Kumar I, Kumari S, Ojha R, Kumari R, Kushwaha K, Singh PK, Verma A. Characterization of endometriosis in patients with Mullerian anomalies using the Enzian classification: A retrospective cohort study. World J Radiol 2026; 18(3): 118143 [DOI: 10.4329/wjr.v18.i3.118143]
Corresponding Author of This Article
Ishan Kumar, MD, Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, BHU Campus, Varanasi 221005, Uttar Pradesh, India. ishanjd@gmail.com
Research Domain of This Article
Radiology, Nuclear Medicine & Medical Imaging
Article-Type of This Article
Retrospective Cohort Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Mar 28, 2026 (publication date) through Mar 26, 2026
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Publication Name
World Journal of Radiology
ISSN
1949-8470
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Kumar I, Kumari S, Ojha R, Kumari R, Kushwaha K, Singh PK, Verma A. Characterization of endometriosis in patients with Mullerian anomalies using the Enzian classification: A retrospective cohort study. World J Radiol 2026; 18(3): 118143 [DOI: 10.4329/wjr.v18.i3.118143]
Ishan Kumar, Shweta Kumari, Ritu Ojha, Rupam Kumari, Kajal Kushwaha, Pramod Kumar Singh, Ashish Verma, Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, Uttar Pradesh, India
Co-corresponding authors: Ishan Kumar and Ashish Verma.
Author contributions: Kumar I and Verma A contributed to concept and they contributed equally to this manuscript as co-corresponding authors; Kumari S, Kumari R, and Kushwaha K contributed to data collection; Kumar I and Kumari S contributed to first draft; Singh PK and Ojha R contributed to revision of manuscript. All authors have read and approved the final manuscript.
Institutional review board statement: The study has been approved Institute Ethics Committee (approval No. IMS/IEC/2025/7869).
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: The data is available with the corresponding author and will be provided at a reasonable request.
Corresponding author: Ishan Kumar, MD, Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, BHU Campus, Varanasi 221005, Uttar Pradesh, India. ishanjd@gmail.com
Received: December 25, 2025 Revised: January 25, 2026 Accepted: March 5, 2026 Published online: March 28, 2026 Processing time: 91 Days and 23 Hours
Abstract
BACKGROUND
Mullerian anomalies are frequently associated with endometriosis, particularly in the presence of genital tract obstruction; however, the anatomical distribution and determinants of disease in this population remain incompletely characterized. Most existing data are derived from surgical series, with limited use of standardized imaging-based classification systems.
AIM
To characterize the prevalence and distribution of endometriosis in patients with Mullerian anomalies using pelvic magnetic resonance imaging (MRI) and the Enzian classification.
METHODS
This retrospective observational study included pelvic MRI examinations performed over a 15-month period. Patients whose MRI reports described Mullerian anomalies were identified, and imaging datasets were re-evaluated. Mullerian anomalies were classified using the Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy system. Endometriosis was assessed on MRI and mapped using the Enzian classification, including ovarian (O), peritoneal (P), and deep infiltrating tissue (T) involvement across pelvic compartments. The presence of genital tract obstruction was determined based on MRI evidence of hemorrhagic collections.
RESULTS
Seventy-five patients with Mullerian anomalies were included. MRI findings consistent with endometriosis were identified in 22 patients (29.3%). Ovarian endometriomas were the most common manifestation, present in 16 patients (21.3%), while tubo-ovarian involvement corresponding to Enzian T2-T3 disease was seen in 11 patients (14.7%). Endometriosis was more frequently observed in complex uterine configurations, particularly bicorporeal septate uterus (U3c), aplastic uterus with a functional rudimentary cavity (U5a), and in patients classified as U0 with associated cervicovaginal anomalies. Vaginal aplasia (V4) was associated with a significantly lower prevalence of endometriosis compared with normal vaginal anatomy (P = 0.019). Genital tract obstruction showed a strong association with endometriosis, with affected patients demonstrating nearly threefold higher prevalence compared with non-obstructive anomalies (61.5% vs 22.6%, P = 0.005).
CONCLUSION
Endometriosis in patients with Mullerian anomalies demonstrates variable distribution on MRI, with higher prevalence in complex and obstructive uterine configurations. MRI combined with standardized Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy and Enzian classifications provides a structured, anatomy-driven approach for evaluating disease patterns in this heterogeneous population.
Core Tip: This study uses magnetic resonance imaging with structured interpretation to characterize endometriosis in patients with Mullerian anomalies, an association traditionally explored through surgical series. By integrating the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy classification of Mullerian anomalies with Enzian mapping of endometriosis, the study demonstrates that disease prevalence and distribution vary with uterine configuration and are strongly influenced by genital tract obstruction. The findings highlight the value of an anatomy-driven, magnetic resonance imaging-based approach for evaluating this complex and heterogeneous patient population.
