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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