Journal of the European Society for Gynaecological Endoscopy


Reproducibility of #Enzian classification by transvaginal ultrasound and its correlation with symptoms

C. Russo1, L. Lazzeri2, T. Siciliano1, A. Selntigia1, D. Farsetti1, C. Chiaramonte3, F. G. Martire1, E. Zupi2, C. Exacoustos1

1 Department of Surgical Sciences, Obstetrics and Gynecological Unit, University of Rome “Tor Vergata”, Italy
2 Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic University of Siena, Italy
3 Department of Statistics, University of Rome Tor Vergata, Italy


Endometriosis, #Enzian classification, transvaginal ultrasound, endometriosis staging, endometriosis symptoms

Published online: Mar 28 2024


Background: The #Enzian classification represents a system to describe endometriotic lesions during surgery. Its use is well established in correlating ultrasound and surgical findings.

Objectives: To describe interobserver reproducibility of ultrasound use and symptom correlation with compartments involved using #Enzian classification.

Materials and methods: Two experienced operators performed transvaginal sonography (TVS) in 52 patients affected by pelvic endometriosis. A rate agreement was determined. A further 200 women with endometriotic TVS signs, with no previous surgery and not taking any hormonal therapy, were staged by one of three different operators according to the #Enzian (compartments A, B, C, O, T, FA, FB, FI, FU, FO). Statistical analysis compared all the compartments, as single or associated, with single or combined symptoms (dysmenorrhea, dyspareunia, heavy menstrual bleeding - HMB, bowel symptoms).

Main outcome measures: Evaluation of the reproducibility of #Enzian classification in assessing pelvic endometriosis among different operators using TVS, and of possible associations between symptoms and specific #Enzian compartments.

Results: Excellent agreement between the two operators in evaluating almost all the compartments (k >0.8) was observed. Dysmenorrhea did not correlate with any specific compartment. We observed a significant association between dyspareunia and B compartment (p=0.02). HMB is associated with FA (p=0.02). Bowel symptoms were associated with B (p=0.02). Combining more symptoms, we observed more significant associations with different compartments.

Conclusions: #ENZIAN classification is reproducible in the evaluation of pelvic endometriosis. Some symptoms are correlated to specific ultrasound signs of the disease.

What is new? An accurate evaluation of symptoms could guide TVS examination to detect specific endometriotic lesions and establish the best management for the patients.