DOI: 10.1148/rg.226025062
(Radiographics. 2002;22:1327-1334.)
© RSNA, 2002
Spectrum of CT Findings in Acute Pyogenic Pelvic Inflammatory Disease1
Joseph W. Sam, MD, PhD,
Jill E. Jacobs, MD2 and
Bernard A. Birnbaum, MD2
1 From the Department of Radiology, University of Pennsylvania Medical Center, Philadelphia. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received March 21, 2002; revision requested April 26 and received July 17; accepted July 22. Address correspondence to J.E.J., Department of Radiology, NYU Medical Center, 560 First Ave, TCH HW205, New York, NY 10016 (e-mail: jill.jacobs@med.nyu.edu).
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Abstract
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Pelvic inflammatory disease (PID) is a common medical problem, affecting nearly 1 million women each year. Although the radiology literature is replete with discussions of the sonographic manifestations of PID, little has been published regarding the computed tomographic (CT) appearances of this entity. CT findings in early PID include obscuration of the normal pelvic floor fascial planes, thickening of the uterosacral ligaments, cervicitis, oophoritis, salpingitis, and accumulation of simple fluid in the endometrial canal, fallopian tubes, and pelvis. As the disease progresses, this simple fluid may become complex and the inflammatory changes may progress to frank tubo-ovarian or pelvic abscesses. Reactive inflammation of adjacent structures is common and can manifest as small or large bowel ileus or obstruction, hydroureter and hydronephrosis, right upper quadrant inflammation (Fitz-Hugh-Curtis syndrome), or peritonitis. Familiarity with the CT appearances of these manifestations is important for timely diagnosis and treatment of PID and its complications.
© RSNA, 2002
Index Terms: Genitourinary system, CT, 85.1211 • Genitourinary system, diseases, 85.217 • Pelvic organs, diseases, 80.217 • Pelvic organs, inflammation, 80.217 • Peritoneum, CT, 791.1211, 791.295 • Peritonitis, 791.295
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LEARNING OBJECTIVES
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After reading this article and taking the test, the reader will be able to:
- Recognize the CT findings commonly seen in early and advanced PID.
- Describe the risk factors associated with PID.
- Discuss the optimal CT techniques for evaluating patients with suspected PID.
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Introduction
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Pelvic inflammatory disease (PID) refers to infection and resultant inflammation of the upper female genital tract, including the endometrium, fallopian tubes, and ovaries. PID is one of the most common diseases of women, afflicting over 1 million women and accounting for over 275,000 hospitalizations each year (1,2). The financial implications alone of this disease are staggering: The direct and indirect costs of PID to society have been estimated at $10 billion annually (3).
PID usually results from ascending infection by Neisseria gonorrhoeae or Chlamydia trachomatis, although 30%–40% of cases are polymicrobial (3). Risk factors for PID include young age, multiple sex partners, high coital frequency, low socioeconomic status, douching, and use of an intrauterine device (particularly during the first few months after insertion) as well as other forms of pelvic instrumentation. PID frequently causes tubal damage, scarring, and occlusion, which can result in a number of long-term complications. Patients who have had PID have an approximately sixfold higher risk for ectopic pregnancy and an increased risk for subsequent episodes of PID, and nearly 20% of patients with a history of PID will complain of chronic pelvic pain (1). Of even greater concern is the infertility due to fallopian tube occlusion (tubal factor infertility) that will occur in 8% of patients after a single episode of PID, with an increase in risk to 20% after two episodes of PID and to 40% after three episodes (1). Because of the severity of these long-term sequelae, it is important that PID be diagnosed accurately and treated promptly. Unfortunately, patients usually present with a myriad of nonspecific symptoms, including fever, abdominal or pelvic pain, vaginal discharge, uterine bleeding, dyspareunia, dysuria, adnexal or cervical tenderness, nausea, vomiting, and other vague constitutional symptoms (1,3). On the other hand, it is believed that as many as 35% of patients with PID have no noticeable symptoms whatsoever.
The standard of reference for diagnosing PID is laparoscopy, which allows direct visualization of purulent exudates and edema of the pelvic structures. However, this is an expensive and invasive procedure that is seldom used in a clinical setting. Thus, the diagnosis of PID and the identification of patients who require hospitalization as opposed to antibiotic therapy on an outpatient basis are usually accomplished with imaging studies. Frequently, patients will undergo transabdominal or endovaginal ultrasonography (US). However, given the vague and nonspecific symptoms of patients with PID, computed tomography (CT) is often the first imaging study performed. Remarkably, although the US findings in PID are well documented, there have been relatively few studies regarding the CT appearance of this prevalent disease (4–8).
In this article, we review CT techniques in PID. We also discuss and illustrate the spectrum of CT findings that may be encountered in early and more advanced PID. In addition, we describe the involvement of adjacent anatomic structures in affected patients.
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CT Technique
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In patients with suspected gynecologic disease, prospective high-resolution thin-section CT with meticulous attention to technique is advised to optimize assessment of the pelvis. At the University of Pennsylvania Medical Center in Philadelphia, 800–1000 mL of 2% dilute barium sulfate (Readi-CAT 2; E-Z-EM, Westbury, NY) is administered orally in equal aliquots over a 45-minute period prior to CT. In patients with signs that suggest acute abdomen, Gastroview (Mallinckrodt, St Louis, Mo) is administered orally instead of dilute barium sulfate. Patients in whom inflammatory pelvic conditions are suspected undergo CT in the supine position. When a multidetector helical CT scanner is used, the scanning parameters are as follows: 5-mm section thickness; 3:1 HQ pitch, and a table speed of 15 mm per rotation. Scanning is performed through the entire abdomen and pelvis. With a single-detector helical CT scanner, a 7-mm section thickness (1.3:1 pitch) is used for scanning from the dome of the liver through the distal abdomen and 5-mm section thickness (1.5:1 pitch) is used for scanning from the distal abdomen to the ischium. All patients undergo intravenous administration of contrast material (unless contraindicated) with a power injector at a minimum rate of 2 mL/sec. The scan delay time may vary with the injection rate (70-sec scan delay for a 4 mL/sec injection rate, 80-sec delay for a 3 mL/sec rate, and 90-sec delay for a 2 mL/sec rate).
Rectal air insufflation is selectively used in patients with inflammatory diseases of the pelvis when colonic distention is initially suboptimal and maximal colonic distention is necessary to diagnose or confirm the presence of eccentric or circumferential bowel wall thickening. Rectal air insufflation is contraindicated in patients with suspected perforation, profound neutropenia, clinically severe forms of colitis, or radiation enteritis. All patients who undergo rectal air contrast studies receive 0.5 mg of glucagon intravenously immediately prior to scanning to minimize bowel peristalsis.
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CT Findings in Early PID
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CT findings are typically subtle early in the course of PID. Often the only finding is mild pelvic edema that results in thickening of the uterosacral ligaments and haziness of the pelvic fat with obscuration of the pelvic fascial planes (Figs 1, 2). Patients may also have a mild salpingitis with inflammatory thickening of the fallopian tubes (Fig 1) and mild oophoritis with enlarged and abnormally enhancing ovaries that may demonstrate a polycystic appearance (Figs 1, 3). This latter finding has also been noted during US evaluation of patients with PID (9). Periovarian stranding and enhancement of the adjacent peritoneum are occasionally noted (Fig 3). Abnormal endometrial enhancement and simple fluid within the endometrial canal are findings that are consistent with endometritis (Fig 4). At multidetector CT, endometrial enhancement is normally less than that of the surrounding inner myometrium. If necessary, abnormal endometrial thickening and endometrial fluid can be differentiated from the normal enhancement pattern of the endometrial canal with delayed imaging through the uterus. Similarly, the uterine cervix may also be enlarged and contain an abnormally enhancing endocervical canal, findings that are consistent with cervicitis (Fig 1).
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Figure 1a. Early PID in a 16-year-old girl. (a-c) Contrast material-enhanced CT scans demonstrate salpingitis with enhancing, thickened fallopian tubes (arrows in a). The ovaries are enlarged, inflamed, and have a polycystic appearance due to early oophoritis (arrowheads in b and c). Pelvic fat inflammation is also demonstrated in c and obscures the normal pelvic fascial planes. (d) Contrast-enhanced CT scan obtained caudad to a-c demonstrates cervicitis, which manifests as cervical enlargement, abnormal enhancement of the endocervical canal, and pericervical inflammation. Pelvic fat inflammation is again seen (cf c).
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Figure 1b. Early PID in a 16-year-old girl. (a-c) Contrast material-enhanced CT scans demonstrate salpingitis with enhancing, thickened fallopian tubes (arrows in a). The ovaries are enlarged, inflamed, and have a polycystic appearance due to early oophoritis (arrowheads in b and c). Pelvic fat inflammation is also demonstrated in c and obscures the normal pelvic fascial planes. (d) Contrast-enhanced CT scan obtained caudad to a-c demonstrates cervicitis, which manifests as cervical enlargement, abnormal enhancement of the endocervical canal, and pericervical inflammation. Pelvic fat inflammation is again seen (cf c).
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Figure 1c. Early PID in a 16-year-old girl. (a-c) Contrast material-enhanced CT scans demonstrate salpingitis with enhancing, thickened fallopian tubes (arrows in a). The ovaries are enlarged, inflamed, and have a polycystic appearance due to early oophoritis (arrowheads in b and c). Pelvic fat inflammation is also demonstrated in c and obscures the normal pelvic fascial planes. (d) Contrast-enhanced CT scan obtained caudad to a-c demonstrates cervicitis, which manifests as cervical enlargement, abnormal enhancement of the endocervical canal, and pericervical inflammation. Pelvic fat inflammation is again seen (cf c).
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Figure 1d. Early PID in a 16-year-old girl. (a-c) Contrast material-enhanced CT scans demonstrate salpingitis with enhancing, thickened fallopian tubes (arrows in a). The ovaries are enlarged, inflamed, and have a polycystic appearance due to early oophoritis (arrowheads in b and c). Pelvic fat inflammation is also demonstrated in c and obscures the normal pelvic fascial planes. (d) Contrast-enhanced CT scan obtained caudad to a-c demonstrates cervicitis, which manifests as cervical enlargement, abnormal enhancement of the endocervical canal, and pericervical inflammation. Pelvic fat inflammation is again seen (cf c).
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Figure 2. Early PID in a 13-year-old girl. Contrast-enhanced CT scan shows mild pelvic edema, which causes haziness of the pelvic fat and obscuration of the normal pelvic fascial planes.
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Figure 3. Early PID in a 33-year-old woman. Contrast-enhanced CT scan demonstrates abnormal enhancement of the ovaries (arrowheads) with periovarian and peritoneal inflammation (arrows). An enlarged myomatous uterus (U) is incidentally noted.
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Figure 4. Early PID in a 25-year-old woman. Contrast-enhanced CT scan demonstrates abnormal endometrial enhancement and simple fluid due to endometritis. Ovarian engorgement is also present (arrowheads).
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CT Findings in More Advanced PID
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Later in the course of PID, the fallopian tubes exhibit an even greater degree of wall thickening and enhancement and fill with complex fluid, findings that usually indicate pyosalpinx (Figs 5 –7). Ultimately, frank tubo-ovarian and pelvic abscesses form, indicated by the presence of a thick-walled, complex fluid collection that may contain internal septa, a fluid-debris level, or gas (Fig 8), although the latter finding is relatively uncommon (2,6,7).
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Figure 5a. Advanced PID in a 43-year-old woman. Contrast-enhanced CT scans demonstrate enhancing, dilated fallopian tubes filled with complex fluid (arrows in a), inflammatory collections adjacent to the right ovary (arrowhead in b), and a 7 x 8-cm cul-de-sac abscess (a), findings that are consistent with pyosalpinx and tubo-ovarian abscess.
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Figure 5b. Advanced PID in a 43-year-old woman. Contrast-enhanced CT scans demonstrate enhancing, dilated fallopian tubes filled with complex fluid (arrows in a), inflammatory collections adjacent to the right ovary (arrowhead in b), and a 7 x 8-cm cul-de-sac abscess (a), findings that are consistent with pyosalpinx and tubo-ovarian abscess.
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Figure 6. Advanced PID in a 33-year-old woman. Contrast-enhanced CT scan demonstrates dilated, thick-walled, enhancing fallopian tubes containing complex fluid (arrows), a finding that is consistent with pyosalpinx.
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Involvement of Adjacent Structures in PID
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In addition to the female reproductive tract, other pelvic and even abdominal organs may be affected by PID (eg, small or large bowel ileus or obstruction, ureteral and renal obstruction, Fitz-Hugh-Curtis syndrome). Pelvic small bowel loops may be dilated due to an adynamic ileus resulting from adjacent inflammation or to mechanical obstruction resulting from the inflamed, enlarged, and tethered pelvic structures (Fig 9). Colonic wall thickening, ileus, or obstruction may also be seen (Fig 10). In addition, functional or mechanical obstruction of the ureters may result in hydroureter and hydronephrosis (Figs 11, 12). Finally, inflammation of the right upper abdominal quadrant caused by PID (Fitz-Hugh-Curtis syndrome) may be seen (Fig 13). In this syndrome, bacteria spread by means of direct extension along the right paracolic gutter or through the lymphatic system, causing inflammation of the right upper quadrant peritoneal surfaces and the right lobe of the liver (10). CT has a decided advantage over US in the detection of these complications because it allows continuous and complete visualization of the gastrointestinal and urinary tracts and is not hampered by the presence of bowel gas.
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Figure 9a. Tubo-ovarian abscesses with small bowel obstruction due to PID in a 48-year-old woman. Contrast-enhanced CT scans show multiple dilated small bowel loops with a transition point (arrowhead in a) occurring where a loop of small intestine passes between segments of an enlarged, pus-filled right fallopian tube (arrows in a). Bilateral pyosalpinx is also identified, with plaque-like debris (arrows in b) seen along the walls of several fallopian tube segments.
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Figure 9b. Tubo-ovarian abscesses with small bowel obstruction due to PID in a 48-year-old woman. Contrast-enhanced CT scans show multiple dilated small bowel loops with a transition point (arrowhead in a) occurring where a loop of small intestine passes between segments of an enlarged, pus-filled right fallopian tube (arrows in a). Bilateral pyosalpinx is also identified, with plaque-like debris (arrows in b) seen along the walls of several fallopian tube segments.
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Figure 10. Colonic wall thickening due to PID in the same patient as in Figure 5. Contrast-enhanced CT scan obtained cephalad demonstrates marked wall thickening of the cecum (arrows) and moderate mural thickening of the sigmoid colon (arrowheads).
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Figure 11. Hydroureteronephrosis due to PID in the same patient as in Figure 6. Contrast-enhanced CT scan obtained cephalad demonstrates dilatation of the right kidney and right ureter due to inflammatory changes surrounding the distal ureter.
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Figure 12. Hydroureter due to PID in the same patient as in Figure 4. Contrast-enhanced CT scan obtained cephalad demonstrates a dilated right ureter (arrow) with thickening and enhancement of the ureteral wall, findings that represent ureteral ileus due to surrounding inflammation.
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Figure 13a. Fitz-Hugh-Curtis syndrome in the same patient as in Figure 2. Contrast-enhanced CT scans of the right upper abdominal quadrant (a) and pelvis (b) demonstrate inflammatory stranding along the right paracolic gutter and inferior right lobe of the liver (arrows in a). Findings in the pelvis include a polycystic appearance of the ovaries (arrowheads in b), obscured fascial planes, and an enlarged cervix (arrow in b).
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Figure 13b. Fitz-Hugh-Curtis syndrome in the same patient as in Figure 2. Contrast-enhanced CT scans of the right upper abdominal quadrant (a) and pelvis (b) demonstrate inflammatory stranding along the right paracolic gutter and inferior right lobe of the liver (arrows in a). Findings in the pelvis include a polycystic appearance of the ovaries (arrowheads in b), obscured fascial planes, and an enlarged cervix (arrow in b).
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Conclusions
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PID is one of the most prevalent disorders afflicting women. Radiologic diagnosis of PID is imperative because affected patients often present with nonspecific or minimal symptoms and the consequences of untreated PID are grave, including infertility and an increased risk of ectopic pregnancy. CT is often the first imaging study performed. CT findings in early PID can be subtle, with the only findings being mild pelvic edema or inflammatory engorgement of the cervix, ovaries, or fallopian tubes. As the infection progresses, pyosalpinx develops, characterized by enhancing, thickened fallopian tubes filled with complex fluid and debris. In the later stages of the disease, tubo-ovarian and pelvic abscesses may develop. In addition, numerous other pelvic and abdominal structures including the bowel and upper urinary tracts can become inflamed, infected, and obstructed. Thus, it is important that radiologists be familiar with the spectrum of CT findings in PID so that this common disease can be diagnosed and treated in a timely fashion.
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Footnotes
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2 Current address:Department of Radiology, NYU Medical Center, New York, NY. 
Abbreviation: PID = pelvic inflammatory disease
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Abstract
LEARNING OBJECTIVES
