Acute female pelvic infection . ESUR Congress.
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Infection of:
- Upper genitalia (endometrium, fallopian tubes, ovaries)
- Adjacent pelvic structures
FEMALE PELVIC INFECTION
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Gynecological causesPelv ic inf lammatory disease (PID )
Endomet r i t i s
Sa lp ing i t i s
Tubo-ovar ian abscess
F i t z -Hugh-Cur t i s Syndrome
Puerperal infect ions
Cesarean sec t ion
Vagina l de l ivery
Post-operat ive gynecolog ica l surgery
Pe lv ic abscess
Pos t l e iomyomas embol iza t ion in fec t ion
F i s tu lae
Abort ion-assoc iated infect ions Endomet r i t i s Incomple te sep t ic abor t ion
PELVIC INFECTION CAUSES
Non-Gynecological causes
Intestinal: appendicitis, diverticulitis, Crohn…
Urinary: ureteritis, cistitis
Tuberculosis, Actinomycosis: chronic, acute
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No specific international data are available for PID incidence worldwide
The annual rate of PID in high-GNP countries has been reported to be as high as 10-20 per 1000 women of reproductive age (most < 25 year-old)
24% of visits to the E. departments for gynecological pain are attributable to PID
Annual cost: $ 10 billion (acute care and sequelae: tubal factor infertility, ectopic pregnancy, chronic pelvic pain, recurrent infection, life treatening condition if TOA rupture)
P o t t e r AW. R a d i o G r a p h i c s 2 0 0 8
C ro s s m a n S H . A m e r i c a n F a m i l y P h y s i c i a n . 2 0 0 6
S r i k a r A d h i k a r i . T h e J o u r n a l o f E m e rg e n c y M e d i c i n e , 2 0 0 8
PID
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RISK FACTORS FOR PID
Young age Multiple sex partners High coital frequency Low socioeconomic status Douching Use of intrauterine device (particularly during the first few months
of insertion)
Barre t S e t a l . I n t e rna t i ona l Jour na l o f ST D & AIDS 2005
Mi ndy M. Horrow. U l t ra sound Quar t e r l y 2004
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Extension to: parametrial structures
Direct ascent to the upper genital tract: pyosalpinx, TOA salpingitis endometritis
Acquisition of a vaginal or cervical infection: endocervicitis
Soper DE. Obs te t Gyneco l 2010
PIDPATHOPHYSIOLOGY
Beyond the pelvis
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Less commonly: - Direct spread from nearby appendicitis or diverticulitis- Hematogenous, lymphatic, peritoneal spread: TB salpingitis
PID
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70%• N. Gonorrhoeae • C. Trachomatis• Mycoplasma genitalium
30%
• Polymicrobial• Streptococcus species,
Escherichia coli, Hemophylus influenza, Bacteroides species, Peptostreptococcus, Peptococcus…………..
MICROBIAL ETHIOLOGY
Barret S. Int J STD AIDS. 2005Soper DE.Obstetrics and Gynecology 2010
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PID DIAGNOSIS
Clinical history:
Asymptomatic (30%) - non-specific symptoms:
Abdominal/pelvic pain
Abnormal discharge Intermenstrual bleeding
FeverUrinary frequency
Low back pain Nausea/vomiting
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PID should be suspected and treatment in i t ia ted i f :- High r i sk of PID and- Uter ine , adnexal , o r cerv ica l mot ion tenderness on b imanual pe lv ic examinat ion
Findings that support the diagnos i s (1 or more)- Cerv ica l o r vag ina l mucopuru len t (g reen or ye l low) d i scharge- Elevated ery t rocy te sed imenta t ion ra te or C-reac t ive pro te in- Labora tory conf i rmat ion of gonorrhea l or ch lamydia l in fec t ion- Oral t empera ture (38 .3 ºC) or g rea ter- White b lood ce l l s on vagina l secre t ion sa l ine wet mount ( per iphera l whi te b lood ce l l
count i s commonly normal )
Elaborate cr i ter ia (addi t ional f indings)- Pos i t ive l aparoscopy or endomet r ia l b iopsy- Pyosa lp inx , TOA on imaging
CDC: Centers for Disease Contro l and Prevent ion guide l ines on sexual ly t ransmi t ted d i seases . MMWR Recomm Rep 2006.
CDC DIAGNOSTIC CRITERIA FOR PID
PID DIAGNOSISPHYSICAL EXAMINATION AND LABORATORY STUDIES
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TREATMENT
Up to 90% of women have mild PID - treated as outpatients
10% of women have severe PID: complications
The identification of patients who require hospitalization are usually accomplished with imaging studies
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Imaging is required:
- to determine the origin and the extent of the process, if symptoms are nonspecific
- to evaluate for complications such as abscess, if the patient is not responding as expected to treatment, and
- to decide if a known abscess is amenable to percutaneous drainage.
Maryam Rezvani . RadioGraphics 2011
Abraham A. Ghiatas , Eur Radiol 2004
PID DIAGNOSISIMAGING
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USTransvaginalSensitivity: 81%
Specificity:78%
Accuracy: 80%
Transabdominal
CTSensitivity: <65% Specificity: >90% Accuracy: 84%
- After-hours availability
- Symptoms are nonspecific
- Process beyond the pelvis - Limiting factor: ionizing radiation
MRSensitivity: 95%
Specificity: 89%
Accuracy: 93%
- No radiation
- Limiting factor: expensive, less available
- Pregnant patient
- Complex adnexal mass
- Diff. pyosalpinx/ hematosalpinx
- Chronic PID: fibrosis, adhesions
Tukeva TA et al. Radiology 1999Young SI et al. J. Obstet. Gynaecol. Res.2011
- No cooperate because they are suffering from excessive pain
- Large amounts of gas preventing ultrasound penetration
- Obesity
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US
Transvaginal
Transabdominal
CT
MRACR: 9
ACR: 5 - Gyn 9 - N- Gyn
ACR: 6 - Gyn 3 - N- Gyn
• ACR Appropriateness Criteria® acute pelvic pain in the reproductive age group. http://www.guidelines.gov/content.aspx?id=15779&search=Acute+pelvic+pain
• Heverhagen JT. RadioGraphics 2009
The American College of Radiology Appropriateness Criteria® still rate MR imaging below CT and US for the evaluation of acute abdominal and pelvic conditions
1 = least appropriate; 9 = most appropriate
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EARLY STAGE OF PIDIMAGING FINDINGS
Normal
Non- specific findings:
. Fluid in the endometrial and endocervical cavities
. Mild enlargement or indistinctness of the uterus
. Enlarged ovaries with “polycystic ” appearance
. Fluid in the cul-de-sac (50% of patients with PID)
Horrow MH. Ultrasound Quarterly 2004
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EndometritisAbnormal endometrial enhancement and fluid
Mild oophoritis
Sam JW.RadioGraphics 2002
MILD STAGE OF PIDIMAGING FINDINGS
Mild salpingitisNot tubal dilatation but wall tickening (> 5mm), enhancement, and surrounding inflammation
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Mild pelvic edemaThickening of the uterosacral l igaments and haziness of
the pelvic fat
Sam JW.RadioGraphics 2002
MILD STAGE OF PIDIMAGING FINDINGS
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Pyosalpinx
ADVANCED STAGES OF PID
Most specific sign of PID at CT
Sam JW.RadioGraphics 2002
Potter AW. Radiographics 2008
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- Stranding of the
pelvic fat
- Lymphadenopathy
ADVANCED STAGES OF PID
Jung SI et al. J. Obstet. Gynaecol. Res. 2011
Peritonitis- Thickening of
pelvic ligaments
- Obscuration of the pelvic fascial planes
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MR Hematosalpinx/Pyosalpinx
FST1w
T2w
FST1w- Gd
T2w
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PID
16 year-old girl: pelvic pain, fever, nauseaBimanual uterine and adnexal tendernessLeukocytosis (white blood cell count, 17,200/μL [reference value, <10,000/μL])
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FS T1 w +C T2 w
STIR STIR
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TVUS – guided drainage
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HYDROSALPINX VS PYOSALPINX
PYOSALPINX: - Active and acute infection with obstruction of the FT- Thick enhancing wall and surrounding inflammation- Image: depends on the content of protein US: hipoechoic-hyperechoic. MR: hypointense, heterogeneous T1W, hyperintense T2W
HYDROSALPINX: - Chronic disease - Results from the obstruction of the ampullary segment: PID, tubal surgery…. - Thin-thick wall, no enhancement and no surrounding inflammation - Image: US: anechoic MR: hypointense T1W, hyperintense T2W
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CE T1 w
Courtesy: Dr. John SpencerTubal and peritubal adhesions with obstruction of the fimbrial end lead to:
Tubal shape changes - Sharp change of shape: “ beak sign”
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HYDROSALPINX
”cogwheel sign”: or small round projections on axial imaging-- thickened longitudinal folds
Accurate findings for diagnosing hydrosalpinx
Tubular “C” “S”
“waist sign”: incomplete septa result from the distended tube folding on itself
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1/3 women with severe PID
TOA
Heterogeneous mass Indistinct ovaries
- Fluid-containing mass with a thick enhancing wall and septations
- Anterior displacement of thickened broad ligament
Kim SH. RadioGraphics 2004
- Pyosalpinx adjacent to or in a portion of TOAs
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- Extension to form abdominal abscesses
TOA
- A more specific sign of tubo-ovarian abscess: gas bubbles
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TOA
30 % of patients with TOA respond to treatment: (parenteral antibiotics 48 h ---- oral antibiotics for up to 14 days)
If conservative treatment fails:- Image-guided percutaneous (US, CT) or surgical drainage
(laparotomy, laparoscopy)
L evenson RB . J Vasc In t e rv Rad i o l 2011
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PID ABDOMINAL COMPLICATIONS
Spread of infection via the right paracolic gutter
Rezvani M.RadioGraphics 2011
- Perihepatitis: thickening and enhancement of the anterior liver capsule
- Subcapsular and periportal alterations of perfusion
Fitz-Hugh-Curtis Syndrome
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Ureteral obstruction
PID COMPLICATIONS
Small or large bowel ileus or obstruction
Right ovarian vein thrombosis
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EctopicRupture of ovarian cyst: corpus luteum, follicle, endometrial
cystAdnexal torsionOther pelvic cystic masses
PID DD
AppendicitisInflammatory bowel diseases (Crohn, ulcerative colitis), infectious
terminal ileitis (Yersinia enterocolitica, Y. pseudotuberculosis,Campylobacter jejuni, and M.tuberculosis)
DiverticulitisBladder – ureteral infection
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Right ovarian torsion
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Appendix diameter (>10 mm), wall (> 2 mm)
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Appendicitis PID
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Crohn disease
22 year-old woman
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Terminal ileitis
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Diverticulitis
65 year-old. Right adnexal tenderness, fever, leukocytosis
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Chronic infection by Actinomyces israelii
Opportunistic pathogen: normally present in oral cavity or colon
Gynecological Actinomycosis is highly associated with the use of IUDs.
Chronic suppurative disease Abundant granulation Dense fibrous tissue Multiple abscesses Sinus tracts
ACTINOMYCOSIS
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Heterogeneous, well or badly defined adnexal masses, contrast enhancement (rim-enhancement) in the solid portion
ACTINOMICOSIS IMAGING
Courtesy: Dr. A. J Van der Molen
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ACTINOMICOSISIMAGING
- Abscess
- Thick, linear, enhancing lesions extending into the adjacent tissue planes, which reflects the invasive nature of actinomycosis
Courtesy: Dr. A. J Van der Molen
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Genital tract involvement is detected in 1.3% of female patients with tuberculosis: endometrium (72%), salpinx (34%), ovary (12.9%), and cervix (2.4%).
It can mimic ovarian cancer by both radiological findings and
clinical settings (elevated serum CA-125)
TUBERCULOSIS
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Findings can be various according to the stage and the route of this infection
General peritoneal tuberculosis, minimal salpingitis with enlarged FT, without obstruction
Image findings mimic those of peritoneal carcinomatosis
TUBERCULOSIS AT IMAGING
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TUBERCULOSIS AT IMAGING
Tubo-ovarian involvement is usually caused by hematogenous or lymphatic spread.
- Cystic or both solid and cystic adnexal masses, usually bilateral
- Ascites, omental or mesenteric infiltrations, and peritoneal thickening
(*peritoneal carcinomatosis from ovarian cancer)
- Calcifications, not frequently observed
- Lymph node enlargement
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PID and other gynecological issues
ACUTE PELVIC INFECTIONDIAGNOSIS
AppendicitisCrohn, terminal ileitis, diverticulitis TB, Actinomycosis
DiagnosisClinical history, laboratory,
US, MR US, CT, biopsy, MR
Imaging
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