Acute Pelvic Pain

C H A P T E R
Acute Pelvic Pain

Manjiri Dighe
10
Acute pelvic pain in the female patient is usually caused 6. Appendicitis occurs when fecal material or calcifica-
by inflammation or infection of the gastrointestinal or tions become trapped within the tubular appendix,
genitourinary organs. Forging a differential diagnosis leading to inflammation and sometimes rupture.
based on physical findings and symptomatology can be 7. Diverticulitis is caused by perforation of a colonic
exceedingly difficult, particularly in patients with obe- diverticulum, most commonly in the sigmoid colon.
sity or chronic disease of the pelvic structures. Imaging 8. Renal colic is secondary to a stone lodged within
is of great value in directing the physician to the organ the ureter, causing inflammation, obstruction of
of interest and determining therapy. A focused differen- urine flow, and severe pain with peristalsis of the
tial diagnosis of acute pelvic pain includes ovarian or ureter.
tubal infection including abscess, ovarian torsion, hem- 9. Fibroids are benign muscular tumors of the uterus that
orrhagic or ruptured ovarian cyst, inflammatory bowel may bleed or undergo necrosis.
disease such as Crohn’s disease or ulcerative colitis,
appendicitis, diverticulitis, and renal colic. Less common
pathology includes perforation of the uterus by an intra-
uterine device (IUD) and dilation of an endometrioma
Prevalence and Epidemiology
resulting from internal hemorrhage. It is important for It is difficult to estimate the prevalence of pelvic pain.
both the referring physician and radiologist to remember Almost every woman has experienced it at least once
that acute pelvic pain is not always caused by ovarian in her lifetime. In the United States, approximately 1.5
disease. million women are affected with PID every year.1 Fre-
quency of ovarian torsion is highest in the reproductive
age group with a few cases seen in children and post-
menopausal women. Adnexal torsion is the fifth most
DISEASE common gynecologic emergency condition with a prev-
Definition alence of 2.7%.
1. Pelvic inflammatory disease (PID) is inflammation of

the upper genitalia (endometrium, fallopian tubes, and
ovaries) and the adjacent pelvic region. Etiology and Pathophysiology
2. Ovarian torsion is defined as partial or complete rota-
tion of the ovarian vascular pedicle causing obstruc-
Pelvic Inflammatory Disease
tion to venous outflow and arterial inflow. The etiologic agent is often never identified, but Chla-
3. Ectopic pregnancy is a viable fetus located outside the mydia trachomatis, Neisseria gonorrhoeae, and aerobic
uterus, usually in the fallopian tube. and anaerobic vaginal flora (including organisms involved
4. Hemorrhagic ovarian cysts are common in women of in bacterial vaginosis) are known to be the cause in some
menstrual age. When a large cyst ruptures, the blood cases.2 Sexually transmitted diseases like chlamydia and
products irritate the peritoneal surfaces. gonorrhea account for one third to one half of PID infec-
5. I nflammatory bowel disease is a heritable disorder tions.3 Risk factors include young age, high frequency
that manifests with circumferential wall thickening of partner change, lack of barrier contraception, low
and adjacent inflammation and, when perforation socioeconomic group, and smoking.4,5 Risks associated
occurs, abscesses. In the case of Crohn’s disease, with IUD insertion have been shown to be limited to the
the area most frequently affected is the terminal 4 weeks after insertion in women at low risk for sexually
ileum. transmitted infections.
161
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162 S E C T I O N T W O l Pelvic Pain
occlusion of the orifice lead to the classic presentation

Ectopic Pregnancy
of right lower quadrant pain, obstipation, and vomiting.
Tubal pregnancy has become more common as a result of Left unchecked, most cases will proceed to rupture and
the high prevalence of PID and increasing use of infertility abscess formation.
treatments. A woman with a positive pregnancy test and
no intrauterine pregnancy likely has an ectopic pregnancy. Diverticulitis
The most common location is the ampullary portion of the
fallopian tube.6 As the fetal sac increases in size, pain and This disease occurs most commonly in middle-aged and
rupture will occur. Absence of an intrauterine pregnancy elderly populations. Over time, peristalsis of the colon
with a mass adjacent to the ovary is virtually diagnostic of leads to the development of pulsion diverticula at weak
ectopic pregnancy. Blood within the cul-de-sac is a com- points in the colonic wall. When one of these diverticula
mon feature. becomes obstructed, a small perforation occurs, leading to
severe colonic inflammation and wall thickening. Abscess
formation is a common complication.
Ovarian Torsion
Multiple factors have been found to be responsible for Renal Colic
the development of ovarian torsion. Most patients with
ovarian torsion have pathology in the involved ovary or Formation of renal stones is extremely common, par-
tube that likely causes abnormal twisting.7 Most frequent ticularly in those living in the southeastern United
pathologic findings with adnexal torsion include benign States. In most cases the cause of stone development
cystic teratomas, hemorrhagic or follicular cysts, and is unknown, but diet is thought to play a part. Even
cystadenoma; however, paratubal cysts or hydrosalpinx small stones can irritate the ureteral wall, causing
may also cause torsion. Torsion in a normal ovary is rare inflammation and proximal dilation of the ureter and
and is most common among young children, in whom hydronephrosis.
developmental abnormalities such as long fallopian tubes
or absent mesosalpinx may be responsible. Other etiolo- Fibroids
gies for adnexal torsion include adnexal venous conges-
tion resulting from constipation, sigmoid distension, or Fibroids are common and present in approximately 40%
pregnancy.8 of women. Although many women suffer little symptom-
atology, some have severe pain, bleeding, and bowel and
bladder problems.
Hemorrhagic Cysts
All ovulating women will develop ovarian cysts. In the
majority of cases, a dominant follicle develops in prepara- Manifestations of Disease
tion for ovulation. Pain with ovulation may occur 10 to 12 Clinical Presentation
days after the onset of menstruation. Occasionally a cyst
fails to rupture or is associated with localized bleeding. Virtually all the diseases listed above present with pelvic
The dilated, blood-filled cyst causes pressure and pain. pain, often accompanied with nausea and vomiting. Loca-
When rupture occurs, the majority of patients will feel tion of the pain can sometimes be helpful, such as appen-
relief, although occasionally a large volume of blood will dicitis in the right lower quadrant and diverticulitis in the
cause irritation of the peritoneal surfaces and continued left; however, referred pain is common, and usually abdom-
pain. inal examination is inadequate to identify exact origin. On
pelvic examination, cervical motion tenderness is virtually
diagnostic of PID. Severe episodic pain extends from the
Inflammatory Bowel Disease
flank with renal colic. Fever is common to all infectious
Crohn’s disease usually manifests during the third decade processes, including diverticulitis and appendicitis, partic-
of life with abdominal pain, diarrhea, and systemic symp- ularly when rupture or abscess formation occurs.The pres-
tomatology, including fever and perianal abscess. This is ence of a perianal abscess is a strong predictor of Crohn’s
likely a heritable disease because it is more common in disease.
those of Semitic descent, although it has been reported
to occur in all races. Circumferential and transmural wall Imaging Indications and Algorithm
thickening can involve any portion of the gastrointestinal
tract but most commonly the terminal ileum. On endos- A woman with unstable vital signs or an acute abdomen
copy, transmural inflammation and the presence of crypt on physical examination should be taken to the operat-
abscesses are diagnostic of Crohn’s disease. ing room. In a stable patient, ultrasound (US) is the test of
choice for imaging the pelvis. US is accurate in the identifi-
cation of virtually all diseases arising from the gynecologic
Appendicitis
organs and has no ionizing radiation. When US is negative,
Roughly 10% of Americans will suffer appendicitis during computed tomographic (CT) scan with oral and intrave-
their lifetimes. The appendix, a narrow tubular structure nous contrast media should be performed. Magnetic reso-
arising from the tip of the cecum, likely has no current nance imaging (MRI) is usually reserved for cases in which
gastrointestinal function. Inflammation of the wall and CT is nondiagnostic.
CHAPTER 10 l Acute Pelvic Pain 163
Imaging Technique and Findings Pelvic Inflammatory Disease

Radiography
In the early stages of PID, US may be normal, and hence
Radiography is not routinely helpful in imaging of the pel- a normal US in a patient with clinical suspicion of PID
vis outside of trauma. Plain films may be helpful to diag- does not exclude the diagnosis. The presence of free
nose bowel obstruction, locate a foreign body, and identify fluid in the cul-de-sac or pouch of Douglas (see Figure
calcifications including appendicoliths and renal stones. 10-1, B) is also not a specific sign of PID and may be
present in other conditions such as follicular rupture,
ovarian cyst, malignancy, or ectopic pregnancy, in addi-
Ultrasound
tion to other nongynecologic causes of fluid.9 Fifty per-
US is the test of choice for the diagnosis and evaluation of cent of patients with PID may demonstrate free fluid in
pelvic pain. It can be performed transvaginally or trans- the cul-de-sac that appears anechoic and may be small
abdominally; the transvaginal approach provides more in quantity. With inflammation, there is dilation of the
detail, whereas transabdominal imaging provides a larger tube with formation of a hydrosalpinx or pyosalpinx. As
field of view (Figure 10-1). It is essential that the uterine the disease progresses, the ovary can become involved
fundus be seen in its entirety to identify pedunculated and enlarges with loss of corticomedullary distinction.
fibroids. Images showing the iliac vessels are important to When the ovary adheres to the tube, it forms a tuboovar-
exclude adnexal masses abutting the pelvic sidewall. US ian complex. A tuboovarian abscess (TOA) is caused by
can also be used to guide abscess drainage. complete breakdown of ovarian and tubal architecture
A B
C
n FIGURE 10-1 A, Transabdominal image showing fluid collections (double arrows) posterior to the uterus (arrow). B, Transvaginal image in the same
patient showing the fluid collection in the left adnexa with debris in it. C, Another patient with hydrosalpinx and fluid collections seen on panoramic
image.
n FIGURE 10-2 Transvaginal image shows an

encapsulated fluid collection in the pelvis with septations
in it, consistent with a tuboovarian abscess.
without the ability to differentiate them. TOA may

Ectopic Pregnancy
appear as a homogenous, hypoechoic cystic mass or
a mass containing mixed echogenicity areas (Figure Normal findings of a developing intrauterine pregnancy
10-2). Septae within this mass may appear thickened on transvaginal US (TVUS) are an intrauterine gestational
and asymmetric. sac at 5 weeks, yolk sac at 5.5 weeks, and fetal heart
motion at 6 weeks. When these findings are absent in the
Ovarian Torsion presence of a positive pregnancy test, an early pregnancy,
spontaneous abortion, or ectopic pregnancy should be
The spectrum of reported imaging findings in torsion considered. The most specific appearance of an ectopic
varies as a result of the degree and duration of adnexal pregnancy is a thick-walled cystic mass adjacent to the
torsion. If the torsion is incomplete, massive ovar- ovary (Figure 10-4).12 A dilated fallopian tube, fetal pole,
ian edema may result (Figure 10-3, A); however, with and blood in the cul-de-sac are other common findings.
increasing degree of obstruction, there is complete lack Even with a normal appearance, ectopic pregnancy is
of flow to the ovary, and the ovary may be normal size present in up to one third of cases. Serial β–human chori-
but without any flow in it. With torsion, however, a large onic gonadotropin (hCG) examinations are useful to fol-
ovary is the most constant finding in multiple previ- low the course of a possible ectopic pregnancy.
ous articles with the enlargement caused by either the
edema or a mass.10
Hemorrhagic Cysts
Other findings seen on gray scale imaging include
hyperechoic central areas of edema and peripherally Blood within a cyst changes in appearance with age.
placed follicles and large cystic mass with internal debris. In the acute phase, hemorrhage is brightly echogenic
The color and spectral Doppler findings in ovarian tor- with minimal through-transmission. As the hemorrhage
sion are also highly variable and are based in part on the evolves, more anechoic fluid is seen centrally, although a
degree of vascular compromise. The classic finding of thick vascular rim may remain. Mature hemorrhagic cysts
absent ovarian arterial flow is seen in only 73% of cases, contain gracile septa within a thin rim (Figure 10-5, A).13
and some cases may even have a normal color Doppler In the case of endometrioma, the classic appearance is
flow to the ovary. Venous flow abnormality, however, is that of a cyst containing shifting echoes indicative of
the most frequent finding with either decreased or absent blood products (Figure 10-5, B).
venous flow seen in 93% of cases.10 Other findings include
a twisted vascular pedicle sign and the whirlpool sign.
Inflammatory Bowel Disease
The twisted vascular pedicle sign is the rotation site of the
vascular pedicle itself and is seen as an echogenic round In most cases the uterus and ovaries appear normal.
or beaked mass with multiple concentric hypoechoic and Adjacent small bowel loops show wall thickening and
target-like stripes. Visualization of the circular or coiled hyperemia. Fluid often extends into the mesentery and cul-
vessels within this twisted pedicle on color Doppler is the de-sac. A contained fluid collection suggests abscess. When
whirlpool sign.11 these findings are identified, the patient should undergo CT
A B
n FIGURE 10-3 Ovarian edema. A, Ultrasound showing an enlarged appearance of the ovary with small peripheral cysts from edema. B, Axial
computed tomography (CT) in the same patient shows enlarged hypodense appearance of the right ovary with a significant difference in size between
the right (black arrow) and left ovary (white arrow). C, Coronal CT image shows the twisted vascular pedicle sign (arrow).
or MRI scanning to better delineate the length of bowel junction and within the distal ureter. Using color Doppler
involved with disease and other organ involvement. imaging, ureteral jets indicating at least some passage of
urine can spare the patient emergent placement of a ure-
Appendicitis teral stent.
In thin women and adolescents it is possible to identify the Fibroids

noncompressible tubular structure within the right lower
quadrant, diagnostic of appendicitis (Figure 10-6, A). In US is the test of choice for diagnosis of fibroids. Although
practice, most women will undergo CT scan because it is it is not as accurate as MRI in determining exact location
extremely accurate with reproducible findings. Abscess or necrosis, pain with palpation using the endovaginal
can also be identified (Figure 10-6, B). probe usually indicates the problem.
Diverticulitis Computed Tomography

US is not useful in the diagnosis of diverticulitis. Pelvic Inflammatory Disease
CT is increasingly ordered as an initial examination in
Renal Colic
patients who present with abdominal or pelvic pain.
US is extremely useful in the diagnosis of renal stones Although CT is often sensitive for pelvic pathology, it may
and hydronephrosis. Echogenic stones with shadowing not be as specific as TVUS, and US is often obtained after
( Figure 10-7) can often be identified near the ureteropelvic an abnormal CT study to better delineate the pathology.
n FIGURE 10-4 Ectopic pregnancy in the left adnexa

(arrow). Note the adjacent ovary (double arrows).
A B
n FIGURE 10-5 Hemorrhagic cyst (A)—note the fine lacelike appearance in the cyst—compared with an endometrioma (B), which has a homogenous
appearance with low-level echoes in it.
As seen with US, noncomplicated acute PID may pre near the level of the renal hila.15 Reactive inflammation
sent with a normal CT scan or have a small amount of of surrounding structures may be seen, including a small
fluid or fat stranding in the cul-de-sac.14 As the disease or large bowel ileus, hydronephrosis or hydroureter, peri-
progresses, imaging findings seen are similar to those tonitis with peritoneal enhancement, and right upper
on US and include (1) enlarged ovaries with a polycystic quadrant inflammation, also called Fitz-Hugh–Curtis
appearance, (2) enhancing and dilated endocervical and syndrome.
endometrial cavities with hypodense fluid collections, (3) CT has a leading role in the aspiration or drainage of
pyosalpinx, seen as a serpiginous or tubular structure, fluid collections. In their study, Gjelland et al.16 dem-
and (4) TOA appearing as a complex fluid collection with onstrated a 93.4% response to primary drainage of pel-
thick walls, internal septations, and/or fluid–debris lev- vic abscesses. Success rates usually vary between 86%
els in the adnexal area (Figure 10-8). Gas is infrequently and 100%. Abscesses can be drained by transabdomi-
seen in the fluid collections but when present is a spe- nal, transvaginal, transgluteal, and transrectal routes.
cific sign of infection.15 Other findings include anterior Route of choice depends on the access to the abscess;
displacement of the mesosalpinx, uterosacral ligament however, the majority of drainage procedures are car-
thickening, presacral and periovarian fat stranding, loss ried out by either the transabdominal or transgluteal
of normal fat planes, and paraaortic lymphadenopathy route.
A B
C
n FIGURE 10-6 Sagittal (A) and axial (B) ultrasound images with dilated tubular structure in the right lower quadrant with appendicoliths at the
base (arrow), suggesting appendicitis. C, Computed tomography in another case of appendicitis. Note heterogeneous fluid collection around the
appendix with involvement of the surrounding bowel. This was due to appendiceal perforation with periappendiceal abscess formation.
n FIGURE 10-7 Small calculus in the lower pole of the

right kidney (arrow) without any hydronephrosis.
A B
n FIGURE 10-8 Axial (A) and coronal (B) postcontrast computed tomographic images showing bilateral tuboovarian abscesses (arrows).
n FIGURE 10-9 Computed tomographic image showing

large cystic teratoma with fat and calcification posterior
to the uterus. Note thickened vascular pedicle along the
left side. This had undergone torsion and was causing
mass effect on the uterus (arrow).
Ovarian Torsion
hypoattenuating cystic structures in an edematous ovary,
CT is increasingly used in the emergency department lack of enhancement (see Figure 10-3, B and C), oblit-
for initial evaluation of patients with abdominal pain. eration of fat planes, hematoma, and gas within a torsed
CT may also be useful if US findings are ambiguous or mass.15,17
if the lesion is not well seen on US. In general, US has a
very limited role in gastrointestinal, musculoskeletal, and
Ectopic Pregnancy
neurologic cases of CPP. CT findings in torsion include
an adnexal mass either in the midline or rotated toward CT examination is contraindicated when pregnancy is a
the contralateral side, deviation of the uterus to the side diagnostic possibility. It is prudent to require a pregnancy
of the affected ovary (Figure 10-9), and ascites.14 Other test for all women of menstrual age who are unsure of
findings seen include a thickened fallopian tube with their pregnancy status with the exception of women who
an amorphous or tubular masslike structure, peripheral require emergent scans secondary to trauma.
1 cm below the terminal ileum. An inflamed appendix

Hemorrhagic Cysts
appears as a tubular structure with a blind end, diameter
In cases in which the cyst is intact, a fluid or low density larger than 6 mm (Figure 10-12), with circumferential
structure is seen within the adnexa. The wall is usually wall thickening and stranding of adjacent fat.19 Free fluid
thin and does not enhance. Septations may be seen. Rup- is common and occurs with both serositis and perfora-
tured cysts usually show high density blood within the tion. Free air and a contained fluid collection are diagnos-
cul-de-sac and paracolic gutter. tic of perforation.
Inflammatory Bowel Disease Diverticulitis

For several years, CT scan, usually with administration of CT scan has also become the test of choice for diagnosis
oral and intravenous contrast media, has been the test of diverticulitis. The appearance is that of circumferential
of choice for evaluation of patients with Crohn’s disease bowel wall thickening usually involving a long segment of
and pain.The goal of the test is to determine the length of the sigmoid (Figure 10-13). Diverticula are usually present.
bowel segment involved, whether the bowel wall is viable, The differential diagnosis for short segment disease includes
and to identify complications such as abscess and fistula. colon cancer. Identification of abscess is critical because per-
An acute flare manifests as circumferential thickening of cutaneous drainage usually allows for a single bowel resec-
a long segment of bowel with associated inflammation of tion rather than a two-step colostomy and reanastomosis.20
fat (Figure 10-10).18 Increased mesenteric fat is common
in those patients with longstanding disease (Figure 10-11). Renal Colic
A non–contrast-enhanced CT scan of patients with flank
Appendicitis
pain and hematuria will demonstrate a ureteral stone in
CT scan with administration of oral and intravenous con- approximately 40% of cases. In an additional 15% of cases,
trast media has become the test of choice for diagnosis of disease beyond the urinary tract will be identified (Figure
acute appendicitis in women. The appendix usually arises 10-14). A plain radiograph should be obtained after the
n FIGURE 10-10 Coronal reformat from a contrast-

enhanced computed tomographic scan shows thickening
in the terminal ileum with enhancement (arrows)
suggestive of Crohn’s disease.
A B
n FIGURE 10-11 Axial and coronal reformat from a contrast-enhanced computed tomographic scan showing enhancement in the distal ileal loops,
abnormal angulation from adhesions, strictures, and fluid collections (arrows) in a patient with known Crohn’s disease.
A B
n FIGURE 10-12 Dilated tubular structure arising from the cecum (arrow) with appendicoliths seen within it and fat stranding around the appendix
suggestive of appendicitis; axial (A) and coronal (B) images.
CT so that this low radiation dose technique can be used of the fibroid. Occasionally a pedunculated fibroid may
to follow passage of the stone and stent placement. Mul- mimic an ovarian mass.22
tiple CT scans are usually unnecessary.21
Magnetic Resonance
Fibroids
MRI is particularly helpful in characterization of ovarian
Fibroids are difficult to see on non–contrast-enhanced CT masses indeterminate on US. MRI has a high sensitivity
scans. They enhance to a variable degree on enhanced and specificity rate of 95% and 98%, respectively, with an
scans. It is possible to measure size and describe location overall accuracy rate of 93%.23,24
n FIGURE 10-13 Axial and coronal postcontrast images show a redundant sigmoid looping to the right with thick wall and pericolonic fat stranding
(arrow) suggestive of diverticulitis.
n FIGURE 10-14 Calculus seen at the right ureterovesicular junction in a patient with right-sided pain (arrow). Note the decreased perfusion in the
right kidney, suggesting pyelonephritis.
Pelvic Inflammatory Disease Ectopic Pregnancy

TOA can be confused with an ovarian neoplasm on TVUS. MRI is not used in the diagnosis of ectopic pregnancy
The multiplanar capability of MRI with the superior tis- because it is more expensive and less sensitive than US.
sue characterization and contrast capability can help dif-
ferentiate between a malignant ovarian lesion and TOA. Hemorrhagic Cysts
Specific features of an inflammatory lesion include a
mass with an ill-defined border, presence of an ill-defined MRI can be useful when differentiating various types of
hyperintensity around the mass on T2-weighted images, adnexal cysts. In particular an endometrioma is usually
diffuse thickening of the bowel wall, fat stranding, and of high T1 signal on fat-suppressed images with areas of
adhesions.25 The mass may appear cystic or solid. Sig- shading on the T2-weighted images.
nal intensity is usually mixed with high signal on the
T1-weighted images, usually indicative of blood or pus. Appendicitis, Crohn’s Disease, and Diverticulitis
Signal voids within the mass usually indicate gas. Other
findings seen in PID on MRI include fluid in the cul- Although CT remains the test of choice for diagnosing
de-sac, which appears homogenously hyperintense on bowel disease, MRI can be helpful in diagnosis of com-
T2-weighted images if simple and heterogeneous in pres- plications of disease (Figure 10-17). Oral contrast agents,
ence of pus. Dilated fallopian tubes appear as tortuous, including milk, combined with intravenous gadolinium
tubular, and fluid-filled structures with mucosal plicae chelates highlight inflamed areas of bowel.27
within them (Figure 10-15).26
Renal Colic
Ovarian Torsion
Although MRI has high contrast sensitivity, stones appear as
MRI is used less frequently in evaluation of ovarian tor- signal voids and cannot be accurately measured. CT scan cou-
sion and usually only in subacute cases with ambiguous pled with plain film of the abdomen remains the standard.
presentation. Similar findings as seen on CT are seen on
MRI. These include deviation of the uterus, engorged ves- Fibroids
sels on the twisted side, pelvic ascites, obliteration of fat
planes, in addition to enlarged appearance and lack of MRI is the test of choice for surgical planning before removal
enhancement (Figure 10-16). of fibroids or uterine artery embolization (Figure 10-18).
n FIGURE 10-15 Hydrosalpinx on sagittal T2-weighted

magnetic resonance imaging—tubular fluid-filled
dilated structure (arrows) in the adnexa with thickened
endosalpingeal folds.
Nuclear Medicine/Positron Emission Tomography Imaging

Nuclear medicine scans are not routinely performed for Infections of the bowel and adnexa have no specific find-
imaging of inflammatory diseases of the pelvis. ings, and diagnosis can be difficult.
A specific finding for ovarian torsion is a twisted vascu-
lar pedicle, best seen on TVUS.
Angiography
Angiographic studies are not routinely performed for
imaging pelvic disease. DIFFERENTIAL DIAGNOSIS
From Clinical Presentation
Classic Signs
l Appendicitis
Clinical
l Ectopic pregnancy
Virtually all the diseases discussed in this chapter present l Ovarian torsion
with nausea, abdominal pain, fever, and vomiting. Cervi- l Diverticulitis
cal motion tenderness is diagnostic of PID. l Hemorrhagic ovarian cyst
A B
C D
n FIGURE 10-16 Torsion of right ovary. A, Transabdominal image showing a complex mass (arrow) posterior to the uterus. Differential diagnosis
included an ovarian mass and bicornuate uterus. Magnetic resonance imaging performed to differentiate between these two entities shows a large
mass posterior to the uterus on coronal T2-weighted image (B) separate from it and arising from the right ovary. Note right broad ligament seen
between the ovary and the uterus. C, Postcontrast T1-weighted image shows lack of enhancement in the mass (arrow). D, Intraoperative image shows
the large mass with twisted pedicle (arrow) confirming the diagnosis of ovarian torsion.
A B
n FIGURE 10-17 Axial and coronal T2-weighted images from a magnetic resonance enterography showing thickening of the terminal ileum (arrow)
with fat stranding (double arrow) in the surrounding mesentery in a patient with known Crohn’s disease.
n FIGURE 10-18 Magnetic resonance appearance of

fibroid—multiple T2 hypointense areas (arrows) are seen
in the uterus, consistent with fibroids.
l PID/TOA using a combination of US findings and blood levels of

l Crohn’s disease β-hCG. Renal colic has a distinctive appearance.
l Renal colic
l Fibroids
SYNOPSIS OF TREATMENT OPTIONS
From Imaging Findings Medical
The majority of inflammatory and infectious diseases of PID is usually treated with antibiotics. If a TOA is present,
the gastrointestinal tract can mimic disease of the ovaries. percutaneous drainage is often performed. Ovarian tor-
Careful assessment using US and CT will usually allow sion requires surgery; the ovary may be preserved in some
for a specific diagnosis. Ectopic pregnancy is diagnosed cases. Hemorrhagic cysts usually resolve spontaneously.
Endometriomas may be removed, depending on symp- l Ovaries: Including adnexal mass with description of
tomatology. Treatment of ectopic pregnancy depends on Doppler flow pattern
the size and location of the mass. Bowel disease is treated l Bowel: Location of wall thickening
with antibiotics, steroids, or surgery, depending on the l Fluid collections
etiology and location. Renal stones may pass spontane- l Ureters: Dilation and presence or absence of stone
ously or require intervention such as stenting.
REPORTING: INFORMATION FOR THE KEY POINTS

REFERRING PHYSICIAN n A specific diagnosis can rarely be made using physical
examination.
Key points for the radiology report include description of: n A pregnancy test should be performed before imaging.
l Ascites: Volume, density, and location n US is the test of choice when gynecologic disease is suspected.
l Inflammation and stranding of fat n Once gynecologic disease is excluded, CT is the test of
l Uterus: Location of fibroids and presence of fluid in the choice for bowel disease and renal colic.
endometrial canal, presence or absence of intrauterine
pregnancy
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