ACUTE PELVIC
INFECTION
M. Otero-García
mila.oterogarcia@gmail.com
Infection of:
- Upper genitalia
(endometrium,
fallopian tubes,
ovaries)
- Adjacent pelvic
structures
FEMALE PELVIC INFECTI...
 Gynecological causes
Pelvic inflammatory disease (PID)
Endometritis
Salpingitis
Tubo-ovarian abscess
Fitz-Hugh-Curtis Sy...
 No specific international data are available for PID incidence
worldwide
 The annual rate of PID in high-GNP countries ...
RISK FACTORS FOR PID
 Young age
 Multiple sex partners
 High coital frequency
 Low socioeconomic status
 Douching
 U...
Extension to: parametrial structures
Direct ascent to the upper genital tract: pyosalpinx, TOA
salpingitis
endometritis
Ac...
 Less commonly:
- Direct spread from nearby appendicitis or diverticulitis
- Hematogenous, lymphatic, peritoneal spread: ...
70%
• N. Gonorrhoeae
• C. Trachomatis
• Mycoplasma genitalium
30%
• Polymicrobial
• Streptococcus species,
Escherichia col...
PID DIAGNOSIS
 Clinical history:
Asymptomatic (30%) - non-specific symptoms:
Abdominal/pelvic pain
Abnormal discharge
Int...
 PID should be suspected and treatment initiated if:
- High risk of PID and
- Uterine, adnexal, or cervical motion tender...
TREATMENT
 Up to 90% of women have mild PID - treated as outpatients
 10% of women have severe PID: complications
The id...
 Imaging is required:
- to determine the origin and the extent of the process, if
symptoms are nonspecific
- to evaluate ...
US
Transvaginal
Sensitivity: 81%
Specificity:78%
Accuracy: 80%
Transabdominal
CT
Sensitivity: <65%
Specificity: >90%
Accur...
US
Transvaginal
Transabdominal
CT
MRACR: 9
ACR: 5 - Gyn
9 - N- Gyn
ACR: 6 - Gyn
3 - N- Gyn
• ACR Appropriateness Criteria®...
EARLY STAGE OF PID
IMAGING FINDINGS
Normal
Non- specific findings:
. Fluid in the endometrial and
endocervical cavities
. ...
Endometritis
Abnormal endometrial
enhancement and fluid
Mild oophoritis
Sam JW.RadioGraphics 2002
MILD STAGE OF PID
IMAGIN...
Mild pelvic edema
Thickening of the uterosacral ligaments and haziness of
the pelvic fat
Sam JW.RadioGraphics 2002
MILD ST...
 Pyosalpinx
ADVANCED STAGES OF PID
Most specific
sign of PID at
CT
Sam JW.RadioGraphics 2002
Potter AW. Radiographics 2008
- Stranding of the
pelvic fat
- Lymphadenopathy
ADVANCED STAGES OF PID
Jung SI et al. J. Obstet. Gynaecol. Res. 2011
 Per...
MR
Hematosalpinx/Pyosalpinx
FST1w
T2w
FST1w- Gd
T2w
PID
16 year-old girl: pelvic pain, fever, nausea
Bimanual uterine and adnexal tenderness
Leukocytosis (white blood cell co...
FS T1 w +C T2 w
STIR STIR
TVUS – guided drainage
HYDROSALPINX VS PYOSALPINX
PYOSALPINX:
- Active and acute infection with obstruction of the FT
-Thick enhancing wall and s...
CE T1 w
Courtesy: Dr. John SpencerTubal and peritubal adhesions with obstruction of
the fimbrial end lead to:
Tubal shape ...
HYDROSALPINX
”cogwheel sign”: or
small round projections
on axial imaging--
thickened longitudinal
folds
Accurate findings...
1/3 women with severe PID
TOA
Heterogeneous mass
Indistinct ovaries
- Fluid-containing
mass with a thick
enhancing wall an...
- Extension to form
abdominal abscesses
TOA
- A more specific sign of tubo-
ovarian abscess: gas bubbles
TOA
 30 % of patients with TOA respond to treatment: (parenteral
antibiotics 48 h ---- oral antibiotics for up to 14 days...
PID
ABDOMINAL COMPLICATIONS
Spread of infection via the
right paracolic gutter
Rezvani M.RadioGraphics 2011
-Perihepatitis...
Ureteral obstruction
PID COMPLICATIONS
Small or large bowel
ileus or obstruction
Right ovarian vein
thrombosis
 Ectopic
 Rupture of ovarian cyst: corpus luteum, follicle, endometrial
cyst
 Adnexal torsion
 Other pelvic cystic mas...
Right
ovarian
torsion
Appendix diameter (>10 mm), wall (> 2 mm)
Appendicitis PID
Crohn disease
22 year-old woman
Terminal ileitis
Diverticulitis
65 year-old. Right adnexal tenderness, fever, leukocytosis
 Chronic infection by Actinomyces israelii
 Opportunistic pathogen: normally present in oral cavity or colon
 Gynecolog...
Heterogeneous, well or badly defined adnexal masses, contrast
enhancement (rim-enhancement) in the solid portion
ACTINOMIC...
ACTINOMICOSIS
IMAGING
- Abscess
- Thick, linear, enhancing lesions
extending into the adjacent tissue
planes, which reflec...
 Genital tract involvement is detected in 1.3% of female patients
with tuberculosis: endometrium (72%), salpinx (34%), ov...
 Findings can be various
according to the stage and the
route of this infection
 General peritoneal tuberculosis,
minima...
TUBERCULOSIS AT IMAGING
Tubo-ovarian involvement is usually caused by
hematogenous or lymphatic spread.
-Cystic or both so...
 PID and other gynecological issues
ACUTE PELVIC INFECTION
DIAGNOSIS
Appendicitis
Crohn, terminal ileitis, diverticulit...
Acute female pelvic infection . ESUR Congress.
Acute female pelvic infection . ESUR Congress.
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Acute female pelvic infection . ESUR Congress.

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  • Pelvic infection refers to
  • Pelvic infection can be divided into 2 important categories according to the origin of the infection: Gynaecological and non-gynaecological causes. PID and intestinal diseases are the most frequent causes of acute pelvic infection.In the next 19 minutes we are going to see, the broad spectrum of PID presentation and some of its mimics and possible complications
  • As many as 24%It represents an amount of$ 10 billion as annual cost related to the acute care and sequelae of PID.
  • Strong association with sexually transmitted disease (STD).
  • At presentation, women with PID may range from no symptoms (30%) – non-specific and may simulate urinary or gastrointestinal pathology
  • There are physical and laboratory findings that support the diagnosis and elaborate criteria such as laparoscopy, or imaging studies as additional findings .
  • Therefore the diagnosis of PID remains clinical in nature.
  • US is the initial study in female patients with pelvic sympthomatology.MR imaging is not traditionally used in the acute setting or in the evaluation of PID because MR still is expensive, less available. MR imaging can be particularly useful in the evaluation of a complex adnexal mass, in the setting of chronic PID in helping differentiate pyosalpinx from hematosalpinx in the context of endometriosis. And in the chronic setting of PID to define fibrosis and adhesions..
  • The fallopian tubes become edematous
  • The fallopian tubes become edematous
  • On the other hand Pyosalpinx, depends on the protein of the fluid, but more frequently is
  • The fallopian tube becomes elongated, C- or S-shaped anechoic tubular structure which contains fluid which, may appear anechoic (clear).
  • Differential diagnosis of PID in a young woman includes other non infectious gynecological issues, and And other infectious pelvic diseases, with the same clinical presentation most of the cases
  • In postmenopausal women, ascending PID is very rare. If it is suspected clinically, we have to think of a direct spread from a nearby appendicitis or diverticulitis, like in this patient.
  • Acute female pelvic infection . ESUR Congress.

    1. 1. ACUTE PELVIC INFECTION M. Otero-García mila.oterogarcia@gmail.com
    2. 2. Infection of: - Upper genitalia (endometrium, fallopian tubes, ovaries) - Adjacent pelvic structures FEMALE PELVIC INFECTION
    3. 3.  Gynecological causes Pelvic inflammatory disease (PID) Endometritis Salpingitis Tubo-ovarian abscess Fitz-Hugh-Curtis Syndrome Puerperal infections Cesarean section Vaginal delivery Post-operative gynecological surgery Pelvic abscess Post leiomyomas embolization infection Fistulae Abortion-associated infections Endometritis Incomplete septic abortion PELVIC INFECTION CAUSES  Non-Gynecological causes Intestinal: appendicitis, diverticulitis, Crohn… Urinary: ureteritis, cistitis  Tuberculosis, Actinomycosis: chronic, acute
    4. 4.  No specific international data are available for PID incidence worldwide  The annual rate of PID in high-GNP countries has been reported to be as high as 10-20 per 1000 women of reproductive age (most < 25 year-old)  24% of visits to the E. departments for gynecological pain are attributable to PID  Annual cost: $ 10 billion (acute care and sequelae: tubal factor infertility, ectopic pregnancy, chronic pelvic pain, recurrent infection, life treatening condition if TOA rupture) Potter AW. RadioGraphics 2008 Crossman SH. American Family Physician. 2006 Srikar Adhikari. The Journal of Emergency Medicine, 2008 PID
    5. 5. RISK FACTORS FOR PID  Young age  Multiple sex partners  High coital frequency  Low socioeconomic status  Douching  Use of intrauterine device (particularly during the first few months of insertion) Barret S et al. International Journal of STD & AIDS 2005 Mindy M. Horrow. Ultrasound Quarterly 2004
    6. 6. Extension to: parametrial structures Direct ascent to the upper genital tract: pyosalpinx, TOA salpingitis endometritis Acquisition of a vaginal or cervical infection: endocervicitis Soper DE. Obstet Gynecol 2010 PID PATHOPHYSIOLOGY Beyond the pelvis
    7. 7.  Less commonly: - Direct spread from nearby appendicitis or diverticulitis - Hematogenous, lymphatic, peritoneal spread: TB salpingitis PID
    8. 8. 70% • N. Gonorrhoeae • C. Trachomatis • Mycoplasma genitalium 30% • Polymicrobial • Streptococcus species, Escherichia coli, Hemophylus influenza, Bacteroides species, Peptostreptococcus, Peptococcus………….. MICROBIAL ETHIOLOGY Barret S. Int J STD AIDS. 2005 Soper DE.Obstetrics and Gynecology 2010
    9. 9. PID DIAGNOSIS  Clinical history: Asymptomatic (30%) - non-specific symptoms: Abdominal/pelvic pain Abnormal discharge Intermenstrual bleeding Fever Urinary frequency Low back pain Nausea/vomiting
    10. 10.  PID should be suspected and treatment initiated if: - High risk of PID and - Uterine, adnexal, or cervical motion tenderness on bimanual pelvic examination  Findings that support the diagnosis (1 or more) - Cervical or vaginal mucopurulent (green or yellow) discharge - Elevated erytrocyte sedimentation rate or C -reactive protein - Laboratory confirmation of gonorrheal or chlamydial infection - Oral temperature (38.3ºC) or greater - White blood cells on vaginal secretion saline wet mount ( peripheral white blood cell count is commonly normal)  Elaborate criteria (additional findings) - Positive laparoscopy or endometrial biopsy - Pyosalpinx, TOA on imaging CDC: Centers for Disease Control and Prevention guidelines on sexually transmitted diseases. MMWR Recomm Rep 2006. CDC DIAGNOSTIC CRITERIA FOR PID PID DIAGNOSIS PHYSICAL EXAMINATION AND LABORATORY STUDIES
    11. 11. TREATMENT  Up to 90% of women have mild PID - treated as outpatients  10% of women have severe PID: complications The identification of patients who require hospitalization are usually accomplished with imaging studies
    12. 12.  Imaging is required: - to determine the origin and the extent of the process, if symptoms are nonspecific - to evaluate for complications such as abscess, if the patient is not responding as expected to treatment, and - to decide if a known abscess is amenable to percutaneous drainage. Maryam Rezvani. RadioGraphics 2011 Abraham A. Ghiatas, Eur Radiol 2004 PID DIAGNOSIS IMAGING
    13. 13. US Transvaginal Sensitivity: 81% Specificity:78% Accuracy: 80% Transabdominal CT Sensitivity: <65% Specificity: >90% Accuracy: 84% - After-hours availability - Symptoms are nonspecific - Process beyond the pelvis - Limiting factor: ionizing radiation MR Sensitivity: 95% Specificity: 89% Accuracy: 93% - No radiation - Limiting factor: expensive, less available - Pregnant patient - Complex adnexal mass - Diff. pyosalpinx/ hematosalpinx - Chronic PID: fibrosis, adhesions Tukeva TA et al. Radiology 1999 Young SI et al. J. Obstet. Gynaecol. Res.2011 - No cooperate because they are suffering from excessive pain - Large amounts of gas preventing ultrasound penetration - Obesity
    14. 14. US Transvaginal Transabdominal CT MRACR: 9 ACR: 5 - Gyn 9 - N- Gyn ACR: 6 - Gyn 3 - N- Gyn • ACR Appropriateness Criteria® acute pelvic pain in the reproductive age group. http://www.guidelines.gov/content.aspx?id=15779&search=Acute+pelvic+pain • Heverhagen JT. RadioGraphics 2009 The American College of Radiology Appropriateness Criteria® still rate MR imaging below CT and US for the evaluation of acute abdominal and pelvic conditions 1 = least appropriate; 9 = most appropriate
    15. 15. EARLY STAGE OF PID IMAGING FINDINGS Normal Non- specific findings: . Fluid in the endometrial and endocervical cavities . Mild enlargement or indistinctness of the uterus . Enlarged ovaries with “polycystic ” appearance . Fluid in the cul-de-sac (50% of patients with PID) Horrow MH. Ultrasound Quarterly 2004
    16. 16. Endometritis Abnormal endometrial enhancement and fluid Mild oophoritis Sam JW.RadioGraphics 2002 MILD STAGE OF PID IMAGING FINDINGS Mild salpingitis Not tubal dilatation but wall tickening (> 5mm), enhancement, and surrounding inflammation
    17. 17. Mild pelvic edema Thickening of the uterosacral ligaments and haziness of the pelvic fat Sam JW.RadioGraphics 2002 MILD STAGE OF PID IMAGING FINDINGS
    18. 18.  Pyosalpinx ADVANCED STAGES OF PID Most specific sign of PID at CT Sam JW.RadioGraphics 2002 Potter AW. Radiographics 2008
    19. 19. - Stranding of the pelvic fat - Lymphadenopathy ADVANCED STAGES OF PID Jung SI et al. J. Obstet. Gynaecol. Res. 2011  Peritonitis - Thickening of pelvic ligaments - Obscuration of the pelvic fascial planes
    20. 20. MR Hematosalpinx/Pyosalpinx FST1w T2w FST1w- Gd T2w
    21. 21. PID 16 year-old girl: pelvic pain, fever, nausea Bimanual uterine and adnexal tenderness Leukocytosis (white blood cell count, 17,200/μL [reference value, <10,000/μL])
    22. 22. FS T1 w +C T2 w STIR STIR
    23. 23. TVUS – guided drainage
    24. 24. HYDROSALPINX VS PYOSALPINX PYOSALPINX: - Active and acute infection with obstruction of the FT -Thick enhancing wall and surrounding inflammation - Image: depends on the content of protein US: hipoechoic-hyperechoic. MR: hypointense, heterogeneous T1W, hyperintense T2W HYDROSALPINX: - Chronic disease - Results from the obstruction of the ampullary segment: PID, tubal surgery…. - Thin-thick wall, no enhancement and no surrounding inflammation - Image: US: anechoic MR: hypointense T1W, hyperintense T2W
    25. 25. CE T1 w Courtesy: Dr. John SpencerTubal and peritubal adhesions with obstruction of the fimbrial end lead to: Tubal shape changes - Sharp change of shape: “ beak sign”
    26. 26. HYDROSALPINX ”cogwheel sign”: or small round projections on axial imaging-- thickened longitudinal folds Accurate findings for diagnosing hydrosalpinx Tubular “C” “S” “waist sign”: incomplete septa result from the distended tube folding on itself
    27. 27. 1/3 women with severe PID TOA Heterogeneous mass Indistinct ovaries - Fluid-containing mass with a thick enhancing wall and septations -Anterior displacement of thickened broad ligament Kim SH. RadioGraphics 2004 - Pyosalpinx adjacent to or in a portion of TOAs
    28. 28. - Extension to form abdominal abscesses TOA - A more specific sign of tubo- ovarian abscess: gas bubbles
    29. 29. TOA  30 % of patients with TOA respond to treatment: (parenteral antibiotics 48 h ---- oral antibiotics for up to 14 days)  If conservative treatment fails: - Image-guided percutaneous (US, CT) or surgical drainage (laparotomy, laparoscopy) Levenson RB. J Vasc Interv Radiol 2011
    30. 30. PID ABDOMINAL COMPLICATIONS Spread of infection via the right paracolic gutter Rezvani M.RadioGraphics 2011 -Perihepatitis: thickening and enhancement of the anterior liver capsule - Subcapsular and periportal alterations of perfusion Fitz-Hugh-Curtis Syndrome
    31. 31. Ureteral obstruction PID COMPLICATIONS Small or large bowel ileus or obstruction Right ovarian vein thrombosis
    32. 32.  Ectopic  Rupture of ovarian cyst: corpus luteum, follicle, endometrial cyst  Adnexal torsion  Other pelvic cystic masses PID DD Appendicitis Inflammatory bowel diseases (Crohn, ulcerative colitis), infectious terminal ileitis (Yersinia enterocolitica, Y. pseudotuberculosis,Campylobacter jejuni, and M.tuberculosis) Diverticulitis Bladder – ureteral infection
    33. 33. Right ovarian torsion
    34. 34. Appendix diameter (>10 mm), wall (> 2 mm)
    35. 35. Appendicitis PID
    36. 36. Crohn disease 22 year-old woman
    37. 37. Terminal ileitis
    38. 38. Diverticulitis 65 year-old. Right adnexal tenderness, fever, leukocytosis
    39. 39.  Chronic infection by Actinomyces israelii  Opportunistic pathogen: normally present in oral cavity or colon  Gynecological Actinomycosis is highly associated with the use of IUDs.  Chronic suppurative disease  Abundant granulation  Dense fibrous tissue  Multiple abscesses  Sinus tracts ACTINOMYCOSIS
    40. 40. Heterogeneous, well or badly defined adnexal masses, contrast enhancement (rim-enhancement) in the solid portion ACTINOMICOSIS IMAGING Courtesy: Dr. A. J Van der Molen
    41. 41. ACTINOMICOSIS IMAGING - Abscess - Thick, linear, enhancing lesions extending into the adjacent tissue planes, which reflects the invasive nature of actinomycosis Courtesy: Dr. A. J Van der Molen
    42. 42.  Genital tract involvement is detected in 1.3% of female patients with tuberculosis: endometrium (72%), salpinx (34%), ovary (12.9%), and cervix (2.4%).  It can mimic ovarian cancer by both radiological findings and clinical settings (elevated serum CA-125) TUBERCULOSIS
    43. 43.  Findings can be various according to the stage and the route of this infection  General peritoneal tuberculosis, minimal salpingitis with enlarged FT, without obstruction  Image findings mimic those of peritoneal carcinomatosis TUBERCULOSIS AT IMAGING
    44. 44. TUBERCULOSIS AT IMAGING Tubo-ovarian involvement is usually caused by hematogenous or lymphatic spread. -Cystic or both solid and cystic adnexal masses, usually bilateral -Ascites, omental or mesenteric infiltrations, and peritoneal thickening (*peritoneal carcinomatosis from ovarian cancer) -Calcifications, not frequently observed - Lymph node enlargement
    45. 45.  PID and other gynecological issues ACUTE PELVIC INFECTION DIAGNOSIS Appendicitis Crohn, terminal ileitis, diverticulitis  TB, Actinomycosis Diagnosis Clinical history, laboratory, US, MR US, CT, biopsy, MR Imaging
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