Transvaginal power Doppler findings in laparoscopically proven acute pelvic 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.

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.

Testing for Mycoplasma genitalium in pelvic inflammatory disease: A clinical audit

The records of women attending Gold Coast health hospital sites were retrospectively analysed to determine if women diagnosed with pelvic inflammatory disease (PID) were being tested for Mycoplasma genitalium (MG). Only 11.4% of 299 women were tested for MG despite 74.2% being tested for Chlamydia trichomonas (CT) and Neisseria gonorrhoeae (NG). Only 9% of the women were treated with antibiotics which would treat macrolide-sensitive MG infection. Increasing education and awareness of MG and utilising reflex macrolide testing for MG will help direct effective antibiotic therapy and prevent the long-term sequalae of PID.

Cervical Power Doppler Angiography with Micro Vessel Blood Flow Indices in the Auxiliary Diagnosis of Acute Cervicitis

We have conducted cervical imaging of uterine and micro-vessel flow velocity waveforms in acute pelvic inflammatory disease (PID) by transvaginal power Doppler ultrasound (TVPDU) in order to explore the associations of sonographic parameters with simple and complex cervicitis. Thirty-eight patients with acute PID (26 with acute simple cervicitis and 12 with complex cervicitis) were enrolled for an assessment of vascular grading of cervix and micro-vessel flow velocity using TVPDU before treatment. Seven parameters, including vascular grading (VG), lowest pulsatility index (PI), resistance index (RI), peak systolic velocity (PS), end diastolic velocity (ED), time average maximum velocity (TAMV), and vascular index (VI = PS/ED), were measured and recorded. Forty-one healthy patients were assessed as the control group. Vascular grading (VG) was significantly higher in the study group than the control group (p < 0.0001). The PI, RI, and VI were significantly lower in the study group than control group (p < 0.0001). No significant associations were observed between seven sonographic parameters and acute simple or/and complex cervicitis. For acute simple cervicitis, a PI cutoff of 1.1 had a sensitivity of 85.4% and a specificity of 92.1% (area under ROC curve [AUC], 93.2%). A RI of 0.6 had a sensitivity of 85.4% and a specificity of 78.9% (AUC, 86.1%). A VI of 2.6 had a sensitivity of 85.4% and a specificity of 78.9% (AUC, 84.9%). Power Doppler angiography of micro-vessel flow velocity waveforms in the cervix could represent a practical method to assist the diagnosis of pelvic inflammatory disease presented as acute cervicitis detected on transvaginal ultrasound before medical or surgical treatment. Cervical PI may be a useful index to detect micro-vessel flow velocity waveforms in acute cervicitis and differentiate acute simple cervicitis from complex cervicitis.

The Continued Challenges in the Diagnosis of Acute Pelvic Inflammatory Disease: Focus on Clinically Mild Disease

Many women with lower genital tract infections associated with sexually transmitted pathogens have evidence of upper genital tract inflammation despite the absence of symptoms and signs traditionally associated with pelvic inflammatory disease (PID). New biomarkers are needed to identify these women with clinically mild PID or subclinical PID (silent salpingitis) to facilitate initiation of early treatment and ameliorate the sequelae associated with upper genital tract infection and inflammation.

Chlamydia trachomatis, Pelvic Inflammatory Disease, and Epithelial Ovarian Cancer

Epidemiologic, clinical, molecular and translational research findings support an interrelationship between Chlamydia trachomatis, pelvic inflammatory disease (PID), and epithelial ovarian cancer (EOC). Overall, the link between C. trachomatis, PID, and EOC seems to be relatively weak, although nondifferential misclassification bias may have attenuated the results. The predominant tubal origin of EOC and the role of chronic inflammation in tumorigenesis suggest that the association is biologically plausible. Thus, C. trachomatis and PID may represent potential risk factors or risk markers for EOC. However, many steps in this chain of events are still poorly understood and need to be addressed in future studies. Research gaps include time of exposure in relation to the long-term consequences and lag time to EOC. Data of differential risk for EOC between chlamydial and nonchlamydial PID is also needed. Another major research gap has been the absence of high-performance biomarkers for C. trachomatis, PID, and EOC, as well as EOC precursors. Biomarkers for C. trachomatis and PID leading to increased risk of EOC should be developed. If the association is confirmed, C. trachomatis and PID prevention efforts may play a role in reducing the burden of EOC.

Reproductive system infections in women: upper genital tract, fetal, neonatal and infant syndromes

Lower genital tract infection and bloodborne spread of infection are the two principal modes for infection of the upper genital tract or for infection of the fetus, neonate or infant. Treponema pallidum and human immunodeficiency virus (HIV) are the two most common bloodborne pathogens that infect the fetus, neonate or infant. Most infections of the upper genital tract, however, spread along epithelial surfaces from the vagina or cervix to the upper genital tract or chorioamnion, fetus, neonate or infant. These infections are caused by either pathogens associated with a dysbiotic vaginal microbiome or those that are sexually transmitted. The clinical syndromes that these pathogens produce in the lower genital tract were discussed in part one of this review. We now discuss the syndromes and pathogens that affect the upper genital tract of both non-pregnant and pregnant women as well as fetus, neonate and infant.

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.

Acute pelvic pain in females in septic and aseptic contexts

Acute pelvic pain in women is a common reason for emergency department admission. There is a broad range of possible aetiological diagnoses, with gynaecological and gastrointestinal causes being the most frequently encountered. Gynaecological causes include upper genital tract infection and three types of surgical emergency, namely ectopic pregnancy, adnexal torsion, and haemorrhagic ovarian cyst rupture. The main gastrointestinal cause is acute appendicitis, which is the primary differential diagnosis for acute pelvic pain of gynaecological origin. The process of diagnosis will be guided by the clinical examination, laboratory study results, and ultrasonography findings, with suprapubic transvaginal pelvic ultrasonography as the first-line examination in this young population, and potentially cross-sectional imaging findings (computed tomography and MR imaging) if diagnosis remains uncertain.

Pelvic inflammatory disease: identifying research gaps--proceedings of a workshop sponsored by Department of Health and Human Services/National Institutes of Health/National Institute of Allergy and Infectious Diseases, November 3-4, 2011

In November 2011, the National Institutes of Health convened a workshop of basic researchers, epidemiologists, and clinical experts in pelvic inflammatory disease to identify research gaps hindering advances in diagnosis, treatment, and prevention. This article summarizes the presentations, discussions, and conclusions of this group and highlights significant controversies that reveal aspects of pelvic inflammatory disease research that would most greatly benefit from the application of newer molecular, immunologic, and radiologic techniques. Multiple limitations to performing new clinical trials exist; however, emerging data from ongoing clinical trials will add to the current body of knowledge regarding prevention and treatment strategies. In addition, use of established health care databases could serve as a valuable tool for performance of unbiased epidemiologic outcome studies.

The sensitivity and specificity of transvaginal ultrasound with regard to acute pelvic inflammatory disease: a review of the literature

PURPOSE

This review aims to sum up current knowledge on the sensitivity and specificity of ultrasound features suggestive of acute pelvic inflammatory disease (PID).

METHODS

A PubMed database search was undertaken, using the MeSH terms "(pelvic inflammatory disease or salpingitis or adnexitis) and ultrasonography". We included original articles evaluating the performance of vaginal ultrasound in detecting acute PID.

RESULTS

Seven articles were selected, including between 18 and 77 patients each. The golden standard used was laparoscopy/endometrial biopsy in six studies and mostly clinical evaluation in one. "Thick tubal walls" proved to be a specific and sensitive ultrasound sign of acute PID, provided that the walls of the tubes can be evaluated, i.e., when fluid is present in the tubal lumen (100 % sensitivity). The cogwheel sign is also a specific sign of PID (95-99 % specificity), but it seems to be less sensitive (0-86 % sensitivity). Bilateral adnexal masses appearing either as small solid masses or as cystic masses with thick walls and possibly manifesting the cogwheel sign also seems to be a reasonably reliable sign (82 % sensitivity, 83 %specificity). Doppler results overlap too much between women with and without acute PID for them to be useful in the diagnosis of acute PID, even though acutely inflamed tubes are richly vascularized at color Doppler.

CONCLUSIONS

Even though the results of our review suggest that transvaginal ultrasound has limited ability to diagnose acute PID, it is likely to be helpful when managing women with symptoms of acute PID, because in some cases the typical ultrasound signs of acute PID can be detected.

Criteria for pathology recognition in optical coherence tomography of fallopian tubes

An increase of infertility and chronic pelvic pains syndrome, a growing level of latent diseases of this group, as well as a stably high percentage (up to 25% for infertility and up to 60% for the chronic pelvic pains syndrome) of undetermined origin raises the requirement for novel introscopic diagnostic techniques. We demonstrate abilities of optical coherence tomography (OCT) as a complementary technique to laparoscopy in diagnostics of fallopian tubes pathologies. We have acquired OCT images of different parts of fallopian tubes in norm and with morphologically proven pathology. Based on comparative analysis of the OCT data and the results of histological studies, we have worked out the subjective OCT criteria for distinguishing between unaltered and pathologic tissues. The developed criteria are verified in blind recognition tests. Diagnostic efficacy of OCT diagnostics in the case ofpelvic inflammatory diseases has been statistically evaluated, and high diagnostic accuracy (88%) is shown. Basing of the subjective criteria, an attempt to develop independent criteria aimed for automated recognition of pathological states in fallopian tubes is undertaken. Enhanced diagnostic accuracy (96%) of the developed independent criteria is demonstrated.

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

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Three-dimensional ultrasound inversion rendering technique facilitates the diagnosis of hydrosalpinx

PURPOSE

To test the utility of three-dimensional (3D) ultrasound (US) inversion rendering technique in the evaluation of fluid-distended fallopian tubes.

METHODS

Fifty-two patients with fluid-filled adnexal masses suspected of being abnormal fallopian tubes were scanned by two-dimensional and 3D transvaginal ultrasound (TVUS). Six patients had bilateral disease. The acquired volumes were then "inverted" to display a cast-like appearance of the fluid-filled structures. The ipsilateral ovaries were identified in all patients. Five patients had acute tubal disease.

RESULTS

Fifty-two of the 58 inversion renderings yielded acceptable images of hydrosalpinges. Only in four patients were the two-dimensional images more informative than the 3D-rendered and inverted views. In nine patients adjacent corpora lutea, ovarian cysts, and follicles within normal ovaries were also identified, but appeared separate from the fluid-filled tubes. The tubes in the patients with acute disease were all successfully inverted.

CONCLUSIONS

The 3D inversion technique is a simple and effective way to render fluid-filled spaces, which may be tortuous and follow various directions. The rendered images increased the confidence in diagnosing hydrosalpinx.

ACR Appropriateness Criteria on acute pelvic pain in the reproductive age group

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation.

Characterising acute gynaecological pathology with ultrasound: an overview and case examples

This article summarises the ultrasound features of a number of gynaecological emergencies: ectopic pregnancy, haemorrhagic corpus luteum, twisted adnexa, pelvic inflammatory disease, acute myoma necrosis, haematocolpos and haematometra. The basis of all diagnosis in women with acute gynaecological conditions is history and clinical examination. An ultrasound examination should only be performed if it is likely to provide information that would change the likelihood of the diagnosis suspected on the basis of clinical data. If ultrasound findings are abnormal, then it is important to thoroughly evaluate if they do explain the woman's symptoms or if they are merely an incidental finding. If ultrasound findings are completely normal, then the risk of significant pelvic pathology is probably small.

Diagnosis and treatment of pelvic inflammatory disease

Pelvic inflammatory disease (PID), the infection and inflammation of the female upper genital tract, is a common cause of infertility, chronic pain and ectopic pregnancy. Diagnosis and management are challenging, largely resulting from varying signs and symptoms and a polymicrobial etiology that is not fully delineated. Owing to the potential for serious sequelae, a low threshold for diagnosis and treatment is recommended. As PID has a multimicrobial etiology, including Neisseria gonorrhoeae, Chlamydial trachomatis and anaerobic and mycoplasmal bacteria, treatment of PID should consist of a broad spectrum antibiotic regimen. Recent treatment trials have focused on shorter duration regimens, such as azithromycin, and monotherapies including ofloxacin, but data are sparse. Research comparing sequelae development by differing antimicrobial regimens is extremely limited, but will ultimately shape future treatment guidelines.

Imaging in gynecology

This chapter summarizes the diagnostic performance (sensitivity, specificity, positive and negative likelihood ratios) of ultrasound, computer tomography, and magnetic resonance imaging in the diagnosis of various gynecological diseases and tumors. Positron emission tomography is not discussed. Imaging in infertility, in the diagnosis of Mullerian duct anomalies and in gynecological oncology (staging of gynecological cancers, diagnosis of recurrence of gynecological cancer, diagnosis of trophoblastic tumors) is not dealt with. Ultrasound is the first-line imaging method for discrimination between viable intrauterine pregnancy, miscarriage and tubal pregnancy in women with bleeding and/or pain in early pregnancy, for discrimination between benign and malignant adnexal masses and for making a specific diagnosis in adnexal tumors (e.g. dermoid cyst, endometrioma, hemorrhagic corpus luteum, etc.), for diagnosing intracavitary uterine pathology in women with bleeding problems, and for confirming or refuting pelvic pathology in women with pelvic pain. Magnetic resonance imaging can have a role as a secondary test in the diagnosis of adenomyosis, 'deep endometriosis' (e.g. endometriosis in the rectovaginal septum or in the uterosacral ligaments), and in the diagnosis of extremely rare types of ectopic pregnancy (e.g. in the spleen, liver or retroperitoneum).

The clinical diagnosis of pelvic inflammatory disease--reuse of electronic medical record data from 189 patients visiting a Swedish university hospital emergency department

BACKGROUND

The pelvic inflammatory disease (PID) diagnosis is mostly based on clinical findings. However, few studies have examined the clinical basis for the diagnostics of PID, which was the aim of this study.

METHODS

A retrospective study was performed of 189 out-patients diagnosed as having PID at the obstetric and gynecological emergency department of a Swedish university hospital. Data on symptoms, signs, pelvic examination and laboratory tests were extracted from the electronic medical records in comparison with the diagnostic criteria of the PID Guideline of the US Center of Disease Control from 2002 (CDC 2002 Guidelines).

RESULTS

Eight symptoms in varying combinations were associated with the PID diagnosis. Most of them are mentioned in the CDC 2002 Guidelines. Detected rates of C. Trachomatis (CT) and N. Gonorrhoeae (NG) were 5% and 0%, respectively, among the tested patients (CT = 52% and NG = 12%). The C-reactive protein was normal in the majority of tested patients.

CONCLUSION

The clinical basis for the diagnostics of PID was largely in accordance with the criteria in the CDC 2002 Guidelines. The limited number of CT tests performed is somewhat disappointing, considering the fact that effective disease prevention includes widespread CT screening. Further studies in different settings are needed in order to analyze how the testing rate for CT can be improved in clinical praxis.

Epidemiology, pathogenesis and treatment of pelvic inflammatory disease

Pelvic inflammatory disease, the infection and inflammation of the female upper genital tract, is a common cause of infertility, chronic pain and ectopic pregnancy. Diagnosis and management are challenging, due largely to a polymicrobial etiology which is not fully delineated. Signs and symptoms of this syndrome vary widely, further complicating diagnosis and treatment. Due to the potential for serious sequelae, a low threshold for diagnosis and treatment is recommended. Since pelvic inflammatory disease has a multimicrobial etiology including Neisseria gonorrhoeae, Chlamydia trachomatis and anaerobic and mycoplasmal bacteria, treatment of pelvic inflammatory disease should be broad spectrum. Recent treatment trials have focused on shorter duration regimens such as azithromycin and monotherapies including ofloxacin, although data are sparse. Research comparing sequelae development by differing antimicrobial regimens is extremely limited, but will ultimately shape future treatment guidelines. Several promising short-duration and monotherapy antibiotic regimens should be evaluated in pelvic inflammatory disease treatment trials for compliance, microbiological and clinical cure, and reduction of subsequent adverse reproductive and gynecological morbidity.

Sexually transmitted infections: screening, syndromes, and symptoms

STI are among the most common pathological conditions affecting sexually active adolescents. Both screening of asymptomatic adolescents and a thoughtful, thorough approach to the evaluation of symptoms are critical measures in STI identification and control.

Likelihood Ratio of Sonographic Findings in Discriminating Hydrosalpinx from Other Adnexal Masses

OBJECTIVE

The objective of our study was to describe the "waist" sign as a feature of hydrosalpinx and to calculate the likelihood ratio of sonographic findings for predicting that a cystic adnexal mass is a hydrosalpinx.

MATERIALS AND METHODS

Consecutive institutional records were reviewed to identify patients with surgically excised cystic adnexal masses and preoperative sonograms that had been used to identify the mass. Two radiologists blinded to outcome reviewed the sonograms and recorded the presence of five specific sonographic findings: incomplete septation, short linear projection, small round projection, tubular shape, and presence of a waist. The likelihood ratios of these signs and combinations of signs for the diagnosis of hydrosalpinx were calculated.

RESULTS

There were 55 patients with 67 cystic adnexal masses. Of the 67 cystic adnexal masses, there were 26 hydrosalpinges (39%), 36 cystic ovarian neoplasms (54%), and five paraovarian masses (7%). The likelihood ratios for the sonographic findings were as follows: incomplete septation, 2.1; short linear projection, 3.5; small round projection, 2.7; tubular shape, 10.5; and waist sign, 20.5. The waist sign in combination with tubular shape was found in 12 hydrosalpinges and no other masses (likelihood ratio of between 18.9 and infinity). Small round projection combined with tubular shape was found in 14 hydrosalpinges and one other mass (likelihood ratio of 22.1).

CONCLUSION

Hydrosalpinx can be diagnosed with the highest likelihood when a tubular mass with the waist sign or a tubular mass with small round projections is encountered. Incomplete septations and short linear projections are less discriminating findings of hydrosalpinx.

Women presenting with lower abdominal pain: A missed opportunity for chlamydia screening?

INTRODUCTION

Many young women presenting with lower abdominal pain are referred to general surgeons with possible appendicitis. For some of these patients there will be a gynaecological cause for their pain. There has been a steady increase in the incidence of Chlamydia infections and pelvic inflammatory disease (PID) among the general population. Therefore, are general surgeons considering this as a diagnosis for lower abdominal pain in women?

METHODS

One hundred and ninety three women who had been admitted with lower abdominal pain to a single hospital between 1999 and 2001 were identified using computerised records and the notes were examined. One hundred and eighty six women were included in the audit. Investigations and treatments instigated for these patients were then carefully recorded.

RESULTS

Seventy-four patients underwent appendicectomy, of which 59 were histologically confirmed. Eighty-nine patients (47.8%) of admissions had no final diagnosis and were not screened for Chlamydia trachomatis. Sexual history was recorded in only 51% of admissions. Vaginal swabs were sent in only 7.3% of admissions.

CONCLUSION

Current guidelines for Chlamydia trachomatis screening produced by the Chief Medical Officer (CMO) include screening in women presenting with lower abdominal pain as well as those with post-coital or intermenstrual bleeding. Most women who present with classical symptoms of PID will present to gynaecological specialities for further management. However, a significant number of women presenting atypically will be referred to surgeons to exclude gastrointestinal causes for their lower abdominal pain. These women could and probably should be screened for Chlamydia trachomatis.

Diagnostic and therapeutic capabilities of ultrasound in the management of pelvic pain

PURPOSE OF REVIEW

This review discusses the current diagnostic and therapeutic role of ultrasound in the management of pelvic pain.

RECENT FINDINGS

Recent advances in ultrasound technology and expertise have facilitated the accurate diagnosis of common gynaecological and nongynaecological pathologies. Peritoneal and deep infiltrating endometriosis can now be diagnosed using hard and soft ultrasound-based markers. The combination of ultrasound-guided aspiration and instillation of a sclerosant is an alternative to surgery in the management of adnexal masses.

SUMMARY

Experience is a key factor in the ability of transvaginal ultrasound to characterize common gynaecological disorders with accuracy. Therapeutic ultrasound provides an alternative to surgery.

Ultrasound of Pelvic Inflammatory Disease

Pelvic sonography is commonly performed in patients with a clinical diagnosis of pelvic inflammatory disease. Though the study may be normal or sometimes non-specific, there are a variety of findings that are characteristic of this process. Understanding of the sonographic features of pelvic inflammation, salpingitis, pyosalpinx, tubo-ovarian complex and tubo-ovarian abscess will allow the interpreter to make more specific, clinically useful diagnoses. Sonography can also help to distinguish acute from chronic abnormalities in the fallopian tubes. Correlation of sonography with pelvic CT is important as CT is ordered with increasing frequency in patients with unexplained lower abdominal pain.

Use of morphology to characterize and manage common adnexal masses

The use of grey-scale ultrasound morphology to characterize a pelvic mass may also be called 'pattern recognition'. The grey-scale ultrasound image provides us with the same information as that obtained by the surgeon or pathologist when he or she cuts a surgical specimen to see what it looks like inside. Many pelvic masses have such a typical macroscopic appearance that a fairly confident diagnosis can be made on the basis of their macroscopic appearance alone, i.e. on the basis of their grey-scale ultrasound image. This is true of most dermoid cysts, endometriomas, corpus luteum cysts, hydrosalpinges and peritoneal pseudocysts, and of many paraovarian cysts and benign solid ovarian tumours, for example, fibromas, fibrothecomas, thecofibromas, thecomas and Brenner tumours. A mass with irregularities should always evoke suspicion of malignancy. A mass that is completely smooth is almost certainly benign. Papillary projections--considered a strong sign of malignancy--are more common in borderline tumours than in invasive cancers but may also be seen in benign tumours, for example, in adenofibromas. They explain many false-positive ultrasound diagnoses of malignancy. Pattern recognition is superior to all other ultrasound methods (e.g. simple classification systems, scoring systems, mathematical models for calculating the risk of malignancy) for discrimination between benign and malignant extrauterine pelvic masses. Today's often too liberal use of transvaginal ultrasound gives clinicians problems. Many adnexal masses that probably would have remained undetected before the ultrasound era are now found incidentally at transvaginal ultrasound examination in women without symptoms of an adnexal tumour. The natural history of incidentally detected pelvic masses with benign ultrasound morphology is not known. Therefore, the optimal management of such tumours is also unknown.

The role of ultrasound in the management of women with acute and chronic pelvic pain

Pelvic pain (acute or chronic) is a common symptom in women of all ages. Ultrasonography is the least invasive investigative tool available to the clinician. Transvaginal probes produce high-resolution images of the pelvic organs, providing reliable and reproducible information without the need for a full bladder. Common gynaecological pathology involving the uterus, Fallopian tube and/or the ovary can be diagnosed with confidence. Non-gynaecological pathology involving the bowel can also be diagnosed with accuracy, and will often be seen in the acute gynaecological setting. Ultrasound can be used to triage patients into appropriate treatment protocols, enabling the clinician to avoid surgery in some cases and select the correct surgical approach in others. If the patient has a negative pregnancy test, no pelvic tenderness on bimanual examination and a normal scan, significant pathology is very unlikely.

The effect of semen extender, seminal plasma and raw semen on uterine and ovarian blood flow in mares

Transrectal color Doppler sonography was used to evaluate the effect of intrauterine infusion of skim milk semen extender, seminal plasma and raw semen on the endometrium and blood flow in the uterine and ovarian arteries in mares. Six Trotter mares (mean age: 12 years) were examined during estrus in three cycles. Each mare received an intrauterine infusion of 20 ml of skim milk semen extender, seminal plasma or raw semen during estrus in one of three cycles. Blood flow measurements in both uterine and ovarian arteries and the determination of intrauterine fluid via sonography were performed before each infusion and 1, 3, 6, 12, and 24 h after infusion. Forty-eight hours later, the intrauterine infusion and measurements were repeated using the same time intervals. Changes in blood flow were detected using transrectal color Doppler sonography and were evaluated using the mean time-averaged maximum velocity (TAMV) of the blood flow. Cytological and bacteriological examination of uterine swabs performed 48 h after the second infusion revealed less inflammation and bacterial growth in mares infused with skim milk semen extender than in those infused with seminal plasma or raw semen. There was an increase in intrauterine fluid as early as 1 h after infusion of any of the substances. The infusion of skim milk semen extender had no effect on uterine blood flow. Within 1 h after infusion of seminal plasma or raw semen, there was an increase in the TAMV values of both uterine arteries (P<0.05). In contrast, ovarian blood flow increased only in the artery ipsilateral to the preovulatory follicle and only after the infusion of raw semen (P<0.05). In conclusion, the changes in uterine perfusion observed after intrauterine infusion may be associated with endometrial inflammation and vasodilatory components in the seminal plasma, whereas the changes seen in ovarian blood flow are possibly attributable to the interaction between sperm and oviduct.

Pelvic inflammatory disease: how should it be managed?

PURPOSE OF REVIEW

To review the published literature on pelvic inflammatory disease over the past year and put into context the major findings.

RECENT FINDINGS

remains the commonest identified cause of pelvic inflammatory disease, and yet our understanding of how it causes mucosal damage and the factors explaining why only a subgroup of women develop pelvic inflammatory disease are not known. The increasing evidence for a chlamydial toxin may help to explain how tissue damage occurs and the indolent nature of many chlamydial infections. The evidence for as an important sexually transmitted cause of pelvic inflammatory disease is growing, with implications for treatment regimens and diagnostic testing. Power Doppler ultrasound has been reported to be both sensitive and specific in diagnosing pelvic inflammatory disease, although larger studies are needed to confirm these early results. Outpatient treatment with cefoxitin and doxycycline appears to be as effective when given in an outpatient setting compared with inpatient management with the same agents in a large randomized controlled trial with almost 3 years' follow-up.

SUMMARY

There remain many gaps in our knowledge of pelvic inflammatory disease, but the reviewed studies increase our understanding of the pathogenesis of infection, and offer the possibility of better diagnosis and reassurance about the long-term success of antibiotic treatment.

Transvaginal sonography in the diagnosis of acute appendicitis

OBJECTIVES

To evaluate transvaginal sonography with power Doppler capacity in the diagnosis of acute appendicitis and in discriminating appendicitis from pelvic inflammatory disease.

PATIENTS AND METHODS

We describe transvaginal sonographic findings of six women with acute appendicitis selected from 31 women seen in an emergency room setting for clinically suspected pelvic inflammatory disease. The study population underwent gray-scale transvaginal sonography, and specific sonographic landmark findings for acute appendicitis and pelvic inflammatory disease were used. Hyperemia of any infectious complex was identified by power Doppler. Laparoscopy was performed after transvaginal sonography and was used as the gold standard.

RESULTS

Laparoscopy showed acute appendicitis in six (19%) of the 31 patients. A thick walled non-compressible gas-containing tubular structure with a diameter exceeding 6 mm was seen by transvaginal sonography in four of the six cases, consistent with uncomplicated appendicitis. A heterogeneous complex with surrounding hyperechogenic soft tissue was seen in two cases with gangrenous appendicitis. Power Doppler detected hyperemia in all six cases. Normal adnexal structures were imaged next to the inflamed appendix. The sonographic criteria consistent with acute appendicitis were clearly different from those of acute pelvic inflammatory disease.

CONCLUSIONS

Transvaginal sonography provides an opportunity to distinguish between appendicitis and acute pelvic inflammatory disease. Prospective trials are needed in order to evaluate the impact of transvaginal sonography in the diagnosis of acute appendicitis.

An update on pelvic inflammatory disease

A review of the publications on pelvic inflammatory disease (PID) over the past 18 months reveals a number of common themes. This brief article highlights some relevant papers which may be of interest and summarises their main messages.