:

Endometriosis can also be differentiated from conditions that present with lower abdominal pain in young women. The following is a list of diseases that present with acute onset severe lower abdominal pain:

Disease Findings
Ectopic pregnancy History of missed menses; positive pregnancy test; ultrasound reveals an empty uterus and may show a mass in the fallopian tubes.[5]
Appendicitis Pain localized to the right iliac fossa; vomiting; abdominal ultrasound sensitivity for the diagnosis of acute appendicitis is 75% to 90%.[6]
Rupturedovarian cyst Usually spontaneous; can follow the history of the trauma; mild chronic lower abdominal discomfort may suddenly intensify; ultrasound is diagnostic.[7]
Ovarian cyst torsion Presents with acute severe unilateral lower quadrant abdominal pain, nausea, and vomiting; tender adnexal mass palpated in 90%; ultrasound is diagnostic.[8]
Hemorrhagic ovarian cyst Presents with localized abdominal pain, nausea, and vomiting; Hypovolemic shock may be present; abdominal tenderness and guarding are physical exam findings; ultrasound is diagnostic.[8]
Endometriosis Presents with cyclic pain that is exacerbated by the onset of menstruation and dyspareunia. Laparoscopic exploration is diagnostic.[8]
Acute cystitis Presents with features of increased urinary frequency, urgency, dysuria, and suprapubic pain.[9][10]

References

  1. ↑ Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P (2006). "Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis". Fertil Steril. 86 (3): 711–5. doi:10.1016/j.fertnstert.2006.01.030. PMID 16782099.
  2. ↑ Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J; et al. (2016). "Long-term medical management of uterine fibroids with ulipristal acetate". Fertil Steril. 105 (1): 165–173.e4. doi:10.1016/j.fertnstert.2015.09.032. PMID 26477496.
  3. ↑ Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections (2014). "2012 European guideline for the management of pelvic inflammatory disease". Int J STD AIDS. 25 (1): 1–7. doi:10.1177/0956462413498714. PMID 24216035.
  4. ↑ Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES (2001). "Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women". AJR Am J Roentgenol. 176 (1): 119–22. doi:10.2214/ajr.176.1.1760119. PMID 11133549.
  5. ↑ Morin L, Cargill YM, Glanc P (2016). "Ultrasound Evaluation of First Trimester Complications of Pregnancy". J Obstet Gynaecol Can. 38 (10): 982–988. doi:10.1016/j.jogc.2016.06.001. PMID 27720100.
  6. ↑ Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C (1994). "Acute appendicitis: CT and US correlation in 100 patients". Radiology. 190 (1): 31–5. doi:10.1148/radiology.190.1.8259423. PMID 8259423.
  7. ↑ Bottomley C, Bourne T (2009). "Diagnosis and management of ovarian cyst accidents". Best Pract Res Clin Obstet Gynaecol. 23 (5): 711–24. doi:10.1016/j.bpobgyn.2009.02.001. PMID 19299205.
  8. ↑ 8.0 8.1 8.2 Bhavsar AK, Gelner EJ, Shorma T (2016). "Common Questions About the Evaluation of Acute Pelvic Pain". Am Fam Physician. 93 (1): 41–8. PMID 26760839.
  9. ↑ {{Cite journal | author = W. E. Stamm | title = Etiology and management of the acute urethral syndrome | journal = Sexually transmitted diseases | volume = 8 | issue = 3 | pages = 235–238 | year = 1981 | month = July-September | pmid = 7292216
  10. ↑ {{Cite journal | author = W. E. Stamm, K. F. Wagner, R. Amsel, E. R. Alexander, M. Turck, G. W. Counts & K. K. Holmes | title = Causes of the acute urethral syndrome in women | journal = The New England journal of medicine | volume = 303 | issue = 8 | pages = 409–415 | year = 1980 | month = August | doi = 10.1056/NEJM198008213030801 | pmid = 6993946
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