Pelvic Pain in Women - SD

Introduction to Pelvic Pain in Women

Good afternoon.

I'm Dr. Ted Lyons from Winnipeg, the University of Manitoba in Canada.

And I'm gonna be talking about pelvic pain.

This lecture is a pelvic pain in women, a very common problem and a very perplexing problem, but a problem in which if the ultrasonographer or the physician really does a good job, provides a tremendous service to women.

I'm going to put this in two parts.

The first part is uterine pain, and the second part is other causes of pain.

Assessing Pelvic Pain

It's very important to ask the patient what's wrong, find out where it hurts.

She may well tell you the diagnosis.

So talk to the patient.

When assessing a woman with pelvic pain, it is critical to examine the patient, usually with the ultrasound probe, and then to answer the question.

That's, I emphasize that day in and day out with my staff.

It's so important.

If you look at the requisition, what is the question?

The clinical information we've been given is pelvic pain.

The presumptive diagnosis is ovarian cyst or whatever.

But remember, that's just a guess, albeit an educated guess on the part of the gynecologist.

But what are you being asked to do?

Are you being asked to decide whether or not there's an ovarian cyst?

Or what you're really being asked for is what is the cause of the pelvic pain?

That is the question you have to answer, not is there an ovarian cyst or not.

The patient came in with pelvic pain.

You have to hopefully get her out of the department with an answer to what is causing the pain.

The sonographer's job is actually to make the diagnosis, and if you don't, it's lost.

Or is it?

The sonologist job ideally, is to report the findings in light of the total picture and then confirm the diagnosis.

But they really have to see and examine the patient to make the diagnosis in light of the total picture.

In the real world, I suspect only 10% of patients are seen in all, just in some labs.

Of course, all of the patients are seen all of the time in other labs, none of the patients are ever seen.

But in the search for pelvic pain, it makes a huge difference.

What you have to ask yourself, what's tender?

First of all, is the pain still there?

I mean, when the requisition was filled out, may have been a few hours ago, a few weeks ago, a few months ago.

Is the pain still there?

Is it continuous and or intermittent?

Is it localized or generalized?

Is it related to the menstrual cycle such as dysmenorrhea?

Is it related to intercourse like dyspareunia?

Is it related to the GI tract or to even the bladder?

You have to ask all these questions.

Really, it's a puzzle and you have to solve the puzzle.

Scanning Techniques for Pelvic Pain

Do you need a full bladder when you're doing the pelvic scan?

First we always do a transabdominal scan to look for a mass that might be outside the field of view, but then we always do the endovaginal scan because we can then examine the pelvis with the probe.

So you don't need a full bladder, but you must do the endovaginal scan.

And the endovaginal scan really is like an eight inch extension of the gynecologist or of the examiner's finger because it allows you to examine the patient and in fact, not only feel an organ, but actually see what that organ looks like.

So this is a unique tool that really allows you to make the diagnosis.

So when you're touching the uterus, when you're examining the uterus, press on the uterus, you have to be right on the uterus to know whether or not it's tender and palpate the whole body of the uterus from the fundus down to the lower segment, from the right to the left, pushing on it and asking the question, does it hurt if you just are touching the cervix, as in this case, you can't say anything about the rest of the uterus.

The sonographer here has identified that the uterus was non-tender, but I would suggest that in fact, you can't make that diagnosis by just pressing on the cervix.

So here we have starting off in the lower segment, then moving up to the fundus, touching the uterus.

And as the sonographer has identified on the film, this is a tender uterus, and that's very, very important in trying to figure out exactly what's wrong in this patient.

Here we have a patient with an acutely retroverted retroflex uterus, and you can see that here is the cervix and really you're just touching the cervix.

So you can't talk about uterine tenderness, but in reality, if you go behind the cervix right on to the posterior surface of the uterus, as you have in the next image, you can actually palpate the uterus and decide whether or not there is any tenderness.

So don't just touch the cervix, whether it's retroverted or not, you have to actually touch the body of the uterus.

Here's another example.

Here you can see a nice anteverted uterus, a full bladder, and you can see on the endovaginal examination, the sonographer is touching the anterior lip of the cervix.

You can see in this diagram, you can't tell anything about the uterus by just pressing on the cervix.

So unless you're touching the uterus itself, don't talk about anything.

And here she said that it was non-tender, but in fact, you just simply must discount that you're pushing on the anterior lip of the cervix, and that just simply doesn't count.

Pelvic Anatomy Overview

In the midline, we have the various organs.

We have the urinary bladder uterus, and then we have bowel behind it.

In the adnexa, you have the tube and the ovary, and then you have other things such as bowel, retroperitoneal structures, et cetera.

Here you can see in the left lower quadrant, you have the sigmoid colon, a source often of pelvic pain, but due to bowel.

In the right lower quadrant, you have the terminal ileum and you have the appendix, another source of pelvic pain not related to the uterus, tubes or ovaries.

And these have to be identified.

So the normal uterus you have nice endometrial canal, the body and cervix you have, here, the fallopian tube, and then the ovary in this particular specimen.

In the coronal view here, you can even see a remnant of the wolffian duct, a small paratubal or paraovarian cyst, pelvic tenderness.

It's really important to check all of the organs, the uterus, fallopian tubes, the ovaries, vagina, the bowel.

Don't forget the bowel, the bladder, peritoneal cavity, retroperitoneum, and even the pelvic muscles.

Uterine Causes of Pelvic Pain

So the uterine causes pain.

They can be related to the endometrial canal such as hematometra, which may be congenital or acquired post endometrial ablation.

It can be due to inflammation.

Endometritis can be related to myometrial difficulty such as adenomyosis, misplaced IUD or fibroids.

Now, the reason I've written fibroid as a very, very small word is that the incidence of tender fibroids in the non-pregnant patient is very, very, very low.

And so fibroids for the most part, are not a cause of pelvic pain.

Congenital Hematometra

Let's just look at various issues.

Congenital causes congenital hematometra.

Here's a 16-year-old patient with a large abdominal with pain, abdominal pain, and a large abdominal mass.

And the only interesting thing really is that she has regular periods.

So let's look at the top of this mass.

And on the top you see a thick walled oval mass with low level internal echoes just to the left of midline.

It is avascular on doppler and in fact, on transverse scan, as you can see on the diagram, you can see a cystic space on the right or on the patient's left.

And on the right you can see what looks like a more normal appearing uterus with a small empty endometrial canal.

And what this patient has actually is two uterus, a didelphic uterus with a double vagina.

The left side of the reproductive system is occluded by an imperforate hymen.

And so she has hematosalpinx, hematometra, and hematocolpos on the left.

But her right uterus is quite normal and that's why she is having normal periods.

She also has only a single kidney on the right side with some hydronephrosis, no kidney on the left side.

So to review her, she has two complete uterus, two fallopian tubes, two vaginas.

The vagina on the left is obstructed, giving you the large mass, which is the hematocolpos.

She has blood in the endometrial canal giving you hematometra blood in the fallopian tube, giving you hematosalpinx.

The treatment is easy.

You just, the gynecologist does, takes a scalpel and incise the distended hymen and all of the blood rushes out.

And now you can see on transverse scan through the now normal size uterus on the left and the normal size uterus on the right, they look identical.

The endometrial canals are both empty.

You can see that on longitudinal section on the right and left.

The uterus is look normal.

And as we sweep from the cervix up to the fundus, you can see the endometrial canals, nice and normal with no fluid in them at all.

So beautiful example of a didelphic uterus post treatment.

So this patient had the hematocolpos, hematometra, and hematosalpinx all drained away and diagrammatic, or not diagrammatically in another patient.

This is what it might look like.

You have the uterus on the left and cervix on the left and on the right, each one having their own fallopian tube and ovary and not included, of course, would've been the vaginas, the two separate vaginas in this particular patient.

Acquired Hematometra

Now we have a 49-year-old patient, had four pregnancies, comes in with left-sided pelvic pain and has a bulky uterus with heterogeneous myometrium, an endometrial canal, and a cystic, a somewhat eccentric cystic mass with low level internal echoes.

What is it?

First of all, the clue is to look at the myometrium.

The myometrium is heterogeneous with changes, absolutely typical of adenomyosis.

Is there a question that you might want to ask this patient, such as, have you had any previous surgery?

And she says, yes, I have had amenorrhea, but still some pain since my endometrial ablation a year ago.

So here's a patient who had menorrhagia, had an endometrial ablation in a situation where she has adenomyosis and she has developed a cystic mass within the myometrium.

Now, it would be, you can see this beautifully in the transverse scan, there is the cystic mass within the central portion of the uterus.

The adenomyosis, which gives you a heterogeneous myometrium and also distension of the intramural portion of the fallopian tube, a hematosalpinx very typical in this patient now, or not uncommon in patients who have had endometrial ablation with in the face of the adenomyosis.

What was interesting is that I got a call from the operating room where the gynecologist was doing a hysteroscopy.

He put a tube in the endometrial canal and called me and he said, I cannot see a hematometra the endometrial canal.

It's absolutely clear.

In reality, what's happening is that this patient with adenomyosis has a adenomyotic cyst within the myometrium, beneath a scar.

And so when I went in there with the probe from the transabdominal approach, I could see his scope.

I could guide him towards this cyst that was causing pain, and he was able to put in a small knife and drain the cyst.

So just remember, it's very easy to call these acquired hematometra, but in fact, they're not.

And it will be confusing to the surgeon who will expect to see this when they do a hysteroscopy, and it's just simply not there.

So even though I've called it a hematometra, it's really a myometrial adenomyotic cyst.

So congenital and acquired hematometra is one of the causes of pelvic pain.

Here's another example.

Exactly the same post endometrial ablation, this irregular adenomyotic cyst with the heterogeneity of the myometrium and a previous endometrial ablation.

Very, very typical when you see that large cyst.

Think of post endometrial ablation adenomyotic cyst.

Here's another patient, almost looks like a gestational sac, but again, endometrial ablation, heterogeneous myometrium.

And in the scan, she also has distension of the intramural portion of the fallopian tube.

Again, an avascular structure.

So hematometra adenomyosis.

Next is in patients who have endometrial ablation, don't think that the endometrial canal is in fact occluded.

In some cases there is synechiae bands and an Asherman's type syndrome where there's absolutely complete obliteration of the endometrial canal, but not in this case.

This patient had in fact, hematometra.

This was a true hematometra where she did have blood collections in the endometrial canal.

Obviously, they've drained away on this coronal view of the actual specimen.

What's also interesting is on the longitudinal scan of the uterus in this patient with post endometrial ablation and adenomyosis, you can see the echogenic endometrium, but in fact, it's not endometrium at all.

It's actually just scarring of the myometrium.

But it looks like what you would expect endometrium to look like.

So be very, very careful when you're looking at these post endometrial ablation patients, patient who had had an endometrial ablation and has a large distended endometrial canal that was very tender.

She was having pain.

We did a 3D scan, and then we remove the uterus.

So the gynecologist removed the uterus, and as you open it up in the coronal view, you can see the blood draining out.

And then the coronal view of the uterus shows that big distended endometrial canal from a large blood filled cyst following endometrial ablation.

Now, here is a wonderful, wonderful case.

Here's a patient who has pelvic pain one year post endometrial ablation, and you can see that she has this heterogeneous myometrium areas of increased and decreased echogenicity.

She has a myometrial cyst, but she has this large echogenic mass.

And you might say, maybe this is a polyp or regrowth of the endometrium, and probably give a list of five or six different things.

But in this particular case, if you just sit and watch the uterus, watch what happens to the uterus, the diagnosis is absolutely very simple.

And here you can see that this is a hematometra or an adenomyotic cyst.

And this is actually blood filling in the cyst and swirling around.

This is fresh blood, which we know is echogenic.

So the diagnosis here, because you just sat and watched the uterus, is very, very simple.

It's just again, a adenomyotic cyst or hematometra in a patient with adenomyosis and post and previous endometrial ablation.

Here she is again, and a year and a half later, she came back for a follow-up, still has the heterogeneous myometrium.

That cystic mass is gone.

There's a small amount.

I asked her, have you had a procedure or did you have bleeding?

Did you have a gusher?

No, no, no, nothing.

So it obviously just simply reabsorbed.

She also has blood in the intramural portion of the fallopian tube.

So hematometra just simply resolved.

Endometritis

Another cause of pelvic pain due to muscle, or is patients who have endometritis.

This patient had a previous delivery.

She's three weeks postpartum.

She has fever, pain and pain.

Obviously, you're wondering about infection and were there any inciting causes?

As well as she had manual removal of the placenta, which again has a higher incidence of infection.

You can see she has some fluid in the endometrial canal and a small amount of air.

So that's another cause.

And again, just ask the patient what's going on.

And she tells you the diagnosis, patient who had a therapeutic abortion now has a vaginal discharge, small amount of fluid in the endometrial canal.

The uterus was tender to palpation.

And so she also has endometritis and some degree of myometritis giving you the uterine tenderness.

One of the questions you might ask is, is there any evidence of retained products?

And in fact, there was none in this patient.

Adenomyosis

So what other causes and related to the myometrium, not the endometrial canal, but the myometrium, adenomyosis is a very, very, very common cause of pelvic pain, misplaced IUCD and other cause.

And as I said before, fibroids almost a non-existent cause of pelvic pain.

Adenomyosis is not fibroids.

You see it every single day, but you have to look for it.

For the longest time we weren't making the diagnosis of adenomyosis, and in fact, we were calling everything fibroids.

Well, a fibroid is a well-defined, distinct big white mass that displaces myometrium, whereas adenomyosis is a diffuse infiltrative process that invades the myometrium.

So they're really totally different conditions.

But you have to know about it.

You have to think about it.

And in fact, the diagnosis is very, very common.

So, typical characteristics of a uterine fibroid, often seen in women who have never been pregnant, but obviously you can see it in women who have been pregnant.

It's a well-defined discreet mass that you can see here.

It has a hypo echoic periphery that in fact is often associated that that is associated with compressed myometrium.

The density can vary from decrease to the same as myometrium to increased cystic changes are uncommon.

There's peripheral vascularity, there's distal shadowing.

The fibroids are non-tender, and they can have calcification, but often late.

So here's another example where you can see the ultrasound and the pathology specimen.

It is a well-defined mass compressed myometrium around it.

Here you have that well-defined mass with a compressed hypo echoic myometrium.

And behind it, there's this diffuse shadowing behind the fibroid.

Here's a fibroid that in fact is a cornual fibroid, seen in a number of different images.

And this particular fibroid was tender.

And I don't know exactly why I find it unusual.

On the other hand, typically adenomyosis is the cause of pain.

And here is a beautiful example of an adenomyotic uterus.

So it's often found in patients who have had previous pregnancies, but you can see it in women who have never been pregnant.

It is an ill-defined asymmetrical thickening of the myometrium.

You can see the anterior myometrium is very thick compared to the posterior myometrium.

The echogenicity within that myometrium is mixed.

There are small cysts.

They're very common, more common in the second half of the cycle.

And even three millimeter cyst is abnormal.

And a sign of adenomyosis, you have central rather than peripheral vascularity.

You have this irregular shadowing or streaky shadowing seen behind the adenomyosis.

And there is tenderness, often focal tenderness, and they don't calcify.

Here is an interesting patient where she had adenomyosis.

I did a hysterosonogram.

I put in a balloon within a catheter with a balloon in the endometrial canal.

I injected saline.

And you can see on a magnified view the what appear to be ducts extending into the myometrium.

And in fact, these ectopic endometrial glands in adenomyosis do connect to the endometrial canal.

Some of them give you cysts in the myometrium, but most of them will connect to the endometrial canal.

And you can see them on hysterosalpingogram or sonohysterogram.

Remember in this pathologic specimen, you can see that diffuse heterogeneous pattern within the myometrium.

Very typical adenomyosis.

The cysts within, even in the sub endometrial portion of the myometrium, are actually dilated ectopic endometrial glands.

Clinically, adenomyosis is seen in women over 30 years old who have had pregnancies.

It causes menorrhagia often with clots, they have pain.

The pain can be unexplained, it can be throughout the cycle.

It can be associated with menstruation.

And the uterus is tender, tender during intercourse to give dyspareunia.

And similar tenderness can be elicited with the endovaginal examination.

So check it out.

Ask the patient when you're pushing on the uterus, say to the patient, does this hurt?

Don't just assume because she's not complaining or whatever, that it in fact is non-tender.

Push on the uterus and say the words, does this hurt?

Now obviously, if the uterus is tender, but also the adnexa and bowel and everything around in the pelvis is tender, then it's not going to be a focal problem of adenomyosis, but may well be a generalized problem such as endometriosis or pelvic inflammatory disease.

When you see focal myometrial densities, some people have called this scarring, but in fact it's not.

This patient has diffuse heterogeneity in the myometrium, and these small echogenic lesions are in fact collapsed sub endometrial myometrial cysts.

This is all adenomyosis.

Here's another patient with multiple densities.

And these are very small sub endometrial myometrial cysts.

It's all adenomyosis.

And here you can see this patient has another adenomyotic cyst.

It's all adenomyosis.

Another patient has a grouping of small cysts giving you those focal densities.

This isn't calcification 'cause there's no shadowing behind it.

So there is these small focal densities.

It's different in patients that have densities secondary to calcification and fibroids.

Here you see calcification with dense distal shadowing.

And on X-ray, of course, this patient has a calcified uterine fibroid.

So the small focal densities of adenomyosis are different than those of calcified fibroid.

Here's another patient.

She's 52 years old.

She has menorrhagia, and look at that myometrium.

There are cysts, there are holes throughout the myometrium.

There's areas of increase in decreased echogenicity, and the uterus was tender.

This is a transmural extent of adenomyosis, extensive adenomyosis.

So all of the typical features, and remember this is adenomyosis.

Adenomyosis is very, very common and a common cause of pelvic pain.

What's important is look at the whole package.

Look at the patient's symptoms.

If they have bleeding, clots, pain, tenderness, and dyspareunia, then this is very, very important.

Then look at the sonographic findings of asymmetrical thickening cysts, heterogeneity of texture, and streaky shadowing.

And finally, on the ultrasound physical examination, they have focal uterine tenderness.

Well, if in fact this is, if they have all three of them, adenomyosis is almost for sure, two outta three, it's probable and one out of three.

They can still have adenomyosis.

But it's not quite as certain.

Why is it so important to make the diagnosis of adenomyosis?

Because it is treatable.

It is treatable.

Obviously, you can treat it with hysterectomy, but there are less invasive ways of treating it.

And that is with the Mirena IUCD that has levonorgestrel within the stem and actually gives a relatively high dose of hormone to the myometrium and a shrinkage of the adenomyosis.

You can give anti-inflammatories, synthetic androgens, Lupron, or even high doses of birth control pills can all be used.

But I think most people are opting to use the Mirena IUCD as the first line In these patients, in patients who have had uterine artery embolization, this isn't entirely a recommended treatment for adenomyosis, however, about 50% of them can get improvement in the clinical symptoms.

So here's a patient six months after having uterine artery embolization.

It doesn't look much different One year.

It again, the myometrium still looks heterogeneous, and the patient still has pain.

We looked in our lab at patients who came in for gynecologic studies.

On ultrasound, the main symptoms for their referral were pain, bleeding, and mass.

You can see abnormal bleeding was about 40%, but half the women came in for pelvic pain.

So pelvic pain is a very important indicator as to sending people to see us in the lab.

What was the outcome?

Well, almost 60% of those patients who presented with pelvic pain had adenomyosis.

Some were normal, some had intrauterine pregnancies, and a few had pelvic inflammatory disease.

So adenomyosis is the most common cause of pelvic pain diagnosed by ultrasound.

Adenomyosis usually presents with pain, but obviously it can present with menorrhagia and clots.

Now, fibroids are somewhat more common in our lab than was adenomyosis.

But fibroids usually present with abnormal bleeding.

And if there was pain, there was also adenomyosis.

So they didn't present with pain.

They presented with abnormal bleeding and uterine enlargement.

Misplaced IUCD

Well, what other causes are there for uterine pain?

For pelvic pain due to the uterus?

A misplaced IUCD?

I think it's important to recognize, sometimes it's difficult to figure out.

Here we have an adenomyotic uterus.

We have an IUCD, and it's actually not right up against the fundal portion of the endometrial canal.

It was back a bit, and in fact, it was misplaced.

Here's another patient who had post insertion bleeding and pain after the IUCD.

And here you can see the top of the IUCD is quite a ways from the fundal portion of the endometrial canal.

You can see it the arms extending laterally, not very easy to identify.

If we do a sweep, you can see how low the fundal portion of the IUCD actually is.

It's very, very low.

It's right in the body of the uterus.

And you can see the arms as you sweep on longitudinal scan.

Let's look at that in a coronal view.

Endometrial canal.

And the fundus is absolutely clear.

There's no IUD.

You get down into the myometrium and there's that IUD, the arms of the IUD sticking into the myometrium.

So the fundal portion is clear and is empty.

And so this patient has a misplaced IUCD and must have it removed and replaced.

Here's another patient who has some inter menstrual bleeding.

You can see the IUCD a little low relative to the fundal portion of the endometrial canal.

And you can see a little bit of that IUD the arm sticking into the myometrium.

It's a lot nicer on the coronal view on 3D, you can see the arm of the IUD sticking right into the myometrium.

And in fact, these patients, it's gonna be tender when you push on the myometrium at that level.

Here's a patient who had a lost IUCD, and she has the IUD right in the myometrium, and the string is sitting in the endometrial canal.

Well, most commonly when IUDs are seen in unusual places, they're placed there by the individual inserting the IUD.

It is uncommon for them to move around due to uterine contractions, although that can happen.

So whenever you see an IUD in a very strange position, your first thought is that it was placed there erroneously.

And it's amazingly simple actually to perforate the myometrium.

So here you can see that myometrium with the IUD in the myometrium.

And the only way we were able to remove it is during laparoscopy, I used the transabdominal probe and I actually monitored where the, I used the endovaginal probe while they were doing a laparoscopy.

And you can see the gynecologist grabbing onto the fundal portion of the uterus where the IUD was, and then actually successfully extracting it.

So the combined approach, using ultrasound and laparoscopy, allowed her to successfully remove this IUD either alone would have been impossible.

You can get some remnants of IUDs, although not very common here is a wonderful IUD almost as an aside, a ring shaped IUD within the endometrial canal.

And this is absolutely typical of a Chinese woman who following delivery had a steel ring placed into the endometrial canal.

Of course, the cervix at that time was patulous and relatively easy to insert one of these large non bendable or distortable IUDs because of the one child policy.

This is an ideal solution.

Here you can have a patient who has some pelvic pain.

And on transverse scan, she has one of these ring IUDs on the right side, another one on the left side.

And in fact, you can see these rings everywhere.

And in reality, she actually had three rings in a bicornuate uterus.

So this is a little bit of an unusual case.

The there's a many different sizes and shapes of IUDs, but these Chinese IUDs are seen here on the left.

This one is a solid metal ring with a string.

Here's a solid metal ring without a string.

Of course, you don't wanna remove it, so why would you have a string?

And here next to it on white is a spring in the shape of a ring that also has a string.

Other Uterine Causes

Other uterine causes of pain, lower segment cesarean section defect.

Very uncommon.

I show this because she did have pelvic pain.

She had a large cesarean section defect.

I don't really think that that's a common cause of pain or even a cause of pain at all.

It was an association in this particular patient, but I'm not really suggesting that cesarean section defects are a cause of pain.

So when you have pelvic pain, do you feel like everything now leave me alone till next year, or do you sit back and just try and cope?

So many women actually just try and cope with this feeling very, very uncomfortable because no one has ever told them what the diagnosis is.

And in the cases that I've had where it's adenomyosis, I mean, not only can I tell the patient what the problem is, but I can assure them that there are ways of treating it well.

Non-Uterine Causes of Pelvic Pain

Let's now look at other non uterine causes of pelvic pain.

Part two.

Fallopian Tube Causes

The fallopian tubes can be a cause of pelvic pain, inflammation such as salpingitis or sexually transmitted diseases or pelvic inflammatory disease, either low grade inflammation or severe inflammation, hydrosalpinx, ectopic tubal torsion, paratubal cyst, torsion and neoplasm.

All of these can or can be tubal causes of pelvic pain.

So let's look at low grade salpingitis.

I think this is not an uncommon cause of pelvic pain.

It presents with chronic pain, focal tenderness.

They may have dyspareunia, it's a low grade inflammation, may have absolutely no fevers, chill or discharge, but there's focal tenderness using the endovaginal probe.

But the fallopian tube actually looks quite normal.

If in fact this is real, and there are some patients for sure who have this, a 10 day course of doxycycline for the patient and her partner or similar antibiotic therapy may in fact result in a resolution of this low grade salpingitis.

You have to look with ultrasound at the proximal end of the fallopian tube seen here.

And so here in this patient left lower quadrant pain tenderness.

She does have a previous history of PID, and when we looked in the axial view at the area where the fallopian tube arises and when you push right there, that's in fact where she was experiencing her tenderness and her pain.

And so I would suggest that in fact, this patient had a low grade salpingitis.

Obviously, in patients who have fever, increased white count may have discharge.

They have fluid in the posterior cul-de-sac.

They have large tubo-ovarian masses.

I mean, this is obviously tubo-ovarian abscess and not that difficult to make the diagnosis.

You put them on IV antibiotics and three weeks later the uterus is back approaching normal.

So obviously severe PID with tubo-ovarian abscess is clearly a cause of pelvic pain.

So most unusual patient, this patient has had one month of pelvic pain.

She had a previous hysterectomy, but they've left in that right fallopian tube and it's filled and it's distended with fluid.

And what's interesting is that she had the discomfort while this fallopian tube obviously still innervated was contracting quite by itself, the fluid was enclosed, and so obviously not going anywhere.

So she had spontaneous contraction of her in vivo fallopian tube.

Here's another patient who had pelvic pain.

And on CT examination years ago, they saw this cystic mass that it was ovarian cyst, but on ultrasound, we saw an oblong mass.

We aspirated the fluid and got tubal cells.

So this was actually, and when you go back to the history and the pathology reports, they had left in her left fallopian tube.

So I drained it.

And then the cyst or the fallopian, distended fallopian tube came back.

And in fact, the pain did not particularly abate following the drainage ectopic pregnancy such as, here again is obviously in the right clinical situation, a cause of pelvic pain.

Here's a non gravid uterus in a patient who is eight weeks pregnant.

Echogenic material in posterior cul-de-sac, which is blood corpus luteum cyst in the right ovary.

And on the left she has this echogenic mass, sorry, on the right, inferior to the right ovary, echogenic mass, which was a hematosalpinx and an ectopic pregnancy.

When they removed the uterus, you could see the ectopic within the tube and actually also see the chorionic villi situated in the tube, again, making the diagnosis of an ectopic pregnancy.

So ectopic is another cause of pelvic pain.

Here's a patient who had an empty uterus.

She was 12 weeks pregnant, 18 years old, her first pregnancy, big distended arcuate veins.

And in fact, in the right cornua, she had this irregular cystic mass.

So she had an interstitial pregnancy, a very low beta interstitial cornual ectopic in the right cornua, clinically stable, but they decided to operate nonetheless on sweeping through the endometrial canal.

You can see in that right cornua very, very vascular mass situated in the right cornual region.

This was a number of years ago.

And so they decided to operate.

And there I am standing at the patient's head, and you can see this mass, they put a rubber tube around the lower uterine segment to occlude the vasculature.

They then dissected off the mass.

And on pathology, you can see this irregular gestational sac.

So this was an early pregnancy failure in a cornual location.

Obviously the management currently because the beta was dropping because she was clinically well, they would have opted for observation of this patient rather than for surgery.

They sewed her up and she did well following whether or not she would be a candidate for future pregnancies is yet to be decided.

We always look in the upper abdomen for the accumulation of blood to give a sense of how much blood is in the abdomen in patients who have suspected ectopic pregnancy.

Here's another patient who has had a CT scan showed a mass following two months ago following an incident of pain, never had a pregnancy.

You can see the normal left ovary.

And in the right adnexa, we thought this was right over.

She has a big irregular mass with some solid components.

You can see it's avascular, the solid components.

And in fact, when you sweep through it, it, there's a jelly-like consistency to this solid component.

We weren't sure exactly what it was, but we were concerned that this was an ovarian mass.

The other pictures, you can see the what appeared to be some calcification in the septum of the mass, a somewhat thickened septum, some nodules.

So we were concerned that this might in fact even be a neoplasm.

Well, here you can see at laparoscopy there was the mass with adhesions around it.

There was the right normal ovary.

I must admit that we sort of got sidetracked by looking at the mass and we missed the ovary.

But that mass, in fact, had a stalk that was twisted.

And this in fact was a hydrosalpinx with torsion, and that's what the mass was.

So to remove it, what they did was they burned through the stalk and then removed the hydrosalpinx.

And the patient has gone on now to have several pregnancies following that.

So here you can see the removal or the bisection of the stalk.

Then they removed all of the adhesions and here a little video during the surgery of them removing the adhesions, they put in a bag into the peritoneal cavity, put the hydrosalpinx within the bag, perforated it, got the fluid out, and then removed the remnants.

And here you can see the remnants of that distended fallopian tube.

So she recovered well.

Paraovarian cysts or paratubal cysts, small thin walled cyst, remnants of the wolffian duct, easily missed or mistaken for ovarian cyst.

To confirm it, just make sure that you can separate it on endovaginal examination.

Here is a little bit of free fluid with the thin walled cyst.

There's the fallopian tube.

And in fact, here is the specimen that small para tubal fallopian cyst.

And these are remnants from the mullerian duct.

They can be cysts in the lateral wall of the vagina.

The Gartner duct along the uterus or along the tube and ovary.

Fallopian tube neoplasms are very uncommon.

Point two to 0.5% of female pelvic tumors, usually papillary serous cystadenocarcinoma.

They can present with pelvic pain in 30 to 50% as a mass in 12 to 61% or with some discharge.

But the classic symptoms are only seen in about 15% of patients.

They are similar to ovarian cancer, need a hysterectomy and chemotherapy.

Here's a 62-year-old patient with some free fluid retroverted uterus.

This oblong mass in the left adnexa on sagittal view.

It has some vascularity within it.

And we were quite concerned that this mass actually had a sausage shape and was in the left fallopian tube.

So wondered in fact, whether this was a fallopian tube neoplasm at surgery, you can see the papillary mass extending through the fimbriated end of the tube.

It was papillary serous cystadenocarcinoma.

Ovarian Causes

Well, the ovaries or another cause of pelvic pain, corpus luteum cyst, polycystic ovary disease, torsion, cyst rupture or infection.

All of these can cause ovarian causes of pelvic pain.

Here you can see in vivo the corpus luteum cyst about a two centimeter mass in vitro the mass with a small low level internal echoes.

And finally on the excised specimen, here's the ovary and nice sort of two centimeter corpus luteum cyst with no blood in it.

Corpus luteum cyst.

Traditionally a stellate appearance having a ring of fire, a very vascular periphery with high velocity flow, quite typical ovarian cyst or corpus luteum cyst.

Here's a 25-year-old who came in for dyspareunia and on examination had this enlarged left ovary, which on examination was the area of focal tenderness and was the cause of her dyspareunia.

Quite typical enlarged ovary with peripheral follicles seen on long axis and on transverse scan.

So this is polycystic ovary disease.

Here's a beautiful example, a water bath specimen, multiple follicles in the periphery.

There's the ovary and there's the ovary bisected.

Again, a very nice example of polycystic ovarian disease.

Ovaries are enlarged in 65% of the cases, 10 to 12 follicles less than five millimeters in diameter.

There are other causes for pelvic pain.

And here you can see an ovary that is somewhat distorted and there's an echogenic mass associated with it.

And this is often called the tip of the iceberg sign for a dermoid.

But the best way of assessing the size of the mass is actually with a bimanual examination where the probe is in the vagina and the examining hand is on the anterior abdominal wall.

And you can see by moving this mass back and forth, you can actually get a sense of exactly how big it is and confirm that this was an ovarian dermoid.

Here's a patient who had some pain and fullness.

She has a big mass On transabdominal examination, you can see the uterus is placed posteriorly, no vascularity within it.

And you can see on a sweep these linear bands and this big mass with distal shadowing.

Well, the linear bands, bright linear bands that you can see are here is hair within the fluid component of this large dermoid.

We delivered this dermoid at surgery, and you can see when they opened it up the wall was relatively thin.

There was some hair within the fluid, this big mass that we see over here with dense shadowing.

Was this a fatty mass or was it bone?

And in fact, it was a big fatty mass with hair.

And finally the rest of it was then like a soupy fluid collection of fat.

So very typical features of an ovarian dermoid that can also present with pelvic pain or pain.

And a mass ovarian torsion.

Localized pain with a large edematous ovary, small peripheral follicles, some free fluid and impaired or absent blood flow.

Here is a patient 29 years old, one day of pain, transabdominal scan, normal uterus, enlarged mass with a cystic area.

You can see that at laparoscopy there was no vascularity within that mass, that laparoscopy.

You can see the big blackened mass of the necrotic ovary when they removed it.

Again, the correlation with this big necrotic ovary with the big irregular cyst seen on ultrasound was perfect.

Here we have the uterus here on November 4th, and a patient with left lower quad pain, nice normal uterus, a cystic mass anterior to it solid mass posterior.

That solid mass you can see is being measured and the solid mass has normal vascularity.

So it's a big cyst with an ovary that looks normal.

But the patient came back five days later and now the cyst and the solid mass are reversed.

The solid mass is much larger and avascular.

And this patient actually had a cystic mass, which was a hydrosalpinx which had torted and pulled along the ovary.

And she has a infarcted ovary as well.

Ovarian cyst rupture.

This patient was known to have bilateral ovarian cysts.

The right ovary is now normal.

There still is a cyst on the left, but there's free fluid and this patient has ruptured one of the cysts, which was the cause of her acute pelvic pain.

Vaginal and Bowel Causes

The vagina is another cause of pelvic pain, but very uncommon.

I'm just gonna pass right through it.

But next is bowel.

Bowel is a very important cause of pelvic pain, both the appendix or the sigmoid, but you have to look behind the uterus to see it.

So sigmoid colon diverticulitis or abscess a cause of pelvic pain, often missed appendix, appendicitis, and torsion of the appendix epiploicae.

So here you can see a patient 53 years old, left lower quadrant pain.

The uterus is normal, both ovaries are normal.

And do you stop there or do you go on and look for what is the cause of the pain?

So if you look for the cause of the pain, and you can look in the bowel and left lower quadrant, you can see thick walled bowel.

This is absolutely abnormal thick walled bowel with some striations, no significant increased vascularity.

This is an abnormal loop of bowel if you compare it on the right hand side to a loop of bowel, which is normal.

This is an abnormal loop of bowel.

Let's look now.

And there's actually a diverticulum with a distal shadow.

So this is diverticulitis with an inflamed area of sigmoid colon.

What's interesting is on a real time scan, you can see normal bowel on the right side contracting with a lot of fluid within it.

And if you look at that abnormal segment as air passes through it, you can see that thick wall that in fact doesn't collapse, and that's an absolutely abnormal loop of bowel.

And had you not looked for that, you would've missed the diagnosis.

Of course, here's another patient and you can see masses adjacent to them that have in fact abscesses within them diverticulum and abscesses.

Here's a patient who was pregnant and came in with left lower quadrant pain.

Nice normal fetus.

But here you can see a loop of bowel with a diverticulum.

Well, you might say on that one shot, it'd be hard to call a diverticulum, but in fact, on the cine you can see there is as you sweep in and out of it, there is the beautiful diverticulum.

And that was the cause of the patient's pain.

You can have rather large abscesses with air within them.

Often seen better on CT scan and now this patient has abscesses within the loops of bowel.

May be very difficult to see.

All you're gonna see really is echogenic fat within the loops of bowel.

And in the right lower quadrant, this patient had tenderness.

They were wondering about ovarian torsion.

There is the ovary and there is the inflamed appendix sitting on top of it.

And as we do a sweep, you can see the inflamed appendix sitting right on top of that otherwise normal ovaries.

So not very common.

But look for appendix and look for left lower quadrant.

Look for sigmoid diverticulitis.

An unusual case, normal tube and ovaries in this patient with pain.

Except we saw this tender mass.

I had no idea what the mass was.

I knew it was fatty when they operated.

This patient had a torsion of the appendix epiploicae, these fatty masses on sigmoid colon.

Other Causes

Well, there are many causes of pelvic pain, the uterus, the tubes, the ovaries, vagina, the bowel, masses within the peritoneal cavity.

The retroperitoneum, remember the bladder, remember cystitis, remember bladder calculi or distal ureteric calculi and even pelvic muscles can cause pain, not something we often think about.

So there are many causes of pelvic pain.

The important thing for the examiner and for the physician is answer the question.

Thank you very much.