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Pelvic pain in reproductive age often represents a diagnostic challenge due to the variety of potential causes characterized by overlapping clinical symptoms, including gynecological and other disorders (e.g., entero-colic or urological). It is also necessary to determine if there is a possibility of pregnancy to rule out any related complications, such as ectopic pregnancy. Although ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are strongly integrated, the choice of which is the ideal diagnostic tool should be guided both by clinical suspicion (gynecological vs. non-gynecological cause) and by the risk ratio–benefit (ionizing radiation and instrumental costs), too.
US Methods |
Probe |
Protocol |
Utility |
Limits |
---|---|---|---|---|
Transabdominal sonography (TSA–US) |
Low-frequency probe (convex probe 3–5 MHz). |
The standard protocol for examining the female pelvis involves an initial TAS with the urinary bladder completely full, so it can act as an acoustic window. Following bladder emptying, the patient assumes a lithotomy position, and TVS is performed. The two imaging techniques are complementary and often provide different diagnostic information. The protocol often also calls for the execution of Doppler, power Doppler, and pulsed wave Doppler flowmetry depending on the clinical situation and pathology that emerge from grayscale imaging. |
TAS offers a wider field of view than TVS and allows better visualisation of the superficial and distal structures of the vagina by bringing the probe closer to the target organs. |
|
Transvaginal sonography (TVS–US) |
High-frequency probe (endocavitary probe > 7 MHz). |
TVS approach requires a greater penetration depth to avoid the attenuating soft tissues that cover the pelvic organs. Therefore, it requires the use of a higher frequency probe, which, in turn, provides greater resolution of the anatomical details of the uterus, ovary, and adnexal structures. |
|
Causes of Pelvic Pain |
Occurrence |
Pain Characteristics |
---|---|---|
• Adnexal |
||
Adnexal torsion |
3% of gynecologic emergencies |
Acute persistent (complete torsion) or intermittent (intermittent torsion) right/left pelvic pain |
Ruptured or bleeding ovarian cysts |
The incidence is difficult to estimate. A broader estimate calculates about 7% of women worldwide experience a symptomatic cyst during their lifetime |
Acute right/left pelvic pain |
Pelvic inflammatory disease |
No specific international data are available for PID incidence worldwide. A study reports a prevalence of self-reported lifetime PID of 4.4% |
Chronic pelvic pain with reacutization |
Endometritis |
Pregnancy-related endometritis with an incidence of 1–3% after a vaginal delivery and of 13–90% following cesarean delivery, and endometritis unrelated to pregnancy that may occur in up to 70–90% of documented cases of PID |
Chronic pelvic pain with reacutization |
Endometriosis |
It affects up to 10% of women of reproductive age |
Asymptomatic/poorly symptomatic/chronic pelvic pain with reacutization during menses |
Peritoneal inclusion cysts |
Approximately 3–5% occur in women of childbearing age following invasive pelvic surgery, infection, or cancer |
Asymptomatic/poorly symptomatic/chronic pelvic pain with reacutization (especially if complicated) |
Ectopic pregnancy |
1–2% of all pregnancies |
Acute pelvic pain |
• Uterine |
||
Fibroids: degeneration, rupture, and torsion |
A study examining the incidence of degeneration of leiomyoma in patients referred for uterine fibroid embolisation underwent MRI found an incidence of 5.1%. Torsion and rupture are a rare entity (reported incidence for torsion of less than 0.25%) |
Acute pelvic pain |
Post-embolisation syndrome |
Occurs in about 40% of women undergoing uterine artery embolisation |
Pelvic pain of variable entity |
• Vascular |
||
Pelvic congestion syndrome |
In patients with presenting complaints of chronic pelvic pain, the prevalence of PCS is nearly 30% |
Chronic pelvic pain |
Thrombosis of the gonadal veins |
Referred incidence of about 0.18% of the general population |
Acute pelvic pain of variable entity |
Adnexal Causes of Pelvic Pain |
US Diagnostic Clue |
US Limits |
---|---|---|
Adnexal torsion |
Twisted vascular peduncle (whirl sign) with absent flows or with increase in resistance indices if represented |
Transabdominal US may be limited in obese patients or when the ovaries are masked by intestinal meteorism. Endovaginal US may be limited in cases of large ovarian masses causing cranial displacement of the ovary, hindering the exploration of the ovarian vessels. |
Ovarian cysts are growths that develop in the ovaries during follicular maturation and are defined as functional cysts as they represent a physiological phenomenon related to ovarian function [1][6]. Functional ovarian cysts are caused by the overgrowth of a follicle due to the accumulation of fluid inside it, which is usually spontaneously reabsorbed without causing pain [6]. In some cases, they can rupture, releasing fluid into the peritoneal cavity, causing intense pain and bleeding complications. Haemorrhagic or ruptured ovarian cysts are common in women of reproductive age; however, the actual incidence is difficult to estimate, as many ruptured cysts are asymptomatic or found incidentally [7]. A broader estimate calculates about 7% of women worldwide experience a symptomatic cyst during their lifetime and in this event, US is the primary investigative tool [6][7][8] (Table 4) [1].
Table 4. Ruptured or bleeding ovarian cysts US diagnostic clue.
Adnexal Causes of Pelvic Pain |
US Diagnostic Clue |
US Limits |
---|---|---|
Ruptured or bleeding ovarian cysts |
Cystic mass with an inhomogeneous echo structure in relation to hemoglobin degradation often with evidence of haematic sediment or in an advanced phase with relief of thin internal echoes arranged in a “fishing net” or fibrin bundles not vascularized by colour-Doppler or CEUS (differential diagnosis with tumor mass). |
US cannot detect and quantify the active bleeding |
Adnexal Causes of Pelvic Pain |
US Diagnostic Clue |
US Limits |
---|---|---|
Pelvic inflammatory disease |
The fallopian tubes with thickened and hyperemic walls, dilated in the presence of pyosalpinx with occluded ovarian fimbria, echogenic intraluminal sediments, and echoes stratified by exudate. The inflamed fallopian tube appears adjacent to or adhering to the ovary with the formation, in more advanced cases, of an ovarian tube abscess represented on US by an inflammatory mass that engulfs the ovary and the fallopian tube, no longer making the ovary distinguishable. |
US may suffer from limited panoramicity and, in cases of extensive adhesions, can be difficult to discriminate each anatomical structure. |
Adnexal Causes of Pelvic Pain |
US Diagnostic Clue |
US Limits |
---|---|---|
Endometritis |
Thickened endometrium with an irregular profile and the presence of more or less echogenic fluid or pus in the uterine cavity (pyometra) |
At US, may be difficult to distinguish severe endometritis from cancer |
Adnexal Causes of Pelvic Pain |
US Diagnostic Clue |
US Limits |
---|---|---|
Endometriosis |
Unilocular swellings, which are often bilateral and multiple, with a thick capsule, regular margins, and homogeneously echogenic content, with fine internal echoes, due to the blood cells flaking off the walls, resulting in a “ground glass” appearance. Useful monitoring for differential diagnosis with hemorrhagic ovarian cyst (persistence to follow-up of the endometriotic cyst addresses the diagnosis) |
At US, may be difficult to detect millimetric foci of ovarian endometriosis and to detect retrocervical or ligaments thickening, as well as possible intestinal or nerve involvement. |
Adnexal Causes of Pelvic Pain |
US Diagnostic Clue |
US Limits |
---|---|---|
Peritoneal inclusion cyst |
Trapped ovary inside a cyst, surrounded by septa and fluid. The fluid is usually anechoic but may contain echoes in some compartments due to haemorrhage or protein-rich fluid |
At US, can be difficult to differentiate the cystic origin. |
Adnexal Causes of Pelvic Pain |
US Diagnostic Clue |
US Limits |
---|---|---|
Ectopic pregnancy |
When the b-hCG value is below the cut-off value of 2000 mIU/mL (IRP) and there is no intrauterine gestational sac, the diagnosis could be an early intrauterine pregnancy, a miscarriage, or an ectopic pregnancy, and therefore follow-up is indicated
|
Related with difficulties in exploring the adnexa and in detecting early pregnancy as well as active bleeding in case of rupture |
Uterine Causes of Pelvic Pain |
US Diagnostic Clue |
US Limits |
---|---|---|
Fibroids torsion |
Hypovascular or avascular mass distinct from the ovary and with a twisted or “pointed” peduncle |
Difficulties in exploring the whole uterus in cases of multiple fibromas and in detecting the twisted pedicle |
Uterine Causes of Pelvic Pain |
US Diagnostic Clue |
US Limits |
---|---|---|
Post-embolisation syndrome |
Fibroid with internal echoes and reverberation artifacts in the context of a poorly defined mass following infarction and tissue necrosis |
Difficulties in exploring the whole uterus in cases of multiple fibromas |
Vascular Causes of Pelvic Pain |
US Diagnostic Clue |
US Limits |
---|---|---|
Pelvic congestion syndrome |
Multiple pelvic veins with a diameter greater than 5 mm and a venous reflux greater than 1 s |
Possible difficulties in sampling the vessel and correctly evaluate the blood flow, and in detecting eventual complications such as thrombosis. |
Vascular Causes of Pelvic Pain |
US Diagnostic Clue |
US Limits |
---|---|---|
Thrombosis of the gonadal veins |
Avascular structure with a tortuous tubular appearance, with adjacent anechoic or hypoechoic areas without any flow detection on the colour Doppler evaluation. |
Possible limits in panoramicity that hinder the detection of thrombosed vessels. Difficulties in Doppler evaluations. |