1. ACUTE PELVIC
INFECTION
M. Otero-García
mila.oterogarcia@gmail.com

2. Infection of:
- Upper genitalia
(endometrium,
fallopian tubes,
ovaries)
- Adjacent pelvic
structures
FEMALE PELVIC INFECTION

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.  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. 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. 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.  Less commonly:
- Direct spread from nearby appendicitis or diverticulitis
- Hematogenous, lymphatic, peritoneal spread: TB salpingitis
PID

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. 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.  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. 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

13.  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

14. 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

15. 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

16. 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

17. 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

18. Mild pelvic edema
Thickening of the uterosacral ligaments and haziness of
the pelvic fat
Sam JW.RadioGraphics 2002
MILD STAGE OF PID
IMAGING FINDINGS

19.  Pyosalpinx
ADVANCED STAGES OF PID
Most specific
sign of PID at
CT
Sam JW.RadioGraphics 2002
Potter AW. Radiographics 2008

20. - 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

21. MR
Hematosalpinx/Pyosalpinx
FST1w
T2w
FST1w- Gd
T2w

22. 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])

23. FS T1 w +C T2 w
STIR STIR

24. TVUS – guided drainage

25. 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

26. 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”

27. 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

28. 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

29. - Extension to form
abdominal abscesses
TOA
- A more specific sign of tubo-
ovarian abscess: gas bubbles

30. 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

31. 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

32. Ureteral obstruction
PID COMPLICATIONS
Small or large bowel
ileus or obstruction
Right ovarian vein
thrombosis

33.  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

34. Right
ovarian
torsion

35. Appendix diameter (>10 mm), wall (> 2 mm)

36. Appendicitis PID

37. Crohn disease
22 year-old woman

38. Terminal ileitis

39. Diverticulitis
65 year-old. Right adnexal tenderness, fever, leukocytosis

40.  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

41. Heterogeneous, well or badly defined adnexal masses, contrast
enhancement (rim-enhancement) in the solid portion
ACTINOMICOSIS
IMAGING
Courtesy: Dr. A. J Van der Molen

42. 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

43.  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

44.  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

45. 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

46.  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