The uterus. The curse of pelvic pain. How to use ultrasound to evaluate patients with pelvic pain. During the scan. Get a history during the exam

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1 How to use ultrasound to evaluate patients with pelvic pain Beryl Benacerraf M.D Harvard Medical School The curse of pelvic pain Many patients never get a diagnosis and live with chronic pain 15% of women - as defined by pain for > 6 months in women years old. (Matthias et al OB GYN 1996;87:321) Pelvic pain accounts for 10% of referrals to a gynecologist and more than 40% of diagnostic laparoscopies (Shwayder JM. Semin Reprod Med ;26:25) Get a history during the exam Acute or chronic Diffuse or focal Cyclical or constant Sharp or dull or cramping? Prior surgery Menopausal and hormonal status Could she be pregnant? During the scan How tender is the patient? Where is the tenderness? Focal? Do organs slide past each other? Push deliberately on each part of the pelvis with the probe and other hand to determine where the pain comes from. Talk to the patient! The uterus Adenomyosis Degerating fibroids Prolapsing fibroids Abnormally placed IUD Adenomyosis: Invasion of endometrial glands into myometrium Common condition: Reported frequency 5-70% due to the different criteria and diligence of pathologists to pursue the dx. Symptoms: Dysmenorrhea abnormal bleeding, uterine enlargement Appearance: Mottled inhomogeneous myometrium, globular & asymmetrical uterus, small subendometrial cysts and an indistinct endometrial stripe.

2 Fuzzy borders of cavity due to adenomyosis Fibroids Very common - most do not cause pain (bleeding more likely) Positioning of fibroid or degeneration may make them symptomatic. Size of fibroid may cause discomfort due to pressure, such as hydronephosis. Many Faces of Degen. Fibroids

3 Abnormally Located IUD: Is this a common cause of pain? Where is the IUD? Where is the IUD? Where is the IUD?

4 Where is the IUD? Objectives To determine whether the 3D coronal view was instrumental in imagining the entire IUD and its position with in the uterus. To determine whether imbedded IUDs could be responsible for pelvic pain and abnormal bleeding. Results 167 consecutive patients with IUDs were evaluated using the 3D reconstructed coronal view. 28 (16.5%) had their IUD imbedded in the myometrium or cervix. Indication for scan IUD Imbedded IUD Not Imbedded Bleeding 10/ % 21/ % Pain 11/ % 27/ % Either bleeding or pain 21/ % 48/ % All of the IUDs that were considered low in the uterus or upper cervix on 2D were imbedded. Fisher Exact test p = 0.02 p = 0.03 p = More examples - is this an explanation for pelvic pain?

5 Using the shadow Very retroverted uterus - where is the IUD? Using the shadow

6 Perforation?? Two difference cases Conclusion The coronal view is necessary to imaging the position of the arms of the IUD An abnormal positioning of the arms of an IUD may result in abnormal bleeding and pelvic pain. A 3D coronal image is a necessary part of a pelvic scan for anyone with an IUD Are IUDs too big for the average uterus? Do women with embedded IUD s have a narrower transverse cavity than whose with normaly located IUD s? We measured the width of the endometrial cavity at the fundus on coronal images using electronic calipers in 132 patients with normal and 29 with embedded IUDs The mean width of the cavity was 3.2mm in patients with normal IUD placement vs. 2.5mm for those with embedded IUD(p= ) The transverse diameter of T-shaped IUD s (Mirena and ParaGard) is 32 mm. Only 4 (13.8%) pts with an embedded IUD had a cavity width > 32 mm vs 43 (32.6%) pts with a normally placed IUD, p = Who decided that the IUDs should measure 32mm across the top? Maybe there should be different sized IUDs to match the uteri. Could it help to do a 3D ultrasound with measurement of the cavity coronaly prior to inserting a 32mm wide IUD Shipp et al. (In press) The Ovary - Adnexa Hemorrhagic cyst / hemorrhagic corpus luteum Torsed ovary or tube (w/wout mass) Endometriosis Hydrosalpinx Adhesions - peritoneal inclusion cyst Tubo-ovarian abcess - PID Ectopic pregnancy

7 Hemorrhagic Cyst with Level Hem Cyst with Clot Torsion with massive ovarian edema Torsed Ovary The Ovary - Adnexa Hemorrhagic cyst / hemorrhagic corpus luteum Torsed ovary or tube (w/wout mass) Endometriosis Hydrosalpinx Adhesions - peritoneal inclusion cyst Tubo-ovarian abcess - PID Ectopic pregnancy

8 Endometrioma Pitfall - struma ovarii Unusual appearances of Endo Endo in bowel wall Lutenized Endo The many faces of endometriosis

9 Endo - vag cuff Tubal Endometriosis Hemorrhagic cyst / hemorrhagic corpus luteum Torsed ovary or tube (w/wout mass) Endometriosis Hydrosalpinx Adhesions - peritoneal inclusion cyst Tubo-ovarian abcess - PID Ectopic pregnancy The Adnexa

10 Focal Pain when tube is moved: Salpingitis at laparoscopy Hydrosalpinges Ovarian cyst? Is there a diff. DX? Two cases

11 ? Nodularity in Ovarian lesion? Peritoneal inclusion cyst TOA Pyosalpinx TOA (air) Hematosalpinx Echogenic free fluid (+clot)

12 Ectopic pregnancy Cornual pregnancy? Confirmed with 3D Is the sac in the uterus? Non-GYN causes of pain Ureteral stone Cystitis Irritable bowel syndrome Diverticulitis Inflamatory bowel disease Adhesions

13 Distal Ureteral Stone Crohn s Appendiceal Mucocele Inflamed appendix

14 Recurrent lymphoma Bartholin duct cyst Urethral Tic Conclusions Pelvic pain is common and impairs quality of life. Accurate Dx requires a combo of ultrasound, physical exam and history. Patients with pelvic pain deserve more than just a series of standard pictures of the uterus and ovaries. Those that we help are among the most grateful of all our patients!