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Type:
Educational Exhibit
Keywords:
Acute, eLearning, MR, CT, Genital / Reproductive system female
Authors:
Y. T. Sim, B. Lawson, A. leslie, M. Cooper, K. Ragupathy, T. Sudarshan; Dundee/UK
DOI:
10.1594/ecr2016/C-0887
Findings and procedure details
Acute gynaecological conditions
Pelvic inflammatory disease (PID)
- infection and inflammation of the female upper genital tract,
involving the uterus,
fallopian tubes and ovaries
- ascending infection from vagina,
usually Chlamydia trachomatis, Neisseria gonorrhoeae,
and polymicrobial infections
- mostly affect sexually active women; other risk factors include young age,
multiple sexual partners,
use of intra-uterine device
- frequently causes tubal damage,
scarring and occlusion,
which may result in long-term complications and concern for infertility,
higher risk of ectopic pregnancy; therefore important for accurate diagnosis and prompt treatment
- most women have mild symptoms: lower abdominal and pelvic discomfort/pain,
vaginal discharge,
uterine bleeding,
dyspareunia,
dysuria; more severe cases may have constitutional symptoms of fever,
vomiting
- gold-standard for diagnosis is laparoscopy for direct visualisation of purulent exudate and oedema of pelvic structures,
but seldom used in clinical setting as it is expensive and invasive
- CT: changes in early PID can be very subtle - mild pelvic oedema with thickening of uterosacral ligaments and hazy stranding of pelvic fat; mild salpingitis with inflammatory thickening of fallopian tubes; mild oophoritis with enlarged enhancing ovaries; endometritis with abnormal endometrial enhancement and fluid in the canal.
In more advanced PID,
the fallopian tubes fill with complex fluid and pus,
demonstrating greater dilation,
wall thickening and enhancement in pyosalpinx.
Tubo-ovarian abscesses may form ultimately,
manifesting as complex fluid collection with thick enhancing walls with internal septations,
fluid-debris level,
or gas.
- MRI: the dilated tubal configuration of pyosalpinx and thick-walled complex abscesses are well-demonstrated
- Involvement of other pelvic and abdominal organs: pelvic bowel loops can become dilated due to adynamic ileus from adjacent inflammation; functional or mechanical ureteric obstruction; direct extension of infection along paracolic gutter or through lymphatic spread can cause inflammation in right upper quadrant peritoneal surfaces and right lobe of liver (Fitz-Hugh-Curtis syndrome)
Adnexal cyst accidents (rupture and torsion)
- adnexal cysts are extremely common,
with extensive differential diagnoses of which most are benign
- the likelihood of benign cysts is much higher in pre-menopausal women as the ovaries produce physiologic cysts
- adnexal cysts may be asymptomatic,
or symptomatic causing abdominal pain and 'bloating'
- physiological (follicular,
or corpus luteal cyst) or pathological cysts (endometriomas,
dermoid cysts,
cystic benign or malignant neoplasm) may rupture,
releasing cyst fluid or blood that may irritate the peritoneal cavity
- whilst most women with ruptured ovarian cyst may be managed conservatively,
some may require surgery based upon severity of symptoms,
haemodynamic stability,
presumptive histological diagnosis; ruptured dermoid cyst usually requires surgical intervention as cyst contents of sebaceous fluid,
hair,
fat,
bone,
or cartilage may result in severe peritoneal irritation
- ovarian torsion occurs when the ovary and portion of the fallopian tube twists on its supplying vascular pedicle,
and if sustained,
venous and arterial stasis ensues eventually resulting in ovarian infarction and necrosis; urgent surgery is required to prevent ovarian necrosis
- two main reasons for ovarian torsion are: hypermobility of ovary; and adnexal mass (masses between 5 and 10cm are most at risk)
- if a cyst ruptures,
the woman may experience sudden severe sharp pain; if a cyst undergoes torsion,
the woman may feel severe pain,
with nausea and vomiting
- CT: a twisted ovarian pedicle is pathognomonic for ovarian torsion if demonstrated; torted ovary/ovarian cyst manifest as a complex adnexal lesion comprising enlarged ovary (> 4cm) due to venous/lymphatic engorgement,
oedema and haemorrhage,
and its distended pedicle as a twisted dilated tubular structure.
There may be surrounding fat stranding and free fluid
- MRI: whilst superior to CT in characterisation of adnexal masses,
MRI is usually not imaging of choice in torsion,
as this gynaecological emergency requires urgent imaging; if there is haemorrhagic infarction of the ovary,
thin rim of T1 high-signal (methaemoglobin) may be present,
and low-signal on T2-weighted images due to interstitial haemorrhage
Fibroid degeneration
- fibroids are extremely common benign smooth muscle tumours of the uterine myometrium,
classified based on their location into submucosal,
intramural and subserosal fibroids
- it is suggested that oestrogen and progestogens play important role in stimulating growth of fibroids,
which occur in women of reproductive age,
often enlarge during pregnancy or oral contraceptive use,
and regress after menopause
- as fibroids enlarge,
often very slowly over years, they may outgrow their blood supply and the central area undergoes degeneration: hyaline or myxoid degeneration,
calcification,
cystic degeneration,
and red (haemorrhagic) degeneration
- red degeneration is haemorrhagic infarction of fibroid that often occurs during pregnancy,
secondary to venous thrombosis within periphery of the tumour or rupture of intratumoral arteries
- most fibroids are asymptomatic,
but can cause troublesome symptoms in many women,
including menorrhagia,
dysmenorrhoea,
pelvic pressure and pain,
urinary frequency,
infertility,
palpable mass
- acute degeneration of fibroids can result in acute severe pain,
low-grade fever,
leucocystosis.
- CT: fibroids are of soft-tissue density often iso-attenuating to surrounding myometrium,
may exhibit coarse calcification,
may distort the usually smooth uterine contours,
demonstrate variable enhancement
- MRI: non-degenerate fibroids are of low SI on T1- and T2-weighted images; fibroids with cystic degeneration show high-signal on T2-weighted imaging and does not enhance; fibroid with red degeneration on T1-weighted images has characteristic high-signal rim around centrally located myoma
Endometriosis
- common condition in women of childbearing age,
defined as presence of functional endometrial glands and stroma outside the uterine cavity,
which can range from microscopic foci to large grossly visible endometriotic cysts (endometriomas)
- symptoms include chronic pelvic pain (not always cyclical),
dyspareunia,
dysmenorrheoa,
infertility
- endometriotic implants in atypical locations may result in unusual symptoms: rectal bleeding and constipation in gastro-intestinal tract involvement; urgency and haematuria in bladder involvement; pleuritic chest pain and pneumothorax in pulmonary involvement
- laparoscopy is the gold-standard diagnostic test
- radiological evaluation of small endometriotic implant is limited; therefore role of imaging is generally to identify endometriotic cysts and complications such as deep adhesions
- CT: sizeable ovarian endometriomas (chocolate cysts) manifest as cystic masses,
some with loculations,
may have high-attenuation content with dependent fluid-fluid level; however not possible to differentiate endometrioma from other causes of ovarian cysts on CT
- MRI: endometriomas show characteristic "shading": hyperintense on T1-weighted and T1-fat-suppressed imaging,
becoming very low-signal on T2-weighted imaging with graded shadowing pattern resulting from blood degradation products of varying ages.
Other MRI features in deep pelvic endometriosis include: nodules or thickening along uterosacral ligaments,
vaginal or rectal wall,
bladder and bowel,
of low-signal on T2-weighted and corresponding high-signal on T1-weighted imaging.
Adjacent adhesions when present are also well seen on MRI.
Acute first presentations of congenital genital tract anomalies
- Mullerian ducts are paired embryologic structures that undergo fusion and resorption in utero to give rise to the uterus,
fallopian tubes,
cervix and upper two-thirds of the vagina; interruption of their normal development result in formation of mullerian duct anomalies (MDAs)
- MDAs comprise a broad complex spectrum of abnormalities,
which are often associated with primary amenorrhoea,
infertility,
obstetrics complications,
and endometriosis; commonly associated with renal anomalies therefore identification of both kidneys is also important
- the anomaly may first come to light with acute complications; for instance,
severe abdominal pain due to haematometra or haematocolpos
- CT: limited role in evaluating and accurately delineating uterine cavity,
tubal and ovarian morphology
- MRI: imaging modality of choice in detection and accurate classification of congenital anomalies
Complications from infertility treatment
- increasing prevalence of infertility and use of fertility treatment
- these women are under close surveillance and ultrasound scans by fertility gynaecological specialists; rarely require imaging by general radiologists
- rare cases of complications may present to acute services; radiologists should be aware of the conditions and imaging appearances
- ovarian hyperstimulation syndrome (OHSS) occurs after induction of ovulation with exogenous gonadotrophins; ovaries enlarge with multi-follicular development,
increased capillary permeability and massive fluid shifts may result in ascites,
pleural effusions; may develop renal failure and coagulopathy in severe cases
- CT: bilateral enlarged ovaries with multiple enlarged follicles,
ascites; risk of ovarian torsion but difficult to diagnose on CT (ultrasound and colour Doppler is more helpful)
- in our institution,
a patient presented acutely with generalised peritonism two days after undergoing oocyte retrieval - CT scan revealed massively enlarged multi-cystic ovaries,
within which active bleeding was shown by contrast extravasation and layering,
associated with significant haemoperitoneum (Fig.
14 and 15)