Pelvic Pain: Negative Pregnancy Test - HD

Introduction

It's my honor to be here and speak after these wonderful lectures today.

We are gonna focus on pelvic pain in a female reproductive age mostly. If they have a negative pregnancy test, I have nothing to disclose.

There are a lot of things which can cause pelvic pain. However, I'd like to take this time or this limited time, rather, to really discuss hemorrhagic cyst and ovarian torsion and then touch upon a little bit on the pelvic inflammatory disease because these three can mimic each other.

Of course there are other causes which can cause pelvic pain, GI or GU etiology. However, we don't really have time to discuss those today.

One of the main diagnostic dilemmas is the process Nexel or is it GI or GU etiology, or is it the hemorrhagic cyst versus torsion? Or less commonly is it tube ovarian abscess?

Why is it very important is that the management would be completely different. Hemorrhagic cyst would be managed expectantly with pain control. However, with the ovarian or possible ovarian torsion or partial torsion would always most, at least most of the time, nearly 99% of the time managed surgically.

Of course, what are the tests? We all know that ultrasound is the best modality to evaluate female pelvis, and it's the primary modality. But CT and MR can be used for problem solving now, but we have to remember that this day and age, most of the time, in the middle of the night, many institutions patient will get the CT as a first modality, even though there's perhaps a possible concern that this might be a Nexel process.

Hemorrhagic Cyst

We're gonna talk about, start out with a ruptured hemorrhagic or unruptured hemorrhagic cyst. They usually have a very characteristic appearance and also very characteristic history.

It's also most common cause of acute pelvic pain in a premenopausal, non-pregnant female presenting to the emergency room. And kind of makes sense because women ovulate and that's common. And common is to get ovulatory follicles, corpus luteums hemorrhage into this. It's a very physiologic process.

Clinical history is important because it's usually described with a sudden onset of excruciating pain. And some people say it could be related to exercise maybe, or physical activity. Sometimes that's more common with ovarian torsion. But really if you talk, at least when I talk to my GYN colleagues, they say you can't really separate or discern between those two just based on this. Was it in the middle of the night or was it during the activity? But anyways, it can really happen anytime.

Obviously anytime you have those symptoms, and also clinical findings, you have to make sure that there's a negative or confirmed negative pregnancy test and then also exclude other etiologies such as ovarian torsion or pelvic inflammatory disease.

Patients who might have some coagulation issues might be at higher risk of bleeding more. But essentially anybody, any normal patient can really have a lot of hemorrhage from a hemorrhagic cyst. And obviously most of those patients are almost, all of them are, they have to be premenopausal because in order to have a hemorrhagic cyst, you have to ovulate.

And then treatment for most of those is pain control. If they are hemodynamically stable and sometimes if they're greater than five centimeters, they are at higher risk of torsion, they could be monitored and it's very, very rare that they actually will be taken to the emergency or to the operating room. And most of the time, these are cases when they're truly hemodynamically unstable.

Here's a case. 25-year-old female woke up with acute left lower quadrant pain with nausea and vomiting, negative pregnancy test. What is the most likely diagnosis?

There's a lot of material in the pelvis. Uterus is displaced anteriorly with this complex material. Ovaries nearly next to each other, almost kissing. There's a lot of dense material. Also noticed there's a lot of free fluid. There is fluid even in the morisonic pouch, but one of the reasons is really you could see there's also hemorrhagic cyst within it.

So in this case, with a proper clinical history, this is almost certainly a, just a simple hemorrhagic event from a physiologic hemorrhagic cyst.

Now the residents might say, past and blood is supposed to look the same in a pelvis, or really anywhere. How do I know this is not an infectious process? Now it's almost unlikely to have this much material within the pelvis and patient doesn't have any kind of symptoms of seriously severe febrile illness.

So there's a lot of talk about and was mentioned in many other talks, the consensus conference in 2009, which came up with the criteria for the benign anti coic unilocular cyst for an NAL imaging. But at the same time, also hemorrhagic cyst were discussed and recommendations were made.

And it was very important to actually recognize that they, when you're talking about some recommendations or criteria, we need to have all same criteria that we actually know that we are dealing with the same process.

So usually hemorrhagic cyst is a complex cystic mass with reticular pattern of internal echoes. And these are due to the fibrinous bands. Sometimes they described as fishnet in appearance.

Now, however, if you have hyperacute hemorrhage or you image the patient when they have hyperacute hemorrhage, then actually these masses can look more dense and there shouldn't be any flow within it. But you can see a stretched wall, normal ovarian parenchyma and flow within that wall.

And then of course pitfalls could be ovarian torsion, ovarian abscess or sometimes even neoplasm.

Now during the consensus conference and this probably everybody's familiar with is the sizes, when should one possibly consider follow up if the cyst is greater than five centimeters, one may consider follow up in six to 12 weeks to ensure a resolution.

I think it's really sort of imager dependent or the clinical team dependent what one should do. If it's really classic, I don't think you always have to follow it up.

And what is very important though, if you see something in a post-menopausal patient and cause you can see hemorrhagic cyst in a perimenopausal patients cause they can occasionally ovulate and those, you should definitely follow up short term such as six to 12 weeks to make sure that this is not a mass or something that would mimic something else.

So here is an example of 36-year-old who woke up from sleep with excruciating left pelvic pain and in this case you could see there is a endometrioma and a normal pairing ovary otherwise, and also a hemorrhagic cyst. Not a lot of free fluid but clearly her pain is due to the hemorrhagic cyst.

So other kind of dilemmas with hemorrhagic cyst as we talked about is, is it a solid mass or is it truly hemorrhagic cyst? If you're uncomfortable, you could follow up this, you don't have to wait for four to eight weeks. You could really do a follow up in three days, 10 days and you'll see change within it. You are reassured that this is a benign process, but the most confusing things tends to happen when you don't know whether it's a hemorrhagic cyst versus torsion.

So here's an example. When we saw this solid appearing ovarian mass, there is no flow within it, but there was this beautiful ring-like flow within the periphery. Three days later you could see that there is retraction within that clot. And this is blood, this is a benign process.

Sometimes the blood clots can look a little bit more funky than in this case it can have angulated margins. But again, no flow internally.

In the next case here, there was sort of both this hyperacute and little bit older blood noted within this hemorrhagic cyst. If you're not familiar with this appearance, unfortunately this was misinterpreted as a dermoid, as the more echogenic part being sort of the possibly fatty component and these fibrinous bands representing this dot dash.

And then it was thought, it's so big and there's acute pain, perhaps there's represents torsion and it was misinterpreted as an ovarian torsion, but which it does happen, it happens to the best of us. And it tends to basically every once in a while, maybe in once in six months or even sometimes more often I get a call from my GYN colleagues and I say, you guys sent us again into the operating room for hemorrhagic cyst.

Now I don't ever get a call when we get it right. So but of course that would be way too many calls.

So I did wanna mention, I know this is an ultrasound meeting, but I do body imaging and it is very, very important to know that we as body imagers. Actually we are not always completely familiar with the blood products appearance on an MRI and MRI can be helpful to sort out which entity what we are dealing with, but you have to remember that those of you who do neuroradiology or read brain MRI know that blood products can have a very different signal characteristic depending on their age. And the same thing happens in the pelvis.

So if we used to characteristically seeing lesions which are super light bulb bright on T1 hyperacute blood does not demonstrate these characteristics and you need to remember in order to interpret those studies correctly.

Now, when or why would you use MRI to do this? For instance, in young pediatric patients when like in this case you have a 16-year-old with incidental left adnexal mass on the ultrasound and we could not perform an EV ultrasound because they're virginal and you don't wanna violate the patient.

And so it was highly concerning. You don't wanna miss ovarian torsion even though it has like this typical ring like a parent around it and that's the stretched parenchyma and internal echogenicity kind of like hyperacute blood. But sure it's very important to make the right diagnosis.

So in this case we did move to MRI and on the T1 pre you have and you could see nicely demonstrate that the cyst is not light bulb bright bright as you would expect with a little bit with acute blood but not with hyperacute blood. But you could see a little bit of bright signal within the cul-de-sac.

So there's blood in the cul-de-sac and on the T2 it has a characteristic very heterogeneous complex kind of appearance. And all of these findings go together are very reassuring that we are dealing with a hemorrhagic cyst.

Here's another example, 13-year-old with incidental right adnexal mass is to, could it be possible be a torsion? I mean you see there's a pattern on ultrasound, it always looks the same but perhaps for a person who's less experienced reader and lot is at stake, this is a very young patient, you don't wanna make a mistake.

Again, it's quite easy to confirm hyperacute blood on the MR imaging.

Here is a pitfall case. We had a 36-year-old female with acute right lower quadrant pain with a history of prior pelvic surgeries. What is the most likely diagnosis when you're looking at those ultrasound findings? Does it look familiar to some of those lesions? What I've showed you, you see flow in the periphery, that's the stretched, the variant parenchyma internal low level echos kind of, but it is an acute process.

Endometrioma could perhaps be in the differential, but we are trying to figure out whether it's hemorrhagic cyst versus torsion. And in this case, again it was maybe perhaps not the most experienced ultrasound reader and they said, it's easy to get an MRI and then I can tell you if it's torsion or not.

So we got the MRI and then unfortunately they misinterpreted the MRI and they said, it's not bright on T1 so it's not blood. And also they looked at the perfusion images and you could see when it's running that there is flow but it's in the periphery and that's how exactly what you expect to see in a hemorrhagic cyst.

But in this case it was misinterpreted as a torsion, which it was not.

And other subtle things where you could see really beautifully on this MR. You see the one dominant follicle which has hemorrhage, it kind of has like at these little follicles in the periphery cause it pushes the others as well. As you could see, that's the hemorrhagic cyst and then that's stretched ovarian parenchyma.

So these are kind of the key findings you're looking at both MR and ultrasound. And here's just a little bit easier example when you could see. So here's a hemorrhagic cyst and a beautiful claw sign from the ovary dealing with a hemorrhagic cyst.

Ovarian Torsion

Okay, moving on to ovarian torsion. It's not as common as hemorrhagic cyst of course, but it's very crucial to identify which entity you are dealing with.

And it's about 2.7% of gynecologic operative emergencies. It's most common in reproductive age and about 20% actually occurs during pregnancy. But when it does occur during pregnancy, it's actually during the first or second trimester because you have increased ligamentous laxity and by third trimester things are so tight that it will very difficult to twist anything or move things around.

Right side is felt to be a little bit more common, but obviously can happen any side and it's really twisting around its ligaments, kind of like we saw in the heard this morning about the testicular torsion. And then can be a lead point. And the lead point can be corpus luteum, could be physiologic cyst or is quite often it's actually a dermoid.

However, very young children and or young adults as well as young women because of their very actively ovulating ovaries. And so you don't, and they also have more ligamentous laxity. They don't really have to have a mass to have the ovary to twist.

However, ovarian torsion can actually present at any time of female life from childhood to postmenopausal period. And in a postmenopausal patients we are more commonly are looking for a mass. And the most common mass is actually a physiologic cyst.

So what are the clinical symptoms? Notice how similar they can be to the hemorrhagic cyst. Acute, severe unilateral pain, anorexia, nausea, vomiting, palpable mass, even leukocytosis and fever. Sometimes it can be intermittent and intermittent pain may precede acute symptoms. And of course again this is a great mimicker of other pelvic processes.

So what happens, the ovary twists and then you initially have compromise to the venous and lymphatic flow because the walls of the veins and lymphatics are much weaker than that are arteries. And eventually the more the ovaries swells, eventually you can completely cut off the arterial flow and then you can infarct or hemorrhage into the ovary.

So what are the imaging findings? So we are looking for asymmetry. Asymmetry. One of the ovary has to be enlarged and it's a very characteristic enlargement. You have the stroma gets very engorged the damages and pushes the follicles to the periphery. And sometimes the follicles can have a little bit of echogenic ring sign around them.

Also the ovary can be displaced anterior, posterior to the uterus. Sometimes the uterus is deviated to the side of the torsion. There's often free fluid.

And one of the very useful signs, which in the past we didn't really feel like we could see that well on the ultrasound. But I have to say that about 80 to 90% of times nowadays we see the twisted vascular pedicle sign. And on the ultrasound, it used to be in the older literature described that it was better seen on cross-sectional imaging.

But I have to say perhaps it's one of those things that one of my great mentors said that you only diagnose what you know or what you are looking for. So if you are looking for, and we've had a lot of teaching sessions with the residents and the sonographers and they're really proud when they come and said, Hey, I just found the vascular pedicle sign and it can really look like an EMS tube with a twist and even a mass next to the ovary and doppler.

And of course the doppler, there's a lot of controversy about the doppler imaging. But if it helps you, if it's not there, but if you have flow, you really have to look at all the other morphologic findings and they trump whatever the doppler findings are.

So if you have flow and you have all these other morphologic findings, you're lucky that you have flow means that it's urgent and you still need to go to the emergency room.

So here's a nice example of a now you had all those findings, beautiful edematous ovary with a little tiny little corp hemorrhagic corpus luteum follicles pushed to the periphery and beautiful twisted vascular pedicle sign every fluid. But look how much nice flow you have. The ovary does not mean that this is not torsion.

Here's another example where you could see really nicely find the twist and notice the vascular pedicle is so edematous because again, it becomes really engorged and doesn't necessarily before the blood but blood flow gets cut off.

So what about CT and MR findings? Now I know it's an ultrasound course again and you say why would I use this cross-sectional modality? But I have to say, sometimes you are reading the CT or reading the MR and there are things that you could look for you and this is helpful to know.

Also, it's important to know that if you know, if there is an abnormality present in the on the CT which is done in the ED, you may and you don't find any other causes for the pain, perhaps it's really helpful to get an immediate ultrasound.

However, if the adnexa looks completely normal on the CT, which you can say really and symmetric, no funny business, basically you can say you don't need to get an ultrasound to confirm it.

So here is a patient who actually this is long time ago we had, and she never even had an ultrasound cause she was so morbidly obese that they could not really see anything on the ultrasound. And it's in a beautiful example of enlarged ovary follicles pushed to the periphery free fluid and a beautiful twisted vascular pedicle sign on the coronal MRI.

And then in that, in this case they also gave gadolinium. But I have to warn you that if you do post contrast, the ovary is so edematous that even though it still has flow, it might take very long time when the enhancement will show up. So that is not, it's quite tricky to diagnose that.

Now I said that a lot of times a benign mass just dermoid can cause the ovarian torsion. And what if the dermoid takes replaces the entire ovary? Like there's no way. Where's the stroma? How can I say it's edematous? Where are all these morphologic signs?

So then it gets really tricky cause dermoid shouldn't really have flow. You know, that's when you really have to look with the twisted vascular pedicle rely on the symptoms. And these cases, one might consider it to go to cross-sectional imaging to see if you can find it depends on, so also on the size of the lesion.

So this is an example when there was a dermoid and you could see that the twisted vascular pedicle kind of looks like mass like next to the ovary. See the other sign is not playing. Here it is. You could see the twist and next to it was the ovary with a dermoid.

So really look for those, this is very helpful in those cases.

This other case we're a little bit more lucky, you could see the edema, the lysed follicles, the twist and an innate image. You could see the dermoid components. So if you have ovarian stroma, obviously you can evaluate it, then you could see this is most likely torsion.

But sometimes you don't have normal stroma and the dermoid has replaced ovary. So here's an example when a CT where the patient came in with acute left lower quadrant pain and was called to have two dermoids and then not much comment on it.

But thankfully the clinical team really sort of said, clinically we really strongly suspect torsion. And so of course we got the ultrasound and it showed edematous ovary with the follicles pushed to the periphery.

And then we went back to the CT, went to the coronal image. And really if you squint your eye you could see these follicles pushed to the periphery and also noticed that that dermoid was actually arising from the left ovary, not from the right. And that's what caused the torsion.

There's another patient, 36-year-old with acute lower quadrant pain and nausea and vomiting. And on the CT it could, was really hard to find the ovary free fluid. And you say, it kind of looks like a twisted vascular pedicle and there's a huge mass. Is the mass coming from the uterus or adnexa?

And in this case we figured there's we're dealing with the torsion, could it be possibly a necrotic fibroid? And then we moved on to the MRI and that beautifully shows you that this there's a claw sign from adnexal tube and the ovary. And this was a torsed fibroma which led to this process here.

What about in pregnancy? Now I told you that the ovaries are usually quite enlarged during ovarian torsion, but in during the pregnancy the ovaries are suppressed, especially in the second and trimester. And so the size discrepancy is not really that big.

So very subtle changes can represent ovarian torsion like in this case. So really with the ovarian torsion and highest predictive values enlarged or with the peripheralized follicles, there could be plus minus abnormal doppler and presence of fluid in the cul-de-sac.

In a patient with acute pelvic pain, recognize with twisted vascular pedicle when you see it and do look for it and look for subtle changes on the CT and MRI if they are ordered first an MR can be used in pediatric patients and in perhaps in larger patient population if ultrasound is inconclusive.

We talked about this a little bit, should we rely on a CT? I would say yes, when it's completely stone cold normal on a CT that adnexa don't pursue the ultrasound. But if you see some findings, I think it's helpful to take the next step and do the ultrasound.

And if you can't explain the symptoms with other etiologies in a pelvis, it's very important to do the ultrasound acutely. Like in this case it was a young woman, 24-year-old presented in emergency room with a chronic intermittent right lower quadrant pain. It was rule out PID versus ovarian torsion. And appendix was normal in order to see the left ovary.

And then right ovary we said, oh there's a perhaps a benign appearing cyst. But the patient ended up having an ultrasound. And look what we found on the ultrasound, what was called a cyst, was actually extremely edematous ovary. We've had all the signs where we have talked about the twisted vascular pedicle peripherally follicles, edema.

And the teaching point from here is actually that a very edematous ovary can mimic fluid or cyst. And so if you see that and you can explain the symptoms with other findings, recommend an urgent ultrasound and don't wait.

So here's another young patient, 11-year-old, right lower quadrant pain was evaluated for appendicitis and this was a second opinion for us. Then we were doing the ultrasound, then we went to the outside CT and unfortunately there wasn't much to do now because this was several weeks later when we did the ultrasound, but there was a twisted vascular pedicle enlarged ovary, which was thought to be a cyst and that's why they waited for a while with ultrasound.

And now we were dealing with a dead ovary. So if you see abnormality important to really get the ultrasound right after.

So now we are looking for pitfall cases or very unusual cases. So this is massive ovarian edema and basically what it is a rare entity, but it's important to keep this in the back of your mind.

So if ovaries enlarged out of proportion to symptoms and there is preservation of parenchymal flow, like those patients don't really have pain. So basically the ultrasound findings and MR imaging findings can be very similar to ovarian torsion.

However, if you look very carefully, the ovary is massive. You could see the follicles in the periphery, you could see that this is really ovarian stroma, which is the damaged. You could see a little bit of stromal strand and the keys also make sure there is no hemorrhage into it on the T1 imaging.

So these patients that can, this can occur during pregnancy and these patients are managed expectantly.

A very similar case, massive ovarian edema. This was a 3-year-old with a subacute right lower quadrant pain, had the ultrasound, very edematous ovary, but she wasn't really tender at all and it was so strange and I actually, it was kind of like, should I get the MRI? Should we not do the MRI?

And then we got the MRI and it was quite surprising to see what we saw. We did see the ovarian edema, but what we found, but that was a subacute appendicitis. So the appendix had been inflamed and was dripping down to the ovarian pedicle and basically caused that to become edematous and twist off the lymphatics and the veins.

I mean obviously totally unusual case and but it happens. So they went back in, did the surgery with the general surgeons and GYNs and they actually managed the ovary expectantly because once the inflammation away, the ovary's size decreased.

Pelvic Inflammatory Disease

Okay, so we're almost done. I just wanted to add one more entity here which can be confusing and we're not gonna go into the details of PID. Just wanted to mention that 35% of the time the initial diagnosis is incorrect.

We have to remember the clinical history that has to be history of sexually transmitted diseases or some sort of intervention or procedure, which can put the patient risk of infection.

And then who gets the imaging is really patients who have a palpable mass severe illness or no response to oral antibiotics. And then on when we do get the imaging, that can be a wide spectrum of findings because there's suffice spectrum from endometritis to tubo-ovarian complex to abscess.

But I'm just gonna get to the point in a minute. So here's the tubo-ovarian complex is if you have an inflamed fallopian tube and you can distinguish a normal ovary from it. And then if you have a tubo-ovarian abscesses, when you can't really distinguish those two and ovarian tube from each other.

So on ultrasound imaging is pretty much usually clear. Now, sometimes when this can be a pitfall is as it was in this case, this was a CT came through the emergency room, 45-year-old, recently diagnosed with diabetes and intermittent right lower quadrant pain had elevated white count.

They said appendix is normal, there's this cyst in the adnexa, maybe follow up as an outpatient, but notice there's a thickening of the cyst wall, there's a lot of stranding and I don't know that we really leave that. And also what then was the cause of the right lower quadrant pain.

So patient had a follow up ultrasound, looked kind of funky, they weren't unsure what it is and they said, let's send it to UCSF for GYN consult. So the patient, it was delay on getting the appointment and so forth.

So patient again came back to the emergency room and now we're got another repeat CT and you could see that there is really rip roaring infection. Now it's involving the adjacent bowel and everything.

So this is sort of a subtle pickup on the CT not to miss a tubo-ovarian abscess perhaps we would've not missed that on the ultrasound in the proper clinical setting. But an important thing if you have adnexal findings, do try to interpret them and try to put them in context with the clinical picture.

Key Takeaways

So the take home points is there is imaging overlap and the keys to correlate the clinical history and talk to your GYN colleagues if things just don't make sense and they, we always tell them, treat the patient not the picture and they tell us the same we have to follow what makes most sense also for the hemorrhagic cyst versus ovarian torsion keys to look for the stretch surrounding ovarian parenchyma versus stromal edema with peripherally follicles.

And MRI is helpful if ultrasound is indeterminate and does not fit the clinical findings. CT you can really do more with a CT than we are doing I think as I always tell the residents, please look at all the multiplanar reformats, make sure you look at all planes and you can really look more and evaluate the adnexa more than we are used to on the CT.

And if you do something, you see something which is abnormal, don't wait for sort of an outpatient follow up. If you can't explain the symptoms on the CT with other processes, do get an urgent ultrasound.

Final Cases

And so just after all this, wanted to see what you think. This is a 25-year-old with acute right lower quadrant pain hemorrhagic cyst versus torsion. Does it look like a torsion? Does it look like it's a hemorrhagic cyst? What do you think?

Well the world is not perfect. Again, I got a call from the OR hemorrhagic cyst was taken mistaken for a torsion. If you go back you could see here's this strange stretched ovarian parenchyma and here's the hemorrhagic cyst and you could really see the sort of the doppler flow as well in the periphery. And you could see a little bit of layering of the hemorrhagic material on the CT.

And very last case here is a 68-year-old with left lower quadrant pain for urgent care five o'clock case. And this I think the CT is running a little bit slow, but if you could see there's a very large complex cystic process happening in the left pelvis.

Now in this case I would say that we immediately went to the MRI and we could see the twisted vascular pedicles. She had a twisted benign ovarian cyst. And why did we go straight to MRIs? Just because of the size of the lesion. It would've been quite difficult to evaluate in a postmenopausal woman to figure out what's normal ovary, what is, what's going on.

And so again, it can happen in postmenopausal patients and if the lesion is large, consider doing that an MRI to find the vascular pedicle.

Thank you for your attention. Keep doing your best and don't give up.