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 optimize 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

or 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-obstructive 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 orientations 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 omentum

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 of MRI

IBD-Conventional radiography

Plain radiographs

• It is useful in case of obstruction or extraintestinal manifestations

Barium enema

• Useful in the detection of ulcerations cobblestoneappearance

• 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% andspecificity 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 oedema

- -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 chronicpelvic 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