FemaleFemale PelvicPelvic PainPain --

ImagingImaging TechniquesTechniques

andand TypicalTypical FindingsFindings

Boris BrkljačićBoris Brkljačić

Department of Radiology, University Hospital “Dubrava”;

Medical School, University of Zagreb, Zagreb, Croatia

Danish Radiology Congress, Aarhus, January 2013.

FemaleFemale pelvicpelvic painpain

� structured approach to image interpretation to

narrow broad spectrum of ddxs

� distinction btw pregnant and non-pregnant pts

� once pregnancy is excluded disorders need to be � once pregnancy is excluded disorders need to be

grouped according to the anatomic origin

� initial imaging work-up should be tailored to

enable dxs of both gynecologic and non-

gynecologic causes; not only pelvic examination

FPP: FPP: ImagingImaging ModalitiesModalities

�Ultrasound

�Computed Tomography

�Magnetic Resonance Imaging

AcuteAcute LowerLower AbdominalAbdominal andand

PelvicPelvic PainPain: :

��UUS S andand CTCT are most commonly used

��MMRIRI beneficial for a subset of pts for whom

CT is not warranted (pregnant pts, younger

pts)

ChronicChronic PelvicPelvic PainPain: :

��UUS S andand MRIMRI are most commonly used

�US (TV US) used initially�US (TV US) used initially

�MRI often used for definitive dx

UltrasoundUltrasound

the first imaging modality to study women w lower

abdominal and pelvic pain

advantages: non-invasive, low cost, no ionizing advantages: non-invasive, low cost, no ionizing radiation, availability, real-time, dynamic exam

US enables final dxs in many clinical conditions and further imaging is indicated when US fxs are inconclusive

UltrasoundUltrasound

� transabdominal US

� transvaginal US

�B-mode, color & power Doppler

�native harmonic and compound imaging�native harmonic and compound imaging

� contrast-enhanced-US

� 3 D Ultrasound

� hysterosonography and hystosalpingo-contrast-sonography (hy-co-sy)

� elastography

TransabdominalTransabdominal vs.vs. TransvaginalTransvaginalBetter panoramic overview

Better to evaluate relations

to surrounding structures

and measure volumes

Better resolution to evaluate small lesions and slight changes of echogenicity; higher sensitivity to flow

It is recommendable to use both TA It is recommendable to use both TA && TV USTV USIt is recommendable to use both TA It is recommendable to use both TA && TV USTV US

Fleischer, AC

J US Med, 1989

transvaginaltransvaginal USUS alone sufficient to visualise all fxs in

>83% pts

both TV and TA USboth TV and TA US w empty bladder needed for 15%

of pts

only 1.5% of pts required full bladder to visualise

normal ovaries → filling of the bladder for pelvic

sonogram is seldom required

Benacerraf B, et al. J Ultrasound Med 2003

• abnormal angiogenesis –neovessels w/o smooth

muscles in walls - ↓RI, A-V shunts, irregular pattern of

vascularisation; 0.40 RI threshold to differentiate

malignant and benign ovarian masses (Kurjak A, et al. J

Ultrasound Med 1991) has not proven accurate

CDI CDI -- malignantmalignant gynecologicgynecologic tumorstumors

In myomas macrovessels are usually seen in the periphery,

resembling a ring

In adenomyosis abundant intralesional vessels w chaotic

distribution, and ↑ # than in adjacent normal myometrium.

ColorColor Doppler: Doppler: adenomyosisadenomyosis vs. vs. myomamyoma

Sonoelastographynew dynamic technique that estimates stiffness of

tissues by measuring the degree of distortion under

application of external force

Elastography can differentiate endometrial polyps from

leiomyoma (Hobson MA, et al. J Clin Ultrasound 2007; 26(7): 899-908) and leiomyoma (Hobson MA, et al. J Clin Ultrasound 2007; 26(7): 899-908) and

malignancy from normal cervix Thomas A, et al. Acad Radiol 2007;

14(2):193-200.

SignificanceSignificance of of normalnormal US US fxfx??

�86 pts w PP and normal US reevaluated after

6-21 mo: 86% w acute/subacute pain & 50%

w chronic pain → resolution of symptoms

� further imaging in 9 pts → only 4 had clin� further imaging in 9 pts → only 4 had clin

sign disease (2 endometriosis, 1 pelvic

adhesions, 1 adenomyosis).

�high NPV (92%) for normal TV US fxs

Harris RD, et al. Clinical outcome in female pts w pelvic pain and

normal pelvic US fxs .Radiology 2000;216:440-3

ComputedComputed TomographyTomography

� not the first-line choice in dxs female pelvic diseases

� pelvis often included as a part of abdominal CT study -

familiarity w appearance of pelvic pathology necessary

� advantage: availability in emergency

� disadvantages: lack of precise definition of pelvic

structures, ionizing radiation (especially problem in

young women and possibly pregnant women)

ComputedComputed TomographyTomography

� indicated when:

� US fxs are equivocal

� clinically or according to US fxs following conditions

are suspected:

� pelvic abscess � pelvic abscess

� hematoma

� postpartum complications

� complications related to PID

� GI or urinary pathology

Bennett GL. Radiographics 2002;22:785-81.

ComputedComputed TomographyTomography

� CT often performed in pts referred for pain beyond the pelvis or in pts who present after hours – ↑frequency of use of CT to evaluate pts w acute PP

� PP may exist in the absence of gynecologic cause; CT will depict non-gynecologic disease if the initial imaging protocols are not tailored too narrowly within the pelvis

Potter AW. Radiographics 2008;28:1645-59

CT CT -- acquisitionacquisition parametersparameters::

� (16-MDCT)

� patient position: supine, with elevated arms; scan

range: diaphragm (iliac crest) to pubic symphisis; tube

voltage: 120KVp,140 - 220mAs

� slice collimation: 16x1.5mm, pitch 1.3-1.5, recon.

kernel B20/ B30f, recon. increment 3-5mm

� unenhanced scans in pelvic disease useful only for

detection of acute hemorrhage

CT CT -- acquisitionacquisition parametersparameters::

�� ii..v. contrastv. contrast: 100-120ml, injection rate 3-4 ml/s

� better delineation of uterus and adnexal structures

� scan delay: 60-80 sec

� bolus-triggering in pts w decreased cardiac function

� 20 s delay after reaching 50 HU in infrarenal aorta-� 20 s delay after reaching 50 HU in infrarenal aorta-

routine

� delayed scans (3-5min) for evaluating stromal invasion,

abscesses, infiltration of bladder wall or distal ureters

CT CT -- acquisitionacquisition parametersparameters::

�� oral administrationoral administration of 1000-1500 ml of iodinated

water-soluble 2% c.m., or barium-sulfate suspension

- taken continuously over at least 45 min– thus

normal bowel loops can be distinguished fromnormal bowel loops can be distinguished from

abnormal bowel and adnexal structures

� rectal administration of contrast not routinely

performed but may help ddx adnexal process from

rectosigmoid colon disorders

MRI MRI protocolprotocol

�has to be tailored according to the clinical question

�slice orientation and thickness +++�slice orientation and thickness +++

� i.v. contrast

�always / when possible correlate fxs of TV / TA GYN US

Current gynecological Current gynecological

indications for pelvic MRIindications for pelvic MRI

� local staging of biopsy proven cervical or

endometrial ca

�characterization of ovarian masses that are �characterization of ovarian masses that are

suspicios or indeterminate at US

�polyfibromatosis / large uteri before

conservative treatment of the uterus

�chronic PP: endometriosis, adenomyosis

Kinkel K, Eur Radiology 2006

Standard protocol: female pelvis MRIStandard protocol: female pelvis MRI

� 3-6 h prior fasting

� no bladder voiding 1-2 h prior to MRI

� pt interview:

� contraindications to MRI

� symptoms (pain – when, where, how often, how � symptoms (pain – when, where, how often, how

intense?; bleeding)

� date of last menstruation / menopause, medication

(contraceptives?), surgical history

� i.m. injection of an antiperistaltic agent (if no

glaucoma): 20mg butyl-scopalamine (Buscopan®)

Kinkel, K. ECR 2006

Rectal or vaginal Rectal or vaginal contrastcontrast

� vaginal contrast: US gel

� better diagnosis of posterior fornix invasion in cervical

cancer (Van Hoe, Radiology 1999)

� rectal contrast: 200 ml US gel / water enema

� diagnosis of rectal wall invasion (Bazot, Radiology 2004)

� Endometriosis, gynaecological cancer invasion

� pelvic floor analysis

Standard Standard sequencesequence choiceschoices

� three T2 w FSE sequences (12min) – anatomical info

� TR/TE 4000/90 msec, 203x512,

� FOV 22-25cm

� 3 nex, 4 mm, 25 slices� 3 nex, 4 mm, 25 slices

� sagittal, short and long uterine axis (oblique)

� one to three T1 w FSE sequences (TR/TE 500/14

msec, 204x512, 4mm) (15min) – biochemical info

� native: always

� fat suppressed: if lesion hyperintense on native T1

� i.v. contrast-enhanced and fat suppression: list

TETE TRTR FLIPFLIP NSANSA N slicesN slices thicknessthickness timetime

T2 TSET2 TSE 9090 40004000 9090 33 2525 44--5 MM5 MM ~4 min~4 min

TechnicalTechnical parametersparameters

T1 TSET1 TSE 1414 500500 9090 33 2525 44--5 MM5 MM ~5 min~5 min

T1 TSE T1 TSE

SPIRSPIR1414 580580 9090 33 2525 44--5 MM5 MM ~5 min~5 min

DYNDYN 1414 550550 9090 22 1818 44--5 MM5 MM~6min~6min

4x1’30’’4x1’30’’

IndicationIndicationss for for contrastcontrast--enhancedenhanced

T1T1--weightedweighted sequencessequences

�endometrial cancer staging

�cervical cancer staging if cancer not seen at T2

�adnexal mass characerization

� rectal, bladder or vaginal wall invasion by

cancer or endometriosis

�uterine versus ovarian origin of a mass

�preoperative mapping of polyfibromatosis

MRI for Acute Lower Abdominal MRI for Acute Lower Abdominal

and Pelvic Painand Pelvic Pain

� high accuracy of MRI

� short imaging protocol of cca 10 minutes w/o use

of i.v. contrast agents in most cases allows

investigation of these ptsinvestigation of these pts

� MRI may not be modality of choice for all pts, but

is beneficial for subset of pts for whom CT is not

warranted (pregnant pts, young pts) and US fxs

are inconclusive

Heverhagen J, Klose JK. Radiographics 2009;29:1781-96

TakeTake--home home pointspoints: :

APP:APP: UUS S andand CTCT most commonly used;

MMRIRI for younger, pregnant pts for whom

CT is not warranted

CPPCPP: : UUS S andand MRIMRI most commonly used

�US (TV) initially, ↑ NPV for normal US fx

�MRI often for definitive dx

TakeTake--home home pointspoints

CT CT protocolprotocol tailored to visualize GYN & non-

GYN pathology; i.v. and oral contrast needed

MRIMRI: optimal protocol to combine 3 T2-w and MRIMRI: optimal protocol to combine 3 T2-w and

T1w (native, FS, CE+FS) sqcs in best

orientation; CE for endometriosis, ovarian

mass characterization, before conservative

surgery in large uteri; fasting & i.m. peristaltic

inhibitors ↑ image quality

focal adenomyoma vs. fibroma: US

Adenomyoma Fibroma

echogenicityhyperechoic(compared to

hypoechoic(compared to echogenicity (compared to

myometrium)

(compared to

myometrium)

border ill- defined well- defined

vascularityinside

(penetrating pattern)

peripheral

(draping pattern)

focal adenomyoma vs. fibroma: MRI

adenomyoma fibroma

border ill defined

well defined

(outside the

junctional zone)

T1W ↑ (hemorrhage) ↓

T2W ↑ ; ↓ ↓

CE MRIdoesn`t improve accuracy in

differentiation