Pelvic ultrasound. Case 35 yo G3P1, LMP “4 wks ago”, lower abdominal pain and “dizziness” IUD in place R > L, sharp, subjective fever, nausea, dysuria,

Pelvic ultrasound

Case

35 yo G3P1, LMP “4 wks ago”, lower abdominal pain and “dizziness”

IUD in place

R > L, sharp, subjective fever, nausea, dysuria, brown vaginal discharge

Differential diagnosisGastrointestinal

Appendicitis

IBD

IBS

Constipation

Urinary tract

Cystitis

Pyelonephritis

Nephrolithiasis

Reproductive

Ectopic pregnacy

IUP

PID

TOA

Ovarian cyst

Hemorrhagic cyst

Ovarian torsion

Fibroids

Endometriosis

ED Workup

U preg neg

U dip + LE, + Prot, + Blood

Physical exam

Point-of-care ultrasound of the pelvis

Indications

Acute lower abdominal or pelvic pain

Acute pelvic inflammatory disease

Evaluation of pelvic or adnexal masses

Yes/No questions

Is there a life or organ-threatening gynecologic emergency?

Ovarian torsion

Tubo - ovarian abscess

Are there other gynecologic abnormalities?

Ovarian cysts

Fibroids

Other

TechniqueTransabdominal

Low frequency probe

Bladder full

Overall view of pelvis

Endovaginal

High frequency

Bladder empty

Better resolution, finer details

Transabdominal Sagittal Transabdominal Sagittal Anterio

r

Posterior

Feet

Head

Transabdominal TransverseTransabdominal Transverse

R L

Anterior

Posterior

Endovaginal - SagittalEndovaginal - Sagittal

Head

Feet

Anterior Posterior

Endovaginal - Endovaginal - TransverseTransverse

R L

Feet

Head

.

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OvariesOvaries

Right Ovary Left Ovary

Ovarian cystsMost common ovarian masses in non-pregnant

Thin-walled, unilocular anechoic spheres

Hemorrhagic cysts have heterogenic internal echoes

Physiologic <2.5 cm

Follicular 2.5 - 14 cm

Corpus luteum cysts up to 13 cm

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Fibroids

Most common gynecologic tumor

May present with dysuria, dysmenorrhea, constipation or low back pain

Discrete masses within uterine wall

May be hyper or hypoechoic

Shadowing

Pelvic inflammatory disease

Inflammation of tubal mucosa

Lumen fills with pus then spills to cul de sac

Pyosalpinx with blockage of fallopian tube

Hydrosalpinx with thinning of walls and distention

Erosion through the distended wall and purulent material spills into ovary

Tubo - ovarian abscess when pus becomes walled off

•Role of Bedside TransvaginalUltrasonography in the diagnosis of Tubo - ovarian Abscess in the ED J Emerg Med 2008 Jan 31 (Epub)

•Retrospective review of 20 patients with TOA

•H & P factors unreliable:

•PID hx 35%, 45% with CMT or Adnx tender, 5% fever

•Ultrasound abnormalities in most

•70% complex adnx mass, 25% echogenic fluid

•15% pyosalpinx

Pyosalpinx

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Hydrosalpinx

Tubo - ovarian abscess

Other masses

Endometrial polyps

Ovarian masses

IUDs

Best practices - EBM•ED endovaginal ultrasound in nonpregnant women with right lower quadrant pain.

• Tayal, et al. Am J Emerg Med 2008

Non-pregnant females presenting with RLQ

Pelvic ultrasound performed looking for:

• enlarged ovary or uterus

• fluid in cul de sac

• tubal dilatation

• large cystic mass

• multitissue density

• la

Failing to provide adequate analgesia

Confusing uterine vasculature with follicles within the ovary

Confusing large ovarian follicles with fallopian tubes

Confusing ovarian cysts with hydrosalpinx

Pitfalls