The clinical manifestations of endometriosis are variable and unpredictable in both presentation and course. Dysmenorrhea, chronic pelvic pain, and dyspareunia, are among the well-recognized manifestations. A significant number of women with endometriosis, however, remain asymptomatic and most women with endometriosis have a normal pelvic examination. However, in some women, pelvic examination can disclose tender nodules in the cul-de-sac or rectovaginal septum, uterine retroversion with decreased uterine mobility, uterine tenderness, or adnexal mass or tenderness.
Endometriosis must be distinguished from pelvic inflammatory disease (PID), ovarian neoplasms, and uterine myomas. Bowel invasion by endometrial tissue may produce blood in the stool that must be distinguished from bowel neoplasm.
Imaging is useful mainly in the presence of a pelvic or adnexal mass. Transvaginal ultrasonography is the imaging modality of choice to detect the presence of deeply penetrating endometriosis of the rectum or rectovaginal septum; MRI should be reserved for equivocal cases of rectovaginal or bladder endometriosis (eFigures 18–5 and 18–6). A definitive diagnosis of endometriosis is made only by histology of lesions removed at surgery.