The role of ultrasound in the management of women with acute and chronic pelvic pain

Development of deep pelvic endometriosis following acute haemoperitoneum: a prospective ultrasound study

STUDY QUESTION

Is acute haemoperitoneum that is managed conservatively a precursor of deep endometriosis?

SUMMARY ANSWER

Our study provides evidence to suggest that acute haemoperitoneum may lead to the development of deep endometriosis in a significant proportion of cases.

WHAT IS KNOWN ALREADY

A recent pilot study was the first to suggest that acute haemoperitoneum could be a precursor of deep endometriosis. However, the sample size was small, and the follow-up was not standardized owing to unknown rates of clot absorption and development of endometriosis.

STUDY DESIGN SIZE DURATION

This was a prospective observational cohort study conducted at a single centre over a 31-month period. A required sample size of 30 was calculated using results from a previous study, with a minimum of 15 women each in the groups with and without significant haemoperitoneum (study and control groups, respectively). A total of 59 women were recruited to the study and eight were lost to follow-up. The final sample comprised 51 women, 15 in the study group and 36 in the control group.

PARTICIPANTS/MATERIALS SETTING METHODS

All non-pregnant, premenopausal women aged 18-50 years who consecutively presented to our dedicated gynaecological diagnostic unit with severe acute lower abdominal pain were eligible for this study. We only included women who were clinically stable and were suitable for conservative management. Those with prior history or evidence of endometriosis on their initial ultrasound scan, previous hysterectomy, or bilateral oophorectomy were excluded. Participants had standardized follow-up visits for 6 months, with pelvic ultrasound scans and the British Society of Gynaecological Endoscopy pelvic pain questionnaires completed at each visit. The primary outcome was the sonographically confirmed presence of newly formed endometriosis. Secondary outcomes were the presence and change of pelvic pain symptoms and health-related quality of life (HR-QOL).

MAIN RESULTS AND THE ROLE OF CHANCE

After completion of follow-up, 7/15 (47%; 95% CI 21.3-71.4%) women presenting with acute haemoperitoneum (study group) developed sonographic evidence of deep endometriosis, compared to 0/36 (0%; 97.5% CI 0.0-9.7%) women in the control group. A ruptured functional haemorrhagic cyst was the most common cause of haemoperitoneum, occurring in 13/15 cases (87%). The time from the initial event to sonographic evidence of endometriosis varied from 2 to 6 months. The EuroQol visual analogue scores were not significantly different at baseline between the groups that developed and did not develop endometriosis [28 (interquartile range (IQR) 15-40, n = 6) vs 56 (IQR 35-75, n = 44), P = 0.09], while the EuroQol-5D values were lower in the endometriosis group [-0.01 (IQR -0.07 to 0.19, n = 6) vs 0.62 (IQR 0.24-0.73, n = 44), P = 0.002]. At 6 months, the EuroQol-5D scores were improved in both groups, but remained significantly lower in the endometriosis group compared to the no endometriosis group [0.69 (IQR 0.66-0.80, n = 6) vs 0.85 (IQR 0.76-1.00, n = 44), P = 0.03]. There was no clinically relevant difference in the pelvic pain scores at either time point.

LIMITATIONS REASONS FOR CAUTION

It remains uncertain whether minimal, superficial endometriosis existed at commencement of the study and had a role in the development of deep endometriosis. Although the ultrasound findings were in keeping with deep endometriosis, this was not confirmed histologically. The pelvic pain and HR-QOL findings could have been influenced by the baseline scores being taken when the patient was admitted with acute pain. Also, the sample size was too small to draw reliable conclusions regarding the impact of newly developed endometriosis on QoL.

WIDER IMPLICATIONS OF THE FINDINGS

Our study provides further evidence showing that significant haemoperitoneum may be a precursor of deep endometriosis. Haemodynamically stable women presenting with acute pelvic pain and significant haemoperitoneum should be counselled about the risk of developing deep endometriosis. Interventional studies should be carried out in the future to see whether laparoscopy and pelvic washout could prevent development of deep endometriosis. Preventative strategies, including treatment to suppress ovulation and formation of functional cysts, should be further investigated. This includes the combined and progesterone-only contraceptive pills. Larger future studies are also required to assess women over a longer period of time, with adjustment for confounding factors, to evaluate a possible effect on HR-QOL and pain symptoms.

STUDY FUNDING/COMPETING INTERESTS

Funding was obtained from The Gynaecology Ultrasound Centre, London, UK. TT received personal fees from GE, Samsung, Medtronic, and Merck for lectures on ultrasound. TT also received a postdoctoral grant from the South-Eastern Norwegian Health Authority (grant number 2020083).

TRIAL REGISTRATION NUMBER

researchregistry6472.

Prevalence of deep and ovarian endometriosis in women attending a general gynecology clinic: prospective cohort study

OBJECTIVES

To assess using transvaginal ultrasound the prevalence of deep and ovarian endometriosis in premenopausal women attending a general gynecology clinic. We also investigated whether the presence of endometriosis was associated with various demographic factors and other pelvic abnormalities.

METHODS

This was a prospective observational cohort study carried out between February 2019 and October 2020. Consecutive premenopausal women who attended our general gynecology clinic underwent pelvic ultrasound examination, performed by a single experienced operator. Pregnant women and those with a history of hysterectomy or oophorectomy were excluded. The primary outcome was the prevalence of deep and/or ovarian endometriosis. Secondary outcomes were the anatomical distribution of endometriotic lesions and the association of endometriosis with demographic characteristics and various pelvic abnormalities, which were analyzed using logistic regression and multivariable analysis.

RESULTS

A total of 1026 women were included in the final study sample, of whom 194 (18.9% (95% CI, 16.6-21.4%)) had sonographic evidence of deep and/or ovarian endometriosis. Of the 194 women diagnosed with endometriosis, 106 (54.6% (95% CI, 47.4-61.8%)) were diagnosed with endometriotic nodules only, 26 (13.4% (95% CI, 9.0-19.0%)) with ovarian endometriomas only, and 62 (32.0% (95% CI, 25.5-39.0%)) women had evidence of both. There was a total of 348 endometriotic nodules in 168 women, located most frequently in the retrocervical area (166/348; 47.7% (95% CI, 42.4-53.1%)), uterosacral ligaments (96/348; 27.6% (95% CI, 23.0-32.6%)) and bowel (40/348; 11.5% (95% CI, 8.3-15.3%)). Multivariable analysis found significant positive associations between endometriosis and both adenomyosis (odds ratio (OR), 1.72 (95% CI, 1.10-2.69); P = 0.02) and pelvic adhesions (OR, 25.7 (95% CI, 16.7-39.3); P < 0.001), whilst higher parity (OR, 0.44 (95% CI, 0.24-0.81); P = 0.03) and history of Cesarean section (OR, 0.18 (95% CI, 0.06-0.52); P = 0.002) were associated with a lower occurrence of endometriosis. A total of 75/1026 women (7.3% (95% CI, 5.8-9.1%)) underwent laparoscopy within 6 months of pelvic ultrasound examination. There was very good agreement between ultrasound and surgical findings, with a kappa value of 0.84 (95% CI, 0.69-0.99).

CONCLUSIONS

Deep and/or ovarian endometriosis was present in nearly one in five women attending a general gynecology clinic. There were significant positive associations with adenomyosis and pelvic adhesions and negative associations with higher parity and previous Cesarean section. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Impact of ultrasound diagnosis for chronic pelvic pain

BACKGROUND

This study aims to assess the impact of ultrasound diagnosis in patients with chronic pelvic pain (CPP).

METHODS

We will carry out a comprehensive electronic search from the databases below: PUBMED, EMBASE, Cochrane Library, PSYCINFO, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, and WANGFANG databases from inception to July 1, 2019. The case-controlled studies focusing on impact of ultrasound diagnosis for patients CPP will be included in this study. Two authors will independently conduct all study selection, data collection, and risk of bias assessment. The risk of bias assessment will be assessed using Quality Assessment of Diagnostic Accuracy Studies tool. We will apply RevMan V.5.3 software and Stata V.12.0 software for data pooling and statistical analysis.

RESULTS

This study will present pooled effect estimates regarding the impact of ultrasound diagnosis for CPP by assessing sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of ultrasound to determine the diagnostic accuracy of ultrasound diagnosis for CPP.

CONCLUSION

This study will provide modest evidence for the diagnostic accuracy of ultrasound in patients with CPP.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019142799.

Hemoperitoneum as a precursor of deep pelvic endometriosis: prospective cohort study

OBJECTIVE

To determine whether significant hemoperitoneum could be a precursor of deep pelvic endometriosis in non-pregnant premenopausal women presenting with severe acute lower abdominal pain.

METHODS

This was a prospective observational cohort study carried out at a dedicated gynecological diagnostic unit over a period of 18 months. We included consecutive non-pregnant, premenopausal women who attended with severe acute lower abdominal pain and underwent a pelvic ultrasound examination. Women were triaged for surgical or conservative management depending on the cause of pain and severity of their symptoms. Those who were selected for conservative management were invited for follow-up ultrasound scans. The main outcome measure was evidence of newly developed deep endometriosis at follow-up examination.

RESULTS

Of 118 non-pregnant women who attended our unit with severe acute lower abdominal pain, 20 underwent emergency surgery and 17 had a history of endometriosis, or evidence of endometriosis on the initial scan, and were excluded from the study. Therefore, conservative management was employed in 81 women, eight of whom had evidence of significant hemoperitoneum at presentation. A total of 35 women attended for all follow-up ultrasound scans. At the completion of follow-up, four of six (67% (95% CI, 22-96%)) women who presented initially with significant intra-abdominal bleeding had developed new evidence of deep endometriosis, compared with one of 29 (3% (95% CI, 0-18%)) of those without hemoperitoneum (relative risk, 19.3 (95% CI, 3-144); P < 0.001).

CONCLUSION

In some women, the presence of significant hemoperitoneum that is managed conservatively precedes the development of deep endometriosis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasonographic and multimodal imaging of pediatric genital female diseases

Ultrasonography is the first-line imaging modality in the evaluation of the female pelvis in childhood and adolescence, because it is easy to perform, non-invasive and it does not require sedation. The transabdominal approach is preferred in children and adolescents, after filling the bladder to move away the bowel loops from the pelvis. The probe frequency must be adapted to age, thickness of tissues and depth of the structures under examination. High-frequency (4-12 MHz) linear or convex probes are used in newborns; high-frequency linear probes (4-12 MHz) in toddler, convex 5-7.5 MHz probes in girls and convex 3.5-5 MHz probes in teenagers. In this article, the main pathological conditions of the genital female tract in pediatric age are examined, such as congenital anomalies, disorders of sex development, ovarian cysts, ovarian tumors, adnexal torsion, primary amenorrhea, precocious puberty and pelvic inflammatory disease.

[The use of ultrasonographic 3D power Doppler to describe an ovarian Sertoli-Leydig cell tumor]

We report one case of unilateral ovarian Sertoli-Leydig tumor with intermediate grade and heterologous element, in a young woman with clinical and biological typical presentation. We discuss 2D and 3D ultrasonographic and doppler features.

Discrimination between benign and malignant adnexal masses by specialist ultrasound examination versus serum CA-125

BACKGROUND

Subjective evaluation of gray-scale and Doppler ultrasound findings (i.e., pattern recognition) by an experienced examiner and preoperative serum levels of CA-125 can both discriminate benign from malignant adnexal (i.e., ovarian, paraovarian, or tubal) masses. We compared the diagnostic performance of these methods in a large multicenter study.

METHODS

In a prospective multicenter study--the International Ovarian Tumor Analysis--1066 women with a persistent adnexal mass underwent transvaginal gray-scale and color Doppler ultrasound examinations by an experienced examiner within 120 days of surgery. Pattern recognition was used to classify a mass as benign or malignant. Of these women, 809 also had blood collected preoperatively for measurement of serum CA-125. Various levels of CA-125 were used as cutoffs to classify masses. Results from both assays were then compared with histologic findings after surgery.

RESULTS

Pattern recognition correctly classified 93% (95% confidence interval [CI] = 90.9% to 94.6%) of the tumors as benign or malignant. Serum CA-125 correctly classified at best 83% (95% CI = 80.3% to 85.6%) of the masses. Histologic diagnoses that were most often misclassified by CA-125 were fibroma, endometrioma, and abscess (false-positive results) and borderline tumor (false-negative results). Pattern recognition correctly classified 86% (95% CI = 81.1% to 90.4%) of masses of these four histologic types as being benign or malignant, whereas a serum CA-125 at a cutoff of 30 U/mL correctly classified 41% (95% CI = 34.4% to 47.5%) of them. Pattern recognition assigned a correct specific histologic diagnosis to 333 (59%, 95% CI = 54.5% to 62.8%) of the 567 benign lesions.

CONCLUSION

Pattern recognition was superior to serum CA-125 for discrimination between benign and malignant adnexal masses.

What is the value of preoperative bimanual pelvic examination in women undergoing laparoscopic total hysterectomy?

OBJECTIVE STUDY: To estimate the value of preoperative bimanual examination of the pelvis in women undergoing total laparoscopic hysterectomy (TLH).

DESIGN

Prospective observational cohort study.

SETTING

Private hospitals and centre.

PATIENTS

One hundred fourteen consecutive women undergoing TLH.

INTERVENTION

All women who were scheduled to undergo TLH from May 2005 through June 2006 had a bimanual examination of the pelvis performed before surgery and the size of the uterus clinically estimated and recorded as gestational equivalents. The operating time, the estimated blood loss (EBL) during TLH, and the final weight of the uterus at histologic study were recorded. Spearman correlation coefficient analysis was used to determine whether there was a correlation between the estimated uterine size before surgery and actual uterine weight, operating time, and EBL.

MEASUREMENTS AND MAIN RESULTS

Of the one hundred fourteen consecutive women eligible for the study, 75 had complete data and therefore were included in the final analysis. The median age was 46 years (range 34-71 years); 22.7% (17/75) had a clinically estimated normal uterus, 10.7% (8/75) had an 8-10/40 uterus, 12% (9/75) had a 10-12/40 uterus, 14.6% (11/75) had a 12-14/40 uterus, 20.0% (15/75) had a 14-16/40 uterus, 9.3% (7/75) had a 16-18/40 uterus, and 10.7% (8/75) had an 18-20/40 uterus. The median operating time was 110 minutes (range 59-240 minutes); the median EBL was 80 mL (range 20-1000 mL); and the median weight of the uterus was 181 g (range 52-1080 g). Histologic diagnoses included leiomyomata in 64.0% (48/75), adenomyosis in 44.0% (33/75), endometriosis in 22.7% (17/75), endocervical polyp in 4.0% (3/75), and normal uterus in 8.0% (6/75). The Spearman correlations between clinical size of the uterus and the weight of the uterus, the EBL, and the operating time were 0.81, 0.33, and 0.29, respectively; that is, the 2 variables tended to increase together. These correlations were all significant (p <.0001, .0044, and .0114, respectively).

CONCLUSIONS

This study showed significant correlation between clinical estimate of uterine size and histologic weight of the uterus, operating time, and EBL in women undergoing laparoscopic hysterectomy. These findings are of great value in preoperative counseling in relation to the risk of bleeding and the potential need for blood transfusion, and in operating room planning.

Diagnostic and therapeutic capabilities of ultrasound in the management of pelvic pain

PURPOSE OF REVIEW

This review discusses the current diagnostic and therapeutic role of ultrasound in the management of pelvic pain.

RECENT FINDINGS

Recent advances in ultrasound technology and expertise have facilitated the accurate diagnosis of common gynaecological and nongynaecological pathologies. Peritoneal and deep infiltrating endometriosis can now be diagnosed using hard and soft ultrasound-based markers. The combination of ultrasound-guided aspiration and instillation of a sclerosant is an alternative to surgery in the management of adnexal masses.

SUMMARY

Experience is a key factor in the ability of transvaginal ultrasound to characterize common gynaecological disorders with accuracy. Therapeutic ultrasound provides an alternative to surgery.