Gynecological causes of acute pelvic pain: common and not so common radiological findings
Number:28ESURABS0053
Type:Educational Electronic Presentation
Authors: Paolo Niccolò Franco, Alejandra García Baizán, Sofia Frade Dos Santos, Sandro Sironi, María Milagros Otero García
Keywords:Acute pelvic pain; PID; ovarian torsion; leyomiomas; ectopic pregnancy; gynecological disorders.
SECTIONS
Educational objective
  • To review the spectrum of gynecological entities that may manifest as acute pelvic pain both in pregnant and non-pregnant women.
  • To identify and describe the most characteristic imaging findings of these gynecological conditions obtained with different imaging techniques.
  • To summarize the most appropriate management of patients with acute pelvic pain underlying the differences between pregnant and non-pregnant patients.
Topic Review
  1. Introduction

Acute pelvic pain (APP) is defined as lower abdominal or pelvic pain of less than three months’ duration. Infemale patients, acute pelvic pain may be caused by gynaecological, gastrointestinal, and urinary tract pathologies. Due to the variety of diagnostic possibilities, the correct assessment of these patients may be challenging. The most frequent gynaecological causes of acute pelvic pain in non-pregnant women are pelvic inflammatory disease, ruptured ovarian cysts, ovarian torsion, and uterine leiomyomas’ degeneration or torsion. On the other hand, spontaneous abortion, ectopic pregnancy, and placental disorders are the most frequent gynaecological entities to cause acute pelvic pain in pregnant patients (figure 1). Not gynaecological causes, such as acute appendicitis, cystitis,...

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Figure 1. Leading gynaecological causes of acute pelvic pain.
Figure 2. Thirty-nine-year-old patient with acute pelvic pain. Axial T2-weighted (a), T1-weighted fat-saturated before (b) and after (c) gadolinium MR pelvic images shows an enlarged left ovary located in Douglas pouch (yellow arrows) with adjacent twisted vascular pedicle (” whirlpool sign,” white arrow). The ovary presents peripheral high signal on T1 extending to the pedicle (rim of methemoglobin) without enhancement on post-contrast sequences. A sizeable cystic lesion arises from the left ovary with internal high signal on both T1 and T2 (red arrows) and a dependent sediment of low signal on T2, suggestive of a hemorrhagic cyst. The patient underwent laparoscopic left annessiectomy, and pathology confirmed the diagnosis of ovarian torsion, possibly due to a hemorrhagic cyst.
Conclusions

Many gynaecological pathologies may manifest with acute pelvic pain, including pelvic inflammatory disease, uterine and ovarian disorders, endometriosis, and ectopic pregnancies. Diagnostic imaging plays a crucial role in diagnosing APP aetiology and distinguishing potentially life- and fertility-threatening conditions from those that can be treated conservatively. Knowledge of the most common imaging findings, obtained through US, CT, and MRI, allows early and correct diagnosis and assists clinicians in proper treatment planning.