Background
Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are both insensitive and nonspecific. Urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be considered. The most common urgent causes of pelvic pain are pelvic inflammatory disease, ruptured ovarian cyst, and appendicitis; however, many other diagnoses in the differential may mimic these conditions, and imaging is often needed. Transvaginal ultrasonography is the best initial imaging test because of its sensitivities across most etiologies and its lack of radiation exposure.
Educational Goals / Teaching Points
Review the main causes of acute pain in the female pelvis diagnosed on ultrasound in the ER. Recognize the key differentiating clinical and imaging features of a variety of conditions. Brief discussion of the relevant pathophysiology and next appropriate steps in management.
Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Case-based review of the following uterine pathologies: prolapsed uterine polyp, fibroid torsion, degenerative fibroid, and pyometra. Case-based review of the following adnexal and pelvis pathologies: pelvic inflammatory disease, pyosalpinx, tubo-ovarian abscess, isolated fallopian tube torsion, hematosalpinx, hematosalpinx and endometriosis, deep pelvic endometriosis, ruptured ectopic pregnancy, retained products of conception, infected endometriomas, round ligamnet and labial varices, ovarian vein thrombosis and thrombophlebitis. Case-base review of the following ovarian pathologies: ovarian torsion, infarcted ovary, ovarian hemorrhage, neoplasm, pelvic AVM/AVF, hemorrhagic cyst, chronic endometritis, malpositioned/perforated IUD. Case-based review of the following nongynecologic pathology mimics: diverticulitis, appendicitis.
Conclusion
Understanding the myriad of causes of acute female pelvic pain is essential for accurately interpreting transvaginal ultrasound findings.
