Ultrasound for the evaluation of women with acute pelvic pain

Beryl Benacerraf M.DHarvard Medical School

Ultrasound is a real-time imaging technique that combines imaging with physical exam

• The ability to examine and image patients simultaneously offers considerable often neglected value, unique to ultrasound as a cross sectional imaging technique.

• Tenderness-guided ultrasound is an effective way of detecting implants of painful deep penetrating endometriosis.

• Testing the movement of lesions while scanning is essential to make the correct dx

Get a history during the exam• How long has she been in pain• Diffuse or focal• Cyclical or constant• Sharp or dull or cramping• ? Prior surgery• Menopausal and hormonal status• Could she be pregnant?

During the scan• How tender is the patient?• Where is the tenderness? Focal?• Do organs slide past each other?• Push deliberately on each part of the

pelvis with the probe and other hand to determine where the pain comes from.

• Talk to the patient!

The uterus – non pregnant

• Degenerating or torsedfibroid • Malpositioned IUD• Hematometra (blockage at

cervix or beyond)

Many Faces of Degen. Fibroids

Localization of IUD reconstructed coronal view of uterus

Abn. Located IUDs may be a common cause of pain and bleeding

Using the shadow

Is the uterus too small? Does the IUD fit?

• Hemorrhagic cyst / hemorrhagic corpus luteum• Torsed ovary or tube• Hydrosalpinx• Tubo-ovarian abcess - PID• Ectopic pregnancy

The Adnexa Hemorrhagic Cyst

Peritoneal inclusion cyst

Two similar size cystic masses in ovary

Ovarian cancer

This 48 year old patient complained of pelvic pain.

Torsed Ovary

12 wks for NT asymptomatic

TorsedTube

Ovarian cyst?

Focal Pain when tube is moved:Salpingitis at laparoscopy

TOA

Could be PID or ectopic

+ BetaSubunit

Second opinion for suspected hydroalpinx

Congenital megaureter Pain with a + pregnancy test• Pregnancy of unknown

location• Tubal, cervical, cornual

pregnancy• Ongoing SAB• C-section scar pregnancy

4.5 weeks sac Is this pregnancy intrauterine?

Is this pregnancy intrauterine? Is the sac in the

uterus?

Pt came in for NT scan

Non-GYN causes of pain

• Ureteral stone• Appendicitis• Irritable bowel syndrome• Diverticulitis• Inflamatory bowel disease• Adhesions

Appen

dix

Acute RLQ pain

Appendicealabcess

Postmenopausal patient with LLQ pain X 1 week

Diverticular abcess

Conclusions

• Accurate Dx requires a combo of ultrasound, physical exam and history, not just still images.

• Most of the diagnoses can be made with ultrasound without the need for CT and MR.

• Patients with pelvic pain are miserable and deserve the extra care and attention.