GYNECOLOGIC EMERGENCIES: BEYOND TORSION Monisha Shetty MD, Syed Zafar H. Jafri MD, FACR Beaumont Health, Royal Oak, MI OUWB School of Medicine, Rochester, MI Society of Abdominal Radiology Annual Meeting, San Diego, CA 2015 DISCLOSURES • The speakers have no relevant financial relationships which may be considered conflicts of interest in regards to this workshop. TEACHING GOALS • To present imaging examples of uterine, fallopian tubal ovarian and vaginal pathology as well as entities in the setting of early pregnancy that can present acutely • To highlight specific imaging features that can aid in the diagnosis of these entities • To focus on more rare acute entities, recognizing that the more common entities, including ovarian torsion, are well covered in the literature BACKGROUND • Gynecologic emergencies most often present with pelvic pain and/or vaginal bleeding • These symptoms frequently send patients to the ER for assessment • Additional information to seek out includes the following: – ß‐HCG – past pelvic surgical history – pregnancy history • While US is the first‐line modality of choice for female pelvic complaints, symptoms may be non‐specific, leading to a CT as the initial imaging study in the ER • Recognition of acute gynecologic conditions on CT as well as US is valuable for this reason UTERINE ENTITIES WILL INCLUDE: • Neglected IUD with infection • Ectopically located IUD • Uterine perforation • Fibroid complications including prolapse, torsion • Uterine inversion, uterine torsion • UAE complications including retained abdominal fibroid • Utero‐enteric fistula • Uterine dehiscence • Pyometra/endometritis • Hematometra • Trauma • CA NEGLECTED IUD WITH ACTINOMYCOSIS • Background: Actinomyces commonly present in normal vaginal flora although can cause endometritis, pelvic inflammatory disease, pelvic abscess, retroperitoneal fibrosis • Approximately 7 % of women using an IUD have actinomyces‐like organisms on a Papanicolaou (Pap) test ; only half of these women will have positive actinomyces cultures • Presentation: If asymptomatic, likely represents colonization • Infection occurs when mucosa is disrupted • Treatment: If woman shows signs or symptoms of pelvic infection: – Antibiotics – Culture IUD anaerobically – Remove IUD (Acitomyces grows preferentially on foreign bodies) • Increased duration of IUD thought to increase risk of infection – In one study, duration of 8 years on average • Imaging findings are not specific to this microbe, but it can cause fistulas IUD PERFORATION • Presentation: Patients may be asymptomatic or have pain/bleeding • Risk factors include the following: – Clinician inexperience – Immobile uterus – Retroverted uterus – Myometrial defect • Pre‐existing or created by uterine sound or IUD insertion device • Imaging: US may reveal IUD embedded in myometrium or in pelvic cul‐de‐ sac – If not seen, obtain radiograph to exclude expulsion • Management: – If in myometrium, can remove hysterscopically – If in peritoneal cavity, requires laparoscopy or laparotomy • Usually embeds in adhesions, next to sigmoid colon, in omentum or in cul‐de‐sac • Reports of bladder perforation • Bowel perforation not reported with newer IUDs UTERINE PERFORATION AFTER D & C • Presentation: History of gynecologic intervention, with abdominal pain (usually not bleeding) • Background: Uterine perforation causes: – Iatrogenic : dilatation and curettage, hysteroscopy, endometrial ablation, insertion of intrauterine contraceptive devices – Spontaneous causes (less common): gestational trophoblastic disease, pyometra, placenta accreta, degenerating myoma • WHO reports risk of uterine perforation with D & C to be 0.07‐1.2 % • Most common site of myometrial perforation in uterine surgeries is relatively avascular anterior or posterior midline surfaces • Imaging: Hypoechoic or anechoic/hypoattenuating transmural myometrial defect +/‐ small bowel filling the defect, free fluid, extrauterine fetal parts if D & C done for abortion – Look for evidence of associated bowel perforation FIBROID COMPLICATIONS • Degeneration of a fibroid when it outgrows its blood supply can present with acute pain • Imaging: Cystic components within fibroid with hypoenhancement • Red degeneration is another type of acute fibroid degeneration caused by thrombosis of the venous outflow – Seen in pregnancy and in patients on the oral contraceptive pill – Results in a rapid increase in fibroid size with acute hemorrhagic infarction – Imaging: Features unique to this entity best appreciated by MRI • Torsion of a pedunculated fibroid • Imaging: Fibroid on a stalk with absent enhancement +/‐ free fluid • Prolapse of a submucosal fibroid – Can rarely lead to uterine inversion, although more commonly a post‐partum complication (look for mirror image of uterus, pseudostripe, target sign) • Imaging: Stalk of fibroid with internal vessels coursing into endocervical canal or vagina FALLOPIAN TUBE ENTITIES WILL INCLUDE: • PID including: – TOA – Pyosalpinx – Fitz‐Hugh Curtis Syndrome • Hydrosalpinx/Hematosalpinx • Tubal torsion • Fallopian tube CA PELVIC INFLAMMATORY DISEASE (PID) • Background: Infection that typically spreads via cervix and endometrium into fallopian tubes, ovaries and peritoneum • Gonorrhea and chlamydia most common pathogens • Increased risk of PID with IUD • Less common causes: – Direct extension from regional infection (appendicitis, diverticulitis) – Post‐partum or post‐abortion complication – Hematogenous spread (TB) • Imaging: – Normal early in course – Endometrial thickening/fluid (endometritis) – Dilated tube with complex fluid or fluid‐pus level (pyosalpinx) • Wall thickness of ≥ 5mm suggests acute disease • Cogwheel sign • Beads on a string • Incomplete septa • Waist sign—best to discriminate hydrosalpinx from other masses – Enlarged, multi‐cystic ovaries with indistinct margins – Echogenic fluid (pus) in cul‐de‐sac TUBO‐OVARIAN ABSCESS (TOA) • Background: Result of progressing infection – Periovarian adhesions form – Fusion of tube and ovary • Structures may be indistinguishable from each other • Cannot be separated by transvaginal transducer pressure • Can mimic other adnexal masses— “clinical correlation” required • Presentation: Clinical findings of fever, leukocytosis, and cervical motion tenderness very important • Imaging: CT findings – Thick‐walled, low‐attenuation adnexal mass with thick septations, fluid‐debris levels, regional fat infiltration – Gas bubbles are the most specific radiologic sign of abscess but are unusual in tubo‐ovarian abscess – +/‐ associated ileus, hydroureteronephrosis, intraperitoneal abscesses secondary to rupture • US findings – Thick‐walled adnexal mass containing complex fluid, with thick septations, increased echogenicity of regional fat • Treatment: ABX or drainage ISOLATED FALLOPIAN TUBE TORSION • Background: Presents with acute pain; definitive diagnosis rarely made pre‐operatively • Incidence: – 1 in 1.5 million women • Right > left; theorized due to tubal immobilization by sigmoid mesocolon • Intrinsic causes include: dilated fallopian tube, chronic PID with adhesions, prior pelvic surgery, congenital tubal abnormalities, paratubal cysts • Extrinsic causes include: adnexal mass, uterine enlargement • Course: Congestion, necrosis and gangrene/superinfection and peritonitis • Imaging: Midline cystic mass (either superior to uterus or in cul‐de‐sac) with a NORMAL ipsilateral ovary OVARIAN ENTITIES WILL INCLUDE: • Ovarian hyperstimulation • Theca lutein cysts • Ovarian cyst rupture with hemoperitoneum • Inguinal hernia containing ovary • Ovarian abscess from diverticulitis • Ruptured endometrioma • Ovarian CA presenting acutely OVARIAN HYPERSTIMULATION • Background: Rare, potentially fatal complication following ovulation induction • Causative medications include: – Injectable gonadotropins – Clomiphene citrate – Gonadotropin‐releasing hormone • Pregnancy can exacerbate condition • High estradiol levels and large number of follicles can lead to: – Ascites and pleural effusions – Depletion of intravascular volume – Oliguria – Thromboembolic symptoms (arterial and venous reported) – Ovarian torsion /hemorrhage/cyst rupture • Imaging features include: – Increased ovarian volume – Numerous large follicles often with thin echogenic borders – Increased blood flow – Ascites, pleural effusions • Management: Close monitoring by US necessary to tailor exogenous hormones – Abort treatment cycle – Withhold hormones for 1‐3 days before oocyte aspiration OVARIAN CYST RUPTURE • Background: Most functional ovarian cysts asymptomatic and resolve in 1 to 2 menstrual cycles • Although rupture and hemorrhage of an ovarian cyst may be a self‐limited process, significant hemoperitoneum is a potential complication • Hemodynamic status or amount of hemoperitoneum may guide operative versus conservative management • Can mimic a ruptured ectopic pregnancy – Correlation with LMP and ß‐HCG essential • Imaging: – Hemoperitoneum—hematocrit level in free fluid or internal echoes/high attenuation – May see active extravasation on CECT – Corpus luteum—thick walled, peripherally vascular, < 3cm, internal echoes, crenulated – Hemorrhagic cyst—internal reticulation, retractile clot with concave margins, no internal flow, variable wall thickness INGUINAL HERNIA CONTAINING OVARY • Background: Inguinal hernias occur in less than 5% of women—may not be recognized – Typically indirect (neck lateral to inferior epigastric artery origin) – Hernia contents most commonly omentum or bowel • Adnexal herniation is rare and more common