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Ultrasound in Patients
with Pelvic Pain
James M. Shwayder, M.D., J.D.President and CEO
Shwayder Consulting, LLC
Venice, Florida
Ultrasound in Patients
with Pelvic Pain
James M. Shwayder, M.D., J.D.
Disclosures: GE Ultrasound - Consultant
Ultrasound and Pelvic PainObjectives
• Overview causes of pelvic pain
• Ultrasound application to patient evaluation
• Case presentations
Etiologies of Pelvic Pain
Gyn
• Endometriosis
• Ovarian remnant
• Ovarian cysts
• PID
• Adhesions
• Hydrosalpinx
• Leiomyoma
• Adenomyosis
• IUD
Bladder
• Malignancy
• Interstitial cystitis
GI
• Diverticulitis
• Irritable bowel
syndrome
Neuromuscular
• Trigger points
• Neuralgia (ilioinguinal)
Psychiatric
Chronic Pelvic Pain. ACOG Practice Bulletin No. 51, March 2004.
Laparoscopic findings with Pelvic Pain (n
= 188)
Finding # %
Endometriosis 88 46.8
Adhesions 87 46.3
Fibroids 25 13.3
Ovarian cyst 15 7.9
Ectopic 8 4.3
Uterine septum 7 3.7
Hydrosalpinx 6 3.2
JM Shwayder 1994
Laparoscopic findings with Pelvic Pain
Finding # %
Endometrial Polyp/myoma 5 2.6
Corpus luteum 2 1.1
PCO 2 1.1
Salpingitis/TOA 1 0.5
Dermoid 1 0.5
Synechiae 1 0.5
Ovarian cancer 1 0.5
NORMAL 25 13.3
JM Shwayder 1994
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Endometriosis Incidence
• Reproductive age 5-45%1
• Infertile women 21-65%2
• Chronic pelvic pain 15-80%3
1Guidice, LC. N Engl J Med 2010;362:2389-98.2Mahmood and Templeton. Hum Reprod 1991;6:544–549.3Carter JE. J Am Assoc Gynecol Laparosc 1994;2:43–47.
EndometriosisSymptoms
Check et al. Gynecol Obstet Invest 1995;40:113-16.
Symptoms/Stage #I
(%)II
(%)III
(%)IV
(%)
Infertility 18 55.6 11.1 22.2 11.1
Pelvic Pain 18 50.0 16.7 16.7 16.7
Ovarian Mass 28 17.9 0.0 46.4 35.7
Uterine Fibroids 12 33.3 25.0 33.3 8.4
Exasoustos et al. Fertil Steril 2014;102(1):143-150.e2
Presurgical EvaluationStaging with Ultrasound
Sequence
• Bladder (Sweep with video file)
• Uterus (Check mobility)
• Right ovary and adnexa (Sliding organ)
• Left ovary and adnexa (Sliding organ)
• Cul-de-sac and US Ligaments (Fluid, peritoneum, mobility of
posterior cervix, uterine body, and fundus. Bowel wall)
• Rectum (3D reconstruction/render)
Location of Implants
• Ovary 54.9%
• Posterior broad ligament 35.2%
• Anterior cul-de-sac 34.6%
• Posterior cul-de-sac 34.0%
• Uterosacral ligament 28.0%
Jenkins et al. Obstet Gynecol 1986;336:1986.
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Endometrioma
• Homogenous, low-
level echoes1
– Sensitivity 90%
– Specificity 97%
• Septations 29%
• Fluid levels 5%
• Color Doppler
1Ubaldi F. Hum Reprod 1998;13:330-3
Depth of Infiltration of Endometriosis
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10 >10
% o
f L
esio
ns
Depth of Infiltration (mm)
Martin et al. J Gynecol Surg 1989;5:55.
35%
EndometriosisDepth of Infiltration
EndometriosisDepth of Infiltration
EndometriosisBroad Ligament
• Power Doppler1
• PRF = 800 Hz
• “Blush”
• Sensitivity 52.4%
• Specificity 47.1%
• PPV 53.2%
• Many lesions are
fibrotic, without
vascular activity2
• ~ 35% of lesions
penetrate > 5 mm3
• Point tenderness with
movement of the
transducer4
1 Papadimitriou et al. Clin Exp Obstet Gynecol 1996; 23: 229.2 Koninckx et al. Fertil Steril 1992; 52: 523. 3 Martin et al. J Gynecol Surg 1989; 5: 55.4Guerriero et al. Hum Reprod 2008;23(11):2452-2457.
“Tenderness-guided” transvaginal
ultrasound
• “Stand-off” TVS
• Increased gel in the probe cover
• Sites evaluated
• Vaginal walls
• Rectovaginal septum
• Rectosigmoid involvement
• Uterosacral ligaments
• Anterior compartment
• Bladder
Guerriero et al. Hum Reprod 2008;23(11):2452-2457.
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“Tenderness-guided” transvaginal
ultrasound
Guerriero et al. Hum Reprod 2008;23(11):2452-2457.
SitSpecificity
% (n)Sensitivity
% (n)
Vaginal involvement 89 (48/54) 91 (31/34)
Rectosigmoid involvement 92 (45/49) 67 (26/39)
Uterosacral ligament involvement 94 (60/64) 50 (12/24)
Rectovaginal septum involvement 88 (37/42) 74 (34/46)
Anterior pouch involvement 100 (70/70) 33 (6/18)
Bladder involvement 100 (84/84) 100 (4/4)
28 y.o. G0
• Pelvic pain x 3 years
• Constant, worse with intercourse and exercise
• Fixed uterus - Anteverted
• Tender adnexa - ? masses
Uterine Sliding SignSliding Organ Sign
Uterine sliding signNegative (no sliding)
Hudelist et al. Ultrasound Obstet Gynecol 2013;41:692-695.
Reid et al. Ultrasound Obstet Gynecol 2013;41:685-691.
Author #Sensitivity
%Specificity
%PPV%
NPV%
Accuracy%
Hudelist et al. 117 85 96 91 94 93.1
Reid et al. 100 83.3 97.1 92.6 93.2 93.0
Sliding Organ Sign
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Sliding Organ Sign Sliding Organ Sign
Ovarian Sliding Sign – Adhesions
• Sensitivity = 99.5 PPV = 96.3
• Specificity = 80.6 NPV = 96.7
Ayachi et al. Ultrasound Obstet Gynecol 2018;51:253-258.
Multiplaner Reconstruction
3-D Rendering
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28 y.o. G0
Preop diagnosis
• Stage IV endometriosis
• Obliterated cul-de-sac
• Endometrioma - left
• Dense adhesions – bilaterally
• Possible rectosigmoid involvement
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28 y.o. G0
• Stage IV endometriosis
• Obliterated cul-de-sac
• Endometrioma - left
• Dense adhesions – bilaterally
• Rectal involvement
• Confirmed diagnosis
TVS - Endometriosis
DIE locationPrevalence
(%)Sensitivity
(%)Specificity
(%)Accuracy
(%)
Uterus 7.7 100 96.8 97.1
US ligaments (R/L) 54.8/61.5 80.7/82.8 87.2/85.0 83.7/83.7
Right parametrium 26.7 67.9 93.4 86.5
Left parametrium 31.7 78.8 94.3 89.4
RV septum/Obliteration 44.2/67.3 73.9/98.6 86.2/94.1 80.8/97.1
Vagina 27.9 58.6 82.7 75.9
Rectum (cranial/caudal) 37.5/68.3 89.7/94.4 86.2/84.9 87.5/91.3
Bladder 7.7 100 96.8 97.1
Ureters (R/L) 12.5/15.4 61.5/68.7 97.8/95.5 93.3/91.3
Exacoustos et al. Fertil Steril 2014;102(1):143-150.e2
TVS detection of deep
pelvic endometriosis
Bazot et al. Ultrasound Obstet Gynecol 2004;24:180-185.
SiteSpecificity
%Sensitivity
%
PPV
%
NPV
%
Accuracy
%
Pelvic endometriosis 96.5 81.5 95.7 84.6 93.7
Deep endometriosis 78.5 85.2 85.4 77.9 85.9
Uterosacral ligaments 70.6 95.9 94.1 78.0 83.8
Vagina 29.4 100.0 100.0 91.2 91.5
Rectovaginal septum 28.6 99.3 66.7 96.4 95.8
Intestine 87.2 96.8 93.2 93.9 93.7
Bladder 71.4 100.0 100.0 98.5 98.6
Endometrioma 90.4 91.5 93.8 87.0 90.8
22 y.o. G0P0
• c/o severe pelvic pain x 2 days
• Associated odiferous discharge
• BC: None
• hCG: negative
• Exam
• Uterus: Anteverted, normal size, with moderate tenderness
• Cervical motion tenderness
• Adnexa: “right adnexal mass”
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TOA
Tubo-ovarian complex vs TOA
• Tubo-ovarian complex
• The ovary can be seen separately from a
presumed hydrosalpinx
• Tubo-ovarian abscess
• The ovary cannot be seen separately from
the tube/hydrosalpinx
“Ovarian cysts”
• 38 y.o. G2P2002 referred for
laparoscopic oophorectomy for
pelvic pain and persistent ovarian
cyst
• US reports x 3: persistent ovarian
cyst with septum, cannot r/o
ovarian cancer
Hydrosalpinx
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32 y.o. G0 with AUBEnlarged Uterus
• Ultrasound (limited)
• Probable myoma
• Planned for myomectomy
• Referred for complete ultrasound
• Findings
• Inhomogeneous myometrial texture 100%
• Globular uterus 95.7%
• Small cystic spaces in myometrium 78.7%
• Indistinct endometrial stripe 78.7%
• If 2 positive findings
• Correct diagnosis by TVUS 84.3%
AdenomyosisUltrasound Diagnosis
Bromley et al. J Ultrasound Med 2000; 19:529–534.
Bromley Criteria
Inhomogeneous myometrium Globular uterus
Cystic spaces (> 2 mm) Indistinct border
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Additional Criteria
Asymmetry Increased myometrial vascularity
Sakhal and Abuhamad. J Ultrasound Med 2012; 31:805–808
Adenomyosis and SIS
Shwayder and Sakhal. J Minim Invasive Gynecol 2014;21:362-76.
Indistinct border
Indistinct border
Cystic spaces
Asymmetry
Shwayder and Sakhal. J Minim Invasive Gynecol 2014;21:362-76.
Courtesy of Beryl Benacerraf, M.D.
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Cystic spaces (> 2 mm)
Increased myometrial vascularity
Cystic spaces (> 2 mm)
• Findings:
• Vessels around myomas produce a rim
around the mass
• Vessels in adenomyosis follow their normal
perpendicular course
Vascular flow and Adenomyosis
Chiang et al. J Assist Reprod Genet 1999;16(5):268-275.
Adenomyosis
• Incidence
• 20-30% of female population
• Up to 70% of hysterectomy specimen
• Symptoms
• Pelvic pain
• Dysmenorrhea
• Menorrhagia
• Inhomogeneous myometrial texture
• Globularly enlarged uterus
• Small cystic spaces in myometrium
• Indistinct endometrial-myometrial interface
• Myometrial asymmetry
• Vascular distribution
Ultrasound CharacteristicsAdenomyosis
28 y.o. G3P2012
• c/o cramping pain, worse with her menses
• BC: IUD x 1 year
• hCG: negative
• Exam
• Uterus: Anteverted, normal size, with mild tenderness
• IUD strings not visible
• Adnexa: “right adnexal mass”
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Bladder
• 46 y.o. G3P3003
• Long history of suprapubic and lower
abdominal pain
• Recurrent bladder infections
Bladder
• 63 y.o. c/o lower abdominal pain for several
months
• UA: + blood
Transitional Cell CA
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Bladder
• 32 y.o. c/o right lower quadrant pain
• Constant
• Worse with activity
• History of Cesarean delivery
• Exam: point tenderness RLQ
Neuropathic PainIlioinguinal Injection
Pelvic Pain and Ultrasound
• Ultrasound offers more accurate diagnosis
• Benign v. Malignant
• Plan operative management
• Appropriate personnel and consults
• Optimize patient outcomes