Pelvic Inflammatory Disease: Figure 8-4

Pelvic Inflammatory Disease
PID should be considered in patients who also have fever, leukocytosis, and cervical
motion tenderness. Patients with acute salpingitis typically have bilateral adnexal
pain.5 Right upper quadrant pain caused by inflammation around the liver may
occasionally occur in patients with PID (Fitz-Hugh–Curtis syndrome). PID is usually
an ascending infection caused by Neisseria gonorrhea, Chlamydia trachomatis, or
superinfecting organisms from the vagina. Sonographic findings of the fallopian tubes
are the most specific and conspicuous indicators of PID (Figure 8-4). With
progression of disease, there is exudation of pus from the distal fallopian tube, and
the ovary can become involved. If a separate ovary is still visualized, this indicates a
tuboovarian complex. A tuboovarian abscess results in complete breakdown of
tubal and ovarian architecture so that separate structures are no longer identified.
If CT or MRI is performed, a pelvic abscess usually appears as a peripherally

enhancing fluid collection (Figure 8-5) and may contain gas. CT can demonstrate
haziness and stranding within pelvic fat with obscura- tion of fascial planes and
thickening of local ligamentous structures. MRI may reveal high signal on T2-
weighted imaging corresponding to areas of inflammation within the parametrial soft
tissues or the mesenteries of adjacent bowel loops in the pelvis.
Ultrasound
In the early stages of PID, US may be normal, and hence a normal US in a patient
with clinical suspicion of PID does not exclude the diagnosis. The presence of free
fluid in the cul-de-sac or pouch of Douglas (see Figure 10-1, B) is also not a specific
sign of PID and may be present in other conditions such as follicular rupture, ovarian
cyst, malignancy, or ectopic pregnancy, in addi- tion to other nongynecologic causes
of fluid.9 Fifty per- cent of patients with PID may demonstrate free fluid in the cul-
de-sac that appears anechoic and may be small in quantity. With inflammation, there
is dilation of the tube with formation of a hydrosalpinx or pyosalpinx. As the disease
progresses, the ovary can become involved and enlarges with loss of corticomedullary
distinction. When the ovary adheres to the tube, it forms a tuboovarian complex. A
tuboovarian abscess (TOA) is caused by complete breakdown of ovarian and tubal
architecture without the ability to differentiate them. TOA may appear as a
homogenous, hypoechoic cystic mass or a mass containing mixed echogenicity areas
(Figure 10-2). Septae within this mass may appear thickened and asymmetric.
Chronic Pelvic Inflammatory Disease
In chronic pelvic inflammatory disease (PID) the acute inflammation subsides, but if
the tubes are occluded, they can give rise to hydrosalpinx. US findings of a hydrosal-
pinx include a dilated fluid-filled tubular structure that is often convoluted in
appearance and may have a “cog- wheel” appearance or the “beads-of-string” sign as
a result of thickened endosalpingeal folds.17 The dilated fallopian tube folds on itself
to form a sausage-like C- or S-shaped cystic mass (Figure 11-6).17 US has a high
sensitivity of 86%, specificity of 98%, and accuracy of 98% for diagnosis of
hydrosalpinx.18
Pelvic adhesions can be related to CPP, although it is not clear whether they can
cause it per se or are merely a manifestation of other processes like endometriosis and
PID. Specific indicators of pelvic fibrosis or the “frozen pelvis” have not been
described on US. The “freely mobile” pelvis, however, was defined by Okaro et al.19
as free glid- ing of the ovary over the internal iliac vessels when gentle pressure was
applied; fixed position of one or both ovaries was defined as lack of free movement
of the ovary. In their series, none of the normal patients had nonmobile ovaries
compared with the patients with pelvic adhesions.19
Computed Tomography
CT provides a more limited assessment of the uterus and ovaries compared with the
superior tissue resolution of US and MRI, but it is extremely valuable assessing extra-
gynecologic pelvic organs like the bowel, urinary system, lymph nodes, and
vasculature. CT is also better if upper abdominal organ assessment is necessary, as in
inflammatory bowel disease (IBD) or cancer staging. Within the limitations of CT
are elevated cost, use of radiation, and the frequent need for intravenous contrast.

CT is increasingly ordered as an initial examination in patients who present with
abdominal or pelvic pain. Although CT is often sensitive for pelvic pathology, it may
not be as specific as TVUS, and US is often obtained after an abnormal CT study to
better delineate the pathology.
As seen with US, noncomplicated acute PID may present with a normal CT scan or
have a small amount of fluid or fat stranding in the cul-de-sac.14 As the disease
progresses, imaging findings seen are similar to those on US and include (1) enlarged
ovaries with a polycystic appearance, (2) enhancing and dilated endocervical and
endometrial cavities with hypodense fluid collections, (3) pyosalpinx, seen as a
serpiginous or tubular structure, and (4) TOA appearing as a complex fluid collection
with thick walls, internal septations, and/or fluid–debris levels in the adnexal area
(Figure 10-8). Gas is infrequently seen in the fluid collections but when present is a
specific sign of infection.15 Other findings include anterior displacement of the
mesosalpinx, uterosacral ligament thickening, presacral and periovarian fat stranding,
loss of normal fat planes, and paraaortic lymphadenopathy near the level of the renal
hila.15 Reactive inflammation of surrounding structures may be seen, including a small
or large bowel ileus, hydronephrosis or hydroureter, peri- tonitis with peritoneal
enhancement, and right upper quadrant inflammation, also called Fitz-Hugh–Curtis
syndrome.
CT has a leading role in the aspiration or drainage of fluid collections. In their study,
Gjelland et al.16 dem- onstrated a 93.4% response to primary drainage of pelvic
abscesses. Success rates usually vary between 86% and 100%. Abscesses can be
drained by transabdominal, transvaginal, transgluteal, and transrectal routes. Route
of choice depends on the access to the abscess; however, the majority of drainage
procedures are car- ried out by either the transabdominal or transgluteal route.
CT is not specific for the diagnosis of chronic PID; however, with the increasing
use of CT as the first imaging modality in patients with abdominal pain, PID can be
diagnosed on CT as well. Mild cases may have a normal CT scan; however, other
findings seen include hydrosalpinx, pyosalpinx, enlarged polycystic-appearing
ovaries, and tuboovarian abscesses (Figure 11-11).26
Magnetic Resonance
MRI is particularly helpful in characterization of ovarian masses indeterminate on US.
MRI has a high sensitivity and specificity rate of 95% and 98%, respectively, with an
overall accuracy rate of 93%.23,24
MRI of the pelvis is an excellent imaging modality for the assessment of the pelvic
organs, providing the best tissue contrast combined with the benefits of the use of
intravenous contrast media.Within the disadvantages are elevated cost and
contraindication for the use of intravenous contrast (gadolinium) in patients with
acute or chronic renal failure.

Normal fallopian tubes are not usually seen on MRI unless they are outlined by
fluid.38 On MRI, hydrosalpinx is seen as a fluid-filled tubular structure arising from
the upper lateral margin of the uterine fundus and separate from the ipsilateral ovary
(Figure 11-16).39 The multiplanar capability of MRI helps determine whether a
multilocular cystic structure in the pelvis is a hydrosalpinx or is arising from the
ovary, suggesting an ovarian tumor.38 Identification of an ipsilateral ovary that is
separate from a lesion helps in the differential diagnosis of hydrosalpinx and other
extra- ovarian masses.39

TOA can be confused with an ovarian neoplasm on TVUS. The multiplanar
capability of MRI with the superior tissue characterization and contrast capability
can help differentiate between a malignant ovarian lesion and TOA. Specific
features of an inflammatory lesion include a mass with an ill-defined border, presence
of an ill-defined hyperintensity around the mass on T2-weighted images, diffuse
thickening of the bowel wall, fat stranding, and adhesions.25 The mass may appear
cystic or solid. Sig- nal intensity is usually mixed with high signal on the T1-weighted
images, usually indicative of blood or pus. Signal voids within the mass usually
indicate gas. Other findings seen in PID on MRI include fluid in the cul- de-sac,
which appears homogenously hyperintense on T2-weighted images if simple and
heterogeneous in presence of pus. Dilated fallopian tubes appear as tortuous,
tubular, and fluid-filled structures with mucosal plicae within them (Figure 10-15).26
DIFFERENTIAL DIAGNOSIS
From Clinical Presentation
l Appendicitis l Ectopic pregnancy l Ovarian torsion l Diverticulitis l Hemorrhagic
ovarian cyst
l PID/TOA l Crohn’s disease l Renal colic l Fibroids
From Imaging Findings

The majority of inflammatory and infectious diseases of the gastrointestinal tract can
mimic disease of the ovaries. Careful assessment using US and CT will usually allow
for a specific diagnosis. Ectopic pregnancy is diagnosed using a combination of US
findings and blood levels of β-hCG. Renal colic has a distinctive appearance.

Pelvic Inflammatory Disease: Figure 8-4

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Pelvic Inflammatory Disease

If CT or MRI is performed, a pelvic abscess usually appears as a peripherally