Week 8 - Adnexa Pathology 2024 PDF

PATHOLOGY OF THE ADNEXA DMS 202 OB/GYN Sonography I Fall 2024 Ch. 45 Copyright © 2018 Elsevier Inc. All rights reserved. Objectives and Outline List the causes and risk factors for pelvic inflammatory disease Describe the sonographic findings of: 1. Sal...

PATHOLOGY OF THE ADNEXA DMS 202 OB/GYN Sonography I Fall 2024 Ch. 45 Copyright © 2018 Elsevier Inc. All rights reserved. Objectives and Outline List the causes and risk factors for pelvic inflammatory disease Describe the sonographic findings of: 1. Salpingitis 2. Pyosalpinx 3. Tubo-ovarian abscess 4. Endometrioma 5. Adenomyosis Identify the locations of endometrial implants in the body Explain the development of endometritis in the postpartum patient Discuss the role of ultrasound in pelvic inflammatory disease Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Diseases PID and endometriosis are diffuse disease processes of the female pelvic cavity PID and endometriosis have very different clinical presentations and pathologies. Early in disease clinical presentation of both endometriosis and PID nonspecific and may mimic functional bowel disease. Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Most common causes: Sexually transmitted diseases/infections including gonorrhea and chlamydia Uncommon causes: Ruptured appendix and subsequent peritonitis. Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease PID is an inclusive term for all pelvic infections: Endometritis Salpingitis Hydrosalpinx Pyosalpinx Periovarian inflammation Tubo-ovarian complex Tubo-ovarian abscess Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Infection usually occurs bilaterally and may be found in: Endometrium (endometritis) Uterine wall (myometritis) Uterine serosa and broad ligaments (parametritis) Ovary (oophoritis) Most common location, oviducts (salpingitis) Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Sonography limited value during acute PID, or early onset when inflammatory changes have not yet begun to manifest In chronic PID, ultrasound can identify dilated fallopian tubes (hydrosalpinx or pyosalpinx), abscess, complex intraperitoneal fluid. Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease General Information Occurrence of PID becoming more common Occurs in 11% of women during reproductive age Peak incidence at 20 to 24 years Affects 750,000 American women each year Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Risk factors: Factors increasing risk of STD/STIs Early sexual contact Multiple sexual partners History of: STD/STI Previous history of PID Intrauterine contraceptive device (IUCD) Douching - may push bacteria up into the upper genital tract Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Other routes of infection possible: Direct extension from ruptured abscess in abdominal/pelvic cavity: Appendiceal Diverticular Postsurgical abscess collections that have ruptured into pelvis String from IUCD Puerperal and postabortion complications Puerperal – during or relating to the period of about 6 weeks after childbirth during which the mother's reproductive organs return to their original nonpregnant condition. Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Inflammatory disease (acute or chronic); infection spreads to pelvis Large, palpable, bilateral complex mass; ovary may be seen separate from mass Free fluid in cul-de-sac Doppler image shows increased vascularity and diastolic flow. Associated with infertility and endometritis Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Complications: Infrequently pelvic infection may travel upward through right flank, causing perihepatic inflammation. Pain may mimic liver, gallbladder, or right renal pain. Perihepatic inflammation can be detected sonographically by scanning along liver margin and identifying hypoechoic rim between liver and adjacent ribs: Fitz-Hugh- Curtis syndrome. Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Causes: Sexually transmitted PID spread via mucosa of pelvic organs through cervix into uterine endometrium (endometritis) and out fallopian tubes (acute salpingitis) to area of ovaries and peritoneum As tube becomes obstructed, it fills with pus (pyosalpinx). In setting of extensive PID, margins of ovaries and other pelvic structures can become difficult to distinguish from each other. Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Symptoms: Clinically, patients may present with intense pelvic pain and tenderness described as dull and aching, with constant vaginal discharge. Other symptoms include fever, pain in right upper abdomen, painful intercourse, irregular menstrual bleeding. History of infertility may be present. Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Clinical findings: Lab tests may show elevated white blood cell count (WBCs) in PID Particularly when caused by chlamydial infection May be asymptomatic or disease may produce only minor symptoms Nevertheless, can seriously damage reproductive organs Copyright © 2018 Elsevier Inc. All rights reserved. Pelvic Inflammatory Disease Sonographic findings: May be normal early in course of disease. As disease progresses or becomes chronic, variety of findings may occur. Differential considerations include hematoma, dermoid cyst, ovarian neoplasm, and endometriosis. Copyright © 2018 Elsevier Inc. All rights reserved. Sonographic Findings of Pelvic Inflammatory Disease Endometritis: thickening or fluid in endometrium Periovarian inflammation: enlarged ovaries with multiple cysts, indistinct margins Salpingitis: nodular thickening, irregularity of tube with diverticula Pyosalpinx or hydrosalpinx: fluid-filled irregular fallopian tube with or without echoes Tubo-ovarian abscess: complex mass with septations, irregular margins, internal echoes; usually in cul-de-sac Copyright © 2018 Elsevier Inc. All rights reserved. Salpingitis Description Inflammation of fallopian tube Acute, subacute, or chronic Clinical Asymptomatic to pelvic fullness or discomfort Low-grade fever Copyright © 2018 Elsevier Inc. All rights reserved. Salpingitis Sonographic findings: Dilated tube Tortuous tube Copyright © 2018 Elsevier Inc. All rights reserved. Salpingitis Copyright © 2018 Elsevier Inc. All rights reserved. Hydrosalpinx Description Obstructed tube filled with serous secretions Occurs secondary to PID, endometriosis, or postoperative adhesions Clinical Asymptomatic to pelvic fullness or discomfort Low-grade fever Copyright © 2018 Elsevier Inc. All rights reserved. Hydrosalpinx Sonographic findings: Walls become thin secondary to dilation Appearance of multicystic or fusiform mass Follow dilated tubes from fundus of uterus By Ekem, CC BY-SA 3.0, Look for pointed “beak” at swollen end of tube https://commons.wikimedia.org/w/index.php?curid=25175486 near isthmus Bilateral Ampullary portion more dilated than interstitial part of tube Copyright © 2018 Elsevier Inc. All rights reserved. Hydrosalpinx Copyright © 2018 Elsevier Inc. All rights reserved. Hydrosalpinx Copyright © 2018 Elsevier Inc. All rights reserved. Pyosalpinx Description Retained pus in oviduct with inflammation Clinical Asymptomatic to pelvic fullness or discomfort Low-grade fever Copyright © 2018 Elsevier Inc. All rights reserved. Pyosalpinx Sonographic findings May appear as complex mass Pus within dilated tube very thick and echogenic—poor sound transmission Bau A, Atri M. Acute female pelvic pain: ultrasound Copyright © 2018 Elsevier Inc. All rights reserved. evaluation. Semin Ultrasound CT MR2000; 21:78 -93 Peritoneal Pseudocyst with Hemorrhagic Mesothelial Cyst Copyright © 2018 Elsevier Inc. All rights reserved. Tubo-Ovarian Abscess (TOA) Description Adhesive, edematous, inflamed serosa may further adhere to ovary and/or other peritoneal surfaces, which distorts anatomy. As infection worsens, periovarian adhesions may form. Ovary cannot be separated from inflamed dilated tube and called tubo-ovarian complex. Copyright © 2018 Elsevier Inc. All rights reserved. Tubo-Ovarian Abscess (TOA) Usually responds well to antibiotic treatment without need for surgical drainage Serial ultrasound images during treatment allow observation of resolution. Sonographic guidance can be used to assist in percutaneous or transvaginal drainage for culture and sensitivity or complete drainage, and thus hasten recovery. Copyright © 2018 Elsevier Inc. All rights reserved. Tubo-Ovarian Abscess (TOA) Copyright © 2018 Elsevier Inc. All rights reserved. Tubo-Ovarian Abscess (TOA) Copyright © 2018 Elsevier Inc. All rights reserved. Tubo-Ovarian Abscess (TOA) Copyright © 2018 Elsevier Inc. All rights reserved. Peritonitis Description Inflammation of peritoneum Serous membrane lining the abdominal cavity and covering the viscera Pelvic peritonitis If infectious process spreads to involve bladder, ureter, bowel, and adnexal area Copyright © 2018 Elsevier Inc. All rights reserved. Peritonitis Causes Inflammation caused by infectious organisms that gain access by way of rupture or perforation of viscera or associated structures Via the female genital tract Piercing abdominal wall Via bloodstream or lymphatic vessels Via surgical incisions Failure to practice antiseptic techniques during surgery Copyright © 2018 Elsevier Inc. All rights reserved. Peritonitis Sonographic findings Gas-forming bubbles Loculated areas of fluid within pelvis, paracolic gutters, mesenteric reflections Evaluation of space between right kidney and liver and left kidney and spleen Copyright © 2018 Elsevier Inc. All rights reserved. Free Fluid Associated with Acute Appendicitis Copyright © 2018 Elsevier Inc. All rights reserved. Free Fluid Associated with Ovarian Torsion Copyright © 2018 Elsevier Inc. All rights reserved. Endometritis Description Endometritis, infection of endometrium Nonobstetric cases: Associated with PID or gynecologic instrumentation Endometritis can be acute or chronic. Obstetric cases Occur in immediate postpartum period. Most common cause of fever in postpartum patient. Copyright © 2018 Elsevier Inc. All rights reserved. Endometritis Sonographic findings Endometrium may appear thick, contain fluid, air or clot or appear normal. Endometrium considered normal up to 20 mm. Measurement of >20 mm should raise suspicion of endometritis, hemorrhage, or retained products of conception. Risk for endometritis increases with premature rupture of membranes, retained clot or POCs and prolonged labor. Copyright © 2018 Elsevier Inc. All rights reserved. Endometriosis Description Is defined as presence of functioning endometrial tissue in abnormal locations Ectopic tissue can be found almost anywhere in body. Copyright © 2018 Elsevier Inc. All rights reserved. Endometriosis Clinical findings Severe dysmenorrhea Chronic pelvic pain from peritoneal adhesions Bleeding Dyspareunia Copyright © 2018 Elsevier Inc. All rights reserved. Endometriosis Causes May arise from peritoneal seeding from: Retrograde travel of endometrial cells through fallopian tubes Metaplastic transformation of peritoneal epithelium into endometrial tissue Traumatic spread from uterine surgery or amniocentesis Copyright © 2018 Elsevier Inc. All rights reserved. Endometriosis - Types 1. Internal endometriosis (within uterus) Adenomyosis – invades myometrium 2. External endometriosis (outside uterus) Pouch of Douglas Surface of ovary Fallopian tube Uterus broad ligaments Rectovaginal septum Copyright © 2018 Elsevier Inc. All rights reserved. Endometriosis (External) More common form of endometriosis is the external, or indirect, form. Varies in extent from small foci to widespread sheets of tissue to focal discrete masses Endometrial tissue in endometriosis cyclically bleeds and proliferates as stimulated by changes in hormonal influence. Copyright © 2018 Elsevier Inc. All rights reserved. Endometriosis (Internal) Internal, or direct form, called adenomyosis Endometrial cells begin to grow into uterine body, invading junctional zone and myometrium Clinical symptoms of adenomyosis are heavy menstrual bleeding, painful menses and uterine enlargement. Adenomyosis most common in women who have had uterine surgery Copyright © 2018 Elsevier Inc. All rights reserved. Endometriosis (Internal) Sonographic findings Uterus may appear bulbous May be myometrial “cysts” Border between endometrium and myometrium becomes indistinct. “Blurred border” appearance more common in posterior aspect of uterus MRI more specific than ultrasound in making this distinction Copyright © 2018 Elsevier Inc. All rights reserved. Endometriosis Sonographic findings Diffuse endometriosis, more common form, rarely detected sonographically unless focal mass, endometrioma, present Endometriomas – Focal mass of endometrial tissue Bilateral or unilateral ovarian masses Patterns ranging from anechoic (rare) to solid Depending on amount of blood and its state of organization Copyright © 2018 Elsevier Inc. All rights reserved. Endometriosis Transvaginal sagittal view of the uterus demonstrates endometrial calcification (arrows) with shadowing in a 34-year-old woman with pelvic fullness. Copyright © 2018 Elsevier Inc. All rights reserved. Endometriosis Ovaries may be difficult to define. Can adhere to posterior surface of uterus or are stuck in cul-de-sac Obscured organ borders and multiple irregular cystic masses also suggestive of either disseminating cancer or pelvic infection Copyright © 2018 Elsevier Inc. All rights reserved. Interventional Ultrasound TA or TVS guidance used for aspiration of benign-appearing cysts TVS drainage helpful in TOAs; other pelvic abscesses, such as appendicitis and diverticulitis; drainage of postoperative fluid collections Transrectal drainage can be used for deep pelvic abscesses TVS also used in obtaining biopsies for benign and malignant solid pelvic masses and to drain recurrent malignant collections Copyright © 2018 Elsevier Inc. All rights reserved. Interventional Ultrasound: TOA Copyright © 2018 Elsevier Inc. All rights reserved.