{"id":4286,"date":"2026-04-08T10:00:08","date_gmt":"2026-04-08T10:00:08","guid":{"rendered":"https:\/\/hjog.org\/?p=4286"},"modified":"2026-04-09T07:45:54","modified_gmt":"2026-04-09T07:45:54","slug":"diagnostic-accuracy-of-trans-vaginal-ultrasound-for-deep-infiltrative-endometriosis-a-systematic-review","status":"publish","type":"post","link":"https:\/\/hjog.org\/?p=4286","title":{"rendered":"Diagnostic Accuracy of Trans-Vaginal Ultrasound for Deep Infiltrative Endometriosis: A systematic review"},"content":{"rendered":"

Review<\/span><\/p>\n

HJOG 2026, 25 (2), 90-101| doi: 10.33574\/hjog.0620<\/p>\n

Fatima Batool1,2<\/sup>, Javeria Khan1,3<\/sup>, Syed Muhammad Yousaf Farooq1<\/sup>, Syed Amir Gillani1<\/sup>, M Mudassar Mahmood1<\/sup>, Syeda Khadija Tul Sughra Maryam1<\/sup><\/p>\n

\u00ad\u00ad\u00ad\u00ad\u00ad1<\/sup>Green International University Lahore, Pakistan
\n2<\/sup>School of Allied Health Sciences (SAHS), CMH LMC & IOD, Lahore, Pakistan
\n3<\/sup>Ibadat International university Islamabad, Pakistan<\/p>\n

Correspondence:\u00a0<\/em>Fatima Batool, PhD, Diagnostic ultrasound, Green International University, Senior Lecturer at School of Allied Health Sciences (SAHS), CMH LMC & IOD, Lahore, Pakistan. Email: fatima_batool@cmhlahore.edu.pk<\/a>, Contact no.:+92 3362726866, ORCID ID: 0009-0006-2592-4519<\/p>\n

\"\"<\/a><\/p>\n

\n
Abstract<\/strong><\/h5>\n

Introduction:\u00a0<\/strong>Deep infiltrative endometriosis (DIE) is a severe form of endometriosis, affecting approximately 20% of women with the disease. It often goes undiagnosed due to its complex presentation and overlap with other pelvic conditions. Early and accurate detection is key to guiding treatment and reducing the disease burden. Transvaginal ultrasound (TVUS) is a first-line imaging method used in clinical settings due to its accessibility and low cost. Despite this, reported accuracy in identifying DIE remains inconsistent.<\/p>\n

Objective:<\/strong> This review aims to assess the pooled sensitivity and specificity of Trans-Vaginal Ultrasound (TVUS) for diagnosing Deep Infiltrative Endometriosis (DIE).<\/p>\n

Methods:<\/strong> A systematic search of PubMed, Web of Science, and Scopus was conducted to identify relevant studies published between 2012 and 2024. Eligible studies included those that evaluated the diagnostic accuracy of TVUS for DIE, using surgical and histopathological findings as reference standards. Methodological quality was assessed via the QUADAS-2 tool.<\/p>\n

Results:<\/strong> Sensitivity of TVUS ranged from 26.7% to 98%, while specificity varied from 46% to 100%. The highest sensitivity noted to be 98%, and the lowest to be 26.7%. Several studies, reported specificity of 100%. Among multicenter prospective studies, reported accuracy values were of 94% and 86.5%, respectively.<\/p>\n

Conclusion<\/strong>: This systematic review reports the diagnostic utility of TVUS in detecting DIE, with many studies reporting high levels of sensitivity, specificity, and overall accuracy. The variation observed across individual studies emphasizes the impact of methodological differences, imaging techniques, and examiner proficiency on diagnostic outcomes. These findings highlight the need for continued efforts to standardize imaging practices and enhance training to ensure consistent and reliable use of ultrasound in clinical settings.<\/p>\n

Keywords:<\/em> Diagnostic techniques and procedures, ultrasonography, endometriosis<\/p>\n

Introduction\u00ad<\/strong><\/h5>\n

Deep infiltrative endometriosis (DIE) is a severe form of endometriosis, affecting approximately 20% of women with the disease. It often goes undiagnosed due to its complex presentation and overlap with other pelvic conditions. Early and accurate detection is key to guiding treatment and reducing the disease burden. Transvaginal ultrasound (TVUS) is a first-line imaging method used in clinical settings due to its accessibility and low cost. Despite this, reported accuracy in identifying DIE remains inconsistent. In more advanced cases, it may also involve distant anatomical sites, including the bowel, bladder, and, on rare occasions, extra-pelvic regions such as the lungs [1].<\/p>\n

Deep infiltrating endometriosis (DIE) often presents with symptoms that can be both severe and disruptive to daily life. Women commonly report chronic pelvic pain, especially around menstruation, along with deep dyspareunia (pain during intercourse), painful bowel movements, and urinary discomfort, depending on the organs involved. In some cases, infertility may be the first sign that leads to further investigation. The intensity of symptoms doesn\u2019t always match the extent of the disease, which can make diagnosis challenging. Since DIE can affect multiple pelvic structures like the bowel, bladder, and uterosacral ligaments, the clinical presentation is often complex and requires a high index of suspicion from clinicians [1,2,3].<\/p>\n

Laparoscopic visualization, followed by histological confirmation, has traditionally been regarded as the gold standard for diagnosing endometriosis. However, its invasive nature, high cost, and potential complications contribute to diagnostic delays, often spanning several years from the onset of symptoms. These limitations underscore the critical need for reliable, non-invasive diagnostic alternatives [3].<\/p>\n

Transvaginal ultrasound (TVUS) has emerged as a promising first-line imaging modality in the evaluation of suspected endometriosis. Compared to other diagnostic tools, TVUS is widely accessible, cost-effective, well-tolerated by patients, and free of ionizing radiation. Advancements in ultrasound technology and growing operator proficiency have markedly enhanced the ability to detect and characterize endometriotic lesions, particularly deep infiltrating endometriosis (DIE)\u2014a severe subtype associated with deep tissue invasion and significant morbidity [4,5,6].<\/p>\n

This systematic review aims to synthesize the current evidence on the diagnostic performance of TVUS in identifying endometriosis. By evaluating the sensitivity, specificity, and accuracy reported across studies, the review seeks to provide clinicians with a comprehensive understanding of the diagnostic utility of TVUS in routine gynecological practice and inform future research directions.<\/p>\n

Methodology<\/strong><\/h5>\n

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [7]. A comprehensive literature search was performed across three major databases PubMed, Web of Science, and Scopus to identify studies published between 2012 and 2024 that evaluated the diagnostic performance of transvaginal ultrasound (TVUS) in detecting deep infiltrative endometriosis. In the absence of a pooled meta-analysis, we presented the diagnostic performance of ultrasound for DIE using a scatter plot of sensitivity versus specificity across 28 studies based on Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy which scatter plots to show sensitivity\/specificity [47,48].<\/p>\n

Eligibility Criteria<\/strong><\/p>\n

Studies were eligible for inclusion if they:<\/p>\n