Table X.

Recommendations of the IDEA consensus for assessment of endometriosis.

Area	Factors	Recommendations
Sonographic steps	Evaluation of uterus and adnexae	Uterus: normal, reduced or fixed. Adenomyosis features must be searched and described by using the MUSA proposal. Endometriomas: Measure in three orthogonal planes - Follow IOTA description - Kissing ovaries
	Soft markers	Evaluation of specific-site tenderness, fixed ovaries, sactosalpinx Their presence is suggestive of superficial endometriosis and adhesions
	Status of the Pouch of Douglas	Use of the real-time ultrasound-based on "Sliding sign" A negative sign (absence of smooth glide between retrocervix - anterior rectal wall) is considered as obliteration of the pouch of Douglas.
	Search for DE nodules in Compartments	Anterior: Transducer in anterior fornix (Bladder - uterovesical region - ureters) Posterior: Transducer in posterior fornix (USLs, recto-vaginal septum, Recto-vaginal nodules, posterior vaginal fornix, anterior rectum, sigmoid)
Anterior Compartment	Bladder	Scan with small amount of urine (to reduce false-negatives) Analyze 4 zones: Trigone, base, dome and the extra-abdominal bladder. DE : Hypoechoic linear or spherical lesions with or without regular contours involving muscularis
	Uterovesical Region	Absence of sliding sign ( Anterior fornix/Uterus): Obliteration (+) Sign of adhesions, not necessary endometriosis
	Ureters	Evaluate in the sagittal plane, from the urethra towards the pelvic Sidewall Endometriosis stricture: Dilated long tubular hypoechoic structures. Measure of distance between distal ureteric orifice and stricture zone. Always scan the ipsilateral kidney.
Posterior compartment	DE Nodule	Hypoechoic thickening of bowel/vagina wall Hypoechoic solid nodules, variable in size and contour regularity
	USL	Place probe in posterior fornix in the midline sagittal plane and then sweep inferolateral to the cervix Measure in three orthogonal planes
	Rectovaginal septum	DE in rectovaginal space below the line passing along the lower border of the posterior lip of the cervix Usually and extension of a DE nodule from posterior vaginal wall, anterior rectal wall or both Measure in three orthogonal planes - Distance to anal verge should be measured
	Rectovaginal nodules	Hourglass-shaped or “Diabolo-like”: DE encompassing the posterior vaginal fornix and the anterior rectal wall
	Posterior vaginal fornix	Thickening or discrete nodule found in the hypoechoic layer of the vaginal wall (forniceal endometriosis) Measure in three orthogonal planes
	Anterior rectum	Bowel DE: Thickening of the hypoechoic muscular propria or hypoechoic nodules. Morphological description: 4 types ( Regular, comet sign, moose antler sign, comet and moose, pulling sleeve sign)
	Rectosigmoid junction	Anatomical location: Lower- anterior rectal, Upper-anterior rectal, Rectosigmoidal junction, Anterior sigmoid.
	Sigmoid	Measure in three orthogonal planes - Distance to anal verge should be measured- Mushroom cap sign: Retraction within the rectosigmoid DE lesion (understimation of real length)
	Pouch of Douglas obliteration	Complete or partial : Bilateral / unilateral negative sliding sign Anatomical location: Retrocervical, Mid-posterior, Fundus, Mid-anterior, lower anterior
	Doppler evaluation	No prospective data about its role in DE. Recommended as an adjunct in bowel DE (differential diagnosis with cancer)
Others	Sonovaginography (Saline or gel)	Create an acoustic window- Better visualisation of vaginal walls and anterior/ posterior vaginal fornices 60-120 mL saline solution injected using a Foley catheter - 20-50 mL ultrasound gel (without bubbles) using a 20 mL syringe
	Transrectal sonography	Only when transvaginal ultrasound is impossible or inappropriate
	Tridimensional sonography	Insufficient data-Promising results