Pelvic Inflammatory Disease/Pyosalpinx

by

Molly Jonna, MS4 and Jennifer Lim-Dunham, M.D.

 

What is pelvic inflammatory disease?

What are the useful imaging modalities in evaluating PID?

What is the utility of each procedure?

Appropriateness Criteria

Link to women’s imaging recommendations:
http://www.acr.org/Quality-Safety/Appropriateness-Criteria/Diagnostic/Womens-Imaging

Link to imaging criteria for acute pelvic pain in the reproductive age group:
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AcutePelvicPainReproductiveAgeGroup.pdf

Link to imaging recommendations for acute abdominal pain and fever or suspected abdominal abscess:
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ AcuteAbdominalPainFeverSuspectedAbdominalAbscess .pdf

 

What are the imaging findings of PID?

Ultrasound 

CT

What is the procedure of choice?

What are the risk factors for acquiring PID?

The risk factors for acquiring PID are similar to those for acquiring an STD and include:

Factors that potentially facilitate PID include:

What is the clinical setting when you will consider PID?

Minimum criteria needed for clinical diagnosis:

Additional criteria, which increase the specificity of the diagnosis

Take Home Points:

 

Imaging

Image 1

Left pyosalpinx. The left fallopian tube, which is marked by the red and green calipers, is dilated and contains anechoic, simple fluid as well echogenic debris representing pus. The white arrow is pointing towards a fluid-fluid level. The black arrow is pointing to an anechoic cyst within the left ovary, which is adjacent to but separate from the dilated fallopian tube.

Image 2

Left pyosalpinx. The green calipers mark the dilated fallopian tube filled with anchoic fluid and echogenic pus. The white arrow is pointing towards a fluid-fluid level.

Image 3

Right tubo-ovarian abscess. The black arrow points towards a hypoechoic structure representing a combined complex collection encompassing both fallopian tube and ovary. Note that the abscess, marked by the green calipers, is characterized by a thick wall and central echogenic fluid representing pus.

Image 4

Right tubo-ovarian abscess. Color Doppler shows that there is no flow within the hypoechoic right adnexal structure ( white arrow ) that represents the abscess. This indicates that the structure is a fluid filled mass as opposed to a solid mass.

Helpful links with Additional Imaging:

 

  1. http://www.med-ed.virginia.edu/courses/rad/edus/pelvic2.html
  2. http://www.learningradiology.com/lectures/facultylectures/pidpptmh_files/v3_document.htm - a powerpoint of information and images that you can scroll through
  3. http://pubs.rsna.org/doi/pdf/10.1148/rg.312105090  - article with several images included, this is also linked in the references section

 

References

  1. Livengood, C. H., & Chacko, M. R. (2012). Clinical features and diagnosis of pelvic inflammatory disease. In N. Hynes & A. Bloom (Eds.), UpToDate. Retrieved from http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-pelvic-inflammatory-disease?source=search_result&search=Pelvic+Inflammatory+disease&selectedTitle=2%7E150
  2. Rezvani, M., & Shaaban, A. M. (2011). Fallopian tube disease in the nonpregnant patient. RadioGraphics, 31, 527-548. Retrieved from http://pubs.rsna.org/doi/pdf/10.1148/rg.312105090
  3. Sam, J. W., Jacobs, J. E., & Birnbaum, B. A. (2002). Spectrum of ct findings in acute pyogenic pelvic inflammatory disease. RadioGraphics, 22, 1327-1334. Retrieved from http://pubs.rsna.org/doi/pdf/10.1148/rg.226025062

 

Case 1

A 26-year-old female presents to you in the STD clinic with a complaint of fever of three days duration, nausea, and lower abdominal pain. She denies a history of dysuria, hematuria, or genital ulcerations. She denies that she may be pregnant. She has an intrauterine device for 2 years. She takes no prescribed medications and she has no allergies. On examination, she has a temperature of 39 0 C, pulse rate of 110 per minute, respiration rate of 28 per minute, and B/P of 100/60. She is ill appearing and diaphoretic. There is no lymphadenapathy. She has right lower quadrant tenderness to deep palpation. Bowel sounds are present but hypoactive. Her pelvic examination reveals right adnexal tenderness and cervical motion tenderness. The uterus is tender and slightly enlarged. Thick yellow vaginal discharge is sent for microbiological studies. Pregnancy test is negative.

Question: Does she need imaging studies? Can she be treated empirically?

Answer: Yes.
Empiric treatment of PID should be instituted on the basis of the presence of all of the following three minimum clinical criteria for pelvic inflammation and in the absence of an established cause other than PID: 1) lower abdominal tenderness, 2) adnexal tenderness, and 3) cervical motion tenderness.

For women with fewer clinical signs, more elaborate diagnostic evaluation is warranted because incorrect diagnosis and management may cause unnecessary morbidity.

 

Case 2

19 year old sexually active girl presents with right lower quadrant pain and fever. Her LMP was one week back. She does not practice protective sex. She has right lower quadrant abdominal tenderness with rebound. On pelvic exam, there is some mucoid discharge from cervix. Uncertain about tenderness on cervical motion. Surgeon is debating between PID and appendicitis.

Question: Does she need any imaging procedure. If so which imaging procedure?

Answer: When you are uncertain of the diagnosis, imaging procedure should be utilized. CT would be the choice in this case as it will provide information about pelvis and abdomen. But pregnancy test must be done to rule out pregnancy before CT.

 

Case 3:

Patient is a 17-year-old sexually active G0P0 who comes to her primary care physician complaining of severe abdominal pain for 2 days.  Her LMP was 2 weeks ago.  She states that she uses condoms for contraception.  Pt has a fever to 101.  She has a tender lower abdomen, but no rebound or guarding. On pelvic exam, the patient has a purulent cervical discharge. Patient has a positive chandelier sign (cervical motion tenderness) as well as bilateral adnexal tenderness. B-HCG is negative. 

This patient has Fitz-Hugh Curtis syndrome, which is perihepatits, a complication of untreated PID. One can see fluid around GB on ultrasound

 

 

12.17.13