ECR 2012 / C-1052
Pictorial Review - Ultrasound appearances of Pelvic Pain of Gynaecologic Origin in Non Pregnant Premenopausal Women
Congress: ECR 2012
Poster No.: C-1052
Type: Educational Exhibit
Keywords: Computer Applications-3D, Ultrasound, Genital / Reproductive system female, Pathology
Authors: R. Mehta1, D. Tzias2, A. K. Sian3, K. L. Shahabuddin2, A. Javed2, W. Pienaar2; 1SW10 9NH/UK, 2london/UK, 3SW17 0PZ/UK

Imaging findings OR Procedure details

Chronic Pelvic Pain (endometriosis, adenomyosis, mittleschmerz, dysmenorrhea, pelvic congestion syndrome)


Endometriosis is defined by the presence of ectopic endometrial tissue outside the uterus, most commonly implanted on the surface of the ovary, uterus, fallopian tube, or on the uterine suspensory ligaments and/or peritoneal surface of the pouch of Douglas. Patients present with chronic pain that is often cyclical in nature. Acute pain can occur from rupture of endometrioma.


Endometriomas are complex cystic masses. US finding of uniform low-level echogenicity or a ground-glass appearance is a result of repeated episodes of cyclic bleeding and corresponds to the finding of a “chocolate cyst” (Fig1). Large endometriomas may be depicted as multiple adjoining cystic structures; less frequently, they appear solid .Endometriomas larger than 3 cm often destroy portions of the ovary as normal ovarian tissue stretches to accommodate the cyst (Fig 2)



Adenomyosis is defined as the ectopic location of endometrial glands within the uterine myometrium, usually the inner third, with surrounding smooth muscle hyperplasia. Patients may present with vaginal bleeding and/or chronic pelvic pain. US imaging reveals asymmetrical uterine wall thickness with or without small myometrial cysts within the thickened wall (Fig 3)



Pain from pre-ovulation – possibly related to leakage of fluid from a dominant follicle or alternatively   pain secondary to the size of a dominant follicle in the ovary just prior to release of oocyte. Pain is typically unilateral, sharp and well localized.



Severe pelvic pain during menses can be seen in young female patients who have recently started menarche (primary dysmenorrhoea) or in women in their 20’s-30’s (secondary dysmenorrhoea). Secondary dysmenorrhoea can be seen with various conditions – typically those that result in chronic pelvic pain (i.e. pelvic inflammatory disease/tubo-ovarian abscess, uterine fibroids, adenomyosis, ovarian pathology, endometriosis, pelvic venous congestion).


Pelvic Congestion Syndrome -Retrograde blood flow through pelvic varicose veins can result in chronic pelvic pain.(Fig 4) Patients typically complain of a deep, prolonged, dull ache associated with movement and activities that increase pelvic pressure.


Transvaginal ultrasound findings:

1)  Multiple dilated structures around the uterus and ovaries with venous blood Doppler signal.

2) Dilated pelvic pain with a diameter greater than 4mm.

3) Slow blood flow (about 3cm/sec)

4) Dilated arcuate vein in the myometrium communicating between bilateral pelvic varicose veins.


Acute Pelvic Pain – Gynaecological Causes (infection, cyst/tumour, or torsion originating from the uterus, fallopian tube, or ovary)


Gynecologic Causes of Acute Pelvic Pain




  Fallopian tube





Tubo-ovarian abscess

Cyst/ Tumour

Fibroid Degeneration


Fallopian tube cyst/tumour (rare)

Cyst rupture


Fibroid Torsion (rare)

Fallopian Tube Torsion (rare)

Ovarian Torsion




Pain Originating from the Uterus



Endometritis is infection of the endometrial layer of the uterus. Non-pregnancy related endometritis is most commonly due to an STD (i.e. pelvic inflammatory disease/PID-see below), but can also be post-procedural, and be seen with chronic infections.


Pelvic inflammatory disease refers to a gamut of infectious conditions of the upper reproductive tract, including endometritis, salpingitis, and tub ovarian abscess (Fig 5) Pelvic inflammatory disease is the most common cause of gynaecologic pain in the nonpregnant female and affects 11% of women at some point during their reproductive years. Although infection with Neisseria gonorrhoea and/or Chlamydia trachomatis is most frequent, other organisms such as anaerobes, G. vaginalis, and enteric gram-negative rods can cause PID.


Patients present with diffuse lower abdominal pain that typically worsens during or shortly after menses – also worse with sexual intercourse. Reported symptoms also include vaginal discharge (75%), fever (50%), vaginal bleeding (40%).


Early in the course of such an infection imaging may be normal. As the infection progresses, US demonstrates a loss of normal tissue planes and an ill-defined uterus. Uterine enlargement may be present and is most noticeable at Tran abdominal US. Thickening of the endometrium may be present but is non-specific.


Degenerating Fibroid


Uterine fibroids (leiomyomas) are the most common benign tumour in women, occurring in 20%-30% of women of reproductive age (Fig 6-7) they are often asymptomatic, but can present with vaginal bleeding and/or chronic pelvic pain/pressure. Acute pelvic pain occurs when a growing (oestrogen-responsive) fibroid outstrips its blood supply, e.g. during pregnancy or with oral contraceptive use, leading to cell death and release of pain and inflammatory mediators. Pain may be associated with a low-grade fever, uterine tenderness, elevated WBC count, or peritoneal signs. Ultrasound imaging of a degenerating fibroid may show a heterogeneous or cystic-appearing mass (Fig 8)


Fibroid Torsion

Subserosal and submucosal leiomyomas may become pedunculated and can undergo torsion of the pedicle with subsequent infarction, degeneration, and necrosis. These appear as juxtauterine masses with peripheral enhancement and necrotic centres on CT.


Pain Originating from the Fallopian Tube




Infection of the fallopian tube most commonly occurs as an extension of endometritis (i.e. extension of PID into the fallopian tube). Salpingitis may progress to hydrosalphinx or pyosalpinx if left untreated. In pyosalpinx, US images show complex fluid with echogenic debris distending the fallopian tubes (Fig 9) other imaging clues include folding of the tubular structure, tapering of the ends, and short linear echogenic foci projecting into the lumen. At later stages, tuboovarian abscesses may form. (Fig 10)


Fallopian Tube Cyst/Tumour A rare condition that is usually identified on imaging (ultrasound/MR).


Torsion of the Fallopian Tube

Isolated fallopian tube torsion is extremely rare and difficult to diagnose. It may only be revealed at pathology following surgery of the gynaecological tract.



Pain Originating from the Ovary


Tubo-Ovarian Abscess (TOA)


Tubo-ovarian abscesses are most commonly seen as a complication of PID, but can also be seen after pelvic surgery or can develop as a complication of an intraabdominal pathology such as appendicitis or diverticulitis. (Fig 10) TOA should be suspected in any patient with PID who has a palpable adnexal mass on pelvic examination, in patients who are severely ill with PID (requiring hospital admission), or in whom outpatient treatment for PID has failed. No historical or laboratory parameters can differentiate PID from TOA.


Ovarian Cyst/Tumour


Ovarian cyst/tumour can cause pain form enlargement, rupture or torsion. Enlargement and pelvic pain can occur just before ovulation or pregnancy. Cyst/tumour >5cm in size is an independent risk factor for ovarian torsion.


Rupture of an ovarian cyst associated with sudden-onset of unilateral pelvic pain may be accompanied by light vaginal bleeding. Blood from the rupture site may leak internally into the ovary (intracapsular haemorrhage) and cause hyper acute pain from stretching of the ovarian cortex, or may leak externally into the abdomen (extra capsular haemorrhage)resulting in haemoperitoneum.


Ultrasound plays a key role in the characterisation of adnexal cysts:


1) Simple cyst – anechoic fluid within a thin-walled cyst (Fig 11a)


2) Intracapsular haemorrhage into an ovarian cyst – fine network of thin linear/ curvilinear echoes, sometimes called a fishnet or reticular pattern (Fig 11b)


3) Extra capsular haemorrhage of ovarian cyst – pelvic free-fluid (12)


4) Dermoid cyst – marked hyperechoic nodule with shadowing; material within the cyst may be hyper echoic or hypoechoic (Fig 13)


5) Endometrioma (pseudocyst) – homogenous low to medium-level echoes in a thick-walled, cystic mass. 


Ovarian Torsion (“compartment syndrome of the ovary”)


Accounts for ~3% of all gynaecologic surgical emergencies. 80% occur in women of reproductive age. 60-70% of cases are right-sided  Three main predisposing factors are increased ovarian mass (i.e. due to a mass lesion or ovarian hyperstimulation syndrome), prior abdominopelvic surgery, and pregnancy (especially 1st trimester pregnancy). Torsion occurs by twisting of the ovary on 2 pedicles, namely the uteroovarian ligament and the infundibular ligament. Most commonly the whole fallopian tube and ovary complex is involved; however isolated fallopian tube torsion has also been described.


A review of several retrospective series of patients with adnexal torsion reports that the pain is often of sudden onset (40%-80%), sharp/stabbing (70%) or a dull ache. It can be unilateral (2/3) or bilateral (1/3) in location and moderate/severe in intensity. Pain often occurs after recent physical activity or sexual intercourse. Fever (up to 25%), associated nausea and vomiting (60%-80%), and prior pain (40%) are also reported. On examination pelvic tenderness (60%) and a palpable pelvic mass (50%-80%) are reported. 


Diagnosis cannot be made on imaging alone, however imaging can aid in the diagnosis. Ultrasound shows an enlarged, commonly cystic, mass in adnexa (usually >5cm), with or without a small amount of pelvic free fluid.(Fig 14) Doppler ultrasound can show normal arterial flow (25%-60%) during initial venous congestion phase or if the torsion has spontaneously resolved. Recent clinical decision rules use a combination of 1) unilateral adnexal pain, 2) pain duration <8 hours, 3) vomiting, 4) absence of vaginal discharge or bleeding, and 5) ovarian mass >5cm by ultrasound to improve diagnostic accuracy.


Specific Entities


Pelvic pain in the setting of fertility treatment can be caused by ovarian hyperstimulation syndrome, ectopic pregnancy (rare, but reported), ovarian rupture, ovarian torsion and multiple gestations.


Ovarian Hyperstimulation Syndrome (OHSS)

OHSS is an iatrogenic complication of fertility treatment, especially during intrauterine insemination (IUI) or in vitro fertilisation (IVF). It often presents <48hrs after an infertility visit. Mild OHSS is defined as enlarged, cystic ovaries (cysts are <5cm) with or without mild pelvic pain. Moderate OHSS (incidence 3-6%) demonstrates enlarged, cystic ovaries (cysts are 5-12cm) accompanied by abdominal distension, nausea, vomiting, or diarrhoea.(Fig16)Severe OHSS (incidence 0.25-1.8%) is characterized by large, cystic ovaries (cysts are >12cm) in addition to severely impaired capillary permeability (i.e. ascites, hydrothorax, anasarca). Pelvic examination is contraindicated in OHSS secondary to the risk of ovarian rupture.


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