Imaging of Acute Pelvic Pain in Girls: Ovarian Torsion and Beyond☆☆

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Identifying the etiology of acute pelvic pain in girls is often clinically challenging. Particularly in young girls, it is often difficult to determine if acute pelvic symptoms are originating from a gynecologic source or from a genitourinary or gastrointestinal etiology based on the childʼs clinical examination alone. Therefore, imaging plays a key role in establishing a diagnosis and in directing medical and surgical treatment. Pediatric gynecologic conditions, which can present acutely with pain or mass or both include ovarian torsion, hematometrocolpos, pelvic inflammatory disease, inguinal hernias containing an ovary or the uterus or both, adnexal cysts, pregnancy, vaginal foreign bodies, and ovarian vein thrombosis. Sources of pelvic pain in girls from nongynecologic etiologies include appendicitis, distal ureterolithiasis, and Crohn’s disease. Owing to the lack of ionizing radiation, widespread availability, and lack of need for sedation, gray scale, with color Doppler ultrasound examination is often the initial imaging obtained when there is suspicion of gynecologic pathology. Radiographs of the abdomen and pelvis are commonly used in the acute setting, when there is concern for a bowel obstruction or free intraperitoneal air. Cross-sectional imaging with computed tomography or magnetic resonance imaging is used, when the diagnosis remains unknown and to clarify findings found on ultrasound and radiographs. Correctly identifying and diagnosing the causes of acute pelvic pain in girls is crucial for the care of these patients. Here, we review the spectrum of causes of acute pelvic pain in female infants to teens with emphasis on imaging approach and age-related characteristics.

Objectives

  • •

    Review the normal anatomy, key anatomical relationships, and age-related changes of the uterus and ovaries.

  • •

    Discuss the appropriate choice of imaging for girls with acute pelvic pain.

  • •

    Review the imaging of pelvic pathologic conditions presenting in girls in the emergent clinical setting.

  • •

    Differentiation of surgical from nonsurgical entities.

Introduction

Acute pelvic pain in girls can be caused by a wide variety of gynecologic and nongynecologic conditions. Identifying the etiology of acute pelvic pain in females, children or adults, is clinically challenging; however, this is particularly the case in young girls in whom the history and physical examination are usually more limited. Moreover, in young children, a pelvic examination may need to be performed under sedation. Furthermore, in addition to the pathologic conditions that affect younger adult women, physicians caring for children need to include congenital and developmental conditions of the genitourinary tract that present more commonly in girls with pelvic pain (Table).1

Adolescent girls engaging in sexual activity may present with acute pelvic pathology from a sexually transmitted disease (STD) or a pregnancy-related condition, such as a miscarriage or ectopic pregnancy. Sexually active adolescents are at higher risk for STDs than are adult women1 owing to high-risk sexual behaviors. Younger girls presenting with pelvic pain owing to STDs or pregnancy need to be evaluated for sexual abuse.

There are a wide range of pathologies that cause pelvic pain in girls from nongynecologic etiologies. These include gastrointestinal sources (eg, appendicitis, Meckel diverticulitis, and Crohn’s disease) and genitourinary conditions (eg, distal urolithiasis and urinary tract infections [UTI]) (Table).2, 3

In view of the difficulty in narrowing the differential diagnosis of acute pelvic pain in girls, imaging plays a key role in establishing a diagnosis and in directing medical and surgical treatment. Owing to its lack of nonionizing radiation, widespread availability and lack of need for sedation, gray scale and color Doppler ultrasound (US) are often the initial imaging obtained when there is suspicion of gynecologic pathology. Radiographs of the abdomen and pelvis are commonly used in the acute setting when there is concern for a bowel obstruction or free intraperitoneal air. Cross-sectional imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is used when the diagnosis remains unknown and to clarify findings found on US and radiographs.

Given the wide variety of etiologic factors and difficulty when performing a pelvic examination in children, diagnostic imaging is crucial for establishing a diagnosis and directing management. Fundamental knowledge of normal anatomy and pathology of the pediatric pelvis on imaging studies is essential for radiologists caring for these children. Here, we review the spectrum of causes of acute pelvic pain in female infants to teens with emphasis on imaging approach and age-related characteristics.

Section snippets

Normal Anatomy

Between the sixth to seventh weeks of embryonal life, a pair of paramesonephric (Mullerian) ducts arise from the Mesonephros (urogenital ridge) and ascend cephalad. After lateral fusion of paramesonephric ducts between the 9th and 12th weeks, the uterovaginal primordium is formed. The latter, between the 12th and 20th weeks, undergoes bidirectional septal degeneration with apoptosis and vaginal plate canalization to form the fallopian tubes, uterus, cervix, and the upper vagina. During the

Imaging Techniques

Given the many possible causes of pelvic pain, a structured approach to image interpretation is necessary to narrow the differential diagnosis.

Common indications for imaging the pediatric pelvis include lower abdominal or pelvic pain, inflammatory disease, pelvic mass, vaginal bleeding, primary amenorrhea, urogenital anomalies, and ambiguous genitalia. Sonography is the initial imaging modality of choice to evaluate many of these disorders, as it is noninvasive, free of ionizing radiation, and

Mullerian Duct Anomalies

Mullerian duct anomalies of a noncommunicating uterine horn, imperforate hymen, vaginal septum, and vaginal atresia can be a source of acute pelvic pain owing to obstruction of endometrial secretions.4, 14 Additionally, retrograde flow of these secretions in obstructed uterine anomalies is associated with an increased prevalence of endometriosis.14

Mullerian duct anomalies are often found on US evaluation during the initial workup of pubertal patients presenting with primary amenorrhea and

Nongynecologic Causes of Acute Pelvic Pathology in Girls

A variety of nongynecologic pathologies can present with acute pelvic pain in girls. Particularly in young infants, gastrointestinal, genitourinary, and musculoskeletal pathologies may be difficult to differentiate as a cause of acute pelvic symptoms. Here, we review the more common nongynecologic etiologies of acute pelvic pain in girls.

Conclusion

In girls, determining the cause of acute pelvic pain is often a clinical challenge. Many of the processes that cause acute pelvic pain in older women of child bearing age can occur in girls from infancy to adolescence, but they may also present with pain owing to congenital or developmental conditions. In infants and children, the clinical examination is often difficult and limited and performance of a pelvic examination may need to be done under sedation. For these reasons, diagnostic imaging

References (34)

  • H.L. Cohen et al.

    Ovarian volumes measured by US: Bigger than we think

    Radiology

    (1990)
  • H.P. Haber et al.

    Ultrasound evaluation of uterine and ovarian size from birth to puberty

    Pediatr Radiol

    (1994)
  • H.J. Paltiel et al.

    US of the pediatric female pelvis

    Radiology

    (2014)
  • C. Comstock et al.

    Pelvic sonography of the pediatric patient

    Semin Ultrasound CT MR

    (1984)
  • A.R. Nussbaum et al.

    Neonatal uterine morphology as seen on real-time ultrasound

    Radiology

    (1986)
  • S. Jequier et al.

    Sonographic measurements of the normal bladder wall in children

    Am J Roentgenol

    (1987)

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    ☆

    Arthur B. Meyers is an author for Amirsys/Elsevier, receiving royalties. Other authors have no potential conflicts of interest.

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