Transvaginal sonographic markers of tubal inflammatory disease

ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update

This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (β-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative β-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive β-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative β-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Systematic, noninvasive endometriosis diagnosis in transvaginal sonography by the Swiss Society of Ultrasound in Medicine

We present a new systematic, comprehensive, checklist-based sonographic assessment of endometriosis in the female true pelvis. Emphasis is placed on practical skills teaching. The newly introduced White Sliding Line (WSL) is the core structure. The WSL separates five compartments (anterior, central, posterior, and lateral right and left) containing dedicated endometriosis signs of mobility and morphology to be checked. This approach relies on the 2016 IDEA Consensus and further developments. It directly connects to the 2021 #ENZIAN Classification Standard. In practice, evaluation follows the proposed checklist in all compartments, judging first sliding mobility between organs and structures in a highly dynamic investigation. A rigorous search for deep endometriosis (DE) is then performed. We treat adhesions due to their great clinical importance and possible, reliable diagnosis by TVS as the fifth endometriosis unit, next to endometrioma, DE, adenomyosis, and superficial endometriosis. Including superficial (peritoneal) endometriosis is a future goal.

The 'onion skin' sign of a low-grade appendiceal mucinous neoplasm: An incidental finding during early pregnancy assessment

A low-grade appendiceal mucinous neoplasm (LAMN) is a cystic dilatation of the appendix resulting from the accumulation of mucinous secretions caused by a luminal obstruction. Although usually benign, pseudomyxoma peritonei may occur in the event of rupture, and 10% of cases may be secondary to appendiceal cystadenocarcinoma. A LAMN is both more common and more likely to have a malignant association in women, making it an entity with which practitioners of gynaecological ultrasound should be familiar. Although not the primary aim, early pregnancy ultrasound assessments can offer the diagnostic opportunity to identify pelvic pathology. A LAMN can be identified on ultrasonography by visualisation of an adnexal mass separate to the ovary, which due to the layers of secretions has a distinctive appearance previously likened to 'onion-skin' or 'whipped-cream'. Here, we describe an incidental finding of a LAMN during an early pregnancy assessment. Practitioners of early pregnancy ultrasound should be familiar with the characteristic morphology of this rare but important finding.

Ureterocele as differential diagnosis of hydrosalpinx-an interesting case from the clinical practice

Hydrosalpinx is a common condition in women of reproductive age that correlates with infertility. A ureterocele is a dilatation of the terminal ureter within the bladder and/or urethra that occurs seldomly in adults, but can sonographically be mistaken for a hydrosalpinx. We report of a 29-year-old patient (G2/P1) who was referred in our department with secondary infertility and suspicion of hydrosalpinx. Intraoperatively, no hydrosalpinx could be visualized. Postoperatively, an intravesical cystic mass was detected, alongside a second-degree urinary retention. Sonographically, a double kidney on the left side and an accentuated calyx system could be diagnosed. Ureteroceles seem to represent a rare but still possible differential diagnosis in suspected hydrosalpinx, given the similar sonographic presentation of both conditions.

Advantages and Limitations of Ultrasound as a Screening Test for Ovarian Cancer

Ovarian cancer (OC) is the seventh most common malignancy diagnosed among women, the eighth leading cause of cancer mortality globally, and the most common cause of death among all gynecological cancers. Even though recent advances in technology have allowed for more accurate radiological and laboratory diagnostic tests, approximately 60% of OC cases are diagnosed at an advanced stage. Given the high mortality rate of advanced stages of OC, early diagnosis remains the main prognostic factor. Our aim is to focus on the sonographic challenges in ovarian cancer screening and to highlight the importance of sonographic evaluation, the crucial role of the operator΄s experience, possible limitations in visibility, emphasizing the importance and the necessity of quality assurance protocols that health workers have to follow and finally increasing the positive predictive value. We also analyzed how ultrasound can be combined with biomarkers (ex. CA-125) so as to increase the sensitivity of early-stage OC detection or, in addition to the gold standard examination, the CT (Computed tomography) scan in OC follow-up. Improvements in the performance and consistency of ultrasound screening could reduce the need for repeated examinations and, mainly, ensure diagnostic accuracy. Finally, we refer to new very promising techniques such as liquid biopsies. Future attempts in order to improve screening should focus on the identification of features that are unique to OC and that are present in early-stage tumors.

Superinfection of Rectovaginal Endometriosis: Case Report and Review of the Literature

BACKGROUND

A peculiar complication of endometriosis is a superinfection. However, the superinfection of extra-ovarian endometriosis is anecdotal, and only a few cases have been described. We wanted to present the first cases of the superinfection of rectovaginal endometriosis and to perform a literature review of the superinfection of extra-ovarian endometriosis.

METHODS

We present a case of a 24-year-old woman who was referred to our Pelvic Floor Unit for rectal-perineal pain, dyspareunia, and recurrent episodes of dense purulent vaginal discharge for one year, in which the superinfection of rectovaginal endometriosis was diagnosed. Moreover, we performed a systematic search of the literature indexed on PubMed up to 31 January 2023.

RESULTS

Laparoscopic drainage was successful in managing this condition. In the literature, clinical presentation and instrumental and microbiological findings are very heterogeneous. However, the gold standard of management is represented by surgical or percutaneous drainage.

CONCLUSIONS

In the case of a pelvic abscess, the superinfection of endometriosis lesions should be suspected, and this can represent the onset symptom of endometriosis. Ultrasonography may show nodular or flat hypoechoic lesions with hyperechoic debris and peripheral positive color/power Doppler intensities. The goal of management is to drain the abscess, either percutaneously or via traditional surgery, followed by proper hormonal therapy to reduce recurrence.

Basic Gynecologic Ultrasound Examination (Level I): DEGUM, ÖGUM, and SGUM Recommendations

Ultrasound has become an essential diagnostic tool in gynecology, and every practicing gynecologist must be able to differentiate normal from pathologic findings, such as benign or malignant pelvic masses, adnexal torsion, pelvic inflammation disease, endometriosis, ectopic pregnancies, and congenital uterine malformations at least on a basic level. A standardized approach to the correct settings of the ultrasound system, the indications for gynecologic ultrasound investigations, and the sonographic appearance of normal anatomy and common pathologic findings in the standard planes are important prerequisites for safe and confident clinical management of gynecologic patients. Based on current publications and different national and international guidelines, updated DEGUM, ÖGUM, and SGUM recommendations for the performance of basic gynecologic ultrasound examinations were established.

Transvaginal Ultrasound Accuracy in the Hydrosalpinx Diagnosis: A Systematic Review and Meta-Analysis

Hydrosalpinx is a condition with a crucial prognostic role in reproduction, and its diagnosis by a non-invasive technique such as ultrasound is key in achieving an adequate reproductive assessment while avoiding unnecessary laparoscopies. The aim of the present systematic review and meta-analysis is to synthetize and report the current evidence on transvaginal sonography (TVS) accuracy to diagnose hydrosalpinx. Articles on the topic published between January 1990 and December 2022 were searched in five electronic databases. Data from the six selected studies, comprising 4144 adnexal masses in 3974 women, 118 of which were hydrosalpinxes, were analyzed as follows: overall, TVS had a pooled estimated sensitivity for hydrosalpinx of 84% (95% confidence interval (CI) = 76-89%), specificity of 99% (95% CI = 98-100%), positive likelihood ratio of 80.7 (95% CI = 33.7-193.0), and negative likelihood ratio of 0.16 (95% CI = 0.11-0.25) and DOR of 496 (95% CI = 178-1381). The mean prevalence of hydrosalpinx was 4%. The quality of the studies and their risk of bias were assessed using QUADAS-2, evidencing an overall acceptable quality of the selected articles. We concluded that TVS has a good specificity and sensitivity for diagnosing hydrosalpinx.

Identification and Treatment of Acute Pelvic Inflammatory Disease and Associated Sequelae

Pelvic inflammatory disease (PID) is an ascending polymicrobial infection of the upper female genital tract. The presentation of PID varies from asymptomatic cases to severe sepsis. The diagnosis of PID is often one of exclusion. Primary treatment for PID includes broad-spectrum antibiotics with coverage against gonorrhea, chlamydia, and common anaerobic and aerobic bacteria. If not clinically improved by antibiotics, percutaneous drain placement can promote efficient source control, as is often the case with large tubo-ovarian abscesses. Ultimately, even with treatment, PID can result in long-term morbidity, including chronic pelvic pain, infertility, and ectopic pregnancy.

Study of fallopian tube anatomy and mechanical properties to determine pressure limits for endoscopic exploration

Falloposcopy is the endoscopic examination of the fallopian tubes, which are challenging to access due to their deep body location, small opening from the uterus, and lumen filled with plicae. We and others have developed endoscopes that are inserted through the uterus guided by a hysteroscope into the tubal ostium. To better understand how to utilize these endoscopes either as standalone devices or in concert with everting delivery balloons, a preliminary study of anatomy and mechanical behavior was performed ex vivo on porcine and human fallopian tubes. Segments of fallopian tubes from the isthmus, ampulla and infundibulum were inflated with saline either to bursting or held at sub-burst pressures with saline or a saline-filled balloon. Formalin fixed, paraffin embedded tissue sections stained with Masson's trichrome were examined for damage to the mucosa and muscularis. Porcine fallopian tubes tolerated saline pressurization at 15 psi for 1 minute without morphological damage. Balloon inflation to 15 psi caused no apparent damage to the muscle layer or rupture of the fallopian tube, but balloon movement within the tube can denude the mucosal epithelial layer. Human fallopian tubes averaged higher burst pressure values than porcine tubes. Under pressurization, the external tube diameter expanded by minimal to moderate amounts. Human and porcine tissues were similar in histological appearance. These studies suggest that moderate pressurization is acceptable but will not appreciably expand the fallopian tube diameter. The results also indicate that pigs are a reasonable model to study damage from falloscopy as seen in human tissue.

Imaging of Endometriosis: The Role of Ultrasound and Magnetic Resonance

Endometriosis is a chronic gynecological disease characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus. It causes pelvic pain, dysmenorrhea, dyspareunia, or infertility. Diagnosis requires a combination of clinical history, non-invasive and invasive techniques. The aim of the present review was to evaluate the contribution of imaging techniques, mainly transvaginal sonography and magnetic resonance imaging to diagnose different locations and for the most appropriate treatment planning. Endometriosis requires a multidisciplinary teamwork to manage these patients clinically and surgically.

Indirect and atypical imaging signals of endometriosis: A wide range of manifestations

Background

Whilst some imaging signs of endometriosis are common and widely accepted as ‘typical’, a range of ‘subtle’ signs could be present in imaging studies, presenting an opportunity to the radiologist and the surgeon to aid the diagnosis and facilitate preoperative surgical planning.

Objective

To summarise and analyse the current information related to indirect and atypical signs of endometriosis by ultrasound (US) and magnetic resonance imaging (MRI).

Methods

Through the use of PubMed and Google scholar, we conducted a comprehensive review of available articles related to the diagnosis of indirect signs in transvaginal US and MRI. All abstracts were assessed and the studies were finally selected by two authors.

Results

Transvaginal US is a real time dynamic exploration, that can reach a sensitivity of 79-94% and specificity of 94%. It allows evaluation of normal sliding between structures in different compartments, searching for adhesions or fibrosis.

MRI is an excellent tool that can reach a sensitivity of 94% and specificity of 77% and allows visualisation of the uterus, bowel loop deviation and peritoneal inclusion cysts. It also allows the categorisation and classification of ovarian cysts, rectovaginal and vesicovaginal septum obliteration, and small bowel endometriotic implants.

Conclusion

The use of an adequate mapping protocol with systematic evaluation and the reporting of direct and indirect signs of endometriosis is crucial for detailed and safe surgical planning.

Tubo-ovarian abscess: A proposed new scoring system to guide clinical management

OBJECTIVE

To create a risk scoring system comprised of clinical and radiological characteristics that can predict the likelihood of antibiotic treatment failure of tubo-ovarian abscesses. The score should guide clinicians in identifying patients to whom early intervention should be offered instead of a prolonged trial of antibiotics.

METHODS

A multicenter, retrospective cohort study carried out between January 1, 2013 and September 30, 2019, identified consecutive patients with tubo-ovarian abscess. Using a chronological split, patients were allocated to two groups for the development and subsequent validation of the postulated scoring system. Univariate and bivariate analyses were performed to identify statistically significant variables for the failure of intravenous antibiotic treatment.

RESULTS

In total, 214 consecutive patients with tubo-ovarian abscesses were identified. Data from the first 150 patients were used for the development of the postulated scoring system; data from the subsequent 64 patients were used for validation. Statistically significant clinical features between those having successful and unsuccessful management were: temperature (median = 37.1℃ vs 38.2℃, P = 0.0001), C-reactive protein (151 mg/L vs 243 mg/L, P = 0.0001), and tubo-ovarian abscess diameter (6.0 cm vs 8.0 cm, P = 0.0001). These parameters were used to create a risk prediction score. A score of four or more was predictive of requiring surgical/radiological intervention of tubo-ovarian abscess (P < 0.001). The score had a sensitivity of 69% and a specificity of 88%, with area under the curve (AUC) = 0.859.

CONCLUSION

Currently, there is no guidance for clinicians on when to operate on a tubo-ovarian abscess. Our prediction score is simple, using only three easily obtained clinical characteristics.

Minimally invasive approach to the management of tubo-ovarian abscesses

PURPOSE OF REVIEW

The purpose of this publication is to review the most up-to-date literature regarding the pathogenesis, diagnosis and management of tubo-ovarian abscesses.

RECENT FINDINGS

Prior to the advent of broad-spectrum antibiotics, tubo-ovarian abscesses necessitated total abdominal hysterectomy and bilateral salpingo-oophorectomy. Although it carries a risk of treatment failure, antibiotic therapy enabled fertility-sparing treatment for many women. Recent studies have identified key predictors for antibiotic treatment failure, including age, BMI and abscess diameter. C-reactive protein was also found to be a strong predictor of antibiotic treatment response. Given the growing evidence of treatment failure with antibiotic therapy alone, along with increased availability and access to interventional radiology, image-guided drainage with or without catheter placement, combined with broad-spectrum antibiotics, is now considered first-line therapy.

SUMMARY

Tubo-ovarian abscess is a diagnostic challenge, as presentation can vary. Inadequate treatment is associated with severe morbidity and mortality. Despite adequate conservative treatment, recurrence risk is high and clinical sequelae can have devastating effects on reproductive health. Recent evidence-based developments, including a risk score system to predict antibiotic failure, serve to provide appropriately directed risk-based care. However, large-scale randomized controlled trials are needed to clarify the most appropriate treatment modalities.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumors, including imaging techniques, biomarkers and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumours

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumours, including imaging techniques, biomarkers and prediction models.

ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumours and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised.

Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements.

This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumours and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on pre-operative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group, and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the pre-operative diagnosis of ovarian tumors, including imaging techniques, biomarkers, and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the pre-operative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the pre-operative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

Imaging spectrum of common and rare infections affecting the lower genitourinary tract

In this review, we will discuss the imaging findings of common as well as uncommon lower genitourinary tract infections. For both clinicians and radiologists, it is imperative to understand etiopathogenesis, epidemiological information, clinical presentation, imaging findings and management options of such conditions. Knowledge of salient imaging features of these infections is of utmost importance because prompt recognition enables appropriate management.

Imaging for evaluation of endometriosis and adenomyosis

Endometriosis and adenomyosis are two frequent diseases that impair women's quality of life by causing pain and infertility. Both endometriosis and adenomyosis are heterogeneous diseases that manifest as different forms. Adenomyosis may be described as diffuse adenomyosis, focal adenomyosis especially of the outer myometrium and cystic adenomyoma. Endometriosis has three phenotypes: superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). These two diseases are closely linked, and it is now clear that adenomyosis can either arise on its own or coexist with endometriosis. There is a strong clinical relationship between endometriosis and adenomyosis according to their respective phenotypes. Various classifications are available to describe both diseases. Transvaginal ultrasonography (TVUS) and/or pelvic magnetic resonance imaging (MRI) are the first examination performed when endometriosis or adenomyosis are suspected. These two imaging techniques, used in a combination manner, allow accurate description of both endometriosis and adenomyosis, to assess the diagnosis and to improve clinical and surgical care. In this review, we described the different imaging aspects of endometriosis and adenomyosis to help the less experienced radiologist or gynecologist in the diagnosis and evaluation of those diseases.

Effect of Recurrence of Hydrosalpinx after Tubal Ligation on the Outcome of In vitro Fertilization Treatment: A Retrospective Cohort Study

Objective:

The objective of the study was to evaluate the effects of recurrent hydrosalpinx after proximal tubal ligation and distal salpingostomy on the outcomes of in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment.

Materials and Methods:

Seven hundred and twenty-six patients with hydrosalpinx undergoing laparoscopic surgery before IVF were enrolled in the study. Five hundred and sixty-two patients treated with proximal tubal ligation and distal salpingostomy were included in Group A. One hundred and sixty-four cases managed with salpingectomy were grouped into Group B. Group A were further divided into two subgroups. One hundred and forty-six patients in Group A1 had a recurrence of hydrosalpinx. Four hundred and sixteen patients in Group A2 had no repetition of hydrosalpinx. We compared the pregnancy outcomes of their subsequent fresh embryo transfer cycles among the three groups.

Results:

There were no significant differences among the three groups in terms of age, body mass index (23.56 ± 3.27 vs. 23.13 ± 3.42 vs. 23.63 ± 3.73, P = 0.195), basal hormone level (7.03 ± 1.75 vs. 7.08 ± 2.26 vs. 7.44 ± 2.93, P = 0.195), antral follicle count (12.25 ± 5.92 vs. 12.63 ± 5.71 vs. 11.70 ± 4.98, P = 0.188), duration of gonadotropin (Gn) (11.19 ± 2.1 vs. 10.93 ± 1.84 vs. 10.79 ± 2.03, P = 0.182), consumption of Gn (2136.73 ± 855.65 vs. 1997.15 ± 724.72 vs. 2069.05±765.12 , P = 0.14), endometrial thickness (1.1 ± 0.27 vs. 1.1 ± 0.24 vs. 1.1 ± 0.17, P = 0.352), base follicle-stimulating hormone (6.21 ± 3.43 vs. 6.52 ± 3.20 vs. 5.89 ± 3.10, P = 0.1), number of embryos transferred (1.87 ± 0.36 vs. 1.83 ± 0.42 vs. 1.88 ± 0.37, P = 0.224), and number of high-grade embryos (3.77 ± 2.42 vs. 4.01 ± 2.72 vs. 4.17 ± 2.74, P = 0.41). No differences were detected in clinical pregnancy rate (50% vs. 54.8% vs. 50%, P = 0.439), the live birth rate (86.3% vs. 82.0% vs. 87.8%, P = 0.398), fertilization rate (64.1% vs. 64.4% vs. 64.7%, P = 0.928), and biochemical pregnancy rate (4% vs. 4.5% vs. 7%, P = 0.332) among the three groups.

Conclusion:

The recurrence of hydrosalpinx after tubal ligation does not affect the outcomes of IVF/ICSI. It is not necessary to worry about the effect of recurrent hydrosalpinx on pregnancy outcomes of IVF/ICSI that may due to the spread of inflammation through lymphatic circulation or blood circulation.

Differential Diagnosis of Endometriosis by Ultrasound: A Rising Challenge

Ultrasound is an effective tool to detect and characterize endometriosis lesions. Variances in endometriosis lesions’ appearance and distorted anatomy secondary to adhesions and fibrosis present as major difficulties during the complete sonographic evaluation of pelvic endometriosis. Currently, differential diagnosis of endometriosis to distinguish it from other diseases represents the hardest challenge and affects subsequent treatment. Several gynecological and non-gynecological conditions can mimic deep-infiltrating endometriosis. For example, abdominopelvic endometriosis may present as atypical lesions by ultrasound. Here, we present an overview of benign and malignant diseases that may resemble endometriosis of the internal genitalia, bowels, bladder, ureter, peritoneum, retroperitoneum, as well as less common locations. An accurate diagnosis of endometriosis has significant clinical impact and is important for appropriate treatment.

Algorithmic Approach to Sonography of Adnexal Masses: An Evolving Paradigm

BACKGROUND

Pelvic US remains the workhorse for detection and characterization of adnexal masses in most centers worldwide. While the differentiation of benign from malignant masses remains the foremost concern, it is imperative to narrow the differential diagnosis for management of benign masses as well as prognostication of malignant masses. The IOTA group as well as ACR have described a five category classification system for adnexal lesions based on morphological patterns. In addition, a six category risk stratification has been proposed, incorporating the probability of malignancy as well as management recommendations.

LEARNING OBJECTIVES

1) Understand pattern based approach to adnexal lesion classification and the possible entities fitting into each pattern with the help of illustrations. 2) Classify lesions into appropriate risk categories based on diagnostic algorithms provided at the end of each section.

Salpingovesical fistula mimicking an enterovaginal fistula

Fallopian tube fistula with the bladder can mimic an enterovaginal fistula. A 34-year-old woman presented with continuous urinary incontinence after hysterectomy. A cystogram confirmed a vesicovaginal fistula and a possible additional intestinal communication. Further imaging, however, ruled out an enterovaginal fistula and diagnosed a fallopian tube prolapse with salpingovesicovaginal fistula. This case demonstrates the importance of multiple imaging modalities in identifying and clearly delineating the anatomy of gynecologic fistulous connections. The case illustrates the fact that while salpingovesical fistula is a rare complication of hysterectomy, it is an important consideration in one's differential diagnosis.

[Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment]

Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment Abstract. The 'pelvic inflammatory disease' (PID) describes an ascending inflammation of the upper female genital tract, beginning with a local cervicitis and proceeding to endometritis and adnexitis. It is a common clinical picture with rising numbers in recent years, and it occurs both in gynaecological and general practice. The symptoms are often unspecific, discrete or althogehter lacking. In order to reduce long-term risks of chronic pelvic pain, sterility and/or ectopic pregnancies, rapid diagnosis followed by immediate therapy and a good interdisciplinary cooperation are necessary. Screening programs for chlamydia and gonococcus as the most common pathogens of PID have not yet been implemented in Switzerland so far.

Gynecologic Ultrasound Evaluation of the Nongravid Woman with Pelvic Pain

Pelvic pain is a common condition. Many underlying gynecologic and nongynecologic conditions can contribute to this symptom. Pelvic ultrasound using comprehensive 2-dimensional interactive imaging techniques as well as color Doppler and 3-dimensional imaging optimizes the detection of inciting etiologies.

Ultrasound Imaging in Endometriosis

Ultrasound examination is an indisputable imaging method in the diagnosis of endometriosis, as the first step in the detection, as the fundamental tool in planning the management, and as the best diagnostic instrument during surveillance of affected women. The aim of this article is to provide an update on the role of ultrasound in the detection, in the planning of medical and surgical treatment, and in the surveillance of patients with endometriosis.

[Follow-up and counselling after pelvic inflammatory disease: CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]

OBJECTIVES

To determine the procedures for follow-up and counselling of patients after pelvic inflammatory disease (PID).

METHODS

A search in the Cochrane database, PubMed, and Google was performed using keywords related to follow-up and PID to identify reports published between 1990 and 2018. All studies published in French and English relevant to the areas of focus were included. A level of evidence (LE) based on the quality of the data available was applied for each area of focus and used for the guidelines.

RESULTS

The rate of recurrent PID is 15 to 21%. They are related to a recurrent sexually transmitted infection (STI) in 20 to 34% of cases. Recurrence PID increase the risk of infertility and chronic pelvic pain (LE2). Follow-up is recommended after PID (grade C). The rate of patients lost to follow-up is around 40%. Follow-up is improved by personalized text message reminders (grade B). Vaginal sampling for detection of N. gonorrhoeae, C. trachomatis, (and M. genitalium) by nucleic acid amplification techniques is recommended 3 to 6 months after treatment of PID associated with STI to rule out possible reinfections (grade C). The use of condoms after PID associated with STI is recommended to reduce the risk of recurrences (grade C). The systematic use of contraceptive pills after PID is not recommended to prevent subsequent infertility and chronic pelvic pain. Vaginal sampling for microbiological diagnosis is recommended before the insertion of an intrauterine device (grade B). The risk of ectopic pregnancy is high in these women and must be kept in mind.

CONCLUSION

Patient counselling and microbiological testing after PID decrease the risk of STI and thus the recurrence of PID.

Ultrasonographic and multimodal imaging of pediatric genital female diseases

Ultrasonography is the first-line imaging modality in the evaluation of the female pelvis in childhood and adolescence, because it is easy to perform, non-invasive and it does not require sedation. The transabdominal approach is preferred in children and adolescents, after filling the bladder to move away the bowel loops from the pelvis. The probe frequency must be adapted to age, thickness of tissues and depth of the structures under examination. High-frequency (4-12 MHz) linear or convex probes are used in newborns; high-frequency linear probes (4-12 MHz) in toddler, convex 5-7.5 MHz probes in girls and convex 3.5-5 MHz probes in teenagers. In this article, the main pathological conditions of the genital female tract in pediatric age are examined, such as congenital anomalies, disorders of sex development, ovarian cysts, ovarian tumors, adnexal torsion, primary amenorrhea, precocious puberty and pelvic inflammatory disease.

Ultrasound of Pelvic Pain in the Nonpregnant Woman

Pelvic ultrasound with endovaginal ultrasound is often the imaging test of choice in the initial evaluation of nonpregnant women with pelvic pain. This article considers the sonographic observations and techniques useful in diagnosis of a variety of gynecologic causes of pelvic pain in these women, including ovarian hemorrhage, ovarian torsion, pelvic inflammatory disease, endometriosis (particularly deeply infiltrating endometriosis), endometriomas, adenomyosis, pelvic congestion syndrome, and malpositioned intrauterine contraceptive devices. Sonographic observations regarding a number of non-gynecologic causes of pelvic pain are also described.

Imaging of Female Pelvic Emergencies

Pelvic pain is a common complaint in female patients who present to the emergency department. Although encountered frequently, the path to a definitive diagnosis is not always a straightforward one, and imaging offers a valuable tool to aid in this diagnostic challenge. Radiologists must be familiar with the most common etiologies of female pelvic pain in the emergency setting, their imaging characteristics, and the best way to further evaluate challenging clinical presentations. This allows the radiologist to serve as a valuable asset to the treating physician, aiding in accurate diagnosis, and in guiding the course of treatment, all while ensuring the "Image Wisely" principle. A sonographic approach to female patients presenting to the emergency setting with pelvic pain has been presented in this article and some example entities along with their imaging findings have also been reviewed.

Emergent ultrasound evaluation of the pediatric female pelvis

Ultrasound is the primary imaging modality of the pediatric female pelvis and is often requested to evaluate girls with pelvic or abdominal pain or abnormal bleeding. The US interpretation can help guide the clinician toward medical or surgical management. Here we discuss the normal US anatomy of the female pelvis and illustrate, through case examples, conditions encountered when performing emergent pelvic US for common and uncommon clinical scenarios.

The imaging findings of typical and atypical genital and gynecologic infections

Genital and gynecologic infections are common medical problems, affecting millions of women worldwide. The spectrum of these infections extends from the labia, including processes such as necrotizing fasciitis and anogenital warts, to the upper reproductive tracts in conditions including endometritis and pelvic inflammatory disease. Although often a clinical diagnosis, the radiologist plays an important role in determining the etiology of acute abdominal and pelvic pain as well as facilitating the diagnosis for cases which are not clinically straightforward. Imaging also plays an important role in assessing the complications and sequelae of these conditions, including infertility, chronic abdominal and pelvic pain, and pelvic adhesions. Familiarity with the appearances of these infections, their complications, and their potential mimics on sonography, computed tomography, magnetic resonance imaging, and hysterosalpingography is important for timely diagnosis and optimal clinical outcomes.

Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation

Pelvic inflammatory disease (PID) is a common medical problem, with almost 1 million cases diagnosed annually. Historically, PID has been a clinical diagnosis supplemented with the findings from ultrasonography (US) or magnetic resonance (MR) imaging. However, the diagnosis of PID can be challenging because the clinical manifestations may mimic those of other pelvic and abdominal processes. Given the nonspecific clinical manifestations, computed tomography (CT) is commonly the first imaging examination performed. General CT findings of early- and late-stage PID include thickening of the uterosacral ligaments, pelvic fat stranding with obscuration of fascial planes, reactive lymphadenopathy, and pelvic free fluid. Recognition of these findings, as well as those seen with cervicitis, endometritis, acute salpingitis, oophoritis, pyosalpinx, hydrosalpinx, tubo-ovarian abscess, and pyometra, is crucial in allowing prompt and accurate diagnosis. Late complications of PID include tubal damage resulting in infertility and ectopic pregnancy, peritonitis caused by uterine and/or tubo-ovarian abscess rupture, development of peritoneal adhesions resulting in bowel obstruction and/or hydroureteronephrosis, right upper abdominal inflammation (Fitz-Hugh-Curtis syndrome), and septic thrombophlebitis. Recognition of these late manifestations at CT can also aid in proper patient management. At CT, careful assessment of common PID mimics, such as endometriosis, adnexal torsion, ruptured hemorrhagic ovarian cyst, adnexal neoplasms, appendicitis, and diverticulitis, is important to avoid misinterpretation, delay in management, and unnecessary surgery. Correlation with the findings from complementary imaging examinations, such as US and MR imaging, is useful for establishing a definitive diagnosis. (©)RSNA, 2016.

Past, present and future ultrasonographic techniques for analyzing ovarian masses

Ultrasonography is today the method of choice for distinguishing between benign and malignant adnexal pathologies. Using pattern recognition several types of tumors can be recognized according to their characteristic appearance on gray-scale imaging. Color Doppler imaging should be used only to perform a semiquantitative color score or evaluate the flow location. International Ovarian Tumor Analysis group had standardized definitions characterizing adnexal masses and suggested the use of 'simple rules' in premenopausal women. Recently, the use of 3D vascular indices has been proposed but its potential use in clinical practice is debated. Also computerized aided diagnosis algorithms showed encouraging results to be confirmed in the future.

Magnetic resonance imaging evaluation of non ovarian adnexal lesions

Differentiation of nonovarian from ovarian lesions is a diagnostic challenge. MRI (Magnetic Resonance Imaging) of the pelvis provides excellent tissue characterization and high contrast resolution, allowing for detailed evaluation of adnexal lesions. Salient MRI characteristics of predominantly cystic lesions and predominantly solid adnexal lesions are presented along with epidemiology and clinical presentation. Due to its excellent soft tissue resolution, MRI may be able to characterize indeterminate adnexal masses and aid the radiologist to arrive at the correct diagnosis, thus positively affect patient management.

[Ultrasonographic features in the preoperative diagnosis of primitive fallopian tube carcinoma]

OBJECTIVES

To review the characteristic ultrasound features of primary fallopian tube carcinoma (PFTC) and its relationship to the clinical history in order to establish specific findings useful for the preoperative diagnosis.

METHOD

An extensive review of the current literature was done on Medline via PubMed by using the following keywords: "primary fallopian tube cancer", "tubal cancer", "adnexal malignancy mass" and "ultrasound".

RESULTS

PFTC corresponds to complex, sausage-shaped structures or cystic adnexal masses. A thick and an irregular capsule are in favour of a malignant lesion. Three-dimensional ultrasound is superior to 2D ultrasound for the detection of tubal wall irregularities such as papillary projections or pseudosepta who were suggestive of tubal malignancy and allows a better assessment of the extent of tumor infiltration through the capsule. Neovascularization with low resistance indices are typical of tubal malignancy. Three-dimensional power Doppler sonography acutely detected structural abnormalities of the malignant tumor vessels which are randomly dispersed within the papillary projections. Intra-uterine collection and peritumoral fluid are often found but ascite could be also an indirect proof of peritoneal carcinosis.

CONCLUSION

Sausage-shaped structures or cystic adnexal masses associated with imaging findings such as papillary projections and neovascularization with low resistance indices are in favour of PFTC. A standardized terminology, high-frequency and 3D power Doppler could improve diagnostic performance by allowing a better assessment of tubal wall and chaotic vessels architecture of these tumors.

Risk factors for adverse clinical outcomes in patients with tubo-ovarian abscess

This study assessed the risk factors for poor clinical outcomes in patients with tubo-ovarian abscess (TOA). Patients managed with medical therapy and discharged within 7 days without complications constituted the favourable prognosis group (n = 22), whereas those who were managed surgically or discharged after 7 days of antibiotic therapy constituted the poor prognosis group (n = 87). Variables including age, gravidity, number of dilation and curettage procedures, caesarean delivery, smoking status, serum C-reactive protein levels, serum white blood count, body temperature, abscess diameter, presence of an intrauterine device (IUD), duration of IUD placement and length of hospitalisation were evaluated to assess their relationship with the clinical prognosis of TOA. Abscess diameter of ≥ 6 cm was a significant parameter that increased the risk eightfold for poor prognosis. No significant differences were observed regarding the other variables.

The characteristic ultrasound features of specific types of ovarian pathology (review)

Characterizing ovarian masses enables patients with malignancy to be appropriately triaged for treatment by subspecialist gynecological oncologists, which has been shown to optimize care and improve survival. Furthermore, correctly classifying benign masses facilitates the selection of patients with ovarian pathology that may either not require intervention, or be suitable for minimal access surgery if intervention is required. However, predicting whether a mass is benign or malignant is not the only clinically relevant information that we need to know before deciding on appropriate treatment. Knowing the specific histology of a mass is becoming of increasing importance as management options become more tailored to the individual patient. For example predicting a mucinous borderline tumor gives the opportunity for fertility sparing surgery, and will highlight the need for further gastrointestinal assessment. For benign disease, predicting the presence of an endometrioma and possible deeply infiltrating endometriosis is important when considering both who should perform and the extent of surgery. An examiner’s subjective assessment of the morphological and vascular features of a mass using ultrasonography has been shown to be highly effective for predicting whether a mass is benign or malignant. Many masses also have features that enable a reliable diagnosis of the specific pathology of a particular mass to be made. In this narrative review we aim to describe the typical morphological features seen on ultrasound of different adnexal masses and illustrate these by showing representative ultrasound images.