JOURNAL ARTICLE
REVIEW

[Ultrasonography in acute pelvic pain]

Sanja Kupesić, Alenka Aksamija, Niksa Vucić, Ana Tripalo, Asim Kurjak
Acta Medica Croatica: C̆asopis Hravatske Akademije Medicinskih Znanosti 2002, 56 (4-5): 171-80
12768897
Acute pelvic pain may be the manifestation of various gynecologic and non-gynecologic disorders from less alarming rupture of the follicular cyst to life threatening conditions such as rupture of ectopic pregnancy or perforation of inflamed appendix. In order to construct an algorithm for differential diagnosis we divide acute pelvic pain into gynecologic and non-gynecologic etiology, which is than subdivided into gastrointestinal and urinary causes. Appendicitis is the most common surgical emergency and should always be considered in differential diagnosis if appendix has not been removed. Apart of clinical examination and laboratory tests, an ultrasound examination is sensitive up to 90% and specific up to 95% if graded compression technique is used. Still it is user-depended and requires considerable experience in order to perform it reliably. Meckel's diverticulitis, acute terminal ileitis, mesenteric lymphadenitis and functional bowel disease are conditions that should be differentiated from other causes of low abdominal pain by clinical presentation, laboratory and imaging tests. Dilatation of renal pelvis and ureter are typical signs of obstructive uropathy and may be efficiently detected by ultrasound. Additional thinning of renal parenchyma suggests long-term obstructive uropathy. Ruptured ectopic pregnancy, salpingitis and hemorrhagic ovarian cysts are three most commonly diagnosed gynecologic conditions presenting as an acute abdomen. Degenerating leiomyomas and adnexal torsion occur less frequently. For better systematization, gynecologic causes of acute pelvic pain could be divided into conditions with negative pregnancy test and conditions with positive pregnancy test. Pelvic inflammatory disease may be ultrasonically presented with numerous signs such as thickening of the tubal wall, incomplete septa within the dilated tube, demonstration of hyperechoic mural nodules, free fluid in the "cul-de-sac" etc. Color Doppler ultrasound contributes to more accurate diagnosis of this entity since it enables differentiation between acute and chronic stages based on analysis of the vascular resistance. Hemorrhagic ovarian cysts may be presented by variety of ultrasound findings since intracystic echoes depend upon the quality and quantity of the blood clots. Color Doppler investigation demonstrates moderate to low vascular resistance typical of luteal flow. Leiomyomas undergoing degenerative changes are another cause of acute pelvic pain commonly present in patients of reproductive age. Color flow detects regularly separated vessels at the periphery of the leiomyoma, which exhibit moderate vascular resistance. Although the classic symptom of endometriosis is chronic pelvic pain, in some patients acute pelvic pain does occur. Most of these patients demonstrate an endometrioma or "chocolate" cyst containing diffuse carpet-like echoes. Sometimes, solid components may indicate even ovarian malignancy, but if color Doppler ultrasound is applied it is less likely to obtain false positive results. One should be aware that pericystic and/or hillar type of ovarian endometrioma vascularization facilitate correct recognition of this entity. Pelvic congestion syndrome is another condition that can cause an attack of acute pelvic pain. It is usually consequence of dilatation of venous plexuses, arteries or both systems. By switching color Doppler gynecologist can differentiate pelvic congestion syndrome from multilocular cysts, pelvic inflammatory disease or adenomyosis. Ovarian vein thrombosis is a potentially fatal disorder occurring most often in the early postpartal period. Hypercoagulability, infection and stasis are main etiologic factors, and transvaginal color Doppler ultrasound is an excellent diagnostic tool to diagnose it. Acute pelvic pain may occur even in normal intrauterine pregnancy. This may be explained by hormonal changes, rapid growth of the uterus and increased blood flow. Ultrasound is mandatory for distinguishing normal intrauterine pregnancy from threatened or spontaneous abortion, ectopic pregnancy and other complications that may occur in patients with positive pregnancy test. Incomplete abortion is visualized as thickened and irregular endometrial echo with certain amount of intracavitary fluid. If applied, color Doppler ultrasound reveals low vascular resistance signals in richly perfused intracavitary area. Transvaginal sonography has high sensitivity and specificity in visualization of uterine and adnexal signs of ectopic pregnancy. Color Doppler examination may aid in detection of the peritrophoblastic flow. Furthermore, it facilitates detection of ectopic living embryo, tubal ring or unspecific adnexal tumor. Corpus luteum cysts and leiomyomas are another cause of pelvic pain during pregnancy, which can be correctly diagnosed by ultrasound. Detection of uterine dehiscence and rupture in patients with history of prior surgical intervention on uterine wall relies exclusively on correct ultrasound diagnosis. In patients with placental abruption sonographer detects hypoechoic complex representing either retroplacental hematoma, subchorionic hematoma or subamniotic hemorrhage. In closing, ultrasound has already become important and easily available tool which can efficiently recognize patients with possibly threatening conditions of different origins.

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