Acute Female Pelvic Pain: US Features

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Acute Female Pelvic Pain U/S Features
Melissa Kern, PGY-4

• Courtesy Drs. M. Atri A. Menard, H. Dua

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Introduction

• Female pelvic pain common presenting complaint in
  ER radiology
• TV U/S best first-line imaging modality
• More SN and SP than CT
• No radiation or contrast
• Direct patient contact

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Clinical Relevance

• A normal pelvic U/S high negative predictive
  value for serious pelvic pathology.

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Common Causes of ER ? Pelvic Pain

• Gynecologic
• Ovarian cyst rupture or hemorrhage
• PID
• Ovarian torsion
• Ectopic pregnancy
• Non-gynecologic
• Ureterolithiasis
• Appendicitis
• Diverticulitis

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Ovarian Cysts. the basics

• Estrogen phase follicles are at their smallest
  (typically lt 5mm)
• By day 10, one dominates and increases in size to
  about 2-2.5cm (rest regress)
• LH surge at mid cycle causes mature follicle to
  rupture and release egg follicle then normally
  loses its fluid, rapidly shrinks and becomes
  corpus luteum

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Ovarian Cysts

• Pain may occur
• As follicle matures and ovarian capsule is
  stretched
• At time of ovulation
• Due to cyst rupture
• Dominant follicle fails to expel oocyte the
  follicle may further enlarge into a cyst
• Due to cyst hemorrhage
• After shrinking, CL may internally bleeds and
  re-expands hemorrhagic cyst

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Typically reserve the term cyst for structures
larger than 2.5-3.0cm
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TV U/S Findings

• Ruptured Ovarian Cyst
• No detectable ovarian cyst
• Collapsed cyst
• Free pelvic fluid (3-5 ml physiologic)

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TV U/S Findings

• Hemorrhagic Cyst
• Typically, complex mass with internal echoes and
  some degree of through transmission
• Fresh blood may be anechoic initially
• In the first 24hrs. low-level echoes in a fine,
  lacelike, reticular pattern
• Solid pelvic mass
• Amorphous blood clot
• Echogenic free pelvic fluid

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Hemorrhagic Cyst
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The Many Faces of Hemorrhagic Cysts
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Vascular Ring Sign
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Mixed solid cystic hemorrhagic cyst.
Vascularity of the periphery of a mass is a
very helpful sign to differentiate a functional
mass from an endometrioma or a cancer . Ovarian
cancers are not usually predominantly solid
(exception rare granulosa cell tumor). Cystic
cancers do not show a vascular ring in the
absence of a vascular solid component.
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Retractile clot
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Hemorrhagic Cysts.the Bottom Line

• Can be any size and echogenicity
• Caution in post menopausal women
• Helpful signs
• Vascular ring
• Through transmission
• Retractile clot

Almost all will resolve within 1-2 menstrual
cycles
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??? Hemorrhagic Cyst
Endometrioma
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Endometrioma

• Affect 10 premenopausal women
• Complex cystic masses with homogenous low-level
  echoes or ground glass appearance (due to
  repeated episodes of cyclic bleeding)
• Follow-up imaging may be necessary to
  differentiate endometriomas from hemorrhagic
  ovarian cysts

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Pelvic Inflammatory Disease

• Complication of STDs (chlamydia, gonorrhea)
• Estimated incidence US 1 million acute cases
  per year
• Can lead to infertility or ectopic pregnancy
• PID is a clinical and laboratory diagnosis and a
  negative u/s doesnt exclude milder forms

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Utility of U/S

• Determine the extent of disease
• Evaluate the non-responders to treatment
• Follow-up patients post treatment
• Approach to drain abscesses

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PID U/S Findings

• Thickened vascular fallopian tube (often
  bilateral)
• Fluid-filled /- debris (non-specific)
• Collapsed
• Increased volume and indistinct margins of
  ovaries
• Adnexal inflamed fat and tenderness
• Tubo-ovarian abscess
• Echogenic pelvic fluid

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Thickened Fallopian Tube
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PID
LEFT FT
RIGHT FT
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PID
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OV
OV
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LEFT FT
RIGHT FT
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Pyosalpinx
OV
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RIGHT FT
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Pyosalpinx
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Surrounding inflammation
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Ovarian Torsion

• Partial or complete twist of ovarian pedicle
• Venous/lymphatic obstruction ? ovarian edema ?
  arterial compromise ? ischemia/infarction

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Ovarian Torsion

• Pre-pubertal ? idiopathic
• Adults often associated with benign mass
• Often present with acute pain vomiting

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Ovarian Torsion - Treatment

• Emergent surgical de-torsion
• Salvage rates better for ovarian vs. testicular
  torsion
• Symptom duration does not always predict
  viablility

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U/S Findings

• Twisting (whorl) sign
• Increased ovarian volume (stromal edema)
• Multiple small peripheral ovarian cysts
• Multiple echogenic cysts in the same ovary
• Free fluid
• Associated mass

Presence of Doppler flow does not exclude torsion!
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U/S Findings

• Absence or high resistance to arterial flow with
  absent venous flow, particularly when accompanied
  by ovarian enlargement is highly suggestive of
  ovarian torsion

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The Whorl Sign
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Ovarian Torsion
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Ectopic Pregnancy

• Implantation of fertilized ovum outside
  endometrial lining
• 2 of all pregnancies
• Leading cause of death during 1st trimester
• 9-14 mortality rate

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Ectopic Pregnancy

• Symptoms
• 5-9wk hx amenorrhea
• Mild pelvic pain
• Vaginal spotting
• Asymptomatic (50)

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Ectopic Pregnancy

• Risk Factors
• Previous hx ectopic pregnancy
• Tubal surgery
• PID
• Use of IUD
• Previous c-section
• IVF
• Congenital uterine anomalies

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(12)
(2-4)
(70)
(11)
(1-3)
(lt1)
(lt1)
Intra-abdominal 0.03-1 Heterotopic 1-3 IVF pts

• fallopian tubes (95)

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Ectopic Pregnancy - Treatment

• Medical (Methotrexate)
• Hemodynamically stable
• No evidence of tube rupture
  (small volume free fluid)
• ßHCG and size criteria (site specific)
• Surgical
• Salpingotomy
• Salpinectomy
• US-guided local injection of Methotrexate or KCL
• Preferred for cornual or cervical ectopics

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U/S Criteria

• Discriminatory level for detecting IUP is ßHCG gt
  2000
• If ßHCG gt 2000 and no IUP
• EP
• Early pregnancy failure
• If ßHCG lt 2000 and no IUP
• EP
• Early pregnancy failure
• Normal early IUP

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U/S Findings

• Normal IUP
• Intradecidual sign (4.5wks) small collection of
  fluid eccentrically located within the
  endometrium
• Double decidual sign (5wks) 2 concentric
  hyperechoic rings that surround an anechoic
  gestational sac
• Yolk sac (5.5wks) when GS reaches 8mm

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Double decidual sac sign in a normal IUP
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EP U/S Findings

• No IUP
• Normal endometrium
• Thin-walled decidual cysts (found at junction
  endo- and myometrium in normal and abnormal
  pregnancies)
• Pseudogestational sac sign
• Thick decidual reaction surround intrauterine
  fluid (no double decidual sign)
• Located centrally within endometrial canal
• 10 patients with EP

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Pseudogestational sac in an ectopic pregnancy
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EP U/S Findings

• Tubal/adnexal mass SEPARATE FROM OVARY
• Tubal ring sign hyperechoic ring surround an
  extra-uterine gestational sac
• Ring of fire sign peripheral hypervascularity
  of hyperechoic ring

non-specific, may also be seen surrounding
normal maturing follicle, CL.. confirm
that separate from the ovary.
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EP U/S Findings

• Echogenic free-fluid in cul-de-sac
• U/S completely negative in 5-10
• 85 of ectopics on same side as CL

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EP vs. CLC
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EP vs. CLC
EP
CLC
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EP vs. CLC
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Ring of Fire
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Tubal Ectopic
CLC
EP
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Acute pelvic pain and ßHCG is EP until proven
otherwise!
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Follow-up

• Average doubling time ßHCG in a normal, viable
  IUP is 48hrs
• If no IUP, no ectopic identified in ßHCG ve ?,
  suggest serial ßHCG and f/u u/s as clinically
  indicated
• In EPs serum HCG levels rise at much slower rate

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Case 1
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Case 2
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Case 3
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Case 4
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Case 5
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Case 6
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Case 7
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Case 8
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Case 9
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THANK YOU!!!!