Acute Pelvic Pain: What we have learned from the ER - SD

Introduction to Acute Pelvic Pain

My name is Dr. Anna Lev Toof. I'm professor of radiology in the Department of Radiology at the hospital of the University of Pennsylvania in Philadelphia.

During this presentation I would like to discuss acute pelvic pain, particularly those types of cases that we see from the emergency room.

Pelvic pain in women accounts for 10 to 40% of all gynecologic visits. Most patients with gynecologic emergencies complain of pelvic pain with or without vaginal bleeding.

The first step in women of reproductive age is establishing pregnancy status in pregnant women. Of course, ectopic pregnancy and abnormal pregnancy is the main concern. This latter group will not be discussed in this lecture.

Advantages of Pelvic Sonography

What are the advantages of pelvic sonography in these patients? Both the transabdominal and the transvaginal approach can be valuable. We know about the lack of ionizing radiation and the fact that ultrasound is readily available and provides superior visualization of the female genital tract compared to ct.

I like to think of pelvic sonography as a direct extension of the examining hands. By direct contact with the patient, she will guide you to the focus of pain.

Origins of Acute Pelvic Pain

The origin of acute pelvic pain defined as less than one month duration in the non-pregnant patient may be gynecologic such as PID, functional ovarian cysts and others, gastrointestinal, most commonly acute appendicitis, abdominal wall hernia, Crohn's disease, or finally urologic such as lower urinary tract infection and calculi.

Objectives of the Presentation

The objectives of this presentation are to familiarize the practicing radiologist with the entities most likely to be encountered from the emergency room as well as to demonstrate the primary role of pelvic sonography in diagnosing these conditions.

Case Example: Misinterpretation of Corpus Luteum

Here's an example of a recent case of a 30-year-old woman who was status post gastric bypass and adominoplasty. She presented with severe right lower quadrant pain and had a CT of the abdomen and pelvis, the orange arrow points to what was initially thought to represent either an inflamed meles diverticulum or a stump appendicitis with an enhancing ring-like structure here and she was taken to the operating room. Note, the enhancing rim around a fluid collection.

Here are some sagittal and coronal reconstructions of her CT scan and again, we see a rounded structure with an enhancing rim and a central fluid collection. Of course, we don't routinely ask patients when we do CT scans about their last menstrual period, but subsequently we found out that her LMP was two weeks ago.

So the question arises is the LMP relevant to current interpret correct interpretation? Let me repeat that. Is the LMP relevant to correct interpretation of a CT as it is in ultrasound what was found at surgery? Note also a little bit of fluid in her cul-de-sac.

Did we find stump appendicitis? Did we find Meles diverticulitis a corpus lium of the right ovary or ad nexel torsion? Well, the answer is a normal corpus lium because her menstrual period was two weeks ago. So this patient had an unnecessary laparotomy because of failure to recognize a normal physiologic structure.

An article published in the Journal of Computer Assisted Tomography in 2004 served to describe the appearance of Corpus Ludia on CT and described a thick granulated or hyperdense wall, usually less than three centimeters in diameter associated with free fluid. The authors indicated that recognition of these CT findings should prevent misinterpretation or inappropriate management. Unfortunately in this case, this was not prevented.

Acute Pelvic Inflammatory Disease (PID)

One of the most common entities to present to the emergency room is acute pelvic inflammatory disease. This is an acute ascending infection of the uterus, fallopian tubes, ovaries and pelvic peritoneum usually caused by RIA, gonorrhea, chlamydia, or co-infection with other bacteria.

An important thing for the radiologist to realize is that this condition typically presents not mid cycle like the corpus lutetium, but during or after menses.

The clinical manifestations are lower abdominal and pelvic pain, vaginal discharge fever with or without nausea, vomiting, malaise, and a leukocytosis. On examination, the typical findings are bilateral at tenderness, cervical motion tenderness, and a purulent cervical discharge.

What are the findings on pelvic sonography? In acute PID, the early sonographic signs can be very subtle. Here we see a sagittal image of the uterus and notice that there is an indistinct cirr sal surface of the uterus, just a tiny bit of fluid here anterior to the uterus and in the cul-de-sac and an astute observer might see that there is some increased echogenicity of the pelvic fat due to the inflammation.

The free pelvic fluid that contains typically low level echoes actually represents some pus. One may also see endometrial fluid and as seen here on this color Doppler image, an overall mild to moderate hyperemia of the uterus due to endometritis.

If the disease progresses, we may see acute titis as manifested by slightly enlarged ovaries with multiple small follicles and an ill-defined outer margin with further progression. We have acute saling in which there are swollen fallopian tubes with thickened mucosal folds and the tube which is normally not visible at all is now readily visualized but still separate from the ovary.

So here is an example of a slightly enlarged ovary and a swollen emus fallopian tube. Notice that the mucosal folds here are thickened and blunted, but we can still recognize the fallopian tube here pointed to by blue arrows as a distinct structure from the ovary.

Very important to turn on the color doppler because before the tube is visible we may still be able to pick up marked tubal hyperemia and that is occasionally the only clue to an early sitis.

As this disease progresses, the tube fills with inflammatory fluid or pus and the distal end becomes obstructed. So with obstruction of the distal end, the fallopian tubes becomes more dilated and it is seen as a thick walled pear shaped structure filled with dependent low level echoes. Occasionally one may see a fluid fluid level.

Here is the hyperemic fallopian tube in sagittal and here it is in transverse. Again, to emphasize that using the color can be very helpful to detect hyperemia. And once we have a pio, somethings that may be very difficult to distinguish to separate the ovary from the fallopian tube and we use the term tubo ovarian complex.

There is also extensive posterior through transmission which reflects the fluid content of the fallopian tube. Another example of acute sitis here with a fluid, fluid level, thick walled fallopian tube perhaps more dependent PU and some complex fluid in the non-dependent position.

Another example of acute sal meningitis with the cogwheel sign, these are the thickened blunted mucosal folds. And here in another example, slightly more chronic of the cogwheel sign as the disease progresses.

We may go on to Frank Tubo ovarian abscess, which presents as a multilocular cystic adnexal mass, which typically abuts the posterior aspect of the uterus. So here in sagittal is the uterus, and here we have a multilocular pelvic mass extending into the cul-de-sac seen here in transverse.

The uterus is displaced slightly to the left and we have multiple LOEs of this complex adnexal mass. The complex fluid represents puss. Now the large size of this cystic mass in comparison to the uterus is worthy of note and notice that the mass is inseparable from the uterus.

Acute PID could be confidently diagnosed in most cases by a gynecologist based on clinical and laboratory data and imaging in that case would be reserved for patients who failed medical therapy in order to assess for tub ovarian abscess.

However, in our current reality, many patients are referred by ER clinicians for an imaging study as an early diagnostic tool and therefore failure to detect the subtle early sonographic findings may lead to additional imaging, unnecessary imaging with CT and potentially to unnecessary surgery.

Functional Ovarian Cysts

Functional ovarian cysts are a common etiology for acute pelvic pain and these can be divided into follicular cysts which develop because of failure of involution of a developing follicle, typically up to four centimeters. And while these are usually asymptomatic, they may lead to pain due to leakage, torsion or hemorrhage.

This is the typical appearance of a follicular cyst. This is very common. This is a physiologic or functional cyst. It's lined with granulosis cells and the cyst forms when the follicle fails to rupture or regress.

Another common functional cyst is known as the corpus lutetium cyst and this is caused by continued growth of the corpus lithium after ovulation. These tend to be slightly larger, typically four to six centimeters, and typically they cause local pain and delayed menses due to progesterone secretion.

A corpus lutetium cyst is often the underlying mass, when adnexal torsion occurs. Another thing is the corpus luteum cyst may rupture and cause hemoperitoneum when we speak of hemorrhagic cysts where talking in most cases about corpus lutetium cysts that have bled internally.

Sonography of Hemorrhagic Cysts

Well what about the sonography of these hemorrhagic cysts? It's important to realize that the appearance depends on the extent of bleeding and the stage. At imaging, we may see a smooth ocular cyst filled with low level echoes. We may see a septated cyst with irregular walls.

A cyst that contains organized blood may simulate a solid mural nodule and the organizing blood may appear as strands of linear density With a lace like pattern or bizarre shapes of retracting clots within a cyst, in all cases it must be emphasized that there should be no internal vascularity.

The walls of a hemorrhagic cyst are often vascular, but none of the bizarre central organizing blood clot should be vascularized. The extent of hemoperitoneum is variable. Occasionally one may need to use transabdominal ultrasound in order to assess the extent because occasionally the hemorrhage will extend up into the abdomen.

And here is an example of a hemorrhagic cyst. Notice that there is blood flow in the wall of the cyst. There are diffuse echoes within the cyst representing organizing blood. This is the so-called lace like pattern and here is more hemoperitoneum or blood clot behind the uterus in the cul-de-sac.

Another example of a hemorrhagic ovarian cyst in this case, smaller here is a unilocular cyst with some retracting clot and two months later it has resolved BC only a normal ovary.

Other examples of hemorrhagic ovarian cysts here is a retracting clot, kind of like a spider in a web with web like strands arising from it. Here's a retracting clot that looks like a mural nodule and another one with a concave margin.

What all of these hemorrhagic cysts have in common is that there is no internal vascularity to this solid component. Keep in mind that most hemorrhagic ovarian cysts resolve in two months and it's important to schedule a follow-up sonogram in the first 10 days from the onset of the menses because we don't want to encounter a fresh corpus lium and misinterpret the findings as persistence.

Here we see on CT an example of a large hemoperitoneum blood around the spleen, the kidney, and around the ovaries due to an unusual example of a ruptured hemorrhagic ovarian insist.

Endometrioma

Now another quote unquote hemorrhagic mass that may present acutely is an endometrioma. This is a 36-year-old woman with acute left lower quadrant pain. She had no fever or elevated white count, and on questioning her further, she indicated that she had a history of cyclical pelvic pain during the menses.

The CT finding is nonspecific. We see a low density mass in the left and nal region with a left and nal structures displaced and draped over them. But the sonographic appearance is classic for an endometrioma.

We have a cyst with an adjacent smaller endometrioma. Notice that it's full of low level echoes representing hemorrhagic material and this is not a solid lesion because of the enhanced through transmission posteriorly.

In this example we have bilateral ovarian endometriomas. Here is the one on the right and here is the endometrioma smaller on the left. The left one had ruptured and resulted in this small hemoperitoneum. Here we see a blood clot in the cul-de-sac behind the cervix.

Now when CT is ordered first, we still need to think about endometriosis because occasionally they can occur in bizarre locations and here we have endometrial implants in the abdominal wall and in a scar in a woman who has had a prior cesarean section.

Adnexal Torsion

Moving on to a nexel torsion, this entity is caused by twisting of the ad nexa around its vascular pedicle. In the case of the ovary, we're talking about the ovarian artery and the ovarian branch of the uterine artery, which results in vascular impairment of the ad nexa.

In fact, the majority of cases involve the tube and the ovary. If torsion is not relieved, hemorrhagic infarction occurs followed by necrosis and peritonitis. So early diagnosis and treatment is critical.

There are preexisting conditions underlying the adnexal torsion. In many cases, in 50 to 80% there's an underlying cyst, often simply a corpus lutetium cyst. It may be a neoplasm benign or malignant or it may be due to previous surgery which resulted in adhe adhesions and as the underlying etiology of the torsion, this entity typically occurs in the reproductive years.

But in our recent work we found that 24% of women were postmenopausal. In fact, how does nexel torsion present? Typically with acute unilateral pelvic pain of sudden onset nausea, vomiting and in a slightly elevated white count, the adnexa rx the adnexa is extremely tender and enlarged on palpation and enlarged and tender on transvaginal sonography.

Keep in mind that adexo torsion is not an all or none entity because of various degrees of torsion and also because of spontaneous torsion and detorsion or so-called intermittent torsion. The clinical presentation may be atypical confusing. Our patients may often, in the cases of a of atypical torsion, patients may say, I've had this before it went away. This is the second or third time this has happened.

The sonographic findings are variable depending upon the duration and degree of torsion. Intermittent torsion causes variable findings on color and spectral doppler and also what we're going to see depends on the nature of any underlying adnexal mass which cause the torsion. And so clearly whether we're gonna be seeing a solid mass or a cystic mass depends on the nature of that underlying mass.

The ovary must be enlarged. It is frequently abnormally located above or behind the uterus. Now there is a so-called classic appearance of the enlarged ovary with prominent heterogeneous stroma and small peripheral follicles. This classic presentation in fact is seen in the minority of patients.

So here's an example of a transvaginal sonogram. This is the uterus with the endometrium on transabdominal ultrasound, we were more readily able to appreciate a large cystic structure and then what looks like a rather large ovary. So here we have a cyst and next to it a swollen ovary that measured approximately eight centimeters in maximum diameter.

And here are the findings on ct. This is the uterus. The bladder here was the swollen ovary and this torsion occurred because of this large para ovarian cyst. In this example at surgery, the right ovary was torsed three to four times and yet we still have arterial signal within the ovary.

This 30 5-year-old woman presented with sudden onset of pelvic pain. Here is her right ovary with normal vascularity and her left ovary with little if any vascular flow. She also had a para ovarian cyst as the underlying cause of twisting of this ovary.

Here's another unusual case of a para ovarian cyst as an underlying cause of ovarian torsion. So when I say that there is an underlying mass, it can either be in the ovary or adjacent to the ovary and cause the ovary to twist with it. Notice that the uterus is deviated to the left because of the twisting of this adnexa.

This is the enlarged tors left ovary and here's the para ovarian cyst which caused this torsion. We see a little bit of fluid in the cul-de-sac and this is the corresponding sonogram of the emus devascularized left ovary.

Gastrointestinal Causes of Acute Pelvic Pain

Acute Appendicitis

Let's move on to the gastrointestinal causes of acute pelvic pain. One of the most common is acute appendicitis was classically presents with anorexia, low grade fever and diffuse periumbilical pain. Now within one to 12 hours, usually around four to six hours, the pain becomes localized to the right lower quadrant.

However, the pain can be variable in location and this depends on the location of the appendix. So in patients with a retrocecal appendix, they may present with flank or back pain. Patients with a pelvic appendix will present with supra pubic pain and if patients have mal malrotation of the colon or a mobile seum, in fact the pain can be almost anywhere in the abdomen or pelvis.

On examination, there is right lower quadrant tenderness plus rebound and guarding usually a moderate leukocytosis if the appendix perforates patient will present with more severe and diffuse right lower quadrant pain. Although occasionally, once the appendix perforates the patient indicates that there is no longer severe pain in women of reproductive age, the diagnostic error rate is greater than in men and up to 40% of cases are misdiagnosed because gynecologic conditions may simulate acute appendicitis.

This is why I have always argued that when we do pelvic sonography, we should not look not only at the uterus and the adnexal structures, but also at the gastrointestinal tracted structures that live in the pelvis.

So in acute appendicitis, the sonographic findings are a normal appendix will look as a tubular blind ending structure arising from the base of the cecum, typically on the same side as the ileocecal valve. How often is it visualized on ultrasound? Highly variable from zero to 82%, which reflects the operator experience and location.

If the normal appendix is out of the field of view of the transvaginal probe, we won't see it. Now the abnormal appendix on sonography is defined as one that is greater than six to seven millimeters in cross-section from cosa to cosa. Keep in mind that the normal appendix, unlike the small bowel, is a peristaltic, but it should be compressible on ultrasound and it should be surrounded by homogeneous non-inflamed fat. Often one can detect visible gas bubbles in the lumen.

In acute appendicitis, the inflamed appendix is enlarged and surrounded by hyper coic inflamed fact just as it is in pelvic inflammatory disease and it will be hyperemic on color Doppler sonography. The detection of a fecal lift is highly suggestive of acute appendicitis in women.

Transvaginal sonography is an important complementary tool to right lower quadrant compression sonography and also should be kept in mind when CT is indeterminate. Now when the appendix extends infra medially into the right adnexal region or the cul-de-sac as it does in approximately 21% of women, it is ideally imaged by transvaginal sonography.

Now with the transvaginal probe, one may not be able to compress or see the entire appendix, but high resolution of the transvaginal probe allows identification of bowel wall layers. If we notice that there is a lack of continuity of the echogenic submucosa, it suggests mural necrosis and impending perforation.

And here's an example of acute appendicitis on transvaginal sonography. Here is a sagittal view through the appendix posterior to the uterus. This is a transverse view. We're measuring this appendix here medial to the iliac vessels as eight millimeters. We see that there is flu, a fluid filled appendix. This is the proximal aspect which we're not seeing quite as well. And here is the round of appendiceal tip.

So this appendix is early inflamed and early in its course and hyperemic. Now in this case we have a slightly more severe acute appendicitis and here we see it on transvaginal sonography. Notice that the hyperemia is more severe and look how close this appendix is located to the right ovary.

So here is the right ovary, here's the appendix and there is the uterus I mentioned before that high resolution sonography using the transvaginal probe can detect the various layers of the bowel wall. In this example of a more advanced appendicitis, we see transabdominally the S sous muscle and a hypo coic structure that no longer has bowel signature.

We've lost the echogenic submucosa and this suggests mural necrosis as well as impending perforation. Another example of a perforated appendix here is where we see the normal echogenic submucosa more distally. We have lost the echogenic submucosa due to perforation.

This 65-year-old woman presented with right lower quadrant pain review of her CT demonstrates what appears to be the origin of the appendix. But the question is what is this soft tissue structure more deeply in the pelvis? It was unclear, whether she had had an ectomy.

This is the terminal ileum and here are some small echo dent structures, uncertain whether they represented surgical clips or something else. Well, we could say what is the next step in the evaluation of this woman? Should we do a barium enema? Should we bring her back for a follow-up CT in 24 hours? Go on to a pelvic MRI or proceed directly to transvaginal sonography.

Given the title of this lecture, we know that the answer is transvaginal sonography, which can be extremely valuable in women with appendicitis. The pelvic appendix is accessible by transvaginal sonography for both diagnosis and abscess drainage. And here we see clearly that she had a tip appendicitis. The tip of her appendix measured 18 millimeters in diameter. Notice the loss of a bowel signature and the early leggs fluid collection near the tip.

This is an example of a woman with a persistent dull right lower quadrant pain. Initial trans vaginal sonography demonstrates calcification in a degenerated myoma as well as an an A both cyst. We see this tubular structure in the right ad nexa. Here it is. This was considered a possible hydro sole pinks.

She did not have signs of, acute peritonitis and she continued to complain and had a finally had a CT scan. We see her calcified myoma and again we see this round structure with a soft tissue rim and fluid on the inside. This was an appendiceal mucosal secondary to assist adenocarcinoma of the appendix, which could mimic appendicitis or a hydro sole. Pinks.

Remember that tubular structures may be related to the tubes, but in women they may also be related to other tubular parts such as here the appendix.

Sigmoid Diverticulitis

Occasionally women will present with acute si sigmoid diverticulitis and the picture can be confusing with more common gynecologic entities. Colonic diverticulosis affects 10% of patients over the age of 45 and ca cases in women in their thirties are not unusual.

However, the most common location is the sigmoid colon and the patient will present with pain in the left lower quadrant of a mild to moderate nature anorexia with or without nausea, diarrhea or constipation. And a low grade fever, typically the tenderness is in the left lower quadrant or SRA pubic region. Occasionally one can actually feel a palpable mass.

Acute sigmoid diverticulitis may result in partial colonic obstruction due to the edema and spasm. Rarely one may present with complete intestinal obstruction. Acute sigmoid diverticulitis may present with symptoms of partial colonic obstruction, but in a small percent of patients, complete colonic obstruction may be present.

Perforation of the inflamed diverticulum may occur with local inflamma inflammation and peric clic abscess fistula. The bladder or urinary symptoms are actually less common in women with uterine free perforation leading to free air outside the sigmoid meco is rare.

We're all familiar with the appearance of sigmoid diverticulitis on ct. We notice here that there are multiple diverticula and there's bowel wall thickening as well as haziness of the pericolonic fat. And these are classic findings of sigmoid diverticulitis On ct, the diagnosis is usually straightforward, but the woman may present with symptoms that are somewhat atypical and may end up having an ultrasound. First.

The diagnosis of acute sigmoid diver diverticulitis can also be made using pelvic sonography and that is important when the patient is younger or when acute sigmoid diverticulitis is in fact not suspected. The transvaginal sonogram is helpful when the inflamed sigmoid colon is located deep in the pelvis and we may be able to see a long segment of thick colonic wall and a prominent outer hypoechoic muscularis propria.

That is the sonographic equivalent of the thickened sigmoid wall on ct. Now the inflamed diverticular machine is a bright echogenic focus with shadowing projecting beyond the margins of the thick colon. Of course, the pericolonic fat will be hyper echogenic and as a reflection of in inflammation on ultrasound.

And here's an example of the sigmoid colon with a thickened muscularis appropriate and here is the sigmoid diverticulum with an echogenic focus of gas and dirty shadowing. This patient presented further in her course and we see that she has a thick walled sigmoid colon. Notice that the anterior wall is thicker and there's a ocular abscess, contin contiguous with the colon and markedly echogenic pelvic fat.

You see for in this example how transvaginal sonography can be an indispensable tool in guiding drainage of these abscesses.

Crohn's Disease

Crohn's disease is a chronic transmural inflammatory process that can involve any part of the gut. Typically, patients present between the age of 20 and 40 and have multiple remissions and exacerbations. The small intestine is involved in 80% of the cases, most commonly the terminal ileum.

And of course most patients do not present with acute pelvic pain, but rather with chronic diarrhea, chronic pain, weight loss and fever. Adhering bowel loops can form masses, fistula, obstruction, perforation and abscess.

However, one third of patients with ileocecal Crohn's actually present with initial. Their initial presentation is so acute that it mimics other causes of acute abdominal and pelvic pain and it may mimic acute appendicitis and pelvic inflammatory disease.

In the acute presentation of Crohn's disease, ultrasound may be performed to evaluate lower abdominal and pelvic pain. The ultrasound findings include transmural bowel wall thickening, again prominent echogenic submucosal layer of the bowel wall and hyper echogenic fat surrounding the bowel wall, which reflects mesenteric inflammation. We may also see enlarged mesenteric lymph nodes.

Ultrasound can be useful to distinguish between phlegm versus a well-defined drainable abscess. And again, transvaginal sonography can be effective when the involved segment of bowel is in the true pelvis and to guide transvaginal drainage of any interloop abscess.

This is an example of the transmural bowel wall thickening seen in Crohn's disease involving the pelvic ileum. Notice the prominent echogenic submucosal layer and the loss of normal bowel wall signature.

This is the same patient, a 3-year-old woman with a history of Crohn's disease. Her prior CT showed findings of ileocecal Crohn's disease here with bowel wall thickening and stranding of the fat of the ile mesenteric, me of the ileocolic mesentary. One month later she presented again with acute right lower quadrant pain and fever.

And on transvaginal sonography we see thick emus, small bowel draped over this abscess. Again, notice that the surrounding eco surrounding pelvic fat is echogenic.

Urinary Tract Causes of Acute Pelvic Pain

Finally, the urinary tract may be the cause of acute pelvic symptoms. Patients frequently present with frequent urination, dysuria, hematuria, lower abdominal and pelvic pain. Pyuria may be noticed on the urinalysis and imaging is usually unnecessary in acute urinary tract infection.

In young women, ultrasound rather than CT is recommended as the initial evaluation in patients with increased risks such as those with diabetes or immunocompromised states or pregnancy. And what we're doing is to look to assess for calculi, diverticuli, bladder wall thickening debris, any post void residual and rarely tumors.

What is the technique for assessing the urinary tract? The bladder evaluation with transvaginal sonography requires a small to moderate amount of urine. The angled vaginal probe, should be looking anteriorly. The probe should be partially withdrawn to evaluate the bladder base in the urethra.

Keep in mind that an over distended bladder may obscure the trigone and actually obscure the distal ureters and the ureter vesical junction. It's important to recognize that the intramural and distal ureter are located slightly anterior and lateral to the upper vagina.

So the dilated ureter is seen as an elongated tubular structure entering the bladder in an OBL course. Cal calculi in the ureter presents with typical renal colic and it's important to realize that urinalysis initially may be negative if the ureter is completely obstructed. Later on, we may see large numbers of red cells and crystals.

So distal ureteral calculi may present with pelvic pain and be recognized on pelvic sonography if we know where to look for them in obese and pregnant patients. And those with contrast contraindications, transvaginal sonography is helpful to locate distal ureteral calculi.

In this example. This woman actually had a CT scan first and this calculus was missed on the CT scan. But here you see on the sagittal transvaginal sonogram, we see the urinary bladder and we see the somewhat dilated ureter and the shadowing calculus. In the transverse plane, we have the uterus and we have the calculus in the distal right ureter to the right of the uterus.

Significance of Negative Pelvic Ultrasound

What is the significance of a negative pelvic ultrasound in acute pelvic pain? A study by Harris etal showed that pelvic pain improved or resolved in 77% of 86 women. So when a woman with acute pelvic pain, a negative pelvic sonogram is extremely useful because it has an excellent positive predictive value for resolution.

Conclusion

To conclude, acute pelvic pain is one of the most common acute presentations in the emergency room and in women, gynecologic, genital urinary and GI etiologies may mimic each other In our current working environment, definitive diagnosis is expected while the patient is in the er.

The use of pelvic sonography, including transvaginal sonography, should be maximized and used to its full capacity in order to limit the use of ct. Thank you.