Cumulative Sonographic Features From the Morphological Uterus Sonographic Assessment (MUSA) System and Clinical Severity of Adenomyosis in Congolese Women: A Multicenter Study in Kinshasa, Democratic Republic of the Congo.

BACKGROUND

Adenomyosis is increasingly diagnosed noninvasively using transvaginal ultrasound, but the relationship between the cumulative number of standardized sonographic features and clinical severity remains incompletely understood, particularly in African populations. This study aimed to characterize adenomyosis phenotypes according to the revised Morphological Uterus Sonographic Assessment (MUSA) definitions and to evaluate the association between cumulative MUSA feature count and clinical severity.

MATERIALS AND

METHODS

We conducted a multicenter cross-sectional observational analytical study based on retrospective review of routinely acquired clinical data and ultrasound images from three institutions in Kinshasa, Democratic Republic of the Congo. The source ultrasound examinations were performed as part of routine clinical care between January 2023 and June 16, 2026. Among 2,743 women who had undergone gynecologic ultrasonography, 211 with sonographically diagnosed adenomyosis were included. Nine revised MUSA features were assessed. The primary exposure was cumulative MUSA feature count analyzed as a continuous variable. Multivariable logistic regression models were adjusted for age, body mass index, parity, previous cesarean delivery, recorded concomitant endometriosis, uterine fibroids, and study center.

RESULTS

The median cumulative MUSA feature count was 5 (interquartile range: 4-6). Severe chronic pelvic pain was present in 60 women (28.4%). Each additional MUSA feature was associated with increased odds of severe chronic pelvic pain (adjusted odds ratio (aOR): 1.65; 95% confidence interval (CI): 1.26-2.18; p<0.001). When direct and indirect feature counts were entered simultaneously, the indirect feature count remained associated with severe chronic pelvic pain (aOR: 1.89; 95% CI: 1.32-2.70; p<0.001), whereas the direct feature count was not statistically significant (aOR: 1.42; 95% CI: 0.97-2.07; p=0.068). Cumulative feature count was not significantly associated with severe dysmenorrhea (aOR: 1.26; 95% CI: 0.97-1.63; p=0.083) or infertility (aOR: 1.09; 95% CI: 0.87-1.38; p=0.448).

CONCLUSIONS

A higher cumulative MUSA feature count was associated with severe chronic pelvic pain, with the association mainly driven by indirect sonographic features. Cumulative MUSA feature count should be considered an exploratory phenotypic measure rather than a validated severity score. Prospective external validation using standardized image acquisition and independent blinded readers is warranted.