Diagnostic Ultrasound - Abdomen and Pelvis

Tubo-Ovarian Abscess
836
Diagnoses: Female Pelvis
– Wall and adjacent structures have increased
enhancement
– May contain gas, best seen on T2*
DIFFERENTIAL DIAGNOSIS
Endometrioma ± Rupture
• Lack signs of infection, different clinical picture
• Multiple and bilateral lesions common
• Often ovarian
○ ± tube involvement, ± other pelvic organ involvement
• Round masses more often than tubular
○ Diffuse low-level echoes
○ Thick wall and nodularity common
○ May have fluid-fluid levels
Hemorrhagic Ovarian Cyst ± Rupture
• Usually single thin-walled cystic structure in ovary, separate
from tube
○ Internal debris or classic reticular echoes, which may also
be seen in pelvis if ruptured
○ Color Doppler: Halo of increased vascularity
Paraovarian Cyst
• Unilocular anechoic cyst, no endosalpingeal folds
• Thin wall, adjacent to but separate from ovary
Appendicitis
• Inflamed blind-ending tubular structure in right lower
quadrant
○ If ruptured can see adjacent collections
PATHOLOGY
General Features
• Etiology
○ Infectious organism damages endocervical canal and its
mucus barrier and ascends into upper genital tract
– Coinfection with other organisms such as Escherichia
coli, Haemophilus influenza, and Streptococcus are
common
– Extension of cervical columnar epithelium beyond
cervix, and cervical mucosal changes in mid-cycle and
during menstruation, increases risk of ascending
infection
• Associated abnormalities
○ Salpingitis can progress to hydrosalpinx or pyosalpinx if
left untreated; late sequela is tubo-ovarian abscess
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Pelvic pain and cervical motion tenderness
○ Fever, vaginal discharge
• Other signs/symptoms
○ Elevated WBC, ESR, or CRP
○ Right upper quadrant pain rare
– Fitz-Hugh-Curtis syndrome
• Clinical profile
○ Risk factors are similar to those for STDs and include
exposure to STD, multiple sexual partners, use of illicit
drugs or smoking, and young age
Demographics
• Age
○ Women < 25 years at ↑ risk
Natural History & Prognosis
• Sequelae of fallopian tube scarring
○ Tubal infertility
○ Ectopic pregnancy
○ Salpingitis isthmica nodosa
– Diverticula of fallopian tube, mostly at isthmus
• Chronic pelvic pain
Treatment
• Prompt antibiotic therapy
• Goal of treatment is to cure acute state of infection with
short-term antibiotics as well as prevent long-term
sequelae
• If adequate clinical response to outpatient antibiotic
treatment is not achieved, patients may require parenteral
antibiotics, additional diagnostic and laboratory testing, and
possibly surgical intervention
• TOA may require drainage/surgery
• Presence of IUD does not alter treatment, and empirical
removal is not indicated
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
• Acute PID may have subtle findings
○ Pain will be disproportionate to findings
○ Look for mild inflammatory change
○ Look in posterior cul-de-sac for pus
• TOA: Nonspecific complex cystic adnexal mass
○ Use color Doppler to show increased flow
• Abdominal ultrasound or CT important to assess extent of
disease
SELECTED REFERENCES
1. Romosan G et al: The sensitivity and specificity of transvaginal ultrasound
with regard to acute pelvic inflammatory disease: a review of the literature.
Arch Gynecol Obstet. 289(4):705-14, 2014
2. Kaproth-Joslin K et al: Imaging of female infertility: a pictorial guide to the
hysterosalpingography, ultrasonography, and magnetic resonance imaging
findings of the congenital and acquired causes of female infertility. Radiol
Clin North Am. 51(6):967-81, 2013
3. Romosan G et al: Ultrasound for diagnosing acute salpingitis: a prospective
observational diagnostic study. Hum Reprod. 28(6):1569-79, 2013
4. Chappell CA et al: Pathogenesis, diagnosis, and management of severe
pelvic inflammatory disease and tuboovarian abscess. Clin Obstet Gynecol.
55(4):893-903, 2012
5. Rezvani M et al: Fallopian tube disease in the nonpregnant patient.
Radiographics. 31(2):527-48, 2011
6. Moyle PL et al: Nonovarian cystic lesions of the pelvis. Radiographics.
30(4):921-38, 2010
7. Kim JY et al: Perihepatitis with pelvic inflammatory disease (PID) on MDCT:
characteristic findings and relevance to PID. Abdom Imaging. 34(6):737-42,
2009
8. Potter AW et al: US and CT evaluation of acute pelvic pain of gynecologic
origin in nonpregnant premenopausal patients. Radiographics. 28(6):1645-
59, 2008
9. Horrow MM: Ultrasound of pelvic inflammatory disease. Ultrasound Q.
20(4):171-9, 2004
10. Sexually Transmitted Diseases Treatment Guidelines, 2015