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Pelvic Pain: Overlooked and Underdiagnosed Gynecologic Conditions¹

¹ From the Department of Radiology, Boston University School of Medicine, 88 E Newton Ave, Boston, MA 02118. Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received February 23, 2004; revision requested March 22; final revision received June 2; accepted June 4. All authors have no financial relationships to disclose. Address correspondence to E.K. (e-mail: ewa.kuligowska@bmc.org).

View larger version (67K): [in a new window]   Figure 1.  Diagram shows the location of endometriomas and implants of endometriosis. The most common sites of endometriosis are the ovary (OV), pouch of Douglas-rectosigmoid (D), uterine ligaments (Lig), uterus (U), and fallopian tube (Tube); less common sites are the vagina (V), cervix (Cx), and bladder (B).

View larger version (150K): [in a new window]   Figure 2.  Image from a barium enema examination of a 32-year-old woman with chronic pelvic pain demonstrates an abnormal mass defect in the rectosigmoid area. The finding was caused by a subserosal endometrial implant.

View larger version (54K): [in a new window]   Figure 3a.  Scar endometrioma in a 37-year-old woman who had undergone a cesarean section 3 years before and was experiencing cyclic periumbilical pain. (a) Color Doppler US image demonstrates a small hypoechoic mass with blood flow in a subcutaneous periumbilical location. (b) Axial T1-weighted spin-echo MR image (repetition time msec/echo time msec = 450/10) obtained with fat suppression and gadolinium shows enhancement of the mass.

View larger version (133K): [in a new window]   Figure 3b.  Scar endometrioma in a 37-year-old woman who had undergone a cesarean section 3 years before and was experiencing cyclic periumbilical pain. (a) Color Doppler US image demonstrates a small hypoechoic mass with blood flow in a subcutaneous periumbilical location. (b) Axial T1-weighted spin-echo MR image (repetition time msec/echo time msec = 450/10) obtained with fat suppression and gadolinium shows enhancement of the mass.

View larger version (126K): [in a new window]   Figure 4.  Laparoscopic view demonstrates an endometrioma.

View larger version (151K): [in a new window]   Figure 5.  Transvaginal US image shows a cystic mass with diffuse low-level homogeneous echoes, findings typical of endometrioma.

View larger version (117K): [in a new window]   Figure 6.  (6) Transvaginal US image shows an endometrioma with thin septations.

View larger version (77K): [in a new window]   Figure 7.  Transvaginal US image shows an ovarian endometrioma with low-level echogenicity, thick septations, and a soft-tissue component caused by clot formation (arrow).

View larger version (111K): [in a new window]   Figure 8a.  (a) Transvaginal US image of a 37-year-old woman with cyclic pain shows a cystic mass with a fluid-debris level. (b) Color Doppler US image depicts blood flow in the thick septation because of an organizing hematoma in a recurrent hemorrhage.

View larger version (115K): [in a new window]   Figure 8b.  (a) Transvaginal US image of a 37-year-old woman with cyclic pain shows a cystic mass with a fluid-debris level. (b) Color Doppler US image depicts blood flow in the thick septation because of an organizing hematoma in a recurrent hemorrhage.

View larger version (149K): [in a new window]   Figure 9a.  Pathognomonic MR imaging features of endometrioma. (a) Axial T1-weighted spin-echo image (450/10) reveals high-signal-intensity cystic masses within the fallopian tubes. (b) Axial T2-weighted turbo spin-echo (4900/120) MR image demonstrates loss of signal intensity in the cystic masses. This phenomenon is called "shading" and occasionally occurs in a graded pattern, with higher to lower signal intensities as result of high protein content and iron concentration from recurrent hemorrhage.

View larger version (169K): [in a new window]   Figure 9b.  Pathognomonic MR imaging features of endometrioma. (a) Axial T1-weighted spin-echo image (450/10) reveals high-signal-intensity cystic masses within the fallopian tubes. (b) Axial T2-weighted turbo spin-echo (4900/120) MR image demonstrates loss of signal intensity in the cystic masses. This phenomenon is called "shading" and occasionally occurs in a graded pattern, with higher to lower signal intensities as result of high protein content and iron concentration from recurrent hemorrhage.

View larger version (91K): [in a new window]   Figure 10.  Drawing illustrates ectopic endometrial glands located deep in the myometrium, surrounded by smooth muscle hyperplasia. (Reprinted, with permission, from Paul Indman, MD, Advanced Gynecology Solutions, San Jose, Calif.)

View larger version (126K): [in a new window]   Figure 11.  Diffuse adenomyosis in a 27-year-old woman. Transvaginal US image shows uterine enlargement and heterogeneity of the myometrium. The US findings reflect an infiltrative process with islands of heterotropic endometrial tissue scattered diffusely throughout and poorly demarcated from surrounding myometrium.

View larger version (118K): [in a new window]   Figure 12.  Diffuse adenomyosis. Transvaginal US image reveals tiny subendometrial cysts (arrow) representing dilated glands of ectopic endometrial tissue, findings highly specific for diffuse adenomyosis.

View larger version (111K): [in a new window]   Figure 13a.  Focal adenomyosis. (a) Transvaginal US image demonstrates an echogenic mass with ill-defined borders (arrows), findings characteristic of the focal form of adenomyosis. (b) Color Doppler US image shows a penetrating vascular pattern within the mass.

View larger version (106K): [in a new window]   Figure 13b.  Focal adenomyosis. (a) Transvaginal US image demonstrates an echogenic mass with ill-defined borders (arrows), findings characteristic of the focal form of adenomyosis. (b) Color Doppler US image shows a penetrating vascular pattern within the mass.

View larger version (178K): [in a new window]   Figure 14a.  Diffuse adenomyosis in a 37-year-old woman. Coronal (a) and sagittal (b) T2-weighted turbo spin-echo (6000/120) images depict markedly diffuse enlargement of the junctional zone (arrows) replacing normal myometrium.

View larger version (192K): [in a new window]   Figure 14b.  Diffuse adenomyosis in a 37-year-old woman. Coronal (a) and sagittal (b) T2-weighted turbo spin-echo (6000/120) images depict markedly diffuse enlargement of the junctional zone (arrows) replacing normal myometrium.

View larger version (183K): [in a new window]   Figure 15a.  Focal adenomyosis. (a) Sagittal T2-weighted turbo spin-echo (4900/120) MR image shows focal widening of the junctional zone (arrows) in the posterior wall of the uterine fundus. (b) Sagittal image obtained during the secretory stage of the menstrual cycle demonstrates a change in appearance, especially high-signal-intensity foci (arrows).

View larger version (185K): [in a new window]   Figure 15b.  Focal adenomyosis. (a) Sagittal T2-weighted turbo spin-echo (4900/120) MR image shows focal widening of the junctional zone (arrows) in the posterior wall of the uterine fundus. (b) Sagittal image obtained during the secretory stage of the menstrual cycle demonstrates a change in appearance, especially high-signal-intensity foci (arrows).

View larger version (128K): [in a new window]   Figure 16a.  (a) Gray-scale transvaginal US image shows a poorly echogenic mass (arrows). (b) Color Doppler image demonstrates a penetrating vascular pattern. (c) Sagittal T2-weighted turbo spin-echo (4900/120) MR image shows focal widening of the junctional zone (arrows) in the fundus of the uterus.

View larger version (73K): [in a new window]   Figure 16b.  (a) Gray-scale transvaginal US image shows a poorly echogenic mass (arrows). (b) Color Doppler image demonstrates a penetrating vascular pattern. (c) Sagittal T2-weighted turbo spin-echo (4900/120) MR image shows focal widening of the junctional zone (arrows) in the fundus of the uterus.

View larger version (118K): [in a new window]   Figure 16c.  (a) Gray-scale transvaginal US image shows a poorly echogenic mass (arrows). (b) Color Doppler image demonstrates a penetrating vascular pattern. (c) Sagittal T2-weighted turbo spin-echo (4900/120) MR image shows focal widening of the junctional zone (arrows) in the fundus of the uterus.

View larger version (144K): [in a new window]   Figure 17a.  Focal adenomyosis associated with a fibroid. (a, b) Gray-scale (a) and color Doppler (b) images show an echogenic, poorly defined mass (arrows) with penetrating vessels. (c, d) Gray-scale (c) and color Doppler (d) images show a hypoechoic well-defined mass (arrows) with draping peripheral vessels. (e) Sagittal T2-weighted turbo spin-echo (4900/120) MR image demonstrates both a fibroid (arrow) and adenomyoma (arrowheads).

View larger version (103K): [in a new window]   Figure 17b.  Focal adenomyosis associated with a fibroid. (a, b) Gray-scale (a) and color Doppler (b) images show an echogenic, poorly defined mass (arrows) with penetrating vessels. (c, d) Gray-scale (c) and color Doppler (d) images show a hypoechoic well-defined mass (arrows) with draping peripheral vessels. (e) Sagittal T2-weighted turbo spin-echo (4900/120) MR image demonstrates both a fibroid (arrow) and adenomyoma (arrowheads).

View larger version (142K): [in a new window]   Figure 17c.  Focal adenomyosis associated with a fibroid. (a, b) Gray-scale (a) and color Doppler (b) images show an echogenic, poorly defined mass (arrows) with penetrating vessels. (c, d) Gray-scale (c) and color Doppler (d) images show a hypoechoic well-defined mass (arrows) with draping peripheral vessels. (e) Sagittal T2-weighted turbo spin-echo (4900/120) MR image demonstrates both a fibroid (arrow) and adenomyoma (arrowheads).

View larger version (115K): [in a new window]   Figure 17d.  Focal adenomyosis associated with a fibroid. (a, b) Gray-scale (a) and color Doppler (b) images show an echogenic, poorly defined mass (arrows) with penetrating vessels. (c, d) Gray-scale (c) and color Doppler (d) images show a hypoechoic well-defined mass (arrows) with draping peripheral vessels. (e) Sagittal T2-weighted turbo spin-echo (4900/120) MR image demonstrates both a fibroid (arrow) and adenomyoma (arrowheads).

View larger version (146K): [in a new window]   Figure 17e.  Focal adenomyosis associated with a fibroid. (a, b) Gray-scale (a) and color Doppler (b) images show an echogenic, poorly defined mass (arrows) with penetrating vessels. (c, d) Gray-scale (c) and color Doppler (d) images show a hypoechoic well-defined mass (arrows) with draping peripheral vessels. (e) Sagittal T2-weighted turbo spin-echo (4900/120) MR image demonstrates both a fibroid (arrow) and adenomyoma (arrowheads).

View larger version (115K): [in a new window]   Figure 18a.  (a, b) Gray-scale (a) and color Doppler (b) images demonstrate congested pelvic veins. (c) Computed tomographic (CT) scan demonstrates enhanced, bilateral tortuous vessels (arrows), findings that correlate with those seen sonographically.

View larger version (92K): [in a new window]   Figure 18b.  (a, b) Gray-scale (a) and color Doppler (b) images demonstrate congested pelvic veins. (c) Computed tomographic (CT) scan demonstrates enhanced, bilateral tortuous vessels (arrows), findings that correlate with those seen sonographically.

View larger version (119K): [in a new window]   Figure 18c.  (a, b) Gray-scale (a) and color Doppler (b) images demonstrate congested pelvic veins. (c) Computed tomographic (CT) scan demonstrates enhanced, bilateral tortuous vessels (arrows), findings that correlate with those seen sonographically.

View larger version (143K): [in a new window]   Figure 19a.  Polycystic ovary disease associated with pelvic congestion syndrome. Coronal (a) and sagittal (b) transvaginal color Doppler US images demonstrate hypoechogenic masses in the ovaries that are distinct from the vasculature.

View larger version (89K): [in a new window]   Figure 19b.  Polycystic ovary disease associated with pelvic congestion syndrome. Coronal (a) and sagittal (b) transvaginal color Doppler US images demonstrate hypoechogenic masses in the ovaries that are distinct from the vasculature.

View larger version (115K): [in a new window]   Figure 20a.  Pelvic congestion syndrome. Color Doppler US image (a) and corresponding venogram (b) show severely dilated pelvic veins.

View larger version (185K): [in a new window]   Figure 20b.  Pelvic congestion syndrome. Color Doppler US image (a) and corresponding venogram (b) show severely dilated pelvic veins.

View larger version (204K): [in a new window]   Figure 21a.  Pelvic congestion syndrome. Coronal T2-weighted turbo spin-echo (6000/120) image (a), coronal T2-weighted turbo spin-echo fat-suppressed (6000/120) image (b), and coronal T1-weighted (450/10) image obtained with fat-suppression and gadolinium (c) demonstrate severely congested pelvic veins.

View larger version (185K): [in a new window]   Figure 21b.  Pelvic congestion syndrome. Coronal T2-weighted turbo spin-echo (6000/120) image (a), coronal T2-weighted turbo spin-echo fat-suppressed (6000/120) image (b), and coronal T1-weighted (450/10) image obtained with fat-suppression and gadolinium (c) demonstrate severely congested pelvic veins.

View larger version (178K): [in a new window]   Figure 21c.  Pelvic congestion syndrome. Coronal T2-weighted turbo spin-echo (6000/120) image (a), coronal T2-weighted turbo spin-echo fat-suppressed (6000/120) image (b), and coronal T1-weighted (450/10) image obtained with fat-suppression and gadolinium (c) demonstrate severely congested pelvic veins.

View larger version (106K): [in a new window]   Figure 22a.  Pre- and postembolization of gonadal veins for treatment of pelvic congestion syndrome. (a, b) Angiograms obtained before coil embolization show pelvic varices (a) and a dilated left renal vein (b). (c) Angiogram obtained after selective percutaneous coil embolization reveals that treatment was adequate.

View larger version (90K): [in a new window]   Figure 22b.  Pre- and postembolization of gonadal veins for treatment of pelvic congestion syndrome. (a, b) Angiograms obtained before coil embolization show pelvic varices (a) and a dilated left renal vein (b). (c) Angiogram obtained after selective percutaneous coil embolization reveals that treatment was adequate.

View larger version (100K): [in a new window]   Figure 22c.  Pre- and postembolization of gonadal veins for treatment of pelvic congestion syndrome. (a, b) Angiograms obtained before coil embolization show pelvic varices (a) and a dilated left renal vein (b). (c) Angiogram obtained after selective percutaneous coil embolization reveals that treatment was adequate.

View larger version (83K): [in a new window]   Figure 23a.  Gartner cyst. Transvaginal US image (a), axial T2-weighted turbo spin-echo (4900/120) image (b), and axial T1-weighted spin-echo (450/10) image obtained with fat-suppression and gadolinium (c) demonstrate the cystic mass (arrows).

View larger version (158K): [in a new window]   Figure 23b.  Gartner cyst. Transvaginal US image (a), axial T2-weighted turbo spin-echo (4900/120) image (b), and axial T1-weighted spin-echo (450/10) image obtained with fat-suppression and gadolinium (c) demonstrate the cystic mass (arrows).

View larger version (143K): [in a new window]   Figure 23c.  Gartner cyst. Transvaginal US image (a), axial T2-weighted turbo spin-echo (4900/120) image (b), and axial T1-weighted spin-echo (450/10) image obtained with fat-suppression and gadolinium (c) demonstrate the cystic mass (arrows).

View larger version (156K): [in a new window]   Figure 24a.  Periurethral cyst. (a, b) Sagittal T2-weighted turbo spin-echo (4900/120) image (a) and axial T2-weighted turbo spin-echo (4900/120) image (b) demonstrate the cystic mass (arrow). (c) Color Doppler US image demonstrates the vascularity surrounding the periurethral cyst (arrows).

View larger version (154K): [in a new window]   Figure 24b.  Periurethral cyst. (a, b) Sagittal T2-weighted turbo spin-echo (4900/120) image (a) and axial T2-weighted turbo spin-echo (4900/120) image (b) demonstrate the cystic mass (arrow). (c) Color Doppler US image demonstrates the vascularity surrounding the periurethral cyst (arrows).

View larger version (110K): [in a new window]   Figure 24c.  Periurethral cyst. (a, b) Sagittal T2-weighted turbo spin-echo (4900/120) image (a) and axial T2-weighted turbo spin-echo (4900/120) image (b) demonstrate the cystic mass (arrow). (c) Color Doppler US image demonstrates the vascularity surrounding the periurethral cyst (arrows).