Ultrasound assessment of women with pelvic pain

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1 Ultrasound assessment of women with pelvic pain Lil Valentin Department of Obstetrics and Gynecology Skåne University Hospital Malmö, Sweden How to make optimal use of ultrasound in women with pelvic pain 1. Use ultrasound to confirm or exclude a diagnosis suspected on the basis of clinical information 2. Let the patients symptoms and clinical findings guide your ultrasound scan 3. Make full use of the dynamic and interactive nature of vaginal ultrasound 4. Use a systematic scanning technique

2 Painful pelvic conditions ACUTE PELVIC PAIN Miscarriage, ectopic pregnancy Pelvic masses/cysts cysts, unspecified corpus luteum cyst endometrioma peritoneal cyst torsion Pelvic inflammatory disease abscess pyosalpinx Salpingitis Gynecological cancer ACUTE PELVIC PAIN Uterus hemato-pyometra myoma/necrosis/degeneration adenomyosis Bowel appendicitis, sigmoiditis ileus, volvulus Urological bladder stone ureteric stone CHRONIC PELVIC PAIN adenomyosis adhesions peritoneal endometriosis pelvic congestion Painful pelvic conditions ACUTE PELVIC PAIN Miscarriage, ectopic pregnancy Pelvic masses/cysts cysts, unspecified corpus luteum cyst endometrioma peritoneal cyst torsion Pelvic inflammatory disease abscess pyosalpinx salpingitis Gynecological cancer ACUTE PELVIC PAIN Uterus hemato-pyometra myoma/necrosis/degeneration adenomyosis Bowel appendicitis, sigmoiditis ileus, volvulus CHRONIC PELVIC PAIN Adenomyosis chronic PID deep endometriosis adhesions pelvic congestion

3 Ovarian cyst Endometrioma Make Common full use incidental of the interactive finding Does the nature finding of ultrasound explain the pain? Can pain be provoked by touching the lesion? 1.6% of 600 asymptomatic women had endometriomas Jokubkiene et al Adnexal torsion In adnexa with a lesion cyst, hydrosalpinx In normal adnexa prepubertal girls

4 Torsion of adnexal lesion Pathophysiology, ultrasound features Arterial, venous, lymphatic occlusion Congestion edema haemorrhagic infarction Swollen (parenchyma), walls, septa, mucosal folds Echogenic fluid in cysts (haemorragic infarction) (Echogenic) fluid in the pouch of Douglas Torsion of dermoid is difficult to diagnose with ultrasound! Adnexal torsion Ultrasound features Doppler is not decisive Doppler signals may be detected centrally and peripherally Doppler findings parallel the vascular changes Persistent flow is compatible with incomplete occlusion of vessels Detection of flow does not exclude torsion

5 Adnexal torsion Ultrasound features MAY be inconspicuous Patient 1 Patient 2 Patient 2 Patient 3 Torsion of benign cyst

6 Torsion of benign cyst Torsion of benign cyst

7 Twisted normal ovary Enlarged Compare with contralateral ovary Follicles in periphery Follicle ring sign Let the patient s symptoms guide your scan Make use of the interactive nature of ultrasound map out painful areas Ultrasound in the diagnosis of PID Abscess/tubo-ovarian complex Pyosalpinx Early salpingitis

8 Unilocular abscess Endometrioma Pus and old blood look the same Tuboovarian abscess Ovarian cancer Both cancers and abscesses are richly vascularized

9 Tuboovarian complex Pyosalpinx Sausage shape Cog wheel

10 Typical ultrasound findings in early acute salpingitis bilateral adnexal masses 2-3 cm in diameter often solid lying adjacent to the ovary well vascularized Romosan et al Hum Reprod Jun;28(6): Salpingitis grade 2 (Hager)

11 Early salpingitis Let the patient s symptoms guide your scan Make full From use Molander of the et interactive al 2001 nature of ultrasound Non-gynecological conditions that may cause pelvic pain Appendicitis Sigmoiditis Volvulus Ileus

12 Acute appendicitis Muscularis Submucosa A non compressible sausage shaped blind ended structure with concentrical layers > 6 mm in diameter Diverticulitis Abscess Inflamed diverticulum

13 Chronic pelvic pain (CPP) No accepted definition Controversy about causes Some causes cannot be visualized with ultrasound Chronic pelvic pain (CPP) Suggested causes Adenomyosis Peritoneal endometriosis Deep infiltrating endometriosis Chronic PID Adhesions Pelvic congestion Swank et al 2003, Peters et al 1992, Keltz et al 1995, Jarell et al 2005, Thornton et al 1997, Nascimento et al 2002, Rozenblit et al 2001

14 Indirect ultrasound signs of pelvic adhesions Difficulty with obtaining a clear image Blurred margins of the ovary Fixed adnexa Increased distance between probe and ovary (>12 mm) persisting after abdominal palpation Guerriero et al 1997 No marker, negative likelihood ratio 0.1 Three markers, positive likelihood ratio 5 Normal gynecological ultrasound findings in women with pelvic pain 86 women with pelvic pain and normal scan Pain resolved spontaneously in 77% (69/86) Significant pelvic pathology in 6% (5/86) Harris et al

15 Normal ultrasound findings in women with pelvic pain Low risk of significant pelvic pathology..? CAUTION! Only the negative predictive value presented; it depends on prevalence Sensitivity and specificity are unknown Prediction of significant pathology in women with chronic pelvic pain 120 women with chronic pelvic pain Scan 1-2 weeks before laparoscopy Soft marker : site specific tenderness fixed ovaries Soft marker : YES: increased odds 3 times NO: decreased odds 3 times Limited (but some?) clinical usefulness

16 Pelvic congestion A cause of pain? Asymptomic potential female renal donators 38% (8/21) examined with MRI had passive reflux from the left renal vein into the left ovarian vein 47% (16/34) examined with helical CT scans had incompetent and dilated ovarian veins Nascimento et al 2002, Rozenblit et al 2001 Pelvic congestion An ultrasound diagnosis? Ultrasound congestion score diameter of ovarian veins diameter of pelvic veins number of pelvic veins morphology of pelvic veins (pelvic varicocele?) flow direction in ovarian veins Doppler shift waveform during Valsalva Halligan et al 2000, Park et al 2004, Campbell et al 2003

17 Pelvic congestion An ultrasound diagnosis? Variable results no difference between cases and controls difference between cases and controls poor agreement between ultrasound and venography Halligan et al 2000, Park et al 2004, Campbell et al 2003

18 Conclusions Ultrasound in the assessment of acute pelvic pain Use ultrasound to confirm or exclude a diagnosis suspected on the basis of clinical findings Adnexal mass, torsion, PID, appendicitis, diverticulitis, endometriosis, and more Let the patients symptoms and clinical findings guide your ultrasound scan Make full use of the dynamic and interactive nature of vaginal ultrasound Use a systematic scanning technique Torsion Conclusions Ultrasound in the assessment of acute pelvic pain ultrasound findings may be inconspicuous presence of Doppler signals does not exclude torsion difficult ultrasound diagnosis in dermoid cysts INCIDENTAL abnormal ultrasound findings are common! Normal The ultrasound patient will findings not decrease be helped the if odds of pathology how much? we treat an incidental finding Abnormal findings explanation of pain?

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