1. Pelvic ultrasound

2. Case 35 yo G3P1, LMP “4 wks ago”, lower abdominal pain and “dizziness”
IUD in place
R > L, sharp, subjective fever, nausea, dysuria, brown vaginal discharge

3. Differential diagnosis
Gastrointestinal
Appendicitis
IBD
IBS
Constipation
Urinary tract
Cystitis
Pyelonephritis
Nephrolithiasis
Reproductive
Ectopic pregnacy
IUP
PID
TOA
Ovarian cyst
Hemorrhagic cyst
Ovarian torsion
Fibroids
Endometriosis

4. ED Workup U preg neg U dip + LE, + Prot, + Blood Physical exam
Point-of-care ultrasound of the pelvis

5. Indications Acute lower abdominal or pelvic pain
Acute pelvic inflammatory disease
Evaluation of pelvic or adnexal masses

6. Yes/No questions
Is there a life or organ-threatening gynecologic emergency?
Ovarian torsion
Tubo - ovarian abscess
Are there other gynecologic abnormalities?
Ovarian cysts
Fibroids
Other

7. Technique Transabdominal Low frequency probe Bladder full
Overall view of pelvis
Endovaginal
High frequency
Bladder empty
Better resolution, finer details

9. Transabdominal Sagittal
Anterior
Feet
Head
Posterior

10. Transabdominal Transverse
Anterior R L
Posterior

11. Endovaginal - Sagittal
Feet
Anterior
Posterior
Head

12. Endovaginal - Transverse.
Feet R L
Head

14. Ovaries
Right Ovary
Left Ovary

15. Ovarian cysts Most common ovarian masses in non- pregnant
Thin-walled, unilocular anechoic spheres
Hemorrhagic cysts have heterogenic internal echoes
Physiologic <2.5 cm
Follicular cm
Corpus luteum cysts up to 13 cm

21. Fibroids Most common gynecologic tumor
May present with dysuria, dysmenorrhea, constipation or low back pain
Discrete masses within uterine wall
May be hyper or hypoechoic
Shadowing

24. Pelvic inflammatory disease
Inflammation of tubal mucosa
Lumen fills with pus then spills to cul de sac
Pyosalpinx with blockage of fallopian tube
Hydrosalpinx with thinning of walls and distention
Erosion through the distended wall and purulent material spills into ovary
Tubo - ovarian abscess when pus becomes walled off

25. Role of Bedside TransvaginalUltrasonography in the diagnosis of Tubo - ovarian Abscess in the ED J Emerg Med 2008 Jan 31 (Epub)
Retrospective review of 20 patients with TOA
H & P factors unreliable:
PID hx 35%, 45% with CMT or Adnx tender, 5% fever
Ultrasound abnormalities in most
70% complex adnx mass, 25% echogenic fluid
15% pyosalpinx

26. Pyosalpinx

27. Hydrosalpinx

28. Tubo - ovarian abscess

29. Other masses

30. Endometrial polyps

31. Ovarian masses

32. IUDs

33. Best practices - EBM
ED endovaginal ultrasound in nonpregnant women with right lower quadrant pain.
Tayal, et al. Am J Emerg Med 2008
Non-pregnant females presenting with RLQ
Pelvic ultrasound performed looking for:
enlarged ovary or uterus
fluid in cul de sac
tubal dilatation
large cystic mass
multitissue density la

35. Pitfalls Failing to provide adequate analgesia
Confusing uterine vasculature with follicles within the ovary
Confusing large ovarian follicles with fallopian tubes
Confusing ovarian cysts with hydrosalpinx