Why Ultrasound Is All You Need to Evaluate Patients With Pelvic Pain - SD

Introduction

Hi, I'm Beryl Raf.
I'm from Harvard Medical School.
I'm professor of radiology and O-B-G-Y-N,
and I'm gonna be speaking about ultrasound, the use
of ultrasound in pelvic pain.
My subject today is why ultrasound is all you need
to evaluate patients with pelvic pain.
I happen to believe that ultrasound is in fact all you need
because if you do it well
and comprehensively, you shouldn't have to order an MRI
or a CT scan or anything else, for your patient.

The Curse of Pelvic Pain

Now, I call it the curse of pelvic pain
because patients who have pelvic pain are really miserable.
They have chronic pain, they live with it,
and they suffer through it.
And oftentimes they never really get a diagnosis.
In fact, pelvic pain accounts for 10% of all referrals
to a gynecologist and more than 40%
of the diagnostic laparoscopies.

Evaluating Patients with Pelvic Pain

So when you see a patient with pelvic pain
and you're doing an ultrasound, it's important
to do it yourself and
to go in the room and talk to the patient.
Find out, is the pain acute or chronic?
Is it diffuse or focal? Is it cyclical?
Does it happen with
sometime in particular in the cycle?
And of course, is the patient on any hormone,
either hormone replacement, if she's postmenopausal
or birth control pills?
Could she be pregnant?
What is the character of the pain?
Are we talking cramping or sharp stabbing pain?
And of course, any prior surgery
that the patient might have during the exam.
And you've got the vaginal probe in.
And by the way, if the patient cannot take the vaginal probe,
you can do this rectally as well, just as well.
But during the vaginal exam, you have to ask
yourself how tender is the patient?
Is the patient really uncomfortable
or is the patient
quite comfortable lying there while you're doing the exam?
Where is the tenderness? Is it focal?
Can you slide the organs past each other the
way that they should slide?
Or are they stuck to each other?
And by that, you can push deliberately on any part
of the pelvic organs with the probe,
and we maybe even use your other hand to move things around.
And of course, it's very important to talk to the patient
to find out all sorts of things
that may not be on the requisition
or on the information you got ahead of time.

Uterine Causes of Pelvic Pain

So let's talk about the uterus
and what we can learn about the uterus in
a patient that's having pain.
First of all, you look for adenomyosis.
Certainly fibroids can be degenerating.
They can be quite painful when they degenerate.
They can be prolapsing.
And of course, the abnormally placed IUD can cause pain.

Adenomyosis

So let's talk about adenomyosis.
Adenomyosis is the invasion
of endometrial glands into the myometrium.
It's very difficult to pin down the frequency
of this abnormality
because it's reported anywhere between five and 70%.
It's both underdiagnosed and overdiagnosed.
But now I think that most radiologists are learning more,
how to diagnose it appropriately.
You're dealing, first of all with symptoms
of dysmenorrhea and abnormal bleeding.
The uterus is usually enlarged
and the appearance is quite characteristic.
A globoid appearing large
uterus, with asymmetry of
where the endometrial lining is.
You can have small subendometrial cysts
and an indistinct endometrial stripe.
So let's look at some examples.
Here you can see that in this case the endometrium is,
measured here,
but you see these little echolucent or cystic areas.
Here. Somebody tried to measure something,
but there's really nothing to measure here.
It's very heterogeneous here.
The endometrium is very ill-defined
and can't really be measured here.
It is moved over to one side by an asymmetry
of the thickness of the myometrium,
pushing the endometrium over.

Fibroids

Now, when you have fibroids,
of course many people have fibroids
and most of them are not symptomatic.
They certainly don't usually cause pain.
They tend to cause more often bleeding than pain.
But there are fibroids
that can cause quite intense pain.
Sometimes during pregnancy they can degenerate,
and be intensely painful.
They can also be symptomatic in terms
of their size if they're pressing on something
or if they're causing hydronephrosis
by pressing on the ureter.
And these need to be recognized by ultrasound.
So this I call the many faces of degenerating fibroids.
They can mimic just about anything.
These two images are of the same case.
And you can see that this is a complex mass
with a cystic area
and a solid sort of nodular area
with some little septations.
This is very ugly looking mass.
And it would be very important to see whether
or not this was connected to the uterus
and whether you could find a separate ovary.
Otherwise, I think it would be very difficult
to make an accurate diagnosis.
In this particular case, it is easier to make a diagnosis.
This mass is clearly in the uterus.
It looks like a fibroid except for its cystic center,
and I think it would be easier to make that diagnosis
as a degenerating fibroid.
This one is a little bit intermediate.
It does have a thick rim all the way around.
And if it's well attached to the uterus,
you should be able to make the diagnosis.
Now, this case was problematic for us.
This is a patient that I saw
and I made the diagnosis of an endometrioma, which is
what I thought it looked like.
And this turned out to be a degenerating fibroid.
So just to show you that you can be fooled,
because the degenerating fibroids can look very peculiar
and very un-fibroid-like, if you will.

Abnormally Placed IUD

Now, let's go on to the abnormally located IUD.
Could this be a common cause of pain?
Now let me start out by saying that I use a lot
of 3D reconstruction.
And the reason for that is that we can see the outline
of the uterus
and of the endometrium quite nicely
with 3D reconstruction of the coronal view.
And that allows us to see where the IUD is
and where the arms of the IUD might be embedded.
When you think of the Netter diagrams in your anatomy books,
Netter always chose this view to demonstrate the uterus
and the cavity and the tubes and the cervix.
And so we are using the same view here
in a reconstructed 3D volume
to demonstrate the same areas
and to show the presence of the IUD
inside the uterine cavity.
So let's decide where this IUD is
now on this traditional longitudinal view of the uterus,
you can see that the IUD is somewhat low, at least the shaft
of the IUD is somewhat low inside the uterus.
But where are the arms? Are the arms located normally?
And in fact, they're not. You can see that the arms
of the IUD here
and here are actually embedded in the myometrium.
And it makes sense that when the IUD is low, the
endometrial cavity cannot accommodate the arms.
It can only accommodate the arms if the
IUD is all the way up.
So it makes sense that when the IUD is low, as it is here,
that the arms will be embedded
or at least one arm will be embedded.
So with that, we are starting to see more IUDs
in the marketplace.
And we wanted to see how often the IUD was embedded.
It seemed to us that anecdotally it was often embedded
and we wanted to determine whether the embedded IUDs could
be responsible for pelvic pain and abnormal bleeding.
So we looked at 167 consecutive patients who came in
for pelvic ultrasound who happened to also have an IUD.
And it turns out that 16.5% of them had their IUD embedded,
significantly embedded in the myometrium or the cervix.
And interestingly enough, all of the IUDs
that were considered low in the uterus
were actually embedded in the upper cervix.
And that is clear
because the lower uterine segment
cannot really accommodate the entire IUD opened up.
And if you look at why these patients came in, the patients
that had the embedded IUD, 35%
of them came in for bleeding.
And 39, almost 40% of them came in
for pain as the indication.
70% of them came in for both pain and bleeding or either or.
Now, those that had the IUD that was not embedded,
only 15 of them came in for pain in 19 for bleeding.
And only 34% of them came in
for either pain and or bleeding.
And that was statistically significant when doing a 3D.
And this is a volume image of this uterus
that contains an IUD.
You can see that the IUD casts a shadow.
It's an acoustic shadow here,
which is very predictable on the standard 2D image.
But when you set your render bar
just underneath it, what you're gonna render is not the IUD,
you're gonna render the shadow.
And that's in fact what we render here.
So beware that when you see an IUD be,
make sure you're not really seeing the shadow,
which might be in a completely different place.
Now, we do use the shadow, particularly in the Mirena IUDs
that are hard to see by ultrasound.
We do use the shadow to
find the IUD 'cause the shadow is really quite easy to find.
And then you can sort of walk it back to the IUD itself,
which may be more subtle.
Now here's another patient.
The shaft of the IUD was easily seen,
but we couldn't find the arms, and that's
because the arms were way down here.
This IUD is upside down,
and we were looking up here for the arms.
Now, 2D can give you the location of the shaft
of the IUD obviously, and it can also show you the arms,
but what it doesn't show you is the myometrium,
or sorry, the endometrium or the cavity around it.
So you don't know where those arms really are
until you reconstruct this view that shows you the relationship between the arms of the IUD
and the uterine cavity itself.
Here's another example. We have a shaft.
It's down in the cervix, and we have the two arms over here.
Quite nicely seen,
but how can we tell
how those arms are related to the uterine cavity?
It's really only with the 3D
reconstruction that we're able to do that.
Now, here's a patient that came in.
She had a full bladder,
and I thought this was a little fibroid, it was shadowing.
Might have been calcified.
Come to find out this patient is supposed
to have an IUD and there's the IUD,
it's sticking up the front.
This was actually the IUD sitting there
between the uterus and the bladder.
And if you do a 3D, you can see
how the IUD is puckering the serosal surface
of the uterus right here in its attempt to perforate.
And if you look at it in real time,
you'll see the IUD is in fact perforating
and dangerously close to the bowel right here.
So in conclusion, the coronal view is really necessary
to imaging the position of the arms of the IUD
and that abnormal positioning of those arms may in fact be
result in some pelvic pain
and some bleeding for those patients.
Now, you might ask whether some IUDs are too big
for the average uterus.
All IUDs are the same width,
so that they were made to fit
the all the uterus that are out there,
but one size doesn't fit all.
And it is important for one
to recognize that patients may have a uterus
that is too small for the IUD to fit.
And let's look at this example right here.
Here is an IUD that looks like it is pretty well placed,
but if you look at whether the arms got deployed,
the arms were not able to open up
because the uterus was not big enough.
So when we looked at our experience,
and let me tell you
that the standard IUD is 32 millimeters in width,
only 13.8% of the patients
that had embedded IUDs in our study had a width
that was greater than 32 millimeters versus 32.6% of those
who had normally placed IUDs.
So now I think IUDs will have to come out
with a slightly smaller size for patients
who have smaller uterine,
and we may have to measure the size of uterus
before putting an IUD in.
We did a further study, which I'm not going to
show you details about,
but which is published in obstetrics and gynecology
and showed that the width
of the normal uterus varies the width
of the normal uterine cavity.
Measured in this way varies depending on whether
or not the patient has been pregnant.
Patients that have had at least one
or more pregnancies, the measurement is
much more accommodating to the IUD, whereas those
that have not been pregnant tend
to have smaller uterine.

Ovarian and Adnexal Causes of Pelvic Pain

Now going on to the ovary, what are ovarian
or adnexal causes of pelvic pain?
And some of them are listed here.
You can see hemorrhagic cyst, probably the most common.
Hemorrhagic corpus luteum, torsed ovary, endometriosis,
hydrosalpinx, adhesions to ovarian abscess
and ectopic pregnancy are the ones that we'll talk about.

Hemorrhagic Cyst

So the hemorrhagic cyst typically is a mass with
some debris and sometimes some solid areas.
In this case, a solid area is retracting as opposed
to growing inwards.
And if you turn on the color here, as we did here,
there is no color inside.
Here's another one with the typical trabecular
appearance of the clot.
And it is retracting. It's going backwards.
This one may be a little harder to diagnose
because here the clot is actually pointing inwards rather
than retracting.
But if you look at this, first of all,
there would be no color in it,
and if you jiggle it, you'll find that it is gelatinous
and it jiggles just like some jello, and that's a clot.
So these are usually not hard to diagnose
and they tend to regress spontaneously.
Here's a patient, young woman from one of the colleges,
who had an acute episode of pain
in her dorm room in college.
And she came in
and had a very, very large, about 12 centimeter
enlarged ovary.
Very hemorrhagic looking ovary hemorrhagic adnexa.
And if you turn on the color, in fact,
there was no color in here.
You could see that twisted pedicle sign in a patient
that had a torsed ovary.

Endometriosis

Now going on to endometriosis, that is a very complex area
and one that is quite common
and quite commonly the cause
of pelvic pain for a lot of women.
The classic appearance
of the endometrioma is shown here on the left.
And you can see the ground glass appearance of the
contents of the cyst.
The wall can be somewhat thick,
but there is no abnormal color flow within the wall
or within the cyst.
And commonly they are accompanied by hydrosalpinges.
And here you have a hydrosalpinx
and we can measure this
and demonstrate the hydrosalpinx,
but this is usually secondary to adhesions
that is blocking the tube and
causing some scarring.
Now, I call these unusual appearances of endometriosis
because endometriosis, rather than just forming a cyst
as I showed, you can also have little tiny implants
inside the bowel wall
and on the uterosacral ligament,
and you have to look for them in the cul-de-sac along
the back of the cervix.
Here is something that is called a lutein endometrioma.
It's typically seen in pregnant women,
and it can be misleading
because there's usually some nodularity
and sometimes there can even be some color in the
nodularity, which makes it hard to distinguish from a
borderline ovarian tumor.
But these are typically in pregnant patients.
Now, the many faces of endometriosis, you have here
the fusiform thickening of the
floor of the bladder here
and here,
this is very different from a bladder carcinoma,
which would be more inside the bladder.
And then over here we have a small
focal area of endometriosis right here
and right there, which if you were to press on it,
the patient would actually have pain.
And this is very close to the transducer
back in the cul-de-sac.
And you have to be looking for these.
Now, if you look behind the uterus
and ovary, you can see here's the ovary
on the upper left and the uterus.
But below that you have this mass,
which is in the bowel wall.
You can see thickening of the bowel wall on one side,
making it asymmetric.
And here are some implants of endometriosis.
These three are the same case.
You can see here that there's the implant right there in the bowel wall.
Here's the rest of the bowel right there.
Here's the rest of the bowel wall. Here's the lumen.
And this fusiform rather long segment
of endometriosis in this bowel.
Here's a different case, little small implant
back there in the cul-de-sac in the region of the
vaginal rectal interface.
So here is a 3D image of this thickening of the bowel.
And you can see here that we've put several slices across
and showing the lumen of the bowel here with the
thickening of the wall on one side, which are the implants
of endometriosis.
So nowadays, there are a lot
of people looking at the detection of
bowel endometriosis.
In fact, there are 10 prospective studies that were
put together here in this article.
Looking at 1100 patients,
the prevalence of bowel endometriosis was 24 to 73%,
but the sensitivity was really quite good.
71 to 98% with a good specificity.
So people are finding these,
and the patients are very grateful
because they are in a lot of pain.
And unless you look at the bowel when you do a scan
of the pelvis, you're not going to see these.
Here's another example.
Here is a rather long segment in the wall of the bowel,
and they interdigitate the bowel here.
These are sort of finger-like projections that come out
of the wall and sort of into the region
of the lumen right here.
And here again is the lumen. And this is the cross section.
Now this was really stuck to the back of the uterus.
The cervix is up here,
and I'm gonna show you in a real time clip now
that you can push on this.
And the cervix
and the bowel will remain adherent to each other due
to this endometriosis,
and this causes pain to this patient.
So this is really quite an extensive amount
of endometriosis in this patient.

Other Adnexal Causes

Now going on to other causes
of pelvic pain other than endometriosis in the adnexa,
here was a patient that had a thickening of the end of
the tube of the fallopian tube.
You can see it shown by calipers here.
And when we touched it
with the probe, it was quite tender.
And this is definitely too thick.
We suggested that this was a salpingitis
and that's what it was at laparoscopy.
But tubes can most likely are gonna contain fluid
when they're diseased.
And in this case, we have a hydrosalpinx.
And you can see that although in the traditional views
of the uterus of the tube, you
it doesn't really look that much like a tube when you do
your 3D and render your reconstructed plane.
It looks much more like a tube
and much easier to make the diagnosis.
Now, here is another cystic area in the adnexa.
Is this ovarian cyst,
could this be a complex multiseptate ovarian cyst,
or could it be a tube?
Well, in this case, you can take a volume of this area
and use your inverse mode on your volume machine.
And that what that does is it turns everything
that is cystic within the volume into an opaque cast,
and everything that is solid melts away.
And that shows you much more beautifully the extent
of the hydrosalpinx.
And the fact that this is really not ovarian, it is tubal.
And here are a couple of other cases that would've been hard
to diagnose without 3D as being hydrosalpinges as opposed
to adnexal masses of unknown etiology.
And the inverse mode does show very nicely
that these are hydrosalpinges.
Now, here's another septate cystic mass,
but you note that in this one the septations are very fine
and the mass sort of insinuates itself to the nooks
and crannies of the cervix of the side of the uterine
contour and
of the contour of the pelvis so
that it's not really a rounded area.
And if you look really carefully,
you can sometimes find an ovary encased
in these adhesions.
And what these are is a peritoneal inclusion cyst,
which is really a lot of adhesions with fluid
that is trapped amongst these adhesions.
So it's not really a pathologic entity in
and of itself, other than just a series
of adhesions encasing an ovary which then is stuck in that area.
Those can be painful. Here's another cystic mass,
which I thought was ovarian, turned out to be another
peritoneal inclusion cyst.
Very unusual because it's more
rounded than the others.
Now here's a patient that came in with severe pain.
She also was quite toxic.
She had a high fever, she was really sick.
And here is her tube.
It's all swollen,
it has echogenic material in it.
There's a little bit of free fluid here.
This is clearly a dilated tube
and you can see with a lot of color in the wall
of the tube and showing some inflammation.
So this is clearly a tubo-ovarian abscess.
This is basically a swollen tube.
This patient is really quite ill.
Now on the other hand, this could be a patient
who is not ill, who comes in and who may be pregnant.
If this were a pregnant patient who is not ill
and doesn't have a high temperature,
then we'd be talking ectopic pregnancy.
So it's very important to know the history of the patient
that you're dealing with
so you can make the correct diagnosis.

Ectopic Pregnancy

Now, here is a pregnant patient that had pain,
and in this case, the uterus was empty,
as you can see on the left.
And here's the ovary.
The ovary contains a corpus luteum, which is
has a rim of echopoor sort of a type.
Whereas this little mass here has a rim
that is more echogenic than this rim.
And if you move these, you try to move them apart,
they actually fall apart, they move apart.
So this is the ectopic pregnancy in this case.
And you can see that in a real time
clip, which I don't have.
You can just see it move aside from the ovary.
But if you look at the comparison between the corpus luteum
and the ectopic pregnancy,
it's the difference in the echogenicity
of the wall, which is important.
Now, here's a patient that also had a pregnancy.
Now the question is, is this pregnancy
inside the uterus or not?
It seems to be within the confines of the myometrium.
But could this be a pregnancy in the region of the cornua?
So 3D here is really helpful.
You can reconstruct your coronal plane.
Let me blow that up for you.
And you can see that this pregnancy is actually
outside the confines of the uterine cavity where it should be.
And the uterine cavity actually stops right here instead
of just encompassing this area
as it would if it were in fact in the right place.
So this is now clearly shown to be outside the
proper place.
Here's a patient that came in for a nuchal translucency,
and by the by we found that she was having some pain
and we looked in the adnexa
and here is a large tubular area with
sort of solid appearing tubular mass with color Doppler only in the periphery.
And the diagnosis here was made of a heterotopic pregnancy, which was proven
at laparoscopy.
Now sometimes you can take a look
and see that the pregnancy is out to one side,
but the 3D will show you that the reason for that is
because the patient has a Mullerian duct abnormality,
a septate uterus, and that the pregnancy is not really
outside the confines of the uterus
because you've got one horn here and one horn there.
And in fact, 3D is a great way
to look at the anatomy of the uterus.
In this case, there is a septum, a deep septum,
and also two cervices right here.

Floor of the Pelvis Causes of Pain

Now the floor of the pelvis can also be a source of pain,
which ultrasound can now diagnose.
Now that we have 3D showing us a very nice view
of the perineum, here you can see the urethra.
This is the vagina and this is the rectum.
Now this patient had a little cystic mass, a thick wall,
cystic mass right here and right there.
And we are looking down the vagina here.
This is the bladder and this is the front of the uterus.
So we're on the perineum.
Now we can take a 3D of the area and have a look.
And this is the item right here,
right there and right there.
And if you look at this reconstructed view,
which I'll show you better, right there, you can see
that the little mass is just next to the urethra
and in front of the vagina and the rectum.
And so, in fact, this is a urethral diverticulum.
Here is a Bartholin duct cyst.
You can see on the reconstructed view
that the mass in question, which is,
or this one right there, quite a big mass, is more,
is closer to the rectum than it is to the urethra.
And that is a Bartholin duct cyst.

Non-GYN Causes of Pelvic Pain

Well, I'm just gonna end with a few non GYN causes of pain.
There are other things
that live in the pelvis other than gynecologic organs.
Consider ureteral stone, for example, cystitis,
irritable bowel or other bowel abnormalities,
diverticulitis, inflammatory bowel disease, and adhesions.
Here is a patient that came in with some pain.
Here was her kidney showing definite
hydronephrosis in the kidney.
And if you scan transvaginally, you will be able
to look at the distal ureter,
which we're showing right there.
Here's the stone, this is the bladder.
And you can get right up to the distal ureter
and show the shadowing behind this stone.
Now here's a patient that had thickening
of the bowel wall on one side.
You can see the near side is quite
thick compared to the far side.
This is quite extensive.
It's not really just focal like the
endometriosis that I showed you.
This patient had known Crohn's disease
and this patient had a lymphoma, thus a very thickened
and abnormal and echogenic wall of the bowel.
So make sure you look at the bowel and
'cause it does live in the pelvis
and should be looked at.
Here's a patient that came in for pain,
but it was quite superficial pain.
Here we are in the anterior abdominal wall
and there's a little break right there in the middle
where you can see that there are contents coming
through that little break.
And this is a hernia in the anterior abdominal wall.
And last but not least, of course, an inflamed appendix.
Always consider an appendix in somebody
that has right lower quadrant pain
and always take a look transabdominally as well
as transvaginally because some of these things are
best seen transabdominally as in fact this appendix
was better imaged transabdominally.

Conclusion

So in conclusion, pelvic pain is very common
and does impair the quality of life.
So with a 3D ultrasound reconstruction as well
as dynamic real time that you do yourself as you push
around the organs and ask the patient where the pain is, is very, very helpful.
And I don't think MR is necessary after that.
Patients who cannot have a transvaginal scan,
by all means do the rectal scan.
It may not be quite as easy,
but it certainly gives equally good pictures
of the pelvic organs
and those that we do help are
among the most grateful of our patients.
Thank you very much.