Acute Pelvic Pain in the Non-Pregnant Woman - HD

Introduction

Hi, I'm Maitre Patel.

I work at the Mayo Clinic in Arizona,

and I'll be talking to you today about a method

of analyzing heterogeneous adnexal findings in patients

who present with acute pain and who are not pregnant.

I have no disclosures to make. A woman who presents

to the emergency room with acute pelvic pain can have many

different diagnoses that you have to consider.

An ultrasound plays an important role in diagnosing most,

if not all of these conditions.

The things you might consider include the gamut

of GYN diseases, gastrointestinal conditions,

and urinary tract abnormalities in both the

acute and chronic setting.

It's really too much information to try

to cover in one topic or one lecture.

And what I'd like

to do is focus on just one specific subset of patients,

and that's the patient who comes in who has acute pain,

she's not pregnant, and you find something in the

adnexa that's abnormal.

Main Differential Diagnosis

The main differential diagnosis when you see a

heterogeneously enlarged adnexal findings in patients who

present with pelvic pain

acutely are ovarian torsion, ovarian hemorrhage,

and pelvic inflammatory disease.

Ovarian Torsion

Now, with ovarian torsion, the pathophysiology is such

that there's a twist of the adnexa

and specifically the ovary around a pedicle leading

to lymphatic and venous congestion.

And that congestion then results in a limitation

and an impediment of arterial inflow.

And as you might expect on ultrasound, we almost always

or always will find that the ovary is enlarged, oftentimes

with an eccentric mass, which is the lead point

for why the ovary twisted in the first place.

And this is typically a cyst.

Other descriptors of the ultrasound findings in patients

who have ovarian torsion include the presence

of a round ovary that has a ground glass appearance,

ground glass, basically meaning a very fuzzy

sort of echo texture.

The follicles get pushed aside by the stromal edema

and become more peripheral in location.

And what has been shown is that if the ovary still has flow,

that's either described as normal

or even diminished,

that predicts a better outcome for the patient.

And then the absence of flow typically means

that the ovary has infarcted

and will not be one that will still be viable

after surgical intervention.

So here are four pictures of torsed ovaries,

and at first glance, they look very different,

but when you start to analyze them,

they actually have a very similar appearance.

First, you'll notice that in each case the ovary is very

round in shape, that is the hallmark

of a swollen ovary. In a couple of cases,

as you can see here on the screen's left, there are cysts

that are peripherally located, centrally located.

With respect to the ovarian parenchyma.

Here, it's a harder thing to recognize

that this is a cyst on the edge of the ovary,

but this cyst, in fact, is being deformed by the tension

of the swelling of this ovary,

and it has a little bit of hemorrhage in it.

Here is a cyst in this ovary that is towards these two

ovaries do not have an eccentric cyst.

And again, that is not always seen.

All of these ovaries have what might be termed ground glass

echo texture in that there's a smudgy set of echoes

that are seen throughout the parenchyma.

And if you look carefully, you can see

that follicles indeed have been pushed to the side

in all of these examples,

and you can see one here. Here's another example

of a torsed ovary.

It again is round

and reflecting its swollen condition.

There are some follicles that we see

not at the very edge,

and they don't have to be at the very edge.

And the

echo texture can be termed ground glass.

This particular case does show that we are able

to demonstrate arterial flow within the ovary.

Here's another case.

One of the cases I showed you earlier of the torsed ovary

with the slightly eccentric cyst, you can see

that it's clearly abnormal compared to the opposite side,

where the ovary is more normal in shape

and size and appearance.

Looking carefully at this ovary, it is so swollen

and enlarged that it's as big as the uterus,

which is a distinctly unusual feature.

And we do see a little periovarian cyst here sitting in

some free fluid adjacent to this ovary

with its eccentric cyst.

When we analyze this ovary with Doppler, we do see

that there's still preserved flow within the ovary

and adjacent to the ovary, albeit

with a slightly different waveform.

So this begs the question, I've shown you two cases now

where the ovary was towards the morphology is certainly consistent with

or suggestive of torsion,

but the Doppler findings show that there's blood flow.

And this leads me to probably the most important

teaching point I like to make in this lecture is

that there's a large confusion that still exists

amongst certainly many emergency room physicians who ask

for these studies, but even amongst radiologists.

And that is that the diagnosis of torsion has nothing

to do with the Doppler findings.

In fact, the diagnosis of ovarian torsion is suspected

or excluded based on the gray scale appearance,

not the Doppler findings.

Here's another example.

This patient's ovary is quite enlarged.

You can see it measures 7.6 centimeters.

There is a cyst that has some internal echoes,

fairly characteristic of hemorrhage.

If we look at sequential sagittal images of this ovary,

we can see that the echo texture is a bit smudgy

and that there are follicles that have been pushed

to the edge or to the side.

As we can see here, here, here, these are small follicles.

There are in some cases deformed,

in other cases still recognizable as a follicle.

And it's in the midst of this parenchyma

that is slightly ground glass in appearance.

So this has all the morphologic hallmarks of a patient

who might have ovarian torsion.

The contralateral ovary in this patient is normal,

and yet, as part of a thorough evaluation,

we will always evaluate the Doppler findings in any patient

who has an abnormality in the adnexa.

And you can see in this patient, we're able

to identify both arterial

and venous flow within this enlarged ovary.

This was a torsed ovary,

and again, the presence of arterial and

or venous flow does not influence our ability

to recognize this as something we're concerned about.

Torsion. You cannot rule out torsion based on the presence

of arterial or venous flow.

We've known this for many years.

This is a small sample size study

that was published back in the early 2000s,

but it just highlights, I think, in a simple way to show

that less than half of the cases of torsion in this series

had no arterial or venous flow.

In other words, more than half of the cases

had some arterial or venous flow.

And oftentimes, or in some cases,

normal appearing arterial and venous flow.

And this is born out in larger studies.

And for example, this is a meta-analysis

that was just recently done in the surgical literature

in 2015 looking at pediatric torsion.

But you can see that as a result of analyzing all

of these different previous literature

regarding ovarian torsion, you can see

that the Doppler findings

for torsion only at 55% sensitivity

and 87% specificity,

whereas the morphologic findings are far

more sensitive and specific.

So comparing the two, you would not use Doppler

to be your arbiter of whether somebody had torsion or not.

It's not likely to pick it up at least only half the time if

that's your indicator.

And it will not always be right.

Here's a table from that meta-analysis going

through various sonographic features

that indicate the morphologic changes of torsion.

The ones I would like to highlight, of course,

are the ones we're talking about today,

the ovary is enlarged and heterogeneous

and clearly abnormal in comparison

to the contralateral normal ovary.

In addition, many times we'll see these

peripheral cortical follicles.

In this case they talk about them being dilated.

And that hasn't been my experience,

but essentially this is the morphology of torsion

because we know that torsion leads to congestion.

So again, the morphology is the most important finding

to look for the roundness of the ovary, the

edema appearing stroma.

The fact that there are follicles pushed

to the edge are all features.

This is a cyst agreed, that's hemorrhagic,

but that wall of that cyst is way too thick

for the size of this ovary.

And we'll talk a little bit about the wall

of the cyst being something to focus on.

So here's a case, a different case.

You can see that there's no hemorrhage within this

cyst of torsion.

And looking at it, you can see that

it's at a seven centimeter cyst.

And if you look at the wall,

it's just a little bit too thick.

This should be your first clue to the fact

that this patient has torsion

or is one that you should suspect the possibility

of torsion in that when there's a seven centimeter cyst,

the wall should not be this readily observable

and thick throughout its entire course.

Let's take a look at a comparison case to make that point.

Here's a patient who did not have torsion on the top,

and this patient has torsion on the bottom.

And you can see that even though the cyst is about the same

size in both of these cases, the fact

that the wall is visible as this sort of cloak

around the cyst makes us believe that this wall is edematous.

That is not typically what you see in a patient

who has such a large cyst.

Oftentimes in those patients, the wall will be perceptible,

but very thin.

Again, looking at this, is this a torsed

or possibly torsed ovary?

Absolutely, because we see what appears

to be a fairly uniform in this case, but visible

and remarkable wall around this fairly large cyst.

Now the presence

of this blood flow here does not dissuade us from thinking

about the diagnosis of torsion.

This was in fact a cystadenoma that had torsed.

Here's another example.

We have the uterus, something in the right adnexa with a cyst

and an area that's been demarcated

with electronic calipers on the right

and what looks like a relatively normal appearing ovary on

the left on these transabdominal images.

Now, when we went to the EV, you can see

that this right ovarian process

is certainly a heterogeneous process.

There is some blood flow, it has a serpiginous look,

which is somewhat of a clue in that it

may be a whirlpool sign.

But when we take a look at this cyst, we can see

that there's the wall is just a little bit thicker than we

would expect for a patient who had a cyst of this size.

And in fact, this was the lead point

of this torsion of the right ovary.

Here's another set of examples,

and in this case, there's a

different process that's going on.

There's torsion,

but there's also a mass in the ovary.

And you can see that this is a characteristic

dermoid or a benign cystic teratoma of the adnexa.

And it has the features of a dermoid,

which would include areas of hyperechogenicity

shadowing these dot dash appearance.

These are all the features that we would associate

with a dermoid.

But to understand whether this is a torsed dermoid

or not, we wanna look carefully at the wall in this case.

The wall is visible

and there's this cloak of hypoechogenicity

around the dermoid.

You can see here this cloak of hypoechogenicity.

That's the wall that is in this case, visible and prominent.

And I think it's best to compare that torsion case

with many examples of unto torsed dermoids that look similar

in terms of its internal contents, but do not have torsion.

It'll allow you to better understand the feature you need

to look for to suspect torsion.

So here this is case one as a comparison

where there is no torsion,

and you can see that the wall, though perceptible is

by all reckoning thin,

very different than the torsed dermoid that we saw

that had a thicker wall.

Here's another case of a dermoid that does not have torsion.

The wall perhaps perceptible in some areas is not thick.

A third case of dermoid without torsion the wall

perceptible but not thickened as we saw in this case.

So that particular case actually ended up having a CT

because they did not believe us

or they weren't sure how confident

to be about our diagnosis of torsion of that dermoid.

And in fact, you can see

that the CT nicely also demonstrates the thickened wall

of this mass, which from the description

of the surgical procedure, showed that in fact,

a right ovarian torsion was noted and unto with three turns,

but in this case did not improve with blood flow.

And so they removed the ovary.

So looking at this case, this is a dermoid.

Different components

of the dermoid are shown in different images.

This is the echogenic area of

that's showing poor sound transmission

looking at the wall in this patient who has acute pain.

Are we suspicious that this is a torsed dermoid?

And the answer is yes, we are. We can see a wall.

It appears somewhat thickened in some areas.

And in fact, around the cystic part,

this part is just a little bit too thick

for the degree of cyst that we see.

Again, another picture of that torsed dermoid

with a thickened wall.

The fact that we are able to identify blood flow in

that wall does not dissuade us from

worrying about torsion.

And in fact, this was a torsed dermoid with both venous

and arterial flow in the wall.

And you can see here that the dermoid that was twisted,

if I go back here and I show you this example,

and you can see that the wall is thickened,

you can also see that there's this whirling sign,

the whirlpool sign of the twists that we

so nicely demonstrate here on the path.

So having gone through a number of cases, the challenge then

for you is to take a look at this case and tell me,

or tell yourself internally, do you believe

that this dermoid is torsed?

I'll give you a second to look at it.

The way I see this case, I do not see a thickened wall.

The wall may be perceptible, but clearly not thickened.

The fact that I see blood flow here didn't help me in making

the distinction between an unto torsed and a torsed dermoid.

This patient had pain,

but we did not suspect acute torsion based on the wall,

and she did not have acute torsion.

Again, this is a torsed dermoid.

This is not a torsed dermoid. And it's all about the wall.

Here are some CT examples of four different patients

with dermoids, which ones are torsed and which ones are not.

Torsed again, take a look here.

In this case, the dermoid has a thin wall, thick wall,

thin wall, thick wall.

And so it's not a challenge for us to decide

that this is not torsed,

and this is not torsed, which was in fact

what they found at surgery and that this was torsed.

And this patient also had torsion, which is in fact

what they found at surgery.

CT Findings in Ovarian Torsion

So a few words about CT.

All of us know that

ultrasound is the proper first choice to evaluate patients

who are in the emergency room with pelvic pain

and certainly with suspected GYN pathology.

But quite frankly, CT is sometimes done in patients,

especially non-pregnant women who will present

with acute pelvic pain first.

And in these settings, it becomes important for us

to understand and to be comfortable with the CT findings

that would also indicate torsion.

So here in this case, here's the uterus.

We've got a nice thin adnexa,

a thin fallopian tube coming out to the

to the ovary here on the other side, the

fallopian tube is thickened.

This is the ovary,

and here is the lead point for that ovary to be torsed

in this patient who has a left ovarian torsion.

So having seen this on the CT, we need to be able

to recognize this and make the call of torsion

or at least suspected torsion.

And in this case, the emergency room asked us

to do an ultrasound to look for blood flow.

Now, you and I both know now that the presence

or absence of blood flow has nothing

to do with the diagnosis.

We did the ultrasound.

You can see that the right ovary appears normal,

the left ovary looks swollen.

There is that cyst that's essentially located,

but there is blood flow within that ovary on the left

as well as the ovary on the right.

So the presence of blood flow does not mean

that this is not a torsed ovary.

In fact, this was a torsed left ovary.

This is highlighted in the literature time and time again.

Here is a patient who presents with

from Chow's paper with CT findings of torsion in that

the wall of the cyst is a little bit hyperdense.

The tubal findings are thickened.

This is the top of the uterus here.

This was the torsed ovarian CT.

And as the paper goes on, the state ultrasound done,

quote unquote later that day,

shows this our typical swollen ovary, peripheral follicles,

ground glass appearance, patient went to the

or shortly thereafter, necrotic ovary.

And the point here is not to say

that this isn't an elegant picture of torsion,

it clearly is, but it certainly didn't need

to have this time delay between the CT and the ultrasound.

Similarly, this case where the tube is thickened,

and the ovary is sitting here with an eccentric cyst,

has all the CT features of torsion,

and in fact, ultrasound done, quote unquote later that day,

shows the findings that we've talked about in terms

of the thickened wall, the ground glass appearance.

The fact that there is no blood flow doesn't help

us in this diagnosis.

So the diagnosis is suspected

or excluded based on the morphology,

not the Doppler findings.

We can't rule out torsion based on a quote

unquote normal Doppler.

But one question that is important

to consider is can we rule out torsion based on

normal morphology?

And the answer here, I think is yes.

A number of studies have shown

that when patients have adnexal, the

ovary is always swollen.

Adnexal enlargement was seen in a hundred percent

of these cases that were reported in 2007.

Now, in medicine, they teach you

never to say a hundred percent.

But having said that, this is something that makes sense

because in order for there to be pain in a patient

who has an ovarian torsion, there has

to be distension of the capsule.

The ovary must be enlarged.

It must be swollen in order for there

to even have the patient present

because that is the mechanism by which the pain occurs.

So this is a fairly nice investigation

showing over a 52 month period of adult patients

who presented with pain.

And they all had ultrasound and contrast enhanced CT done.

And the important finding here is that

of the 48 cases that had ovarian enlargement,

12 of them had torsion.

So clearly, just

because you have what appears

to be heterogeneously enlarged adnexal findings doesn't

mean that you have torsion.

But of the 235 patients who had

a normal appearing ovary on imaging without consideration

of the Doppler, none of them had torsion.

So if you see a CT that shows a normal ovary,

and certainly normal tubal findings that lead out to

that ovary, you can confidently exclude torsion.

And this patient does not need to go on

to have an ultrasound to look for blood flow

because both you

and I now know that the presence of blood flow had nothing

to do with the diagnosis of torsion.

This is important to consider

because you don't wanna make these sorts of mistakes.

This is a patient who presented with left adnexal pain

after hours, and the radiologist on call

was not an ultrasound expert,

didn't ordinarily do ultrasound.

And the sonographer presents these images showing

what appears to be a normal appearing

ovary in terms of its size.

In fact, probably a little small than you would expect

to see for a 25-year-old woman,

and one in which they could not identify any blood flow,

whereas flow could be demonstrable on the contralateral side.

Well, the radiologist ended up saying in this report

that the findings were consistent with torsion.

Patient had pain.

In this instance, the patient went to the emergency,

to the operating room, emergently, they did surgery,

and they found an atrophic left ovary without torsion,

which is clearly what we might have expected.

Based on the morphologic appearance.

This was a small ovary

without the characteristic features that we've described.

So the fact that there was no blood flow here had only to do

with the fact that this was an atrophic ovary, nothing to do

with the fact that she had acute torsion, which she did not.

Ovarian Hemorrhage

And we've talked quite at length about ovarian torsion

as one of the possible causes

for acute pelvic pain in the patient

who has heterogeneously enlarged adnexal findings.

Let's move on then to ovarian hemorrhage.

Now, here is a patient who has on the right side what looks

to be in the heterogeneously enlarged ovary as compared

to the contralateral left side, which looks normal,

and she has acute pain.

So does she have torsion?

Well, your instinct should not be to put on the flow

because the flow here, remember,

would not help you decide whether she has torsion or not.

But in fact,

after having spent a lot of time on that topic,

flow does help us identify some characteristic features

of other findings that lead to other diagnoses.

So let's take a look at ovarian hemorrhage.

First of all, you can see that

here on the transabdominal images,

that there's a stratified appearance to a part of this ovary.

And when we look on the EV you can see

a fairly unusual looking at first appearance.

But when we look more carefully, we can see

that there is an area

of vascularity within the ovarian parenchyma

that has some retracting.

Clot has a sort of crescent sign of material

that is not vascular.

And also, there's blood flow

around this area in a sort of a circumferential arc,

at least we see for part of the area around this cyst

or this hemorrhagic cyst, an area

of blood flow at the edge.

So let's talk a bit about ovarian hemorrhage

and the things that we wanna look for

for a hemorrhagic ovarian cyst.

A classic hemorrhagic cyst I think has findings

that many people who do ultrasound readily recognize.

One of those is the presence of internal echoes,

oftentimes clumped.

They can be regional in an appearance

or they can be diffusely throughout the cyst

with low level echoes.

These clumped echoes can have,

or the low level echoes can have these

what fibrin strands, what we have termed fibrin strands,

which is like a lace like

or fishnet appearance of these lines that intersect

through this cyst.

Another important feature is the presence

of retracting clot.

So we'll find in these hemorrhagic cysts areas

that have echoes that are clumped,

but they do not have convex margins.

They have concave margins, they're retracting.

And oftentimes,

this material will be distinguishable from the wall

implying that there, it's not actually arising from the

wall, but just sitting on top of the wall

as we can see in this case.

And in this case, there's no internal blood flow within this

retracting clot, which is an important thing to look for.

The other thing to and the presence of the flow

is important, but the morphology of these

retracting clot is clearly different than the morphology

of vegetative nodules in a cancer patient.

As we see in these two examples,

circumferential flow is a hallmark of hemorrhagic cysts.

We may not see the entire circumference of flow as we

almost do in this case.

But these are all arise

for the most part from corpus luteum, which tend

to have exuberant peripheral flow.

And so this becomes a feature that we can help,

that can help us in identifying and recognizing the cyst.

Here's another patient who has a corpus luteum

with a circumferential flow.

So back to our case then.

Well, when we see a heterogeneously enlarged adnexal

and this patient who has acute pain, we of course wanna look

for the morphologic changes

of torsion, which we've talked about.

But we also wanna look for features of hemorrhage

to understand whether what we might be dealing

with is ovarian hemorrhage.

And so when we do that, as we talked about when we see the

circumferential flow, when we see the retracting clot,

when we see the strands, we can feel more confident

that we're dealing with, in this case, a corpus luteum

that had hemorrhage

and that had leaked some of that blood around the ovary.

Here's another patient

who has heterogeneously enlarged adnexal findings

in the setting of acute pain.

And we can see here, we see the right ovary here.

We can see the left ovary

with some small follicles on the transabdominal images,

but we see a whole lot of other material area in the adnexa.

So One of the things that you see

with ovarian hemorrhage

or leaking hemorrhagic ovarian cysts is that the margin

of the ovary oftentimes is preserved.

So if I were to ask you to draw with a pencil, the edge

of the ovary, I think most of us would not find it difficult

to put our pencil

and say, this is probably the edge of the ovary.

Similarly here we'd say, well,

that's probably the edge of the ovary.

And in this case may be a little bit more difficult.

But we might say that that is the edge of the ovary.

So the ovarian margin is oftentimes preserved

or visible when there's hemorrhage around the ovary.

The other thing that helps us is the color flow.

So in this case, color flow demonstrates not only the flow

in the ovary, but also the absence of flow within the clot.

And so in the setting of ovarian hemorrhage

where there is leaking blood around the ovary,

what we do tend to find is peripheral avascularity in

that heterogeneous area.

So, we'll compare these two patients with heterogeneous

and large adnexa to show you how Doppler can help us

recognize the features of hemorrhage.

Here's patient A and patient B.

They both have heterogeneously enlarged

adnexal findings With respect to patient A.

When we look carefully, we can see

that we see a preserved margin of an ovary here

and here that there's no flow within this peripheral

heterogeneous material,

and we see flow leading to the ovary itself.

Here's a companion case for that.

A this is a patient

who has a hemorrhagic ovarian cyst without

flow in the peripheral area that demonstrated some

of that leaking hemorrhage.

So when you have a patient who has acute pelvic pain

and heterogeneous enlargement of the adnexa Doppler is helpful

to look for the clot around the ovary,

but you also need to look at the morphology

and look for those features of hemorrhage within the mass.

So this is patient B from that earlier comparison.

And when we put Doppler here,

we see something quite different.

We see peripheral hypervascularity, not avascularity

around an area centrally that is less vascular.

And so this leads us to the third consideration

for patients in this setting.

And that's pelvic inflammatory disease.

Pelvic Inflammatory Disease

So ultrasound is clearly the right first test

to perform in patients who have suspected PID or TOA.

And we can see thick walled tubes, often times fluid

that contains echoes.

There can be gas that

is visible sometimes on ultrasound is echogenic areas

with bad shadowing or dirty shadowing.

We have

poorly defined ovarian margins is another feature,

but hyperemia is really one of the characteristic findings.

And ultrasound can help us clarify the

extent of the inflammation.

We use the term tubo-ovarian complex

to refer

to those settings where the tissue is inflamed,

but ovarian tissue is still visible.

The term tubo-ovarian abscess is typically reserved

for when ultrasound finds

that the ovarian tissue is not readily demonstrable.

Now clearly ultrasound can be confusing

because this can appear like a solid mass

or even a cancer not as inflammatory disease,

and it can be difficult to perceive

and recognize bowel and gas.

So here's an example of a patient

who has heterogeneously enlarged adnexal findings.

We've got an ovary with some follicles.

The margin is not that easy to define

as to where this

ovary ends and where this heterogeneous

material adjacency though begins.

But I hope I've convinced you that in this case, in fact,

Doppler is going to help us.

'cause when we put the Doppler flow on, we can see

that this is not a vascular clot.

Rather this is hyperemic meso-ovarian.

And this is a patient who has a tubo-ovarian complex

because we can still recognize ovarian tissue.

Here's another patient who has a cyst,

few follicles.

The margin of this ovary

and where the this heterogeneous material begins

and ends is quite difficult to perceive.

Putting flow on helps us recognize

that we have hyperemic tissue adjacent to this ovary

with a tube that has internal echoes.

In fact, this is another case of PID with

something that's probably leading to

what we would term a TOA instead of a TOC

because the ovarian parenchyma is now not recognizable.

So if we take a look at this case

where there's heterogeneous enlargement of the adnexa,

are we gonna be calling this a torsed ovary,

a hemorrhagic ovary, or a inflamed ovary?

Well, clearly based on this set of images,

it doesn't have the classic features of torsion,

although there is a thickened wall, thickened tube.

So that'd be one consideration.

It's not particularly enlarged.

But the color flow helps us to show the hyperemia

of the thickened tube leading to this area

of the ovary and the margin of the ovary

with the tube is very poorly defined.

Conclusion

So in conclusion then,

or in by way of review,

when we see heterogeneously enlarged adnexal findings in a

patient who presents with acute pain,

we wanna consider torsion.

When we see a swollen ovary with follicles pushed

to the edge, the walls of any cyst, of any large cyst,

may be abnormally thickened,

which would be a clue for us.

And in that setting, Doppler is not that useful

because once we've identified those morphological findings,

we need to consider the diagnosis of torsion

and Doppler won't help us exclude that. In a patient

who has hemorrhage.

We wanna look for the characteristic features of hemorrhage,

which would include fibrin strands and retracting clot,

and also look for that peripheral circumferential flow

around a cyst that may actually be collapsed

because it's leaked.

When it's leaked and collapsed, we'll see avascular

material around the ovary.

And oftentimes that will have a distinct margin

with the ovarian parenchyma

because of the nature of the fact

that the hemorrhage is slightly different in echo texture.

And finally, in patients who have inflammatory disease,

that heterogeneous tissue adjacent to the ovary is going

to be hyperemic, not avascular.

The margins with the ovary will be indistinct,

and oftentimes you won't even be able to recognize

where the ovary starts and ends

in which case you have a diagnosis of tubo-ovarian abscess.

So I thank you for your attention.

I hope I've given you a framework to try

to analyze the heterogeneous adnexal findings in patients

who present with acute pelvic pain who are not pregnant.