Notes #2: Endometriosis and Pelvic Inflammatory Disease

Similarities in presentation: endometriosis, PID, ectopic pregnancy, appendicitis

Abdominal Pain

May also present: Unusual vaginal bleeding or discharge; Nausea and vomiting;

Sonographic Similarities between endometriosis and PID:

Chronic conditions which lead to fixed pelvis (retroverted uterus, blurring of margins between organs); caused by matting / adhesions of pelvic structures including bowel, tubes, broad ligament, and omentum.

Both conditions may present with multiple complex masses.

In early stages of both, pelvis may appear normal (especially with endometriosis).

Difference in clinical presentation and symptoms as noted below:

Endometriosis:

Endometriosis: an abnormal, non-neoplastic growth of endometrial tissue within the peritoneal cavity. The implants of endometrial tissue respond to hormonal stimulation and may form chocolate cysts (endometriomas). This condition will remain active as long as ovarian function persists.

Symptoms: may be asymptomatic in early stages

Pain: cyclic, bilateral, increasing in severity, cramping, lower backache, pain on defecation if bowel involved or if lesions are located near the rectovaginal septum, dysmenorrhea, dyspareunia

Abnormal vaginal bleeding: no specific pattern - may be excessive, prolonged, or frequent bleeding

Rectal bleeding: may occur with bowel involvement

Nausea and Vomiting: occurs primarily when bowel involved

Infertility: develops from tubal and ovarian obstruction by endometrial deposits, clots, and adhesions.

Causes and Risk Factors: unknown

Sonographic Appearance:

In the early stages, endometriosis may not be discernable

Generalized Endometriosis may present with a fixed pelvis, retroverted uterus, and a blurring of organ definition.

Endometriomas are most usually found bilaterally in association with the ovaries or in the posterior cul-de-sac

Variable appearance

Most common - low echogenicity solid mass with excellent through transmission

May appear complex, or cystic, or with septae

Rarely over 10 cm. in size

Treatment:

Surgery - palliative (partial removal, scraping)

Surgery - hysterectomy and bilateral salpingoophorectomy

Hormonal treatment - drugs that replicate a menopausal hormonal state

Pelvic Inflammatory Disease:

Symptoms: onset may be gradual with minimal symptoms in the beginning.

Pain: sudden onset of bilateral pain unrelated to menstrual cycle progressing to acute tenderness on palpation; dyspareunia

Abnormal vaginal bleeding: occurs in 35% of women with salpingitis (similar incidence with ectopic pregnancy, endometriosis - uncomon with appendicitis).

Abnormal vaginal discharge: thick, opaque, odoriferous (uncommon with appendicitis or ectopic pregnancy)

Nausea and vomiting: common with PID and appendicitis (less common with ectopic pregnancy and endometriosis)

Other symptoms: leucocytosis (WBC count over 10,000 hallmark of PID), fever and chills, headache, rapid heartbeat,

Infertility: associated with chronic or repeated episodes of PID due to tubal and ovarian obstruction by scar tissue and adhesions.

Risk Factors: Young age (sexually active teenagers), IUD use, history of sexually transmitted disease (STD), douching, poor nutritional status or immune deficiency, multiple sexual partners, previous PID episode.

Normal Defenses:

cervical cilia motion moves bacteria downward (not as well developed in young girls)

cervical mucous

cervical antibodies (increase with age)

Defenses are not as effective when estrogen levels are high because estrogen increases permeability and decreases the viscosity of the cervical mucous - (important for fertilization at mid-cycle)

Incidence: more than 1 million women per year in the U.S. have acute episode.

Sequelae:

Leading cause of infertility

Women with PID:

25% hospitalized without major surgery

25% require major surgery

20% infertile after episode

Of those that do conceive, the risk of ectopic pregnancy is increased 6-10 times

Early detection may prevent sequelae and reduce severity

Types of PID:

Pyogenic PID: infection preceded by invasive or traumatic event

History: Ruptured appendix, diverticulosis with abscess, Crohn's disease with abscess, Pelvic surgery, Abortion, or Delivery

Organisms: Staphylococcus, Streptococcus

Spread: through lymphatics and veins

Associated with thrombophlebitis, lymphangitis

Uterine involvement severe -- often associated with pyometra

Tubal involvement serosal (outer) layer; damage to lumen and infertility less likely; pyosalpinx less common

May be unilateral - indicative of local source

PID associated with IUD's: usually bilateral; similar to venereal; IUD string acts as a source for bacteria

Venereal PID: infection originating from cervix through sexual contact; most common form of PID

History: early stages asymptomatic, followed by flu-like symptoms, increasing abdominal pain

Organisms: Chlamydia, Gonorrhea, multiple others

Spread: through mucosal surfaces on interior of uterus, and tubes then to peritoneum

Cervicitis >

Metritis >

Salpingitis >

Oophitis >

Peritonitis

Elements of PID:

Pyosalpinx: seen with active infection, more common with chronic or repeat episodes

Exudate (pus and debris) within the tube.

Circular, ovoid, or serpentine in shape.

Smooth walls.

Low-level echogenicity.

Fluid / Fluid level may occur.

Generally bilateral.

Hydrosalpinx: seen with and without active infection usually in patients who have had at least one episode previously

Circular, ovoid, or serpentine in shape

Cystic

Unilateral or bilateral

Thickened walls common

Tubo-Ovarian Abscess:

Irregular shape with thick, irregular, shaggy, or indistinct walls

May be multilocuated or septated

Low-level echogenicity, or complex with debris

May contain gas causing shadowing

May be multiple

Resolving TOA:

Distinct borders apparent

Complex to solid echogenicity

Decreases in size in serial examinations

Chronic PID and fixed pelvis:

Fixed, retroverted uterus

Indistinct margins and separation between pelvic organs

Thickened adnexa merges with pelvic musculature

Uterus and masses merge -- may be confused with a fibroid

Resolving abscesses may remain within the pelvis

Tube wall thicked and hydrosalpinx due to tubal obstruction by scar tissue may be present

Progression of the Disease and Sonographic Appearance:

Early PID: cervicitis, metritis; - may resolve at this stage as there is good drainage from uterus

Cervical discharge

Thickened endometrium

Reduction in echogenicity of uterus and endometrium

Small amounts of fluid in the cul-de-sac

Endometritis and Mild Salpingitis:

Same as above with increasing amounts of fluid in the cul-de-sac

"Bogginess" apparent in the adnexa (swollen and congested tubes cause adnexa to appear thickened)

Fluid deposits in the adnexa may be apparent

Moderate Salpingitis/Peritonitis:

Same as above with pus and debris apparent in the cul-de-sac fluid

Oophitis - small abscesses found on surface of the ovary

Small abscesses throughout adnexa

Pyosalpinx may develop

Severe PID:

Multiple tubal-ovarian abscesses

Pyosalpinx and palpable mass

Large amounts of fluid, debris, pus (complex fluid) in cul-de-sac

Resolving PID:

Decreasing amounts of fluid

TOA's coalesce and then shrink

Pyosalpinx may revert to hydrosalpinx

Treatment:

Determination of Organism: - culdocentesis and culture

Medical Management - antibiotics

Drainage or injection of antibiotics into abscesses

Surgery - removal of infected organs and abscesses

Differentials:

Ovarian Masses:

Pelvic Varices: easily distinquishable by Doppler or color flow Doppler

Appendiceal Abscess:

Lymphoceles:

Overinterpretation of Bowel:

Urethral-Vaginal Fistula:

Ectopic Pregnancy:

Chronic Ectopic: form of tubal pregnancy in which there is gradual disintegration of tubal wall with slow or repeated episodes of bleeding; leads to mass composed of blood clots, cul-de-sac fluid.

Endometriosis: