Female Female Pelvic Pelvic Pain Pain - Imaging Imaging Techniques Techniques and and Typical Typical Findings Findings Boris Brkljačić Boris Brkljačić Department of Radiology, University Hospital “Dubrava”; Medical School, University of Zagreb, Zagreb, Croatia Danish Radiology Congress, Aarhus, January 2013.
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FemaleFemale PelvicPelvic PainPain --
ImagingImaging TechniquesTechniques
andand TypicalTypical FindingsFindings
Boris BrkljačićBoris Brkljačić
Department of Radiology, University Hospital “Dubrava”;
Medical School, University of Zagreb, Zagreb, Croatia
Danish Radiology Congress, Aarhus, January 2013.
FemaleFemale pelvicpelvic painpain
� structured approach to image interpretation to
narrow broad spectrum of ddxs
� distinction btw pregnant and non-pregnant pts
� once pregnancy is excluded disorders need to be � once pregnancy is excluded disorders need to be
grouped according to the anatomic origin
� initial imaging work-up should be tailored to
enable dxs of both gynecologic and non-
gynecologic causes; not only pelvic examination
FPP: FPP: ImagingImaging ModalitiesModalities
�Ultrasound
�Computed Tomography
�Magnetic Resonance Imaging
AcuteAcute LowerLower AbdominalAbdominal andand
PelvicPelvic PainPain: :
��UUS S andand CTCT are most commonly used
��MMRIRI beneficial for a subset of pts for whom
CT is not warranted (pregnant pts, younger
pts)
ChronicChronic PelvicPelvic PainPain: :
��UUS S andand MRIMRI are most commonly used
�US (TV US) used initially�US (TV US) used initially
�MRI often used for definitive dx
UltrasoundUltrasound
the first imaging modality to study women w lower
abdominal and pelvic pain
advantages: non-invasive, low cost, no ionizing advantages: non-invasive, low cost, no ionizing radiation, availability, real-time, dynamic exam
US enables final dxs in many clinical conditions and further imaging is indicated when US fxs are inconclusive
UltrasoundUltrasound
� transabdominal US
� transvaginal US
�B-mode, color & power Doppler
�native harmonic and compound imaging�native harmonic and compound imaging
� contrast-enhanced-US
� 3 D Ultrasound
� hysterosonography and hystosalpingo-contrast-sonography (hy-co-sy)
Better resolution to evaluate small lesions and slight changes of echogenicity; higher sensitivity to flow
It is recommendable to use both TA It is recommendable to use both TA && TV USTV USIt is recommendable to use both TA It is recommendable to use both TA && TV USTV US
Fleischer, AC
J US Med, 1989
transvaginaltransvaginal USUS alone sufficient to visualise all fxs in
>83% pts
both TV and TA USboth TV and TA US w empty bladder needed for 15%
of pts
only 1.5% of pts required full bladder to visualise
normal ovaries → filling of the bladder for pelvic
sonogram is seldom required
Benacerraf B, et al. J Ultrasound Med 2003
• abnormal angiogenesis –neovessels w/o smooth
muscles in walls - ↓RI, A-V shunts, irregular pattern of
vascularisation; 0.40 RI threshold to differentiate
malignant and benign ovarian masses (Kurjak A, et al. J
In myomas macrovessels are usually seen in the periphery,
resembling a ring
In adenomyosis abundant intralesional vessels w chaotic
distribution, and ↑ # than in adjacent normal myometrium.
ColorColor Doppler: Doppler: adenomyosisadenomyosis vs. vs. myomamyoma
Sonoelastographynew dynamic technique that estimates stiffness of
tissues by measuring the degree of distortion under
application of external force
Elastography can differentiate endometrial polyps from
leiomyoma (Hobson MA, et al. J Clin Ultrasound 2007; 26(7): 899-908) and leiomyoma (Hobson MA, et al. J Clin Ultrasound 2007; 26(7): 899-908) and
malignancy from normal cervix Thomas A, et al. Acad Radiol 2007;
14(2):193-200.
SignificanceSignificance of of normalnormal US US fxfx??
�86 pts w PP and normal US reevaluated after
6-21 mo: 86% w acute/subacute pain & 50%
w chronic pain → resolution of symptoms
� further imaging in 9 pts → only 4 had clin� further imaging in 9 pts → only 4 had clin
sign disease (2 endometriosis, 1 pelvic
adhesions, 1 adenomyosis).
�high NPV (92%) for normal TV US fxs
Harris RD, et al. Clinical outcome in female pts w pelvic pain and
normal pelvic US fxs .Radiology 2000;216:440-3
ComputedComputed TomographyTomography
� not the first-line choice in dxs female pelvic diseases
� pelvis often included as a part of abdominal CT study -
familiarity w appearance of pelvic pathology necessary
� advantage: availability in emergency
� disadvantages: lack of precise definition of pelvic
structures, ionizing radiation (especially problem in
young women and possibly pregnant women)
ComputedComputed TomographyTomography
� indicated when:
� US fxs are equivocal
� clinically or according to US fxs following conditions
are suspected:
� pelvic abscess � pelvic abscess
� hematoma
� postpartum complications
� complications related to PID
� GI or urinary pathology
Bennett GL. Radiographics 2002;22:785-81.
ComputedComputed TomographyTomography
� CT often performed in pts referred for pain beyond the pelvis or in pts who present after hours – ↑frequency of use of CT to evaluate pts w acute PP
� PP may exist in the absence of gynecologic cause; CT will depict non-gynecologic disease if the initial imaging protocols are not tailored too narrowly within the pelvis