CHRONIC PELVIC PAIN IN WOMEN IMAGING CHRONIC PELVIC PAIN IN WOMEN MOSTAFA ATRI, MD Dipl. Epid. UNIVERSITY OF TORONTO Non-menstrual pain of 6 months Prevalence 15%: 18-50 years of age 10-40% of gynecology visits 35% of laparoscopies/15% of hysterectomies Lower prevalence in black and > 35 year Total cost: 39 billion/year in US CHRONIC PELVIC PAIN IN WOMEN Gynecology causes Adenomyosis Endometriosis Chronic PID Pelvic congestion Ovarian remnant syndrome Pelvic adhesions GI causes Diverticulitis Urology causes (cystitis, urethral diverticulum) MSK causes ADENOMYOSIS ADENOMYOSIS ADENOMYOSIS: PATHOLOGY Perimenopausal Up to 70% of hysterectomy specimens More common dorsally Clinical diagnosis correct in 48% Pain starting before and continuing after period Menorrhagia, metrorrhagia Soft and tender uterus Endometrial glands & stroma One high power field below endometrium; > 2.5 mm Glandular cyst Glandular proliferation in proliferative phase Peri-glandular muscle hypertrophy 1
SONOGRAPHIC FEATURES PATHOLOGY Poor definition Round or elongated echogenic nodules Poor definition of outer endometrium Coarse architecture Edge shadows Globular configuration or asymmetrical wall Hypovascular NODULECYST ENDO DEFINITION ADENOMYOMA FOCAL ADENOMYOSIS EXTENSIVE ADENOMYOASIS 2
CORNUAL ADENOMYOMA ADENOMYOMA ENDOMETRIOTIC CYST ENDOMETRIOSIS PATHOPHYSIOLOGY General population: 7% - 10% 50% - 80% symptomatic Infertile: 20% - 50% 90% of women with chronic pelvic pain/dyspareunia 10 fold increase with affected first degree relative Amount of pain not correlated with extent but with depth of penetration Invasive tissue at a depth > 5mm from peritoneal Surface fibrosis and muscle hyperplasia and different degrees of inflammation Retrograde menstruation Direct implantation: C section Lymphatic/vascular Metaplasia Genetics Rx hypostrogenic or antistrogenic 3
LOCATIONS Ovary/Fallopian tube Uterus Uterine ligaments Cul de sac Pelvic peritoneum Cervix Vagina/Rect-ovaginal septum C-section/hysterectomy scar Rectosigmoid involvement TVUS/TRUS Sensitivity 91%/ 96% Specificity 97%/ 100% 56% of rectal endometriosis had other intestinal lesions 28% had ileo-cecal lesions Piketty et al. Human Reproduction 2009 LIMITATION ULTRASOUND Location outside pelvis Other significant pathologies present (ovary cyst, fibroid) MRI Undistended structurs Feces/gas in bowel peristalsis Chamié L P et al. Radiographics 2011 UTEROSACRAL LIGAMENT Chamié L P et al. Radiographics 2011 4
RECTO-VAGINAL SPACE OVARIAN ENDOMETRIOSIS Extensions from retro-cervical or posterior vaginal lesions Bladder and rectovaginal is difficult to see laparoscopically Most common site of endometriosis (20% 40% of cases) Under-diagnosed because of microscopic size GASTROINTESTINAL TRACT posterior bladder wall and the anterior uterine serosa. Rectum and rectosigmoid junction Appendix, ileum, cecum, and descending colon MR not reliable to detect deep infiltrating endometriotic lesions, especially small nodules (<1.5cm) Goncalves et al. Human Reproduction 2010 Chamié L P et al. Radiographics 2011 RECTO-UTERINE RECTO-CERVICAL 5
KISSING OVARIES KISSING OVARIES UTERO-VESICAL RETROFLEXED UTERUS 6
HYDROSALPINX BLADDER BOWEL WALL ABDOMINAL WALL 7
CHRONIC PELVIC PAIN IN WOMEN Gynecology causes Adenomyosis Endometriosis Chronic PID Pelvic congestion Ovarian remnant syndrome Pelvic adhesions GI causes Diverticulitis Urology causes (cystitis, urethral diverticulum) MSK causes PELVIC CONGESTION SYNDROME 10% of population 60% symptomatic Pathophysiology Obstructive Retroaortic RV, SMA, Rt. CIV Secondary Valve incompetence, portal hypertension, IVC syndrome Risk factors Hormonal, retroverted uterus, pregnancies Dyspareunia, dysmenorrhea, rectal discomfort, urinary frequency, vulvar varicosity, ovarian tenderness IMAGING FINDINGS CT findings Reflux from renal vein to ovarian vein US criteria > 4mm vei Dilated arcuate veins communicating with adnexal varices Cystic ovaries/pcos 50% of patients NO RCT available CHRONIC PELVIC PAIN IN WOMEN Gynecology causes Adenomyosis Endometriosis Chronic PID Pelvic congestion Ovarian remnant syndrome Pelvic adhesions GI causes Diverticulitis Urology causes (cystitis, urethral diverticulum) MSK causes CT/SONOGRAPHIC FEATURES Short to long segment Eccentric predominantly outer layer/ Transmural concentric Layer preservation Inflamed diverticulum Intramural sinus tracts Increased vascularity Peridiverticular changes 8
INFLAMED DIVERTICULUM DIVERTICULITIS Thick muscle layer Thickened wall Inflamed fat د د د TVS Inflamed diverticula 9