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I have no financial rela.onships to disclose. Approach to imaging of pelvic pain •  To emphasize the importance of ultrasound as the imaging modality of choice for the most commonly presen6ng diagnoses in the se7ng of acute and chronic pelvic pain in gynecology •  Discuss imaging findings and an imaging approach useful in making the diagnosis •  Discuss the role of imaging, primarily sonography, in the management of acute and chronic disease •  Acute pain is intense pain characterized by sudden onset. •  Chronic pain is non-­‐cyclic pelvic pain that lasts 6 months or longer which is severe enough to cause func6onal disability or the need for medical care. Acute pelvic pain Chronic pelvic pain Dysmenorrhea Pain associated with the menstrual cycle Dysmenorrhea 1
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•  In a specific situation, if the clinician is
considering an imaging study, what study
(or studies) are most likely to provide the
necessary information?
•  Provides this information for various
clinical problems based on the best
available clinical data
•  Sonography the modality of choice and usually only modality necessary for a suspected gynecologic or obstetric abnormality •  MRI as problem solving tool for suspected GYN abnormality •  CT “may be appropriate” for GYN abnormality but more useful for a GI or GU abnormality although MRI is favored over CT in the pregnant pa6ent Determined by clinically suspected
differential diagnosis following careful
evaluation!
•  Reproductive age female presents with
pelvic pain and gynecologic etiology is
supected
•  Serum β-hCG is negative
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•  Reproductive age female presents with
pelvic pain and non-gynecologic etiology is
supected
•  Serum β-hCG positive
Non-invasive
Radiation free
Cost effective
•  Transvaginal US (TVS )whenever possible
due to better resolution
•  Transabdominal sonography provides
more information when structures are
beyond field of view of vaginal probe
Sonography gives high resolution anatomic
detail of uterus and adnexa!
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•
•
•
•
Displaces bowel
Brings structures closer to the transducer
Identifies focal areas of tenderness
Can use the “sliding organ sign” to
separate structures
Spectral and color or power Doppler
imaging can be used to characterize
vascularity to the:
–  ovaries
–  fallopian tubes
–  uterus
And narrow the differential considerations
Problem-solving tool for specific
indications:
–  If further characterization of a disorder is
required
–  If the patient’s pain fails to resolve becoming
more chronic in nature
•  Should ectopic pregnancy be under
consideration?
•  Is there concern for fetal exposure to ionizing
radiation, making ultrasound the initial imaging
modality of choice?
•  Check a serum β-hCG! Negative level
essentially excludes the diagnosis of an
intrauterine pregnancy and ectopic pregnancy.
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•
•
•
•
•  Urgent life-threatening conditions requiring
surgical intervention
–  ectopic pregnancy
–  appendicitis
–  ruptured ovarian cyst
–  ovarian torsion
•  Fertility-threatening conditions
–  pelvic inflammatory disease
Fever Nausea and vomi6ng Leukocytosis Abnormal vaginal bleeding
Functional ovarian
cysts
Pelvic inflammatory
disease
Ovarian torsion
–  ovarian torsion
Acute abdominal pain caused by :
– large size
(> 3 cm)
–  hemorrhage
–  rupture or leakage
Usually spontaneously resolve
following normal menstruation
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With hemolysis and retraction of
clot a reticular network of stranding
Is demonstrated
10 days later
Fluid-fluid level between fluid
components and congealed
red blood cells
•  Peripheral color Doppler signal
•  No central vascularity
Acute hemorrhage is hyperechoic and may be
suggestive of a solid mass
•  A diffuse pattern of
low level echoes
•  More commonly
associated with an
endometrioma
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•  Inflammation of the endometrium,
fallopian tubes, pelvic peritoneum
and adjacent structures causing
fever, leucocytosis and cervical
motion tenderness.
•  Ascending infection usually by N.
Gonnorhea, Chlamydia and
superinfecting anaerobes from
the vagina
•  Manifested by tubo-ovarian
complexes, peritonitis and
abscess formation
•  Usually bilateral but may be
unilateral in patients with IUD’s
(most commonly within 3 weeks
of insertion)
•  Lower abdominal pain with no other cause
for the illness identified
•  One or more of the following minimum
criteria are present on pelvic examination:
Ø cervical motion tenderness
Ø uterine tenderness
Ø adnexal tenderness
Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis,
STD, and TB Prevention, Centers for Disease Control and Prevention,
August 2014.
•  Clinical findings nonspecific
•  Unnecessary antibiotics prescribed
•  Due to a low threshold for initiating
antibiotic therapy
•  oral temperature >101° F (>38.3° C)
•  abnormal cervical or vaginal mucopurulent
discharge
•  presence of abundant numbers of WBC on
saline microscopy of vaginal fluid
•  elevated erythrocyte sedimentation rate
•  elevated C-reactive protein
•  laboratory documentation of cervical infection
with N. gonorrhea or Chlamydia
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•  Best “gold standard”: Laparoscopic
abnormalities consistent with PID although subtle
inflammation may go undetected
•  Endometrial biopsy with histopathologic evidence
of endometritis (may be only sign of PID)
The accuracy with which signs and symptoms
predict the presence of PID has been evaluated
using a laparoscopic "gold standard.” *
*Simms I, Warbuton F, Westrom L. Diagnosis of pelvic
inflammatory disease: time for a rethink. Sex Transm Infect
2003;79:491–4
•  Transvaginal sonography with Doppler or
magnetic resonance imaging demonstrating
imaging findings of PID
•  The data set included women who attended the
department of O&G, Lund University Hospital, Sweden,
with suspected PID collected between 1960 and 1969.
•  All patients included in the study had an initial diagnosis
based on clinical presentation (signs and symptoms).
•  A total of 623 patients were included in the analysis; 494
patients were laparoscopically confirmed as having PID
and 129 were not.
•  Three variables significantly influenced the
prediction:
Ø elevated ESR
Ø  fever
Ø adnexal tenderness
•  Together, they correctly classified only 65% of
women with laparoscopically diagnosed PID.
•  Can usually only detect complications of PID
•  Early changes are often subtle although color
Doppler may enhance our capabilities
Ø Increased vascularity within fallopian tube wall
•  Difficulty visualizing tubal wall without fluid
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•  In the presence of tubal fluid, common findings
include:
–  wall thickness > 5 mm
–  incomplete septa
–  thickening of endosalpingeal
folds (cogwheel sign)
Thickening of
endosalpingeal folds
(cogwheel sign)
Wall thickening
Increased
vascularity within
fallopian tube wall
•  Nonspecific findings:
–  fluid in the endometrial cavity and /or cul-de-sac
–  ovarian enlargement often with numerous small cysts
(“polycystic ovary” appearance)
Incomplete septa
•  Progression of disease with exudation of pus from
the distal fallopian tube
•  An inflammatory mass including the tube and
adjacent ovary is formed
•  The ovary is still visualized as a separate structure
•  Complete breakdown of architecture
•  Separate structures are no longer
identified
ovary
Fallopian
tube
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•  Retrospective review of 7 studies using
US with laparoscopy or endometrial biopsy
“gold standard”
•  Patients with clinical findings of PID
•  High sensitivity and specificity of 3 findings
Romasan and Valentin, Arch Gynecol Obstet (2014)
289:705–714.
•  ‘‘Thick tubal walls” when tubal walls can be
demonstrated
•  Cogwheel sign (less sensitivity)
•  Bilateral adnexal masses appearing either
as small solid masses or as cystic masses
with thick walls
Romasan and Valentin, Arch Gynecol Obstet (2014)
289:705–714.
•  Given the vague and non-specific symptoms, CT
is often the first imaging study performed
•  Thick walled fluid filled fallopian tubes
•  Difficult to differentiate among pyosalpinx, TOC
and TOA
•  Exposes patients to ionizing radiation,
problematic among young women!
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T2 weighted MRI
•  May be more accurate than TVS without
Doppler*
•  Highly accurate in abscess evaluation
•  However, cost, lack of access and limited
data preclude widespread use
*Ueda H, et.al., Adnexal masses caused by pelvic
inflammatory disease: MR appearance.Magn Reson Med
Sci. 2002 Dec 15;1(4):207-15.
Tubo-ovarian abscess
Images courtesy of Dr. Susanna Lee, Dept of Radiology
Massachusetts General Hospital, Boston, Mass.
T2
T1 fat sat with contrast
•  Fluid and inflammation
•  Wall enhancement
•  Make the diagnosis
•  Determine type of management
Mild or moderate clinical severity- outpatient
therapy yields clinical outcomes similar to inpatient
therapy
Ø  Cefoxitin 2 g IM in a single dose and Probenecid, 1 g
orally administered concurrently in a single dose
PLUS
Ø  Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Ø  Metronidazole 500 mg orally twice a day for 14 days
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Ø surgical emergencies (e.g., appendicitis) cannot
be excluded
Ø  pregnant patient
Ø unresponsive clinically to oral antimicrobial
therapy
Ø unable to follow or tolerate an outpatient oral
regimen
Ø severe illness, nausea and vomiting, or high
fever
Ø tubo-ovarian abscess
•  With mild or moderate clinical severity,
outpatient therapy yields short- and longterm clinical outcomes similar to inpatient
therapy
•  Sonography as well as laparoscopy can
visualize extent and severity of disease
and determine type of management
•  Diagnosis strongly considered with abrupt
onset of severe unilateral pain
•  Most commonly seen with associated
nausea and vomiting
•  Pain constant or intermittent
•  May progress to peritonitis
•  However: Symptoms may be variable,
abdominal pain being the only consistent
symptom
Ø Cefotetan 2 g IV every 12 hours
OR
Ø Cefoxitin 2 g IV every 6 hours
PLUS
Ø Doxycycline 100 mg orally or IV every 12 hours
Parenteral therapy can be discontinued 24 hours
after clinical improvement and oral therapy
continued for 14 days
•  Classically treated with IV followed by oral
antibiotics
•  If fails, laparoscopy or laparotomy with
drainage, BSO and/or hysterectomy
•  Alternatively, image guided drainage in
combination with antibiotics- success rate
of 90% reported
•  Commonly benign ovarian tumors or cysts
(50-80%) may act as a fulcrum to potentiate
torsion due to increased ovarian volume or
weight.
•  Ovarian hormone induction leading to ovarian
hyperstimulation syndrome and enlargement
•  Corpus luteum cyst of pregnancy
•  Hyper mobile adnexa
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Pampiniform plexus
0varian artery
& vein
Uterine
Artery & vein
1.  Lymphatic and
venous drainage is
compromised
2.  Congestion and
edema
3.  Loss of arterial
perfusion
Infundibulo-pelvic
ligament
Utero-ovarian ligament
•  Can progress rapidly to
occlusion of the arterial
circulation.
•  The organ may quickly
become very dark black
in color due to
hemorrhage, necrosis
and gangrenous changes
Enlarged ovary or
ovarian complex
Early intervention is key!
•  Decreases the incidence of complications and
improves ovarian salvage rates
•
The use of pelvic sonography has enhanced
our ability to determine when intervention is
advisable
Irregular internal
texture suggesting
hemorrhage
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Assumption:
Peripherally placed
follicles
“Ground glass” pattern
centrally consistent
with edema
Color and spectral Doppler would prove to
be an accurate tool for the evaluation of
ovarian torsion.
In actuality:
Doppler findings vary depending on degree
of torsion and its chronicity
•  Lack of arterial and venous signal
should enable confident diagnosis
•  False positive diagnoses may be
obtained
–  Depth of penetration greater than beam
capabilities
–  Improper Doppler or grayscale settings
(ie. PRF setting)
Ovarian color Doppler signal has
been frequently reported in cases of
surgically proven torsion!
Retrospective series of 39 patients with
pathologically proven ovarian torsion performed
at Vanderbilt University Medical Center:
–  21 (54%) patients had documented ovarian arterial
Doppler signal
–  13(33%) had documented ovarian venous and arterial
signal
*Shadinger, Andreotti and Kurian. Preoperative sonographic and clinical characteristics as predictors of ovarian
torsion, J Ultrasound in Med 27: 7-13, 2008.
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•  Observation is a reasonable option for
smaller masses with benign sonographic
characteristics
•  Surgical management encouraged for
larger, >7 cm benign appearing mass –risk
of torsion!
•  Highest risk for torsion in pregnancy-late
first trimester & postpartum
SAG
TRV
•  Underwent laparoscopic cyst drainage and
right oophorectomy with intraoperative
finding of a twisted pedicle c/w ovarian
torsion
•  Path report: Luteinized follicular cyst with
torsion
SAG
TRV
•  An enlarged edematous ovary or ovarian
complex is the most consistent finding
•  Doppler findings vary likely depending on degree
and chronicity.
•  Lack of Doppler flow enables fairly confident
diagnosis but ovarian arterial and venous
Doppler signal has been reported in a third of
surgically proven cases of ovarian torsion.*
*Shadinger, Andreotti and Kurian. Preoperative sonographic and clinical characteristics as predictors of ovarian
torsion, J Ultrasound in Med 27: 7-13, 2008.
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•  Sonography is initial exam of choice
•  Computed tomography is being used more
frequently
Appendicitis most common reason!
•  Specific sign
•  Poor sensitivity
Thickening of fallopian tube
Target sign
•  The role in the diagnosis of ovarian
torsion has not been established.
•  Similar diagnostic findings have been
demonstrated both on MR and CT.*
*Rha SE et al. CT and MR imaging features of adnexal torsion.
Radiographics 2002; 22(2)283-94.
Deviation of uterus
Infiltration of fat
•  Most common GI cause of pelvic pain in women
T2
Images courtesy of Dr. Susanna Lee, Dept of
Radiology
Massachusetts General Hospital, Boston, Mass.
•  Marked ovarian
enlargement
•  Heterogeneous,
hyperintense pattern
due to edema and
hemorrhage
•  Peripherally
displaced follicles
•  Diffuse or periumbilical pain that migrates to the
right lower quadrant
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•
CT with contrast imaging modality of
choice to confirm diagnosis in non-pregnant
female (sensitivity 95%-100% and specificity
87%-98%)
•  MRI is favored in the pregnant patient
•  US with graded compression initial
imaging test in pregnant females but often
inconclusive due to large uterus
•  MRI next appropriate imaging modality
due to lack of ionizing radiation
•  But US may be an effective substitute with a
sensitivity (67%-100%) and specificity
(83%-96%)
•  Blind ended thick
walled, tubular, noncompressible,
aperistaltic structure
•  At least 3 mm single
wall thickness
•  Intact echogenic
submucosal layer
•  Surrounding
echogenic fat
Increased color Doppler
vascularity within wall
•  Enlarged appendix
(>6mm) with
thickened enhancing
wall (>2mm)
•  Pericecal fat
stranding
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•  Similar to CT
•  A negative oral
contrast agent
(Gastromark) may be
used to demonstrate
low signal in bowel
and in a normal
appendix
Acute pain
Suspect Gyn
cause
β-hCG
Acute pain
Suspect Gyn
cause
β-hCG
Suspect nongyn cause
+β-hCG
-β-hCG
US
US or
MRI
MRI
?CT
+β-hCG
-β-hCG
US
Suspect nongyn cause
US or
MRI
CT or US
CT or US
MRI
?CT
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