Nongynecological causes of acute and chronic pelvic pain Amela Sofi - - PowerPoint PPT Presentation

Nongynecological causes of acute and chronic pelvic pain

Amela Sofić UKC Sarajevo Bosnia and Herzegovina

• One of the most challenging problems in a clinical routine is the pelvic pain
• It is useful to classify pelvic pain as acute or chronic, because differ in their differential

diagnoses

• The pelvic pain can be of gynecological and nongynecological origin
• The most common cause of nongynecological pain:
• appendicitis
• diverticulitis
• urinary calculus
• IBD
• inguinal hernia

Appendicitis -Conventional radiography

• Plain radiographs are normal in many patients

with acute appendicitis

• An appendicolith is the most specific sign on

plain radiographic films (in 10%) Barium enema

• For evaluation of chronic appendicitis
• Its use is not necessary in the case of a clear

presentation of acute appendicitis Advantage

• Readily available

Disadvantages

• High incidence of nondiagnostic examinations
• Radiation exposure
• Insufficient sensitivity
• Invasiveness

Appendicitis -Ultrasound

Advantages

• Lack of radiation exposure, Non-invasiveness, Short

acquisition time

• Graded-compression in a step-wise approach and aims to
• ptimize visualization of the appendix
• Color Doppler US in detecting increased vascularity of the

apendix

• High accuracy 90%; sensitivity 78%; specificity 83%

Disadvantages

• Intestinal peristalsis
• Pulsation of the iliac artery (when it is near apendix)
• Difficulties keeping the probe in the same location for a long

time

• The US depends on the operator
• Sensitivity of US is lower than of CT/MRI
• Complementary MRI or CT may be performed if diagnosis

remains unclear

Appendicitis-Contrast-enhanced CT

• CT findings in chronic appendicitis are the same as

those in acute appendicitis Advantages

• To evaluate adult patients
• Time-efficient
• Cost-effective
• Good characterization of periapendicular

inflammatory changes, apsces and perforation

• High diagnostic accuracy of 95-98%; sensitivity

91%; specificity 90% Disadvantages

• Radiation exposure
• The potential for anaphylactoid reaction if

intravenous (IV) contrast is used

• Lengthy preparation time if oral contrast is used
• Patient discomfort if rectal contrast is used

Appendicitis-MRI

Advantages

• Better visualization of abnormal appendices and

adjacent inflammatory processes

• Demonstrate the extent of inflammatory

infiltration

• Visualization of the appendix in an atypical

location

• Delineation of pathology
• Operator independence
• Ease of examination of obese patients

Disadvantages

• Use of IV contrast
• Claustrophobic patients
• The inability to observe an appendicolith in the

lumen

• The inability to differentiate between gas and an

appendicolith in the perforation site

Left colonic divertikulitis- Conventional radiography

Plain radiographs

• Free intraperitoneal air (perforation)
• Signs of bowel ileus or obstruction

Barium enema

• It is primary method for patients with chronic

diverticulitis

• Barium enema can superbly depict :
• diverticula
• colonic mucosa
• colonic lumen
• colonic spasm

muscle hypertrophy

Left colonic divertikulitis -Ultrasonography

• The ultrasound finding is rather unclear and

depends on the stage of the disease

• US is not as widely used as a first imaging test
• US is occasionally useful in diagnosing of acute

diverticulitis

• Sensitivity of 77 to 98% and a specificity of 80 to

99% Advantages

• Can be used if CT is not available
• Inexpensive, noninvasive,readily available

Disadvantage

• May not be helpful in excluding diverticulosis or

diverticulitis because of interference due to bowel gas

Left colonic divertikulitis-CT

Advantages

• CT is the technique of choice for the detection of acute

diverticulitis

• CT has replaced barium enema in evaluation of

diverticulitis

• CT is superior to US in the detection of free air and

deeply located or small fluid collection

• Can help in evaluating :
• inflammatory disease
• complications such as bowel obstruction, abscess
• Can exclud other a pelvic disease
• CT help to make modified Hinchey stage
• The grade of severity of acute diverticulitis
• CT sensitivity for diverticulitis is 79 to 99%

Disandvantages

• CT may fail to demonstrate early, mild cases of

diverticulitis

• Potential difficulty in differentiating diverticulitis from

colon carcinoma

• Limited availability in certain regions of the world

Left colonic divertikulitis -MRI

• MRI findings is similar to CT:
• bowel wall thickening
• pericolic stranding
• presence of diverticula
• complications

Advantages

• Radiation-free imaging
• MRI is also comparable with CT to identify

alternative diagnoses

• Diagnose acute diverticulitis, with sensitivity of 86

to 94% and specificity of 88 to 92%

Lower ureteric, Vesico-Ureteric Junction stones-Plain radiograph

Advantages

• For low-dose initial investigation, plain film with

ultrasound is used

• For follow up, plain film is useful when a stone is

visible

• Calcium stones 1-2 mm can be seen
• Cystine stones 3-4 mm may be depicted

Disadvantages

• Smaller calculi and/or radiolucent stones may go

undetected

• 5% of stones are not visible on plain film radiographs
• Uric acid stones are usually not seen
• Obstruction/hydronephrosis cannot be adequately

assessed

Lower ureteric, Vesico-Ureteric Junction stones-Ultrasound

Advantages

• Stones are visible in the distal ureter at or near

the UVJ, especially if dilatation is present

• Good for characterizing lucent filling defects
• Features include:
• echogenic foci
• acoustic shadowing
• twinkle artefact on colour Doppler
• colour comet-tail artefact
• When stones are seen, with a specificity as high

as 90% Disadvantages

• Some patients with acute obstruction have little
• r no dilatation
• Limited sensitivity for smaller stones than 2 mm
• US does not depict the ureters well

Lower ureteric, Vesico-Ureteric Junction stones- Intravenous urography-IVU

Advantages

• Provides physiological information related to the

degree of obstruction

• The radiation dose is generally less than CT, but it is

the same size

• It shows anatomical abnormalities that can predispose

patients to stone formation

• Possibility of delayed recording and use of gravity in a

tilted or upright position

• Distinction of external calcifications, organizational

calculus

• Detection rate as high as 70–90%

Disadvantages

• Can only visualise radiopaque stones (80–90% of

stones)

• Less sensitive to CT, especially for small or non-
• bstructive stones
• Intravenous contrast is required and can hide stones
• Lucent stones do not differ from the transitional cell

carcinoma or blood clot

Lower ureteric, Vesico-Ureteric Junction stones -CT

Advantages

• CT is the modality of choice in the evaluation of acut pelvic urolithiasis
• CT is faster and more effective in detection of missed stones on IVU
• Nonenhanced CT is usually sufficient with the aid of US
• Stones with attenuation values < 200 HU are visible
• Sensitivity of 94-97% and a specificity of 96-100%
• Low-dose CT protocol can be used as the initial imaging technique

Disadvantages

• Stones at the UVJ may be difficult to distinguish from stones in the

bladder (repeat scan through the UVJ in the prone position)

• Distinguishing a ureteric calculus from a phlebolith can be challenging
• Two signs are helpful:

comet-tail sign: favours a phlebolith soft-tissue rim sign: favours a ureteric calculus

• CT urography (CTU or CT-IVU) gives both anatomical and functional

information

• With intravenous contrast in a single acquisition as opposed to the

multiple and more dynamic traditional IVU

• Visualization of other structures in the abdomen is also better with

CTU than with traditional IVU

Lower ureteric, Vesico-Ureteric Junction stones-MRI

Advantages

• MR urography -MRU in case of chronic urolithiasis
• When CT nor sonography can not explain the complicated state
• Useful in case of allergy to Iodine contrast material or radiation

is contraindicated (during pregnancy)

• The T2w-MRU sequence performed with multiple coronal
• rientations and diuretic administration is sufficient to identify

entirely the non-dilated ureter

• HASTE MR urography:
• allows rapid acquisition of images
• has similar accuracy to spiral CT
• MRU showes ureteric calculi 72% of calculi seen by CT
• MRU sensitivity is 93.8%

Disadvantages

• Relative unspecificity of filing defects based in detecting of

stones

• Stones are not directly visible on MRI because they produce no

signal

• Gadolinium-based contrast is linked with nephrogenic systemic

fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD)

Inguinal hernia- Computed tomography

• Using CT scans, the sensitivity in 83%, specificity 67-

83% Advantages

• Computed tomography (CT) remains the best available

imaging tool for evaluation of acute inguinal hernias

• Visualisation of hernia sac and neck, and signs of

edema and inflammation within the hernia sac and bowel wall

• Axial images examined first, then coronal or sagittal

reformatted images are used for problem solving

• Many hernias spontaneously reduce if the patient lies

relaxed in the supine position during the scan

• Valsalva maneuver during a fast helical sequence may

increase sensitivity

• Useful if another disease process is present that may

be mimicking a hernia Disadvantage

• Diagnosis may depend on finding a fascial defect

Inguinal hernia -Ultrasonography

Advantages

• Is useful in non-urgent, chronic cases
• Real-time examination allows to perform

Valsalva or other maneuvers that elicit hernia symptom

• Visualization of peristalsis in herniated

bowel, which may assist in diagnosis Disadvantages

• Fascial defects are difficult to identify with

ultrasound

• An ultrasound finding may be unspecific in

the case of herniation of fat tissue or

• mentum

Inguinal hernia - MRI

• Generally is not a first-line imaging

technique

• MRI allows for hernia evaluation in

multiple imaging planes

• MRI may be useful in cases difficult

to characterize by CT such as Morgagni or traumatic hernias

• In the future, increased availability
• f MRI

IBD-Conventional radiography

Plain radiographs

• It is useful in case of obstruction or extraintestinal

manifestations Barium enema

• Useful in the detection of ulcerations cobblestone

appearance

• Usuful in evaluation of:
• tubular narrowed
• spasm
• sinus tracts and fistula
• chronic changes if they are obstructed
• Barium enema has a 95% accuracy rate in

distinguishing Crohn disease from ulcerative colitis

IBD-Ultrasound

Advantages

• US is useful for Crohn's disease in the ileocaecal

region with sensitivity up to 95%

• Can differentiates the acute ulcerative phase

and chronically reparative phase

• Useful in the extensive extraintestinal

manifestations of IBD

• Sensitivity of 75% and specificity of 95% in the

detection of Crohn's disease

• Doppler shows an increase in vascularity in

inflamed bowel segments

• US Doppler has sensitivity 91.4% and

specificity 96.1%,

• Endoscopic ultrasound of IBD in the pelvis

refers to the evaluation of the rectum

IBD-CT

Advantages

• Like MRI, CT can depict:
• Segmental thickening, hickened folds due to
• edema
• extraluminal lesions, mesenteric and abdominal

manifestations

• complications such as sinus tracts and fistulas
• flegmone and abdominal abscesses
• CT enteroclysis in evaluation IBD of small bowel
• Sensitivity of CT enteroclysis is 87% and

specificity is100%

• CT colonography is reliable for colon analysis in

distinguishing acute and chronic IBD Disadvantages

• Differentiation between peristalsis and skip

lesions may be difficult

• Limitation of artefacts are produced by collapsed

small bowel loops

• CT enteroclysis not detect recurrence of disease

IBD-Routine MRI

Advantages

• Evaluation:
• extraintestinal manifestations of IBD
• perianal fistulae
• superficial ulceration
• loss of haustration
• For differentiate active inflammation

from fibrosis

• Superior to CT scan and fistulography

in assessing perineal complications

• Identifying the levator ani wich is a

landmark for distinguishing supralevator abscesses

• MRI is superior to CT in the

differentiation of fistulous tracts

IBD-MR colonography,MR enteroclysis

• Bright bowel wall due to increased signal of

water on T2 sequences suggests disease activity

• Layered pattern of enhancement on T1 with

gadolinium is highly specific for active disease MR colonography

• MR colonography is an alternative to

colonoscopy

• MR enteroclysis is reliable in evaluation of

Crohn's disease of the small intestine Advantages of MR enteroclysis

• It is superior to MR enterography for detecting

Crohn's disease abnormalities

• It is the only method that excludes small bowel

inflammatory and noninflammatory disease

• Can be a first line modality

Disadvantages of MR enteroclysis

• Inability to compress bowel in real time
• Not evaluate superficial abnormalities or fistulas

To take home

• The role of diagnostic imaging in evaluation of Nongynecological causes of acute and chronic

pelvic pain is: confirm the diagnosis evaluate the severity and extent of disease exclude alternative diagnoses allow for treatment planning

• The decision to obtain diagnostic modality depends on:

institutional preference available user expertise important influencing factors: patient age patient sex patient body habitus

• US and CT are the initial imaging test of choice in many cases
• But US is favor for patients due to the absence of ionizing radiation
• Conventional radiography has limited diagnostic value in the assessment of most patients

with pelvic pain

• MRI is another emerging technique for the evaluation of pelvic pain that avoids ionizing

radiation

• The choice of imaging technique depends on the clinical scenario

To take home