Ultrasound for Pelvic Pain II: Nongynecologic Causes
Section snippets
Appendicitis
Appendicitis is one of the most common nongynecologic causes of acute pelvic pain and right lower quadrant pain. Typically, these patients also present with nausea, vomiting, and anorexia. Physical examination and laboratory test results usually show abdominal tenderness and leukocytosis. However, the diagnosis can often be made on clinical evaluation alone. Ultrasound, CT, and MRI have proven to be useful examinations in avoiding unnecessary surgeries, especially in patients with atypical
Diverticulitis
Diverticulitis is the inflammation of an outpouching of the colon. Left-sided diverticulosis is marked by multiplicity, associated muscular hypertrophy, and dysfunction, whereas right-sided diverticuli are predominantly solitary. It usually presents with symptoms of fever, anorexia, lower abdominal/pelvic pain, and obstination. Like epiploic appendagitis, it usually occurs in the left lower quadrant but can occur in the right lower quadrant.
The role of imaging is primarily to distinguish
Ureteral calculus
Women with ureteral calculi typically present with flank pain that radiates to the ipsilateral groin and vulva. Commonly, the patient will have hematuria, dysuria, and urgency. CT is currently the preferred imaging modality in the evaluation of renal colic. Ultrasound may not be sensitive for detecting ureteral calculi but is still considered very useful in evaluating ureteral obstruction because of its high sensitivity to detect hydronephrosis (Fig. 5). Yilmaz and colleagues11 showed that
Mesenteric adenitis
High-frequency transducers in the evaluation of lower abdominal pain may be able to detect enlarged abdominal lymph nodes. The term mesenteric lymphadenitis is used to describe an inflammatory process of the abdominal lymph nodes when the sole finding is enlarged lymph nodes and the patient presents with abdominal pain. It is usually a self-limiting process. A recent study by Simanovsky and Hiller14 reports that enlarged abdominal lymph nodes of 10 mm or greater in the short axis in the
Epiploic appendagitis
Epiploic appendagitis usually occurs on the left side but can mimic appendicitis when it occurs in the right lower quadrant. Epiploic appendages are visceral peritoneal outpouchings containing fat and blood vessels. Normally these appendages are invisible at sonography because their density is similar to that of surrounding fatty tissue. Epiploic appendagitis occurs from ischemia, inflammation, or spontaneous torsion of an epiploic appendage of the large bowel. The most common clinical
Colitis
Colitis usually shows on ultrasound as a diffuse bowel wall thickening. Thickening of the terminal ileum and the cecum is seen in Crohn's disease. Other findings that may be seen on ultrasound include decreased peristalsis, lack of compressibility, strictures, and hyperemia of the bowel loops. Inflammation and proliferation of the surrounding fat and mesentery leads to noncompressible, echogenic tissues that are seen adjacent to the bowel.17 This description has been referred to as creeping fat
Bowel obstruction
Although sonography is not the gold standard for imaging the bowel, occasionally it can help diagnose bowel obstruction. In the cases of suspected bowel obstruction, sonographic assessment includes evaluation of caliber differences of various parts of bowel from the stomach to the rectum, exaggerated peristaltic activity, or any findings of intussusception. Occasionally, a large gallstones or a foreign body may be seen at the point of obstruction. The fluid in the dilated bowel serves as
Metastatic disease
Peritoneal metastatic disease or peritoneal carcinomatosis is defined as metastatic disease to the omentum, peritoneal surface, peritoneal ligaments, or mesentery. The ultrasound findings are better shown in the presence of ascites and include hypoechoic or hyperechoic nodular omental masses seen through the anechoic ascites (Fig. 11). Nodular masses may be present on the omentum (omental cake), parietal peritoneum, or serosal surface of the bowel walls. In the absence of ascites, detection of
Inguinal hernias
Although most inguinal hernias are diagnosed in childhood, they can also present in adulthood as the cause of acute pelvic pain. Ultrasound is considered the primary imaging modality for evaluating inguinal hernias (Fig. 12). Color Doppler sonography can be used to differentiate indirect versus direct inguinal hernias.24 In direct hernias, the hernial defect is seen medial to the inferior epigastric artery, whereas indirect hernias occur through the inguinal canal. Ultrasound is helpful in
Hydrocele
A hydrocele of the canal of Nuck is a rare cause of pain and sometimes can cause inguinal swelling in women. It is embryologically related to an indirect inguinal hernia because it develops in women who have a patent processus vaginalis accompanying the round ligament of the uterus.26, 27, 28 The sonographic appearance is that of a cystic mass with a well-defined echogenic margin (Fig. 13). Occasionally, the mass may contain septa or cystic internal structures. Hammond26 reported a case in
Varicocele
A varicocele of the round ligament or labial varicocele is a rare entity that can cause pelvic pain and swelling. The round ligament passes from the pelvis, through the internal inguinal ring, and along the inguinal canal to the labia majora.29 The varicocele is usually associated with pregnancy and worsens progressively until delivery. It usually resolves after delivery. Most cases present in the third trimester of pregnancy. Gray-scale sonography shows prominent anechoic tubular channels that
Duplication cysts
Enteric duplication cysts are rare congenital anomalies arising anywhere along the gastrointestinal tract31 that may cause abdominal or pelvic pain, especially when complicated by hemorrhage, infection, or torsion. Complicated cysts may present with symptoms similar to appendicitis or ovarian torsion. Duplication cysts are defined by their histologic appearance. Similar to the native gastrointestinal tract, these cysts contain an inner mucosa–submucosa layer surrounded by an outer smooth-muscle
Summary
Ultrasound is a valuable noninvasive diagnostic tool for evaluating female patients who present with acute pelvic pain. Although gynecologic conditions constitute most causes of acute pelvic pain, particularly in women of childbearing age; nongynecologic conditions should also be considered. These conditions may be easily overlooked and delay diagnosis. Sometimes ultrasound can help diagnose nongynecologic disorders. Not only is sonography helpful from an imaging standpoint but also one can
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A version of this article was previously published in Ultrasound Clinics 5:2.