Pelvic Sir Work

Pelvic inflammatory Radiographic features
Imaging features are often non-specific but are

disease disproportionate to what may be apparent from
Pelvic inflammatory disease (PID) is a broad symptoms. If imaged early (e.g. during the
term that encompasses a spectrum of infection cervicitis stage), there may be no finding. If
and inflammation of the upper female genital imaged very late, there may be an adnexal
tract, resulting in a range of abnormalities. mass-like region with surrounding inflammatory
change, and the fallopian tube and ovary may
Epidemiology not be distinguished.
The highest incidence is seen among sexually- Other associated findings include 7:
active women in their teens, with 75% of cases  soft-tissue stranding and infiltration of
being under 25 years of age. In the United pelvic floor fascial planes
States, approximately 1 million females are  thickening of uterosacral ligaments
thought to be afflicted with pelvic inflammatory Ultrasound
disease per year, and nearly 275,000 of them Ultrasound is usually the first imaging ordered in
are believed to be hospitalised 7. a case of lower abdominal pain.
Clinical presentation Early findings in PID include 12 :
 indistinct uterine margins
More common presentations include acute
pelvic pain (of variable intensity), cervical motion  echogenic pelvic fat
tenderness, vaginal discharge, fever,  fallopian tube thickening
dyspareunia, and leucocytosis. Right upper Few non-specific findings include 8:
quadrant pain from perihepatitis in Fitz-Hugh-  fluid in cul-de-sac
Curtis syndrome is possible.  fluid in endometrial cavity
 increased ovarian volumes
Pathology  increased thickness and vascularity of
PID is defined as an acute clinical syndrome the endometrium
associated with ascending spread of micro- In the most severe cases, ultrasound may show
organisms, unrelated to pregnancy or surgery. adnexal masses with a heterogeneous echo-
The infection generally ascends from pattern.
the vagina or cervix (cervicitis) to Some sonographic signs associated with tubal
the endometrium (endometritis), then to inflammation include:
the fallopian  thickened/dilated fallopian tubes
tubes (salpingitis, hydrosalpinx, pyosalpinx), and o incomplete septa in the tube
then to and/or contiguous structures o fluid collection within the tubes
(oophoritis, tubo-ovarian abscess, peritonitis). (hydrosalpinx)
o increased vascularity around the
PID can result from a number of causative tube on colour Doppler
organisms: o the fat around the tube may be
 common echogenic and there may be a small
o Chlamydia trachomatis: pelvic amount of reactive free fluid in the
chlamydial infection pelvis
o Neisseria gonorrhoeae: pelvic o echogenic fluid in the tube
gonococcal infection (pyosalpinx)
o polymicrobial infection: can account  results from adhesions causing
for ~35% of cases 3 tubal obstruction
 less common  cogwheel sign
o Mycobacterium tuberculosis: pelvic  beads on a string sign
tuberculous infection
o Actinomyces spp.: pelvic
actinomyces infection
CT
PID is usually bilateral, except when it is caused tubular adnexal "mass"
by the direct extension of an adjacent
inflammatory process such as appendiceal,
diverticular, or post-surgical abscesses.
 fallopian tube thickening of >5 mm with
enhancing wall: has high specificity of
95%
 indistinct uterine border
 thickening of the uterosacral ligaments
 complex free fluid in the pouch of
Douglas (cul-de-sac)
 pelvic fat stranding or haziness
 reactive lymphadenopathy
o lymph nodes in the para-aortic and
paracaval regions often become
prominent due to infection draining
into lymphatics along the course of
the gonadal veins
MRI
May show an ill-defined adnexal mass
containing fluid with various signal intensities:
 T1: if there is proteinaceous debris in a
dilated tube, then it may have increased
T1 signal
 T1+C (Gd): wall and surrounding
tissues may enhance
Treatment and prognosis
In the absence of complications, PID is often
treated conservatively with education,
antibiotics, and partner tracing.
Complications
 tubo-ovarian abscess
 pyosalpinx
 infertility due to tubal adhesions
 ectopic pregnancy
 chronic pelvic pain 11
 peritonitis
 ovarian vein thrombosis
 peritoneal adhesion
formation causing bowel obstruction
 Fitz-Hugh-Curtis syndrome
Differential diagnosis
fallopian tube carcinoma
o rare
o consider in a patient without risk
factors for PID and/or a patient in
whom a course of antibiotics did not
resolve the PID
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Pelvic inflammatory Radiographic features

Imaging features are often non-specific but are

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