- Email: [email protected]
The role of ultrasound in the management of the acute gynaecological abdomen
Reviews in Gynaecological Practice 4 (2004) 224–229
The role of ultrasound in the management of the acute gynaecological abdomen Karen Jermy a,∗ , Tom Bourne b b
a Department of Obstetrics and Gynaecology, St. Richards Hospital, Chichester, UK Department of Obstetrics and Gynaecology, St. Georges Hospital and Medical School, Blackshaw Road, London SW17 0RE, UK
Received 23 February 2004; accepted 24 February 2004 Available online 19 June 2004
Abstract Transvaginal ultrasound has an established role in the assessment of gynaecological patients in almost all areas of the speciality. The incorporation of ultrasound into the initial assessment of the patient presenting acutely with suspected gynaecological pathology, provides an effective and rapid means of diagnosis. This will ideally take place within a dedicated ‘emergency gynaecology unit’, with the gynaecologist performing the ultrasound as an extension of the main clinical examination. The majority of these women, will be premenopausal. In the absence of a positive urinary pregnancy test, the main distinction that needs to be made is the presence, or not, of a pelvic mass. Transvaginal ultrasound has an established role in the characterization of adnexal masses and their differentiation from leiomyomas, and we will provide an overview of the ovarian, tubal and uterine pathology which may give rise to acute onset symptoms. The presence of adnexal pathology may be coincidental, as the ovary will naturally exhibit a wide variety of cyclical changes, and pain mapping, using the transvaginal probe, will help confirm this. When considering adnexal torsion, a high degree of clinical suspicion should be maintained as there are no pathognomonic features on ultrasound alone. Even the detection of blood flow within a mass suspected of torsion, using colour Doppler, will not exclude the diagnosis. By adopting a problem orientated approach to acute pelvic pain, ultrasound can facilitate a rapid diagnosis of most gynaecological problems, and allow appropriate and timely surgical intervention, conservative management or referral to other specialities as indicated. © 2004 Elsevier B.V. All rights reserved. Keywords: Pelvic pain; Ovarian cyst; Pain mapping
1. Introduction Transabdominal and transvaginal (TVS) ultrasound are both established imaging modalities in the examination of the pelvic anatomy. They are non-invasive, cost effective and widely available. Using a transvaginal approach, high frequency transvaginal probes in close proximity to the pelvic structures will result in higher resolution images. The use of TVS is well documented within almost all areas of gynaecology, and it has an established role in ovarian cyst characterization, providing information regarding cyst type and probability of malignancy [1–4]. One of the most useful, and least discussed, roles of ultrasonography, is in the assessment of the acute gynaecological patient. It is well suited to be incorporated into the armament of clinical, biochemical and
∗ Corresponding
author. Tel.: +44 208 725 0050. E-mail address: [email protected] (K. Jermy).
1471-7697/$ – see front matter © 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.rigp.2004.02.004
imaging modalities, providing an effective and rapid means of diagnosis and detection of gynaecological pathology. This review aims to deal with the initial assessment of the patient presenting with acute abdominal pain, with a negative urinary pregnancy test, in whom gynaecological pathology is suspected. Transvaginal ultrasonography remains an extension of the clinical examination: a normal scan will not exclude all underlying gynaecological conditions.
2. The premenopausal patient The importance of a complete clinical history and examination cannot be overemphasized, especially with the use of pelvic ultrasound. The premenopausal ovary and endometrium, as visualized with the transvaginal probe, are dynamic structures, constantly exhibiting cyclical changes in morphology and volume throughout the cycle. A knowledge of the normal variations that can be exhibited is important,
K. Jermy, T. Bourne / Reviews in Gynaecological Practice 4 (2004) 224–229
as the most common ovarian pathology is the functional cyst. The presence of adnexal pathology in the patient presenting with pelvic pain may be a coincidence and gentle use of the transvaginal probe to map the pain within the pelvis will help give an indication to the structures giving rise to pain. The overwhelming advantages of the transvaginal approach in the assessment of pelvic pain, are not only the excellent diagnostic capabilities, but in the presence of an acute abdomen, this route is tolerated much better than a transabdominal scan requiring a full bladder. 2.1. Pelvic pain in association with pelvic mass In those patients presenting with pelvic pain in whom there is evidence of a pelvic mass on ultrasound, an assessment needs to be made not only of pain severity and type but also the nature of the mass. Transvaginal ultrasound has a proven track record in experienced hands in the differentiation of uterine myomas from adnexal masses and also in the characterization of adnexal masses. 2.1.1. Ovarian pathology The prevalence of adnexal pathology among premenopausal women is high and the overwhelming majority of these lesions will be benign. A large proportion of benign ovarian cysts will be functional in nature, and if symptoms settle, may be managed expectantly, with a repeat scan in the early follicular phase of a subsequent menstrual cycle to confirm resolution. Endometriomas and dermoids will account for over two-thirds of persistant ovarian cysts in premenopausal women [5].
225
A careful history, and a clear knowledge of the day of the menstrual cycle, will prompt the sonographer to the most likely cause of the pain. For example, acute onset, midcycle pain may be indicative of a follicular or corpus luteal cyst accident. Haemorrhage into a corpus luteal cyst has characteristic sonographic findings (Fig. 1). The condition tends to be self limiting and often responds to non-steroidal anti-inflammatory analgesia. Surgery should be avoided if possible. The cyclical occurrence of a haemorrhagic corpus luteal cyst may result in persistant morbidity. In the absence of contraindications, the use of the combined oral contraceptive pill to suppress ovulation can be beneficial. This is particularly true of women with clotting factor deficiencies; such as von Willebrand’s disease. These women may present with an acute abdomen, secondary to a haemoperitoneum as a result of ovulation or corpus luteal haemorrhage or rupture. Functional ovarian cysts are usually unilocular, with a thin, smooth wall and sonolucent contents. They tend to be asymptomatic, unless they undergo torsion, acute haemorrhage or rupture. Recent cyst rupture may be suggested by the resolution of clinical symptoms and free fluid within the Pouch of Douglas, often with a collapsing, irregular cyst. Those women with a history suggestive of endometriosis presenting with acute pain, may have sonographic evidence of an endometrioma. These rarely undergo torsion, as they are often fixed within the pelvis, but may undergo rupture or acute haemorrhage within the cyst. Rarely they can become infected. Dermoids and endometriomas each have characteristic sonographic patterns (Figs. 2 and 3) which aid recognition. Dermoids may be predominantly cystic, or solid, with poste-
Fig. 1. Haemorrhagic corpus luteal cyst. Fine strands of fibrin are seen within the cyst contents.
226
K. Jermy, T. Bourne / Reviews in Gynaecological Practice 4 (2004) 224–229
Fig. 2. Large endometrioma: ‘ground glass’ appearance to the cyst contents.
rior acoustic shadowing. Fine, short echogenic strands may be visable within the cystic component, representing hair. Endometriomas tend to be thick walled with heterogenous, low level (‘ground glass’) internal echoes. A subjective assessment of ovarian morphology based on characteristic ultrasonongraphic findings has been shown to be highly predictive for the diagnosis of dermoids and endmetriomas, in a population with a low background risk of malignancy [6]. A suggested follow-up regime for women diagnosed with a pelvic mass is shown (Fig. 4). Intervention will be dic-
tated by the resolution—or not—of the patients symptoms. If the symptoms resolve and there are no sonographic features of malignancy on the ultrasound, a repeat scan at 6 weeks should be performed, to confirm cyst resolution. 2.1.2. Ovarian torsion This is unusual with adnexal masses measuring less than 5 cm [7] in diameter. However, there are no pathognomonic features specific to adnexal torsion and a high degree of clinical suspicion is essential. A clinical history of acute onset,
Fig. 3. Benign cystic teratoma, with acoustic shadowing, secondary to a bright echogenic area representing sebum.
K. Jermy, T. Bourne / Reviews in Gynaecological Practice 4 (2004) 224–229
227
Fig. 4. Ultrasound-based pathway for pelvic pain assessment.
constant pain not responding to analgesia, often with nausea and vomiting and systemic upset is common. Because the central feature of ovarian torsion is the cessation of vascular supply, colour Doppler has been used to interrogate the adnexal mass suspected of undergoing torsion, as early action may allow for conservative surgery. It is likely however, that if flow can be visualized within the mass, despite clinical symptoms and signs of ovarian torsion, that ovarian blood flow may still be compromised, as demonstrated by surgically proven ovarian torsion, despite detecting blood flow within the mass [8]. 2.1.3. Uterine leiomyomas These may undergo degeneration, especially during pregnancy. The patient is often systemically unwell, with a pyrexia, leucocytosis and generalized abdominal tenderness. If pedunculated in nature, fibroids may undergo torsion, or prolapse through the cervix. The ultrasound characteristics of leiomyomas are varied and well documented. Before the menopause they tend to be a well defined, heterogeneous or hypoechoic uterine mass.
Cystic areas can be visualized within the fibroid if it is degenerating. TVS is used in conjunction with abdominal scanning to ensure pedunculated, subserosal fibroids are not missed. Occasionally, a pedunculated fibroid may mimic a solid, adnexal mass, and vice versa, an ovarian fibroma may be interpreted as a uterine fibroid. In such cases, magnetic resonance imaging may help in the differentiation. 2.1.4. Tubal pathology Acute pelvic inflammatory disease, with hydrosalpinx, pyosalpinx or a frank tubo-ovarian abscess (Fig. 5), will tend to present with systemic upset, leucocytosis, unilateral progressing to bilateral pelvic pain, menstrual disturbances and vaginal discharge. The differential diagnoses will therefore include adnexal torsion, acute fibroid degeneration, urinary tract infection and appendicitis. Acute inflammatory processes within the fallopian tubes tend to produce thick walled, cystic structures, tender to the touch of the probe. However, a chronic hydrosalpinx will
228
K. Jermy, T. Bourne / Reviews in Gynaecological Practice 4 (2004) 224–229
Fig. 5. Tubo-ovarian abscess: an irregular, thick walled multiloculated structure.
have the appearance of a thin walled structure, not obviously tender on probing and often detected coincidentally [9]. 2.1.5. Acute urinary retention As part of a pelvic scan, the bladder will be visualized. Acute urinary retention can result from a number of diverse causes, such as urinary tract infection, the presence of a fibroid uterus or in early pregnancy with a retroverted uterus. Ultrasound will help elucidate possible underlying pathology. A full bladder may sometimes be confused with an ovarian cyst. If there is any doubt and the patient is unable to void urine a catheter should be passed to ensure the bladder is empty. Occasionally a blood clot may be visible within the bladder. 2.2. Pelvic pain with no mass on scan In the absence of pathology on scan, blood should be taken for leucocytosis and microbiological culture. Urinalysis should be performed, and a complete infection screen, including endocervical and high vaginal swabs. Transvaginal scan may reveal fine echogenic strands and loculated fluid within the pelvis, indicative of adhesions. It is sometimes not possible to elucidate a diagnosis based on clinical, ultrasound and serum findings alone. Medical, surgical and urological opinions should be sought where indicated, with early recourse to laparoscopy in those patients who have persistant or worsening symptoms. Transvaginal ultrasound with power Doppler may be used to help diagnose acute appendicitis and in its differentiation from pelvic inflammatory disease [10,11]. Ultrasound can also contribute
to the diagnosis of other gastrointestinal disorders presenting with lower abdominal pain, such as acute diverticulitis [12].
3. The postmenopausal patient Characterization of any adnexal mass is important within this age group, as the risk of a mass being malignant is high. Unilocular cysts may be found in up to 20% of asymptomatic, postmenopausal women. Numerous studies have shown that simple, unilocular cysts, measuring less than 5 cm in diameter are associated with a very low risk of malignancy [13]. Blood should be taken for tumour markers and emergency laparotomy avoided if at all possible, to allow for adequate oncological work up of the patient if indicated. Urinary retention must be excluded. Other surgical and medical conditions are more predominant in the older age group, such as diverticulitis, constipation and urinary tract infections.
4. Conclusion The time has come to maximize the role of ultrasound within the routine assessment of the acute gynaecological patient. It complements the clinical examination, affording us a ‘view’ of the pelvic structures. Its integration into the gynaecology emergency service—particularly within the setting of an acute gynaecology unit—facilitates a more rapid diagnosis in a number of gynaecological conditions. It also helps to exclude gynaecological pathology, ensuring prompt referral to other specialities.
K. Jermy, T. Bourne / Reviews in Gynaecological Practice 4 (2004) 224–229
Central to its appropriate use will be training and supervision, with up to date protocols, regular audit and an awareness of both our own, and the equipment’s, limitations. References [1] Granberg S, Wikland M, Jansson I. Macroscopic characterisation of ovarian tumors and the relation to the histological diagnosis: criteria to be used for ultrasound evaluation. Gynecol Oncol 1989;35:139–44. [2] Granberg S, Norström A, Wikland M. Tumors in the lower pelvis as imaged by transvaginal sonography. Gynecol Oncol 1990;37:224–9. [3] Tailor A, Jurkovic D, Bourne T, Collins W, Campbell S. Sonographic prediction of malignancy in adnexal masses using multivariate logistic regression analysis. Ultrasound Obstet Gynecol 1997;10:41–7. [4] Timmerman D, Bourne TH, Tailor A, Collins WP, Verrelst H, Vandenberghe K, et al. A comparison of methods for the pre-operative discrimination between benign and malignant adnexal masses: the development of a new logistic regression model. Am J Obstet Gynecol 1999;181:57–65. [5] Koonings P, Campbell K, Mishell D, Grimes D. Relative frequency of ovarian neoplasms: a 10 year review. Obstet Gynecol 1989;74: 921–5.
229
[6] Jermy K, Luise C, Bourne T. The characterization of common ovarian cysts in premenopausal women. Ultrasound Obstet Gynecol 2001;17(2):140–4. [7] Nicholas D, Julian P. Torsion of the adnexa. Clin Obstet Gynecol 1985;28:375–80. [8] Rosado W, Trambert M, Gosink B, Pretorius D. Adnexal torsion: diagnosis by using Doppler sonography. Am J Radiol 1992;159: 1251–3. [9] Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS. Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound Obstet Gynecol 1998;12(1):56–66. [10] Molander P, Paavonen J, Sjoberg J, Savelli L, Cacciatore B. Transvaginal sonography in the diagnosis of acute appendicitis. Ultrasound Obstet Gynecol 2002;20(5):496–501. [11] Caspi B, Zbar AP, Mavor E, Hagay Z, Appelman Z. The contribution of transvaginal ultrasound in the diagnosis of acute appendicitis: an observational study. Ultrasound Obstet Gynecol 2003;21(3):273–6. [12] Ripolles T, Agramunt M, Martinez MJ, Costa S, Gomez-Abril SA, Richart J. The role of ultrasound in the diagnosis, management and evolutive process of acute left sided colonic diverticulitis: a review of 208 patients. Eur Radiol 2003;Dec 13(2):2587–95. [13] Kroon E, Andolf E. Diagnosis and follow up of simple ovarian cysts detected by ultrasound in postmenopausal women. Obstet Gynecol 1995;85:211–4.
The role of ultrasound in the management of the acute gynaecological abdomen Karen Jermy a,∗ , Tom Bourne b b
a Department of Obstetrics and Gynaecology, St. Richards Hospital, Chichester, UK Department of Obstetrics and Gynaecology, St. Georges Hospital and Medical School, Blackshaw Road, London SW17 0RE, UK
Received 23 February 2004; accepted 24 February 2004 Available online 19 June 2004
Abstract Transvaginal ultrasound has an established role in the assessment of gynaecological patients in almost all areas of the speciality. The incorporation of ultrasound into the initial assessment of the patient presenting acutely with suspected gynaecological pathology, provides an effective and rapid means of diagnosis. This will ideally take place within a dedicated ‘emergency gynaecology unit’, with the gynaecologist performing the ultrasound as an extension of the main clinical examination. The majority of these women, will be premenopausal. In the absence of a positive urinary pregnancy test, the main distinction that needs to be made is the presence, or not, of a pelvic mass. Transvaginal ultrasound has an established role in the characterization of adnexal masses and their differentiation from leiomyomas, and we will provide an overview of the ovarian, tubal and uterine pathology which may give rise to acute onset symptoms. The presence of adnexal pathology may be coincidental, as the ovary will naturally exhibit a wide variety of cyclical changes, and pain mapping, using the transvaginal probe, will help confirm this. When considering adnexal torsion, a high degree of clinical suspicion should be maintained as there are no pathognomonic features on ultrasound alone. Even the detection of blood flow within a mass suspected of torsion, using colour Doppler, will not exclude the diagnosis. By adopting a problem orientated approach to acute pelvic pain, ultrasound can facilitate a rapid diagnosis of most gynaecological problems, and allow appropriate and timely surgical intervention, conservative management or referral to other specialities as indicated. © 2004 Elsevier B.V. All rights reserved. Keywords: Pelvic pain; Ovarian cyst; Pain mapping
1. Introduction Transabdominal and transvaginal (TVS) ultrasound are both established imaging modalities in the examination of the pelvic anatomy. They are non-invasive, cost effective and widely available. Using a transvaginal approach, high frequency transvaginal probes in close proximity to the pelvic structures will result in higher resolution images. The use of TVS is well documented within almost all areas of gynaecology, and it has an established role in ovarian cyst characterization, providing information regarding cyst type and probability of malignancy [1–4]. One of the most useful, and least discussed, roles of ultrasonography, is in the assessment of the acute gynaecological patient. It is well suited to be incorporated into the armament of clinical, biochemical and
∗ Corresponding
author. Tel.: +44 208 725 0050. E-mail address: [email protected] (K. Jermy).
1471-7697/$ – see front matter © 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.rigp.2004.02.004
imaging modalities, providing an effective and rapid means of diagnosis and detection of gynaecological pathology. This review aims to deal with the initial assessment of the patient presenting with acute abdominal pain, with a negative urinary pregnancy test, in whom gynaecological pathology is suspected. Transvaginal ultrasonography remains an extension of the clinical examination: a normal scan will not exclude all underlying gynaecological conditions.
2. The premenopausal patient The importance of a complete clinical history and examination cannot be overemphasized, especially with the use of pelvic ultrasound. The premenopausal ovary and endometrium, as visualized with the transvaginal probe, are dynamic structures, constantly exhibiting cyclical changes in morphology and volume throughout the cycle. A knowledge of the normal variations that can be exhibited is important,
K. Jermy, T. Bourne / Reviews in Gynaecological Practice 4 (2004) 224–229
as the most common ovarian pathology is the functional cyst. The presence of adnexal pathology in the patient presenting with pelvic pain may be a coincidence and gentle use of the transvaginal probe to map the pain within the pelvis will help give an indication to the structures giving rise to pain. The overwhelming advantages of the transvaginal approach in the assessment of pelvic pain, are not only the excellent diagnostic capabilities, but in the presence of an acute abdomen, this route is tolerated much better than a transabdominal scan requiring a full bladder. 2.1. Pelvic pain in association with pelvic mass In those patients presenting with pelvic pain in whom there is evidence of a pelvic mass on ultrasound, an assessment needs to be made not only of pain severity and type but also the nature of the mass. Transvaginal ultrasound has a proven track record in experienced hands in the differentiation of uterine myomas from adnexal masses and also in the characterization of adnexal masses. 2.1.1. Ovarian pathology The prevalence of adnexal pathology among premenopausal women is high and the overwhelming majority of these lesions will be benign. A large proportion of benign ovarian cysts will be functional in nature, and if symptoms settle, may be managed expectantly, with a repeat scan in the early follicular phase of a subsequent menstrual cycle to confirm resolution. Endometriomas and dermoids will account for over two-thirds of persistant ovarian cysts in premenopausal women [5].
225
A careful history, and a clear knowledge of the day of the menstrual cycle, will prompt the sonographer to the most likely cause of the pain. For example, acute onset, midcycle pain may be indicative of a follicular or corpus luteal cyst accident. Haemorrhage into a corpus luteal cyst has characteristic sonographic findings (Fig. 1). The condition tends to be self limiting and often responds to non-steroidal anti-inflammatory analgesia. Surgery should be avoided if possible. The cyclical occurrence of a haemorrhagic corpus luteal cyst may result in persistant morbidity. In the absence of contraindications, the use of the combined oral contraceptive pill to suppress ovulation can be beneficial. This is particularly true of women with clotting factor deficiencies; such as von Willebrand’s disease. These women may present with an acute abdomen, secondary to a haemoperitoneum as a result of ovulation or corpus luteal haemorrhage or rupture. Functional ovarian cysts are usually unilocular, with a thin, smooth wall and sonolucent contents. They tend to be asymptomatic, unless they undergo torsion, acute haemorrhage or rupture. Recent cyst rupture may be suggested by the resolution of clinical symptoms and free fluid within the Pouch of Douglas, often with a collapsing, irregular cyst. Those women with a history suggestive of endometriosis presenting with acute pain, may have sonographic evidence of an endometrioma. These rarely undergo torsion, as they are often fixed within the pelvis, but may undergo rupture or acute haemorrhage within the cyst. Rarely they can become infected. Dermoids and endometriomas each have characteristic sonographic patterns (Figs. 2 and 3) which aid recognition. Dermoids may be predominantly cystic, or solid, with poste-
Fig. 1. Haemorrhagic corpus luteal cyst. Fine strands of fibrin are seen within the cyst contents.
226
K. Jermy, T. Bourne / Reviews in Gynaecological Practice 4 (2004) 224–229
Fig. 2. Large endometrioma: ‘ground glass’ appearance to the cyst contents.
rior acoustic shadowing. Fine, short echogenic strands may be visable within the cystic component, representing hair. Endometriomas tend to be thick walled with heterogenous, low level (‘ground glass’) internal echoes. A subjective assessment of ovarian morphology based on characteristic ultrasonongraphic findings has been shown to be highly predictive for the diagnosis of dermoids and endmetriomas, in a population with a low background risk of malignancy [6]. A suggested follow-up regime for women diagnosed with a pelvic mass is shown (Fig. 4). Intervention will be dic-
tated by the resolution—or not—of the patients symptoms. If the symptoms resolve and there are no sonographic features of malignancy on the ultrasound, a repeat scan at 6 weeks should be performed, to confirm cyst resolution. 2.1.2. Ovarian torsion This is unusual with adnexal masses measuring less than 5 cm [7] in diameter. However, there are no pathognomonic features specific to adnexal torsion and a high degree of clinical suspicion is essential. A clinical history of acute onset,
Fig. 3. Benign cystic teratoma, with acoustic shadowing, secondary to a bright echogenic area representing sebum.
K. Jermy, T. Bourne / Reviews in Gynaecological Practice 4 (2004) 224–229
227
Fig. 4. Ultrasound-based pathway for pelvic pain assessment.
constant pain not responding to analgesia, often with nausea and vomiting and systemic upset is common. Because the central feature of ovarian torsion is the cessation of vascular supply, colour Doppler has been used to interrogate the adnexal mass suspected of undergoing torsion, as early action may allow for conservative surgery. It is likely however, that if flow can be visualized within the mass, despite clinical symptoms and signs of ovarian torsion, that ovarian blood flow may still be compromised, as demonstrated by surgically proven ovarian torsion, despite detecting blood flow within the mass [8]. 2.1.3. Uterine leiomyomas These may undergo degeneration, especially during pregnancy. The patient is often systemically unwell, with a pyrexia, leucocytosis and generalized abdominal tenderness. If pedunculated in nature, fibroids may undergo torsion, or prolapse through the cervix. The ultrasound characteristics of leiomyomas are varied and well documented. Before the menopause they tend to be a well defined, heterogeneous or hypoechoic uterine mass.
Cystic areas can be visualized within the fibroid if it is degenerating. TVS is used in conjunction with abdominal scanning to ensure pedunculated, subserosal fibroids are not missed. Occasionally, a pedunculated fibroid may mimic a solid, adnexal mass, and vice versa, an ovarian fibroma may be interpreted as a uterine fibroid. In such cases, magnetic resonance imaging may help in the differentiation. 2.1.4. Tubal pathology Acute pelvic inflammatory disease, with hydrosalpinx, pyosalpinx or a frank tubo-ovarian abscess (Fig. 5), will tend to present with systemic upset, leucocytosis, unilateral progressing to bilateral pelvic pain, menstrual disturbances and vaginal discharge. The differential diagnoses will therefore include adnexal torsion, acute fibroid degeneration, urinary tract infection and appendicitis. Acute inflammatory processes within the fallopian tubes tend to produce thick walled, cystic structures, tender to the touch of the probe. However, a chronic hydrosalpinx will
228
K. Jermy, T. Bourne / Reviews in Gynaecological Practice 4 (2004) 224–229
Fig. 5. Tubo-ovarian abscess: an irregular, thick walled multiloculated structure.
have the appearance of a thin walled structure, not obviously tender on probing and often detected coincidentally [9]. 2.1.5. Acute urinary retention As part of a pelvic scan, the bladder will be visualized. Acute urinary retention can result from a number of diverse causes, such as urinary tract infection, the presence of a fibroid uterus or in early pregnancy with a retroverted uterus. Ultrasound will help elucidate possible underlying pathology. A full bladder may sometimes be confused with an ovarian cyst. If there is any doubt and the patient is unable to void urine a catheter should be passed to ensure the bladder is empty. Occasionally a blood clot may be visible within the bladder. 2.2. Pelvic pain with no mass on scan In the absence of pathology on scan, blood should be taken for leucocytosis and microbiological culture. Urinalysis should be performed, and a complete infection screen, including endocervical and high vaginal swabs. Transvaginal scan may reveal fine echogenic strands and loculated fluid within the pelvis, indicative of adhesions. It is sometimes not possible to elucidate a diagnosis based on clinical, ultrasound and serum findings alone. Medical, surgical and urological opinions should be sought where indicated, with early recourse to laparoscopy in those patients who have persistant or worsening symptoms. Transvaginal ultrasound with power Doppler may be used to help diagnose acute appendicitis and in its differentiation from pelvic inflammatory disease [10,11]. Ultrasound can also contribute
to the diagnosis of other gastrointestinal disorders presenting with lower abdominal pain, such as acute diverticulitis [12].
3. The postmenopausal patient Characterization of any adnexal mass is important within this age group, as the risk of a mass being malignant is high. Unilocular cysts may be found in up to 20% of asymptomatic, postmenopausal women. Numerous studies have shown that simple, unilocular cysts, measuring less than 5 cm in diameter are associated with a very low risk of malignancy [13]. Blood should be taken for tumour markers and emergency laparotomy avoided if at all possible, to allow for adequate oncological work up of the patient if indicated. Urinary retention must be excluded. Other surgical and medical conditions are more predominant in the older age group, such as diverticulitis, constipation and urinary tract infections.
4. Conclusion The time has come to maximize the role of ultrasound within the routine assessment of the acute gynaecological patient. It complements the clinical examination, affording us a ‘view’ of the pelvic structures. Its integration into the gynaecology emergency service—particularly within the setting of an acute gynaecology unit—facilitates a more rapid diagnosis in a number of gynaecological conditions. It also helps to exclude gynaecological pathology, ensuring prompt referral to other specialities.
K. Jermy, T. Bourne / Reviews in Gynaecological Practice 4 (2004) 224–229
Central to its appropriate use will be training and supervision, with up to date protocols, regular audit and an awareness of both our own, and the equipment’s, limitations. References [1] Granberg S, Wikland M, Jansson I. Macroscopic characterisation of ovarian tumors and the relation to the histological diagnosis: criteria to be used for ultrasound evaluation. Gynecol Oncol 1989;35:139–44. [2] Granberg S, Norström A, Wikland M. Tumors in the lower pelvis as imaged by transvaginal sonography. Gynecol Oncol 1990;37:224–9. [3] Tailor A, Jurkovic D, Bourne T, Collins W, Campbell S. Sonographic prediction of malignancy in adnexal masses using multivariate logistic regression analysis. Ultrasound Obstet Gynecol 1997;10:41–7. [4] Timmerman D, Bourne TH, Tailor A, Collins WP, Verrelst H, Vandenberghe K, et al. A comparison of methods for the pre-operative discrimination between benign and malignant adnexal masses: the development of a new logistic regression model. Am J Obstet Gynecol 1999;181:57–65. [5] Koonings P, Campbell K, Mishell D, Grimes D. Relative frequency of ovarian neoplasms: a 10 year review. Obstet Gynecol 1989;74: 921–5.
229
[6] Jermy K, Luise C, Bourne T. The characterization of common ovarian cysts in premenopausal women. Ultrasound Obstet Gynecol 2001;17(2):140–4. [7] Nicholas D, Julian P. Torsion of the adnexa. Clin Obstet Gynecol 1985;28:375–80. [8] Rosado W, Trambert M, Gosink B, Pretorius D. Adnexal torsion: diagnosis by using Doppler sonography. Am J Radiol 1992;159: 1251–3. [9] Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS. Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound Obstet Gynecol 1998;12(1):56–66. [10] Molander P, Paavonen J, Sjoberg J, Savelli L, Cacciatore B. Transvaginal sonography in the diagnosis of acute appendicitis. Ultrasound Obstet Gynecol 2002;20(5):496–501. [11] Caspi B, Zbar AP, Mavor E, Hagay Z, Appelman Z. The contribution of transvaginal ultrasound in the diagnosis of acute appendicitis: an observational study. Ultrasound Obstet Gynecol 2003;21(3):273–6. [12] Ripolles T, Agramunt M, Martinez MJ, Costa S, Gomez-Abril SA, Richart J. The role of ultrasound in the diagnosis, management and evolutive process of acute left sided colonic diverticulitis: a review of 208 patients. Eur Radiol 2003;Dec 13(2):2587–95. [13] Kroon E, Andolf E. Diagnosis and follow up of simple ovarian cysts detected by ultrasound in postmenopausal women. Obstet Gynecol 1995;85:211–4.