What examination findings suggest endometriosis?

On bimanual/speculum examination, signs suggesting endometriosis include: tender nodules in the pouch of Douglas and along thickened uterosacral ligaments, a fixed retroverted uterus (from adhesions), and adnexal masses (endometriomas).

Visible bluish lesions in the posterior vaginal fornix may be seen. Examination can be normal, especially in minimal disease - so normal findings do not exclude it.

Clinical relevance. Recognising the examination signs (uterosacral nodules, fixed uterus, adnexal masses) supports a clinical diagnosis, while normal findings don't exclude it.

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Examination findings in endometriosis

Pelvic examination may reveal characteristic signs, though it can be normal.

Signs

• Tender nodules in the pouch of Douglas and along thickened, tender uterosacral ligaments (deep infiltrating disease).
• Fixed, retroverted uterus - from adhesions tethering the uterus.
• Adnexal masses - endometriomas (may be tender, fixed).
• Generalised pelvic tenderness.
• Occasionally visible bluish lesions in the posterior vaginal fornix on speculum examination.

Timing

• Examination (especially for nodules/tenderness) may be most informative during menstruation.

Caveat

• A normal examination does not exclude endometriosis (common in minimal/mild disease) - so further imaging/laparoscopy may still be needed.