1. Acute Female Pelvic Pain: U/S Features
Melissa Kern,
PGY-4
Courtesy Drs. M. Atri A. Menard, H. Dua

2. Introduction
Female pelvic pain common presenting complaint in ER radiology
TV U/S best first-line imaging modality
More SN and SP than CT
No radiation or contrast
Direct patient contact
CT often used in ER setting when pathology still unknown after US and persistent pain or suspected pathology beyond depth probe can reach or bowel pathology as mimicker

3. Clinical Relevance
A normal pelvic U/S high negative predictive value for serious pelvic pathology.

4. Common Causes of ER ♀ Pelvic Pain
Gynecologic
Ovarian cyst rupture or hemorrhage
PID
Ovarian torsion
Ectopic pregnancy
Non-gynecologic
Ureterolithiasis
Appendicitis
Diverticulitis

5. Ovarian Cysts…. the basics
Estrogen phase: follicles are at their smallest (typically < 5mm)
By day 10, one dominates and increases in size to about 2-2.5cm (rest regress)
LH surge at mid cycle causes mature follicle to rupture and release egg – follicle then normally loses its fluid, rapidly shrinks and becomes corpus luteum

6. Ovarian Cysts Pain may occur:
As follicle matures and ovarian capsule is stretched
At time of ovulation
Due to cyst rupture
Dominant follicle fails to expel oocyte the follicle may further enlarge into a cyst
Due to cyst hemorrhage
After shrinking, CL may internally bleeds and re-expands = hemorrhagic cyst

7. Typically reserve the term cyst for structures larger than 2.5-3.0cm
Normal ovarian follicle
Simple ovarian cyst – well-defined, anechoic, hypoattenuating
Typically reserve the term cyst for
structures larger than cm

8. TV U/S Findings Ruptured Ovarian Cyst No detectable ovarian cyst
Collapsed cyst
Free pelvic fluid (3-5 ml physiologic)

9. TV U/S Findings Hemorrhagic Cyst
Typically, complex mass with internal echoes and some degree of through transmission
Fresh blood may be anechoic initially
In the first 24hrs…. low-level echoes in a fine, lacelike, reticular pattern
Solid pelvic mass
Amorphous blood clot
Echogenic free pelvic fluid
The extra-ovarian findings on TVS include echogenic pelvic fluid which may range from a small amount to a large quantity and since blood can be very irritant, even a small amount could be very symptomatic
This may be associated with a solid pelvic mass or amorphous blood clot.
Ovarian findings vary from no detectable cyst that is ruptured, to a hemorrhagic cyst to a solid mass

10. Hemorrhagic Cyst  
This is a classical example of a hemorrhagic cyst with retracting spider-web like septa. Notice the vascularity in the wall of the cysts. Surprisingly good through transmission cause mostly cystic.

11. The Many Faces of Hemorrhagic Cysts
These are three examples of hemorrhagic cysts
This is a classical example with spider web like debris
The one in the middle is more solid like
And the third like more amorphous debris.
Notice the presence of peripheral rings in all of them that is highly suggestive of functional cyst

12. Vascular Ring Sign   Mixed solid cystic hemorrhagic cyst.
Vascularity of the periphery of a mass is a very helpful sign to differentiate a functional mass from an endometrioma or a cancer .
Ovarian cancers are not usually predominantly solid (exception: rare granulosa cell tumor). Cystic cancers do not show a vascular ring in the absence of a vascular solid component.

13. Retractile clot

14. Hemorrhagic Cysts….the Bottom Line
Can be any size and echogenicity
Caution in post menopausal women
Helpful signs:
Vascular ring
Through transmission
Retractile clot
Almost all will resolve within 1-2 menstrual cycles
Can be up to 15cm
Post menopausal women – 15-20% have small simple cysts <3cm – complexity, growth can be worrisome – short interval FU to exclude ca
Pre-menopausal women – if hemorrhagic cyst persists, may be an endometrioma

15. Endometrioma ??? Hemorrhagic Cyst
Endometrioma – homo low level internal echoes with through transmission

16. Endometrioma Affect ~10% premenopausal women
Complex cystic masses with homogenous low-level echoes or ground glass appearance (due to repeated episodes of cyclic bleeding)
Follow-up imaging may be necessary to differentiate endometriomas from hemorrhagic ovarian cysts

17. Pelvic Inflammatory Disease
Complication of STDs (chlamydia, gonorrhea)
Estimated incidence US – 1 million acute cases per year
Can lead to infertility or ectopic pregnancy
PID is a clinical and laboratory diagnosis and a negative u/s doesn’t exclude milder forms

18. Utility of U/S Determine the extent of disease
Evaluate the non-responders to treatment
Follow-up patients post treatment
Approach to drain abscesses
Although PID is a clinical and laboratory diagnosis and negative US does not exclude it in the mild forms of disease, US is occasionally used for diagnosis
But more commonly to determine the extent of disease
And response to treatment, especially in non-responders to determine need for US guided intervention or surgery
It is also used to follow response to treatment and is an approach to the abscess drainage

19. PID: U/S Findings *Thickened vascular fallopian tube (often bilateral)
• Fluid-filled +/- debris (non-specific)
• Collapsed
Increased volume and indistinct margins of ovaries
Adnexal inflamed fat and tenderness
Tubo-ovarian abscess
Echogenic pelvic fluid
The most specific TVS findings is the presence of a thick FT that is usually bilateral. The thick tube may be collapsed, or distended with debris or echogenic material in the case of pyosalpinx
The ovaries may be enlarged with indistinct margin because of associated oophoritis
In more advanced cases, there is significant fatty inflammation in the adnexa and tuboovarian abscess develops.
Different amount of echogenic fluid is usually present
Can see fluid/debris filled FT in PID, torsion, ectopic

20. Thickened Fallopian Tube
Left fallopian tube in the same patient that is thickened and slightly vascular

21. PID   OV LEFT FT RIGHT FT
This is an example of PID with bilateral mild thickening of the fallopian tubes.
The degree of FT thickening is variable. Remember that the thickened tube is usually located in close proximity to the ovary as in this case and if you do not have a high degree of suspicion and not look for it you may pass it as part of ovary.
Moreover, remember that we do not see a normal tube so once you identify a tubular structure it is abnormal and consistent with mild PID.
LEFT FT
RIGHT FT

22. PID       OV OV OV RIGHT FT LEFT FT
Another example of PID that shows the tubular nature of the process
RIGHT FT
LEFT FT

23. Pyosalpinx       OV RIGHT FT
This is an example of PID with pyosalpinx. So part of the tube is solid looking and thick both on the right and the left side but there is in addition dilatation of the fallopian tube that is full of pus. Again note the proximity of the thick tube to the ovary even causing mass effect on it.  
RIGHT FT

24. Pyosalpinx     

25. Surrounding inflammation
One point to emphasize is the degree of fat inflammation you see with PID that you do not see with any other gynecological acute abdomen but you also see with other inflammatroy causes such as crohn’s, appendicitis or diverticulitis.
Also you may see inflammation of the adjacent bowel that should not detract you from the primary cause. The secondary causes of bowel inflammation affect the outer black muscle layer more than the other layers.
Also see surrounding echogenic fat
Normal bowel wall thickness less than 5mm

26. Ovarian Torsion Partial or complete twist of ovarian pedicle
Venous/lymphatic obstruction  ovarian edema  arterial compromise  ischemia/infarction

27. Ovarian Torsion Pre-pubertal ♀: idiopathic
Adults: often associated with benign mass
Often present with acute pain + vomiting

28. Ovarian Torsion - Treatment
Emergent surgical de-torsion
Salvage rates better for ovarian vs. testicular torsion
Symptom duration does not always predict viablility
Treatment
Urgent surgical de-torsion
Conservation of ovarian tissue is recommended
Oophoropexy is controversial
The ovary is sutured to the peritoneum of the posterior abdominal wall, medially
Attempt to avoid disturbing the tubo-ovarian anatomic relationship
Contralateral oophoropexy is gaining acceptance when unilateral oophorectomy is performed
Long term ovarian viability is not guaranteed, even when organ reperfused in OR
Salvage rates are better for ovarian torsion than for testicular torsion
Length of symptoms prior to evaluation does not always predict viability
Gross appearance at surgery is also not predictive of salvage
Can both over and under-estimate survival
Oral contraceptives commonly prescribed post-operatively

29. Presence of Doppler flow does not exclude torsion!
U/S Findings:
Twisting (whorl) sign
Increased ovarian volume (stromal edema)
Multiple small peripheral ovarian cysts
Multiple echogenic cysts in the same ovary
Free fluid
Associated mass
Presence of Doppler flow does not exclude torsion!
The most specific finding of adnexal torsion is the presence of a twist in the tube presenting as what is called in the literature as whorl sign. However, I find this sign is difficult to appreciate.
The sign that I find more sensitive and in the proper context specific is the presence of increased ovarian volume due to stromal edema.
Other signs are less specific including …..
The absolute absence of flow is helpful to diagnose torsion but its presence does not exclude it.
Twisted ovary is usually more than twice the size of contralateral side

30. U/S Findings:
Absence or high resistance to arterial flow with absent venous flow, particularly when accompanied by ovarian enlargement is highly suggestive of ovarian torsion

31. The “Whorl” Sign
This is the whorl sign of torsion. Notice the presence of flow in spite of torsion.
In general it is the venous flow that is diminshed first and then arterial flow.

32. Ovarian Torsion
Enlarged ovary (maximal diameter, >5 cm) with prominent peripheral nonovulatory follicles and a small amount of free fluid (arrow) around the inferior margin.

33. Ectopic Pregnancy
Implantation of fertilized ovum outside endometrial lining
2% of all pregnancies
Leading cause of death during 1st trimester
9-14% mortality rate

34. Ectopic Pregnancy Symptoms: 5-9wk hx amenorrhea Mild pelvic pain
Vaginal spotting
Asymptomatic (50%)

35. Ectopic Pregnancy Risk Factors: Previous hx ectopic pregnancy
Tubal surgery
PID
Use of IUD
Previous c-section
IVF
Congenital uterine anomalies
FT (ampulla or isthmus) most common location, <1% in the ovary, <0.03% abdominal pregnancy
Within uterus ectopic pregnancies can occur in cornual region of fundus or cervix
Rate of hetero increases with IVF
“interstitial” or “cornual” pregnancy is ectopic in prox portion of FT which transverse the uterine wall

36. fallopian tubes (95%) Intra-abdominal: 0.03-1%
(12%)
(2-4%)
(70%)
(11%)
(1-3%)
(<1%)
(<1%)
Intra-abdominal: %
Heterotopic: 1-3% IVF pts
FT (ampulla or isthmus) most common location, <1% in the ovary, <0.03% abdominal pregnancy
Within uterus ectopic pregnancies can occur in cornual region of fundus or cervix
Rate of hetero increases with IVF
“interstitial” or “cornual” pregnancy is ectopic in prox portion of FT which transverse the uterine wall
fallopian tubes (95%)

37. Ectopic Pregnancy - Treatment
Medical (Methotrexate)
Hemodynamically stable
No evidence of tube rupture (small volume free fluid)
ßHCG and size criteria (site specific)
Surgical
Salpingotomy
Salpinectomy
US-guided local injection of Methotrexate or KCL
Preferred for cornual or cervical ectopics
Treatment
Medical treatment with methotrexate preferred
Patient must be hemodynamically stable
No evidence for tube rupture
Little or no peritoneal fluid
Early, unruptured, small ectopic
90% success rate
EP < 4 cm
HCG levels < 5,000 mIU/mL
≤ 8 wks gestation
70% success rate if living embryo
Multiple doses may be necessary
Ultrasound after treatment is often confusing
↑ Hemorrhage around EP
↑ Size of EP
Use only if suspect tubal rupture
Surgical therapy
Salpingectomy
Segment of tube removed
Ends reconnected if possible
Only choice for ruptured EP
Salpingotomy
Small lengthwise incision in tube
Removal of EP
Ultrasound guided local injection
Methotrexate or potassium chloride (KCl)
Injected directly into GS
Live ectopic + unruptured tube
30% fail systemic treatment
Preferred method for cornual and cervical ectopics

38. U/S Criteria Discriminatory level for detecting IUP is ßHCG > 2000
If ßHCG > 2000 and no IUP: EP
Early pregnancy failure
If ßHCG < 2000 and no IUP:
Normal early IUP
IUP is evident with serum -hCG > 2000

39. U/S Findings Normal IUP:
Intradecidual sign (4.5wks): small collection of fluid eccentrically located within the endometrium
Double decidual sign (5wks): 2 concentric hyperechoic rings that surround an anechoic gestational sac
Yolk sac (5.5wks): when GS reaches 8mm

40. Double decidual sac sign in a normal IUP

41. EP: U/S Findings “Pseudogestational sac” sign: No IUP
Normal endometrium
Thin-walled decidual cysts (found at junction endo- and myometrium in normal and abnormal pregnancies)
“Pseudogestational sac” sign:
Thick decidual reaction surround intrauterine fluid (no double decidual sign)
Located centrally within endometrial canal
10% patients with EP
General Features
Best diagnostic clue: No intrauterine pregnancy (IUP) + tubal mass + echogenic cul-de-sac fluid
Location: Separate from ovary
Morphology
Complex adnexal mass
From hemorrhage
Tubal ring
Similar to IUP gestational sac (GS)
Ultrasonographic Findings
Uterine findings vary
Thin endometrium
Empty uterus
Thick echogenic endometrium
Decidual reaction of pregnancy
Endometrial cysts
Often small and multiple
Large cyst may mimic early IUP
"Pseudogestational sac" sign
Decidual cast
Endometrial fluid (blood)
Lacks double-decidual sac sign of normal IUP
Heterotopic pregnancy (rare)
IUP + EP
Tubal findings
Adnexal abnormality in 80-95%
Tubal hematoma (40-60%)
Nonspecific mass
Heterogeneous echotexture
Tubal ring (50%)
Echogenic ring separate from ovary
+/- Yolk sac
+/- Embryo +/- cardiac activity
Tubal ring "lights up" with color Doppler
"Ring of fire"
May show small EP missed otherwise
Pulsed Doppler findings
High-velocity, low-resistance flow
Trophoblastic flow velocity > ovarian velocity
> 2-4 kHz common for trophoblastic flow
Ovary findings
Identify which ovary contains corpus luteum (CL)
85% of ectopics on same side as CL
Corpus luteum appearance is variable
Echogenic ring
Hypoechoic cyst
Anechoic cyst
Complex cyst from hemorrhage
Corpus luteum can mimic EP
CL is within ovary and tubal EP is outside of ovary
Corpus luteum Doppler findings
Similar to "ring of fire" but in ovary
CL flow velocity < trophoblastic tissue velocity
Low-resistive flow-like EP flow
Echogenic fluid in cul-de-sac
Blood within peritoneal space
Between uterus and rectum
Echogenic fluid
May need ↑ gain settings to see echoes
Small amount of anechoic fluid considered physiologic
Clotted blood may be mass-like and complex
Blood may be an isolated finding
42% will have EP if small amount of fluid seen
73% will have EP if large amount of fluid seen
Role of transabdominal ultrasound
Look for upper abdomen fluid
Paracolic gutters
Morrison pouch (between liver and kidney)
Ultrasound completely negative in 5-10% of cases
No IUP, normal adnexa, no cul-de-sac fluid
Imaging Recommendations
Best imaging tool
Transvaginal ultrasound + color Doppler
91% of EP accurately diagnosed
Protocol advice
Correlate findings with human chorionic gonadotropin (hCG) levels
Should see IUP when hCG levels are > 2,000 mIU/mL IRP (international reference preparation)
Suspect EP if no IUP and hCG > 2,000 mIU/mL IRP
Lack of IUP at low hCG levels does not rule out EP
EP's have lower hCG levels/gestational age
Obtain sagittal cul-de-sac view in every case
Transvaginal probe angled towards rectum
Adjust gain settings to see echoes
Look for CL in every case
EP often on same side as CL
CL hemorrhage or rupture may be cause of pain
Do not confuse CL for EP
Use color Doppler
Look for small EP
Rule out ovarian torsion as cause of pain
Use endovaginal probe as a palpation tool
Gently wedge probe between mass and ovary
Free hand on abdomen palpates same area
EP moves independent of ovary
CL moves with ovary

42. Pseudogestational sac in an ectopic pregnancy

43. Transvaginal gray-scale US image obtained along the longitudinal axis shows an intrauterine pseudo–gestational sac (arrow); there is no yolk sac or fetal pole. Free fluid is seen in the cul-de-sac (*).

44. EP: U/S Findings Tubal/adnexal mass SEPARATE FROM OVARY
“Tubal ring” sign: hyperechoic ring surround an extra-uterine gestational sac
*“Ring of fire” sign: peripheral hypervascularity of hyperechoic ring
General Features
Best diagnostic clue: No intrauterine pregnancy (IUP) + tubal mass + echogenic cul-de-sac fluid
Location: Separate from ovary
Morphology
Complex adnexal mass
From hemorrhage
Tubal ring
Similar to IUP gestational sac (GS)
Ultrasonographic Findings
Uterine findings vary
Thin endometrium
Empty uterus
Thick echogenic endometrium
Decidual reaction of pregnancy
Endometrial cysts
Often small and multiple
Large cyst may mimic early IUP
"Pseudogestational sac" sign
Decidual cast
Endometrial fluid (blood)
Lacks double-decidual sac sign of normal IUP
Heterotopic pregnancy (rare)
IUP + EP
Tubal findings
Adnexal abnormality in 80-95%
Tubal hematoma (40-60%)
Nonspecific mass
Heterogeneous echotexture
Tubal ring (50%)
Echogenic ring separate from ovary
+/- Yolk sac
+/- Embryo +/- cardiac activity
Tubal ring "lights up" with color Doppler
"Ring of fire"
May show small EP missed otherwise
Pulsed Doppler findings
High-velocity, low-resistance flow
Trophoblastic flow velocity > ovarian velocity
> 2-4 kHz common for trophoblastic flow
Ovary findings
Identify which ovary contains corpus luteum (CL)
85% of ectopics on same side as CL
Corpus luteum appearance is variable
Echogenic ring
Hypoechoic cyst
Anechoic cyst
Complex cyst from hemorrhage
Corpus luteum can mimic EP
CL is within ovary and tubal EP is outside of ovary
Corpus luteum Doppler findings
Similar to "ring of fire" but in ovary
CL flow velocity < trophoblastic tissue velocity
Low-resistive flow-like EP flow
Echogenic fluid in cul-de-sac
Blood within peritoneal space
Between uterus and rectum
Echogenic fluid
May need ↑ gain settings to see echoes
Small amount of anechoic fluid considered physiologic
Clotted blood may be mass-like and complex
Blood may be an isolated finding
42% will have EP if small amount of fluid seen
73% will have EP if large amount of fluid seen
Role of transabdominal ultrasound
Look for upper abdomen fluid
Paracolic gutters
Morrison pouch (between liver and kidney)
Ultrasound completely negative in 5-10% of cases
No IUP, normal adnexa, no cul-de-sac fluid
Imaging Recommendations
Best imaging tool
Transvaginal ultrasound + color Doppler
91% of EP accurately diagnosed
Protocol advice
Correlate findings with human chorionic gonadotropin (hCG) levels
Should see IUP when hCG levels are > 2,000 mIU/mL IRP (international reference preparation)
Suspect EP if no IUP and hCG > 2,000 mIU/mL IRP
Lack of IUP at low hCG levels does not rule out EP
EP's have lower hCG levels/gestational age
Obtain sagittal cul-de-sac view in every case
Transvaginal probe angled towards rectum
Adjust gain settings to see echoes
Look for CL in every case
EP often on same side as CL
CL hemorrhage or rupture may be cause of pain
Do not confuse CL for EP
Use color Doppler
Look for small EP
Rule out ovarian torsion as cause of pain
Use endovaginal probe as a palpation tool
Gently wedge probe between mass and ovary
Free hand on abdomen palpates same area
EP moves independent of ovary
CL moves with ovary
*non-specific, may also be seen surrounding
normal maturing follicle, CL….. confirm that
separate from the ovary.

45. EP: U/S Findings Echogenic free-fluid in cul-de-sac
U/S completely negative in 5-10%
85% of ectopics on same side as CL
Echogenic fluid in cul-de-sac
Blood within peritoneal space
Between uterus and rectum
Echogenic fluid
May need ↑ gain settings to see echoes
Small amount of anechoic fluid considered physiologic
Clotted blood may be mass-like and complex
Blood may be an isolated finding
42% will have EP if small amount of fluid seen
73% will have EP if large amount of fluid seen
Role of transabdominal ultrasound
Look for upper abdomen fluid
Paracolic gutters
Morrison pouch (between liver and kidney)
Ultrasound completely negative in 5-10% of cases
No IUP, normal adnexa, no cul-de-sac fluid
Imaging Recommendations
Best imaging tool
Transvaginal ultrasound + color Doppler
91% of EP accurately diagnosed
Protocol advice
Correlate findings with human chorionic gonadotropin (hCG) levels
Should see IUP when hCG levels are > 2,000 mIU/mL IRP (international reference preparation)
Suspect EP if no IUP and hCG > 2,000 mIU/mL IRP
Lack of IUP at low hCG levels does not rule out EP
EP's have lower hCG levels/gestational age
Obtain sagittal cul-de-sac view in every case
Transvaginal probe angled towards rectum
Adjust gain settings to see echoes
Look for CL in every case
EP often on same side as CL
CL hemorrhage or rupture may be cause of pain
Do not confuse CL for EP
Use color Doppler
Look for small EP
Rule out ovarian torsion as cause of pain
Use endovaginal probe as a palpation tool
Gently wedge probe between mass and ovary
Free hand on abdomen palpates same area
EP moves independent of ovary
CL moves with ovary
These are some tips to localize EP.
Identify ovary first. This prevents mistaking ovary for EP
EP is usually closely related to ovary
Once EP is located and if it is close to the ovary confirm …..
Start looking for EP without color Doppler. The flashing form Doppler prvents seeing small EPs

46. EP vs. CLC
CLC EP
The most difficult task when we are looking for EP is to distinguish an ovary or corpus luteum cyst of ovary from an EP.
Here one of these two structures is CLC and one EP. In general the two have similar features.
Both show a rind around the cyst. Although the rind of the EP is more echogenic there is overlap. Echogenic rind is tubal ring
Here this is an EP and this a CLC

47. EP vs. CLC
This is an example of an EP sitting next to the ovary that contains a cyst.
In this case the one on your right is the EP and the one on your left is the ovary. In general EP has a more echogenic rind than CLC but this is a soft finding and I do not recommend using this sign. This is why I emphasize that you need to find the ovary first and then look for an extraovarian mass in its vicinity.
This EP has a sac in it but less than 70% of the EPs have a sac and the other 30% or more look solid. Vascularity does not help since there is overlap between the two. Extreme vascularity is more often seen in EP than CLC but in those cases the grayscale makes the diagnosis.
There is also overlap between the Doppler values of CLC and EP as well.
CLC EP

48. EP vs. CLC
Similar flow

49. Ring of Fire

50. Tubal Ectopic
CLC EP
EP can look more solid

51. Acute pelvic pain and + ßHCG is EP until proven otherwise!
In a women of reproductive age with no established IUP. . .

52. Follow-up Average doubling time ßHCG in a normal, viable IUP is ~48hrs
If no IUP, no ectopic identified in ßHCG +’ve ♀, suggest serial ßHCG and f/u u/s as clinically indicated
In EP’s serum HCG levels rise at much slower rate

53. Case 1
PID

54. Case 2  
This is an example of a ruptured hemorrhagic cyst which is bascially the combination of echogenic, septated as in this case or solid looking pelvic blood and a hemorrhagic cyst.
Again this is a classical hemorrhagic cyst. Note the fine septa in this cyst that you do not see in any other condition. Please remember that in a number of cases, the hemorrhagic cyst is not visible because it is completely drained. Also, the amount of pelvic blood is variable and it could be very small amount and be very painful. On real-time exam. The point of maximum tenderness helps recognizing the small amount of blood as the source of pain.

55. Case 3 TVUS, positive beta greater than 2000
CLC is on left of image and EP on right
This is an example of a more solid looking HSX mimicking a more solid looking CLC. Again both show peripheral vascularity and low RI

56. Case 4
Whorl sign, edematous enlarged ovary with decreased flow and large ovarian cyst.

57. Case 5
Hemorrhagic ovarian cyst. Transverse transvaginal US image of the adnexa shows a complex hemorrhagic cyst with the characteristic lacelike echogenic pattern of fibrin strands that form as blood clots and retracts.

58. Case 6
Endometrioma. Longitudinal transvaginal US image of the adnexa depicts a large, well-defined, complex cystic mass with low-level internal echoes.

59. Case 7
Pelvic inflammatory disease with a tuboovarian abscess. (a) Transverse transvaginal US image of the pelvis reveals bilateral dilated folding tubular structures with thickened walls, internal echogenic fluid, and debris. (b) Axial contrast-enhanced CT image shows dilated tubular structures with thick enhancing walls. Inflammatory stranding of the surrounding fat is most demonstrable on the right (arrow). The presence of a tuboovarian abscess was confirmed at surgery.

60. Case 8
Transvaginal gray-scale US image of the right adnexa reveals an extraovarian adnexal mass with a hyperechoic tubal ring (arrow). A tubal pregnancy was confirmed at surgery. OV = right ovary.

61. Case 9
Lt ureteric calculus

62. THANK YOU!!!!