Imaging of Acute Pelvic Pain in Girls: Ovarian Torsion and Beyond☆☆
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
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Arthur B. Meyers is an author for Amirsys/Elsevier, receiving royalties. Other authors have no potential conflicts of interest.