DOI: 10.1148/rg.251045511
RadioGraphics 2005;25:3-20
© RSNA, 2005
Pelvic Pain: Overlooked and Underdiagnosed Gynecologic Conditions1
Ewa Kuligowska, MD,
Linda Deeds, III, MS and
Kang Lu, III, MS
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).
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Abstract
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Chronic pelvic pain is a common, disabling problem among women. Although chronic pelvic pain can be produced by many conditions, some gynecologic causes are frequently overlooked and underdiagnosed, resulting in inappropriate referral and inadequate treatment. The gynecologic conditions most often unrecognized are endometriosis, adenomyosis, pelvic congestion, and less common congenital and acquired abnormalities. Transvaginal ultrasonography (US) is helpful for assessing endometriotic cysts but has a limited role in the diagnosis of adhesions or peritoneal implants. The classic magnetic resonance (MR) imaging features diagnostic of endometrioma are a cystic mass with high signal intensity on T1-weighted images and loss of signal intensity on T2-weighted images. When transvaginal US findings are suggestive of adenomyosis, MR imaging is used as the definitive imaging modality for diagnosis. High-resolution transvaginal US and MR imaging can help establish the diagnosis of adenomyosis with a high degree of accuracy, since the imaging appearance closely correlates with the histopathologic characteristics. Pelvic varices can be identified by using transvaginal US with color Doppler and Doppler spectral analysis. Three-dimensional T1 gradient-echo sequences performed after the intravenous administration of gadolinium are the most effective MR imaging sequence for demonstrating pelvic varices. Blood flow in pelvic varices appears with high signal intensity. Recent advances in radiologic imaging and therapeutic procedures make it possible to diagnose accurately the conditions producing chronic pelvic pain in most women and to guide effective treatment.
© RSNA, 2005
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LEARNING OBJECTIVES FOR TEST 1
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After reading this article and taking the test, the reader will be able to:
- Discuss the benefits and limitations of the available modalities for imaging pelvic pain.
- Recognize the US and MR imaging appearances of gynecologic conditions that can cause chronic pelvic pain.
- Provide objective criteria for patient treatment.
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Introduction
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Patients with chronic pelvic pain can present both diagnostic and therapeutic challenges for the clinician. Chronic pelvic pain is a common and disabling condition that is defined as nonmenstrual pain of at least 6 months duration (1,2). The sources of pelvic pain are multifactorial, and their causes are difficult to determine.
The prevalence of chronic pelvic pain is 15% in women between the ages of 18 and 50 years (2). Chronic pelvic pain accounts for 10%–40% of all gynecologic outpatient visits (2). In the United States, 35% of diagnostic laparoscopies and 15% of all hysterectomies are performed because of chronic pelvic pain (1). Interestingly, black women have a lower risk of developing this condition (0.73; confidence interval, 0.55–0.99) (1). Women over 35 years of age also have lower odds of developing this problem (0.72; confidence interval, 0.60–0.85) (1).
The economic impact of chronic pelvic pain is substantial: 15% of women with chronic pelvic pain miss an average of 14.8 hours of work per month in the United States, which accounts for $14 billion of lost productivity per year (1,3). The total cost of potentially unnecessary medical, surgical, and psychiatric care or hospitalization amounts to $128 million per year. It is estimated that the total cost of care for women with chronic pelvic pain constitutes $39 billion per year (1,3).
Many conditions produce chronic pelvic pain in women. These conditions range from problems in the gastrointestinal tract to gynecologic diseases and urologic abnormalities. Some of these conditions are easily diagnosed, but other causes of chronic pelvic pain are extremely difficult to recognize. These conditions have often been overlooked and underdiagnosed in the past. Some of the gynecologic conditions most often unrecognized are endometriosis, adenomyosis, pelvic congestion, and less common congenital and acquired abnormalities.
The purpose of this article is to describe the transvaginal ultrasonographic (US) and magnetic resonance (MR) imaging appearances of some gynecologic conditions that can cause chronic pelvic pain. Radiologists familiar with the clinical, pathologic, and radiologic characteristics of the underlying causes of chronic pelvic pain will be able to make an accurate diagnosis in most cases and facilitate referral for appropriate therapy.
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Endometriosis
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Endometriosis is defined as functional endometrial tissue outside the boundaries of the uterine musculature that is implanted on the surface of other organs and that responds to hormonal stimuli. Endometriosis has been found everywhere in the body. The most frequent sites are the ovary, uterine ligament, pouch of Douglas, pelvic peritoneum, fallopian tube, and uterus; less common sites include the bladder, cervix, and vagina (4) (Figs 1, 2). In rare cases, endometriosis can seed abdominal scars in up to 1% of patients who have undergone cesarean delivery, hysterectomy, appendectomy, or other pelvic interventional procedures (5).
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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).
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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.
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Pathophysiology
Several theories have been proposed to explain the presence of endometrial tissue outside the uterus (6,7). The implantation theory proposes the "shedding" of the endometrial glands during retrograde menstruation through the fallopian tubes to the peritoneum. The direct theory speculates that endometrial tissue is transported during surgeries, such as cesarean sections (Fig 3). Dissemination theories describe the possible spread of endometrial cells by passage through lymphatic and blood vessels. The coelomic metaplasia theory postulates a conversion of peritoneal epithelium into endometrial epithelium by unknown mechanisms. Genetics may also play a strong role in the development of endometriosis.
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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.
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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.
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Clinical Characteristics
Endometriosis occurs in women during the reproductive years (primarily 25–29 years of age) and is present in 7%–10% of the general population of women (8). In infertile women, the rate of endometriosis is much higher, between 20% and 50% of this population (9). In women with an affected first-degree relative, there is a 10-fold increase in prevalence (6,10).
Endometriosis can be associated with many debilitating symptoms, in addition to infertility. Symptoms of endometriosis occur in 50%–80% of patients and include dysmenorrhea, dyspareunia, abnormal menstrual bleeding, and infertility (9). Various co-morbid clinical symptoms can be present, depending on the location of the ectopic endometrial tissue (4,6). The amount of pelvic pain is not correlated with the extent of the disease (6,9).
Imaging Appearance
The value of imaging in the diagnosis of endometriosis is limited. Small implants and adhesions are usually not detectable with transvaginal US. Some small implants and adhesions are also difficult to detect with MR imaging. Laparoscopy is often performed to better diagnose and treat these small lesions (7) (Fig 4). Endometrioma is the only form of endometriosis readily diagnosed with transvaginal US. MR imaging is more effective for identifying endometrial implants in other organs.
Transvaginal US.—
Transvaginal US is used for the initial evaluation of endometriosis. US is particularly helpful in the assessment of endometriotic cysts but has a limited role in the diagnosis of adhesions or peritoneal implants. The typical sonographic appearance of ovarian endometriomas consists of cystic masses that have diffuse low-level homogeneous echoes (Fig 5). The contents of the cyst, however, may vary in appearance because of the age of the hemorrhage. Endometriomas can be multilocular, with thin or thick septations and thick irregular walls (Figs 6, 7). Within the mass, fine interdigitating septations are often seen that give a fine reticular appearance (11). Color Doppler US shows no blood flow in the fine septations, whereas blood flow can often be detected in thick septations because of revascularization of chronic hematoma (12). Retracting blood clots (avascular) may appear as triangular or curvilinear soft-tissue components or with reticular patterns because of fibrin strands that often are attached to the wall (Fig 7). Blood products in endometriomas can occasionally be separated into layers, which appear sonographically as fluid-fluid or fluid-debris levels (13,14) (Fig 8). The sonographic appearances of endometriomas are nonspecific, and other conditions causing cystic masses in the ovary, including malignancies, cannot be excluded on the basis of the initial US examination (15–17). A follow-up transvaginal US study in 6 weeks can be helpful in differentiating endometrioma (which will change in size and appearance because of the changing age of the hemorrhage) from other causes.
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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.
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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.
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The overall sensitivity and specificity of transvaginal US for the diagnosis of endometrioma is 83% and 89%, respectively (15).
MR Imaging.—
In cases in which US findings are equivocal, an MR imaging examination may allow for a more definite characterization of endometrioma. MR imaging is often valuable in the diagnosis of superficial peritoneal implants and extraperitoneal lesions, particularly those in the rectovaginal space and uterosacral ligaments. The classic MR imaging features diagnostic of endometrioma are a cystic mass with high signal intensity on T1-weighted images and loss of signal intensity on T2-weighted images. This phenomenon is referred to as "shading" and occasionally occurs in a graded form with higher- to lower-signal-intensity patterns, as a result of high protein and iron concentration from recurrent hemorrhage in the endometrioma. All of these components can shorten T2 and may contribute to loss of signal intensity described as a shading sign (18). This appearance results from cyclic bleeding and is highly specific for endometrioma (Fig 9). T1-weighted sequences after administration of gadolinium are not necessary to evaluate endometriosis.
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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.
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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.
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Overall, the sensitivity and specificity of MR imaging for the diagnosis of endometrioma is 90%–92% and 91%–98%, respectively (19–21).
Treatment
Treatment for symptomatic endometriosis can be medical or surgical and depends on the size of the endometrioma. Medical treatment frequently involves use of nonsteroidal, anti-inflammatory drugs to treat the symptoms of endometriosis when the diagnosis has not been definitely established. Oral contraceptives, which effect an anovulatory state, are often used as treatment.
Laparoscopy can also be used to diagnose and treat endometriosis. Although it is an invasive surgical procedure, laparoscopy is the most sensitive way to diagnose the disease. Treatment may be performed during this procedure and may include ablation of implants, lyses of adhesions, or removal of endometrioma implants. Definitive treatment is hysterectomy and oophorectomy. In young women, a conservative treatment is preferred to preserve fertility (4,6).
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Adenomyosis
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Adenomyosis is an often-overlooked condition that is responsible for uterine enlargement and pelvic pain associated with dysmenorrhea and menorrhagia. These symptoms are not specific and can occur with other common gynecologic disorders. The diagnosis of adenomyosis was, until recently, rarely recognized before surgery (22).
Adenomyosis is a condition characterized by the migration of glands from the basal layer of the endometrium to within the myometrium; the focus of basal endometrial glands is surrounded by smooth muscle hyperplasia. The ectopic glands are located at least 2–3 mm below the endometrial-myometrial junction and produce asymmetry of the uterus with a globular configuration (22) (Fig 10). Adenomyosis is frequently misdiagnosed clinically and radiologically as leiomyomas, which results in inappropriate treatment and persistent symptoms.
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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.)
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Uterine adenomyosis is a common disease. Its reported prevalence varies widely, depending on the analytic technique used by the pathologist. Adenomyosis is found in 5%–70% of posthysterectomy pathologic specimens (23). The disease most commonly (70%–80% of cases) affects parous women aged 40–50 years (24). Seventy percent of women with adenomyosis have symptoms (24).
There are two distinct types of adenomyosis: diffuse and focal (25). In the diffuse form, the ectopic endometrial glands and stroma are distributed diffusely throughout the myometrium, in contrast to the focal form, in which ectopic endometrial glands produce circumscribed nodular aggregates known as adenomyomas.
Pathophysiology
The pathogenesis of adenomyosis is poorly understood and is likely multifactorial. Proposed mechanisms include the lack of a basement membrane or the presence of a basement membrane defect at the endometrial-myometrial interface, which allows endometrial tissue to grow into the myometrium. Another theory postulates that endometrial migration may occur via lymphatic or vascular channels. The risk factors remain unclear, but the possibilities include hereditary factors or uterine trauma from childbirth or abortion. Chronic endometritis and hyperestrogenemia can also predispose a patient to adenomyosis (26,27).
Symptoms
Patients with adenomyosis present with dysmenorrhea, menorrhagia, pelvic tenderness, or infertility. Adenomyosis also predisposes a woman to develop an intramural ectopic pregnancy. Symptoms are rarely seen in nulliparous or postmenopausal women (27).
Imaging Appearance
All patients with chronic pelvic pain are first examined with transvaginal US to identify whether fibroids, focal adenomyosis, or diffuse adenomyosis are present and to rule out other causes (28,29). When transvaginal US findings are suggestive of adenomyosis, MR imaging is used as the definitive imaging modality for diagnosis. High-resolution transvaginal US and MR imaging can help establish the diagnosis of adenomyosis with a high degree of accuracy, since the imaging appearance closely correlates with the histopathologic characteristics of this entity (30). The first goal of transvaginal US and MR imaging is to establish the correct diagnosis for potential treatment. There are multiple conservative treatments possible for uterine fibroids, in contrast to debilitating extensive adenomyosis, for which hysterectomy is the only definitive treatment. The second goal is to determine the extent and depth of myometrial penetration for conservative treatment (endometrial ablation). The third goal is to monitor the evolution of the disease during conservative therapy (26–30). There is no characteristic vascular pattern observed at color and power Doppler US.
Transvaginal US Appearance of Diffuse Adenomyosis.—
The heterogeneous appearance of the myometrium includes uterine enlargement and asymmetry of the anterior or posterior myometrial wall. The heterogeneous appearance reflects the infiltrative process of islands of heterotropic endometrial tissue that are scattered diffusely throughout the myometrium and that are poorly demarcated from the surrounding myometrium (28,29) (Fig 11). In addition, subendometrial tiny cysts or nodules can be seen in diffuse adenomyosis (30). The appearance of these cysts and nodules reflects cyclic functions of ectopic endometrial glands. The presence of myometrial cysts (in up to 50% of cases) is highly specific for adenomyosis (29) (Fig 12).
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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.
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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.
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Transvaginal US Appearance of Focal Adenomyosis (Adenomyoma).—
The characteristic US appearance of focal adenomyosis (adenomyoma) is the presence of an echogenic mass with ill-defined borders. These conglomerations of endometrial tissue are often difficult to recognize. Color and power Doppler US demonstrate the penetrating vascular pattern within the mass and facilitate making the diagnosis of focal adenomyoma (31) (Fig 13).
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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.
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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.
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Differentiation of Adenomyoma from Fibroids with Transvaginal US.—
The echogenicity of the mass, its border characteristics, and its vascular pattern are the three distinguishing features that can be used to differentiate adenomyoma from fibroids. In an adenomyoma, the echogenicity of the mass is increased compared with the surrounding myometrium. The border of the mass is poorly defined, and vascularity is seen inside the mass (penetrating pattern). In contrast, fibroids manifest as hypoechoic masses with well-defined borders. Vascularity in the fibroid is seen only in the periphery of the mass (draping pattern). It has been suggested that color and power Doppler analysis optimized for slow flow is the most effective technique for differentiating adenomyoma from fibroids with transvaginal US.
The overall sensitivity and specificity of transvaginal US for the diagnosis of adenomyosis are 80%–86% and 50%–96%, respectively(30). The technique has an accuracy ranging from 68% to 86% in different studies (30).
MR Imaging of Diffuse Adenomyosis.—
The diffuse form of adenomyosis is characterized by enlargement of the uterus with diffuse thickening of the endometrial-myometrial junction (junctional zone), which has low signal intensity on T2-weighted MR images. The normal width of the junctional zone is up to 8 mm. Widening of the junctional zone from 8 mm up to 12 mm is suggestive of focal adenomyosis, whereas a junc-tional zone that is 12 mm wide or greater is diagnostic of diffuse adenomyosis. The low-signal-intensity thickening of the junctional zone represents pathologic hypertrophy of smooth muscle surrounding islands of heterotropic endometrial glands (30,32–37) (Fig 14).
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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.
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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.
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MR Imaging of Focal Adenomyosis (Adenomyoma).—
The diagnostic features of focal adenomyosis are the presence of oval, ill-defined, low-signal-intensity masses (ie, adenomyomas) on T2-weighted MR images (36). Bright, tiny foci, either linear or round, within the masses are often noticed on T1- or T2-weighted images (Fig 15). High-signal-intensity foci on T1-weighted images represent hemorrhages, whereas high-signal-intensity foci on T2-weighted images correspond to dilated endometrial glands in the secretory phase (35,37,38).
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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).
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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).
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Differentiation of Adenomyoma from Fibroids with MR Imaging.—
MR imaging is highly accurate and more sensitive than transvaginal US in differentiating adenomyoma from fibroids. Focal thickening of the junctional zone greater than 12 mm is diagnostic for adenomyoma, whereas an oval, well-defined mass in the myometrium, separate from the junctional zone, with low signal intensity on T1- and T2-weighted MR images, is characteristic of fibroids (Figs 16, 17). Gadolinium-enhanced T1-weighted sequences do not give information that is useful in the diagnosis of adenomyosis or differentiation from fibroids.
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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.
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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.
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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.
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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).
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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).
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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).
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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).
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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).
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The overall sensitivity of MR imaging in the diagnosis of adenomyosis is 88%–93%, specificity is 66%–91%, and accuracy is 85%–90% (29).
Treatment
Therapy for adenomyosis usually begins with conservative medical treatment, including administration of hormones and analgesics. Surgical treatments include endometrial ablation, laparoscopy, or lesion excision. Uterine artery embolization is a recent, emerging therapy for adenomyosis as well. The only definitive treatment for adenomyosis, however, is total hysterectomy (27).
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Pelvic Congestion Syndrome
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Pelvic congestion syndrome is a common cause of chronic pelvic pain. First described by Richet in 1857, the symptoms of chronic dull pelvic pain, pressure, and heaviness are often a result of dilated, tortuous, and congested veins produced by retrograde flow through incompetent valves in ovarian veins (39–41) (Fig 18).
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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.
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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.
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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.
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The prevalence of pelvic congestion syndrome is closely related to the frequency of ovarian varices, which occur in 10% of the general population of women (39). Within this group of patients, up to 60% may develop pelvic congestion syndrome (40). In general, pelvic congestion syndrome is considered an underdiagnosed cause of chronic pelvic pain because of the nonspecificity of the observations made with conventional imaging. However, with recent advances in imaging technology, a substantial number of women can expect to benefit from an accurate diagnosis (41).
Pathophysiology
The pathogenesis of pelvic congestion syndrome is most likely multifactorial. Pelvic congestion syndrome may result from obstructing anatomic anomalies such as a retroaortic left renal vein, left ovarian vein congestion secondary to compression of the left renal vein by the superior mesenteric artery (nutcracker phenomena), or right common iliac vein compression. Secondary congestion may be seen with a number of different disorders, including valvular incompetence, portal hypertension, or acquired inferior vena cava syndrome (41–44). Risk factors for pelvic congestion syndrome may include hereditary factors, hormonal influence, pelvic surgery, retroverted uterus, a history of varicose veins, and multiple pregnancies. Associated findings of cystic ovaries are found in over 50% of cases (45) (Fig 19).
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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.
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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.
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Symptoms
Patients with pelvic congestion syndrome report a deep, prolonged dull ache, often associated with movement, posture, and activities that increase abdominal pressure. The pain may be unilateral or bilateral and often is asymmetric; it is chronic, has no obvious source, and may be associated with dyspareunia (71% of cases), dysmenorrhea (66%), and postcoital ache (65%). Rectal discomfort and increased urinary frequency may also be reported. Physical findings suggestive of the diagnosis include varicose veins (in the vulva, buttocks, and legs) and ovarian point tenderness upon palpation (41,45).
Imaging Appearance
Imaging is critical in the evaluation of pelvic varicose veins. Several imaging modalities can be used to diagnose pelvic congestion syndrome accurately. Direct visualization of tortuous and dilated ovarian veins with venography is considered to be the standard reference for accurate diagnosis of pelvic congestion (Fig 20).
There are several methods for opacifying these dilated vessels. They include selective catheterization of ovarian veins, transuterine injection of contrast material, and direct injection of contrast material into vulval varices. These techniques are rarely used now, however, because they are invasive and expose the patient, especially those of child-bearing age, to ionizing radiation (42–44,46). The newer noninvasive modalities, such as US, CT, and MR imaging, have nearly replaced venography for diagnostic investigation of pelvic varicose veins (44).
Transvaginal US.—
The initial modality used for patients with pelvic pain is US. Pelvic varices can be identified by using transvaginal US with color Doppler and Doppler spectral analysis. The diagnosis of ovarian and pelvic varices is established by the identification of multiple dilated tubular structures around the uterus and ovary with venous blood Doppler signal. There are three diagnostic criteria for establishing the diagnosis of pelvic congestion: (a) a tortuous pelvic vein with a diameter greater than 4 mm, (b) slow blood flow (about 3 cm/sec), and (c) a dilated arcuate vein in the myometrium that communicates between bilateral pelvic varicose veins (42).
The ovaries of women with pelvic congestion syndrome tend to have cystic components, ranging from a few cysts to polycystic ovary syndrome produced by estrogen overstimulation.
MR Imaging.—
MR imaging, as well as CT, are noninvasive methods used to diagnose pelvic varices. Pelvic varices are imaged as dilated, tortuous, enhanced tubular structures around the uterus and ovary, with possible extension into the broad ligament and pelvic sidewall. They can also involve the paravaginal venous plexus (43).
On T1-weighted MR images, pelvic varices have no signal intensity because of flow-void artifact; on gradient-echo MR images, the varices have high signal intensity. On T2-weighted MR images, they usually appear as an area of low signal intensity; however, hyperintensity or mixed signal intensity may also be noted, possibly because of the relatively slow flow through the vessels (44) (Fig 21). Three-dimensional T1 gradient-echo sequences performed after the intravenous administration of gadolinium are the most effective sequence for demonstrating pelvic varices. Blood flow in pelvic varices appears with high signal intensity.
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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.
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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.
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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.
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Treatment
Several treatments for pelvic congestion syndrome are currently available or under investigation. Medical treatment of the underlying disorder, such as a hormonal imbalance, may be possible with medroxyprogestrone or goserelin (GnRH analog) (45). Procedural treatments of pelvic congestion syndrome include laparoscopic transperitoneal ligation of ovarian veins and percutaneous coil embolization of the gonadal vein. Interventional treatment such as venous stent placement may also be used for anatomic anomalies (46–48).
Coil embolization of the gonadal vein is a safe technique that relieves pelvic pain in many patients with pelvic congestion syndrome. Various centers have technical success rates of 96%–99%, with few immediate or long-term complications. Of the few complications that have been reported, most are mild and usually do not require hospital admission for treatment. The reported rates of symptomatic relief have varied, but they are approximately 75%, with about 60% of patients experiencing complete resolution of symptoms (46–48) (Fig 22).
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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.
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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.
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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.
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Bilateral ligation of ovarian veins near their origin by means of a laparoscopic transperitoneal para-aortic approach has been explored as a treat-ment for pelvic congestion syndrome. In one prospective pilot study performed on 23 women in Italy, there was both complete remission of pain and absence of pelvic varicose veins for at least 12 months in all women (49).
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Rare Conditions
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Gartner Cysts
Gartner cysts are remnants of mesonephric (wolffian) ducts, which in women are present in the uterus, vagina, and hymen until the 3rd month of gestation and which give rise to the ureter. Remains of the Gartner duct may be detected in up to one-fourth of adult women, although Gartner cysts arise only in approximately 1%–2% of the population (50,51). Most Gartner cysts are small (<3 cm), and they are usually paravaginal and in the anterolateral position; however, they can be large and cause urethral or even ureteric obstruction. Infrequently, an ectopic ureter can also terminate in a Gartner cyst.
Diagnosis of a Gartner cyst with transvaginal US and MR imaging relies on identification of the location and cystic nature of the lesion. On T1-weighted images, Gartner cysts typically exhibit high signal intensity because of the proteinaceous nature of the cystic fluid. Gartner cysts are treated with surgical resection (52) (Fig 23).
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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).
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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).
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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).
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Periurethral Cysts and Urethral Diverticula
Tubuloalveolar mucous glands known as periurethral glands drain into the urethra. Congenital dilatation of periurethral glands may form cysts, which are often asymptomatic. Symptomatic infection of these cysts or of normal periurethral glands can result in urethral diverticula. Patients often complain of pain, urinary urgency, frequency of urination, recurrent urinary tract infections, dribbling after urination, or even incontinence. Traditional imaging techniques are limited in the diagnosis of lesions that are continuous with the urethral lumen. Differentiation between a urethral diverticulum and a periurethral cyst can be challenging, but the distinction is crucial because the surgical procedures for treating the two entities are different. Both lesions require surgery. Diverticula, but not cysts, require a urethral reconstruction. Common complications of untreated urethral diverticula include recurrent infection, calculi, and carcinoma (53,54).
MR imaging is emerging as an important imaging technique in the evaluation of female urethral and periurethral regions in symptomatic patients. MR imaging is superior to transvaginal US for demonstrating abnormalities in these areas. The fine details of periurethral masses are
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Abstract
LEARNING OBJECTIVES FOR TEST...
