Magnetic Resonance Imaging (MRI) and Transvaginal Ultrasonography (TVU) at Ovarian Pain Caused by Benign Ovarian Lesions

Transvaginal ultrasound and magnetic resonance imaging in the diagnosis of endometrioma: a systematic review and meta-analysis of diagnostic test accuracy studies

INTRODUCTION

The diagnosis of endometriomas in patients with endometriosis is of primary importance because it influences the management and prognosis of infertility and pain. Imaging techniques are evolving constantly. This study aimed to systematically assess the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) in detecting endometrioma using the surgical visualisation of lesions with or without histopathological confirmation as reference standards in patients of reproductive age with suspected endometriosis.

METHODS

PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov databases were searched from their inception to 12 October 2022, using a manual search for additional articles. Two authors independently performed title, abstract and full-text screening of the identified records, extracted study details and quantitative data and assessed the quality of the studies using the 'Quality Assessment of Diagnostic Accuracy Study 2' tool. Bivariate random-effects models were used to determine the pooled sensitivity and specificity, compare the two imaging modalities and evaluate the sources of heterogeneity.

RESULTS

Sixteen prospective studies (10 assessing TVUS, 4 assessing MRI and 2 assessing both TVUS and MRI) were included, representing 1976 participants. Pooled TVUS and MRI sensitivities for endometrioma were 0.89 (95% confidence interval 'CI', 0.86-0.92) and 0.94 (95% CI, 0.74-0.99), respectively (indirect comparison p-value of 0.47). Pooled TVUS and MRI specificities for endometrioma were 0.95 (95% CI, 0.92-0.97) and 0.94 (95% CI, 0.89-0.97), respectively (indirect comparison p-value of 0.51). These studies had a high or unclear risk of bias. A direct comparison (all participants undergoing TVUS and MRI) of the modalities was available in only two studies.

CONCLUSION

TVUS and MRI have high accuracy for diagnosing endometriomas; however, high-quality studies comparing the two modalities are lacking.

ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update

This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (β-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative β-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive β-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative β-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

A case of periodic abdominal pain and fever due to left ovarian abscess

Tubo-ovarian abscess (TOA) is a late complication of pelvic inflammatory disease. Its diagnosis is difficult because it is occasionally accompanied by atypical symptoms such as abdominal pain and fever. A 45-year-old married woman presented with recurrent abdominal pain and fever. Her medical history included ovarian surgery 14 years prior to presentation. Computed tomography (CT) performed by her local doctor confirmed uterine fibroids and a left ovarian tumor. Following a detailed examination and magnetic resonance imaging at our hospital, a TOA was suspected, and surgery was planned. During surgery, the adhesion was firm and required laparotomy. Ultimately, the left ovarian tumor was confirmed to be a TOA. Although complete surgical resection was not feasible. A surgical drain was inserted, and the pus was drained. Cultures revealed Citrobacter freundii and other organisms, and oral quinolone antibiotics were administered. CT performed on the fourth postoperative day demonstrated a residual abscess; however, 5 weeks after surgery, CT showed complete resolution of the residual abscess. Subsequently, the antibiotic regimen was terminated, and progestins were administered for the treatment of endometriosis, which is still ongoing.

Adnexal torsion: a review of diagnosis and management strategies

PURPOSE OF REVIEW

Adnexal torsion remains a diagnostic challenge heavily reliant on high clinical suspicion, with patient presentation and imaging used as adjuncts to aid in its diagnosis. This review summarizes diagnostic and management techniques of adnexal torsion to assist providers when encountering this surgical emergency.

RECENT FINDINGS

Common findings of adnexal torsion include abdominal pain, nausea, vomiting, and adnexal mass or ovarian enlargement. An elevated neutrophil to lymphocyte ratio may be useful for diagnosis. A 'whirlpool' sign, 'follicular ring' sign, enlarged/edematous ovary, and absent Doppler flow to the ovary are highly suggestive of adnexal torsion. Intraoperative visual diagnosis of ovarian death is highly inaccurate, with only 18-20% of ovaries necrotic on pathological examination. Necrotic appearing ovaries have been shown to have follicular activity on ultrasound one year postoperatively.

SUMMARY

Pelvic ultrasound remains the first-line imaging modality. In patients of reproductive age, we recommend performing detorsion with ovarian conservation, even in cases where the tissue appears necrotic, given poor intraoperative diagnostic rates of tissue death. Retention of ovarian function is also reliant on a timely diagnosis and intervention. We emphasize that the risk of ovarian damage/loss outweigh the risk of a diagnostic laparoscopy in patients of reproductive age.

Magnetic Resonance Imaging Findings in Patients with Benign and Malignant Ovarian Masses Versus Pathologic Outcomes

Background:

The results of the former study confirmed the accuracy of magnetic resonance imaging (MRI) in determining the origin and content of ovarian masses. The present study aimed to evaluate the diagnostic value of MRI in differentiating benign and malignant ovarian masses in women.

Materials and Methods:

This was a cross-sectional study. All candidates for surgery to remove ovarian masses were selected to participate in this study. They underwent MRI with gadolinium before the surgery. MRI images were reviewed by an experienced radiologist who was aware of the ovarian mass found in pelvic ultrasonography (US). A thick-enhancing wall, mural nodules, septations, and internal enhancement within the mass were reviewed by the radiologist. Mass specimens were examined in the laboratory by an experienced pathologist to determine malignancy or benignancy of the masses. Pathological findings were compared with MRI results.

Results:

there was no significant difference between MRI findings and pathology denoted by benign and malignant (P = 0.06), but results showed a significant difference between US and pathology (P = 0.002). In MRI findings related to a thick-enhancing wall (P = 0.18), internal enhancement (P = 0.18), and pelvic fluid (P = 1.00), no significant difference was seen in benign or malignant masses. However, in findings related to septation, all cases had malignant reports (P = 0.006), and in mural nodule, 80% had malignant reports (P = 0.006). CA-125 blood level in patients with benign masses (1.72 ± 0.97) was significantly less than patients with malignant masses (3.20 ± 0.83) (P < 0.001).

Conclusion:

We showed that MRI has better results in diagnosing adnexal masses and their characteristics compared to simple ultrasound imaging based on pathological studies.

Accuracy of imaging modalities for adnexal torsion: a systematic review and meta-analysis

BACKGROUND

Adnexal torsion (AT), a serious gynaecological emergency, often presents with non-specific symptoms leading to delayed diagnosis.

OBJECTIVE

To compare the test accuracy of ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) to diagnose AT.

SEARCH STRATEGY

We searched EMBASE, MEDLINE and Cochrane CENTRAL until December 2019.

SELECTION CRITERIA

Studies reporting on the accuracy of any imaging modality (Index Test) in female patients (paediatric and adult) suspected of AT compared with surgical diagnosis and/or standard clinical/radiological follow-up period until resolution of symptoms (Reference Standard).

DATA COLLECTION AND ANALYSIS

We assessed study quality using QUADAS-2. We conducted test accuracy meta-analysis using a univariate model or a hierarchical model.

MAIN RESULTS

We screened 3836 citations, included 18 studies (1654 women, 665 cases), and included 15 in the meta-analyses. Ultrasound pooled sensitivity (n = 12, 1187 women) was 0.79 (95% CI 0.63-0.92) and specificity was 0.76 (95% CI 0.54-0.93), with negative and positive likelihood ratios of 0.29 (95% CI 0.13-0.66) and 4.35 (95% CI 2.03-9.32), respectively. Using Doppler with ultrasound (n = 7, 845 women) yielded similar sensitivity (0.80, 95% CI 0.67-0.93) and specificity (0.88, 95% CI 0.72-1.00). For MRI (n = 3, 99 women), the pooled sensitivity was 0.81 (95% CI 0.63-0.91) and specificity was 0.91 (95% CI 0.80-0.96). A meta-analysis for CT was not possible with two case-control studies and one cohort study (n = 3, 232 women). Its sensitivity range was 0.74-0.95 and specificity was 0.80-0.90.

CONCLUSIONS

Ultrasound has good performance as a first-line diagnostic test for suspected AT. Magnetic resonance imaging could offer improved specificity to investigate complex ovarian morphology, but more evidence is needed.

TWEETABLE ABSTRACT

To investigate adnexal torsion, ultrasound is a good first-line diagnostic test with a pooled sensitivity of 0.79 and specificity of 0.76.

Gynecological associated disorders and management

BACKGROUND

Chronic pelvic pain syndrome is complex and involves multiple organ systems. The gynecological aspects of chronic pelvic pain syndrome can be divided into four different areas: intra-abdominal, vaginal, pelvic floor muscles and sexual pain. This article provides an overview of gynecological evaluation in patients with chronic pelvic pain and reviews the most common gynecological diagnoses and their management.

METHODS

An extensive review of the literature including guidelines from the International Continence Society, the European Association of Urology, and the International Association for the Study of Pain was performed.

RESULTS

Gynecological evaluation of patients with chronic pelvic pain begins with a thorough history and physical examination. Laboratory tests, imaging studies and diagnostic procedures can be used as adjuncts to make a diagnosis. Treatment modalities include physical therapy, medications, trigger points injections, and surgery.

CONCLUSION

Common gynecological diagnoses of chronic pelvic pain include endometriosis, adenomyosis, vulvodynia, high tone pelvic floor dysfunction, and genitopelvic pain/penetration disorder. Gynecology is one of the many systems that can be associated with chronic pelvic pain. Managing patients with chronic pelvic pain requires a multimodal and multidisciplinary approach.

The role of ultrasound in the evaluation of acute pelvic pain in pregnancy and postpartum period: a review

PURPOSE OF REVIEW

Acute pelvic pain in pregnant and postpartum patients presents diagnostic and therapeutic challenges. Ultrasound remains the primary imaging modality of choice for assessing pregnant and postpartum women. The purpose of this review is to help practitioners ensure a correct diagnosis of acute pelvic pain in pregnancy and the postpartum period.

RECENT FINDINGS

This review describes the various causes and highlights the sonographic features and characteristics of acute pelvic pain in pregnancy and the postpartum period.

SUMMARY

Evaluation of acute pelvic pain in pregnancy and the postpartum period is challenging. Knowledge of the clinical settings and sonographic features of acute pelvic pain in pregnancy and the postpartum period can lead to accurate diagnosis and appropriate management of the condition.