Chapter 39: Pathology of the Adnexa Flashcards
What are two diffuse disease processes of the female pelvic cavity?
- PID
- endometriosis
What are PID and endometriosis most commonly associated with?
gonorrhea and chlamydia
PID is an inclusive term for all pelvic infections including (7):
- endometritis
- salpingitis
- hydrosalpinx
- pyosalpinx
- periovarian inflammation
- tubo-ovarian complex
- tubo-ovarian abscess
Where can PID be be found?
BILATERALLY
- in the endometrium (endometritis)
- in the uterine wall (myometritis)
- the uterine serosa and broad ligaments (parametritis)
- the ovary (oophritis)
- the oviducts (salpingitis)
Where is PID found most commonly?
the oviducts AKA salpingitis
What are 6 risk factors of PID?
- early sexual contact
- multiple sexual partners
- HX of sexually transmitted disease
- previous hx of PID
- IUCD’s
- Douching
T/F: PID is becoming more common?
True
Routes of infection include:
- douching
- direct extensions from post-surgical abscess collection that have ruptured into the pelvis
- the string from IUCD
- puerperal and post abortion complications
- other invasive instrumentation procedures
Infrequently with patients with PID resulting from gonorrhea, where may the PID ascend?
may ascend the right flank causing a perihepatic inflammation..causing pain that might mimic liver, GB, or rt. renal pain
Perihepatic inflammation is AKA
Fitz-Hugh-Curtis syndrome
Sexually transmitted PID is spread via the _____
mucosa of the pelvic organs through the cervix into the endometrium and out the fallopian tubes
If a pregnancy test is positive in a woman with previously treated PID, what is indicated?
careful eval. of the adnexa even with a normal IUP
Clinical symptoms of PID (8):
- intense pelvic pain
- tenderness
- fever
- pain in rt upper abdomen
- painful intercourse
- irregular menstrual bleeding
- hx of infertility
- elevated WBC’s
Son findings of endometritis?
thickening or fluid in the endometrium
Son findings of periovarian inflammation?
enlarged ovaries with multiple cysts, indistinct margins
Son findings of salpingitis?
nodular thickening, irregularity of tube with diverticula
Son findings of pyosalpinx or hydrosalpinx?
fluid-filled irregular fallopian tube with or without echoes
Son findings of Tubo-ovarian abscess?
complex mass with septations, irregular margins, and internal echoes..usually in the cul-de-sac
What is salpingitis?
inflamation of fallopian tube; acute, subacute, or chronic
What are clinical findings of salpingitis?
asymptomatic to pelvic fullness or discomfort, low grade fever
What are sonographic findings of salpingitis?
dilated, tortuous tube
Describe hydrosalpinx?
obstructed tube filled with serous secretions; occurs secondary to PID, endometriosis or postop adhesions
What are clinical findings of hydrosalpinx?
asymptomatic to pelvic fullness or discomfort,low grade fever
What are sonographic findings of salpingitis?
walls become thin secondary to dilation; appearance of multicystic or fusiform mass..follow dilated tubes from the fundus of uterus and look for pointed beak at swollen end of the tube near isthmus..bilateral..ampullary portion more dilated that interstitial part of tube
What is pyosalpinx?
retained pus in oviduct with inflammation
What are clinical findings of pyosalpinx?
asymptomatic to pelvic fullness or discomfort; low grade fever
What are son findings of pyosalpinx?
may appear as complex mass; pus within dilated tube very thick and echogenic; poor sound transmission
In addition to hydrosalpinx or pyosalpinx, son findings of PID include:
-fluid in cul-de-sac, mild uterine enlargement, and endometrial fluid or thickening
In pts of reproductive age, the classic differential diagnosis of a complex adnexal mass is
- ectopic preg
- PID
- endometriosis
Describe TOA:
the adhesive, edematous and inflammed serosa may further adhere to the ovary and/or other peritoneal surfaces, which distorts anatomy
What is the tubo-ovarian complex?
when the ovary cannot be separated from the inflammed dilated tube with TOA..this causes a further loculation of pus known as tubo-ovarian abscess
How does a TOA appear?
may be unilateral OR bilateral and appears as a complex mass in the post culdesac
What is peritonitis?
the inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera
What is peritonitis caused by? (5)
- infectious organisms that gain access by way of rupture or perforation of the viscera or associated structures
- via female genital tract
- piercing the abd. wall
- via bloodstream or lymphatic vessels; via surgical incision
- or by failure to practice antiseptic techniques during surgery
Son findings of peritonitis:
loculated areas of fluid within the pelvis, paracolic gutters, and mesenteric reflections..one should eval. the Morrison’s pouch and area between left kid and spleen
What is endometriosis?
presence of functionoing endometrial tissue in abnormal locations
Endometriosis occurs most commonly in what two forms?
- adenomyosis of uterus (internal)
- endometriosis of adnexa (external)
Which form of endometriosis is less common?
internal/direct/adenomyosis
Where is adenomyosis?
remains confined within the uterus, invading the junctional zone and the myometrium
What is the most common form of adenomyosis?
diffuse (represents a reactive hypertrophy of the myometrial muscle, which produces uterine enlargement but never to the extent seen with leiomyomas
Describe the pt. with adenomyosis?
often multiparous and older than pts with endometriosis
How does the pt. with adenomyosis present?
with heavy, painful abnormal menses, on physical exam the uterus is found to range from normal to three times normal size and is globular in contour, boggy and somewhat tender
What are the son findings of extensive adenomyosis?
diffuse uterine enlargment, and potential thickening of the post myometrium..hemorrhage in the islands of endometrial tissue appears as small hypoechoic myometrial cysts (swiss cheese/honeycomb)
Son findings of localized adenomyomas:
inhomogenous, circumscribed areas in the myometrium having indistinct margins and containing anechoic lacunae..may be difficult to distinguish from leiomyomas
T/F: adenomyosis is reliably diagnosed by sonography?
False, well characterized by MRI
Where can ectopic endometriosis tissue be found?
- ovaries
- fallopian tubes
- broad ligaments
- external surface of uterus
- peritoneum
- bowel
- bladder
- dependent parts of pelvis
What may endometriosis arise from?
peritoneal seeding from retrograde travel of endometrial cells through fallopian tubes, metaplastic transformation of peritoneal epithelium into endometrial tissue, or through traumatic spread from uterine surgery or amniocentesis
What is the most common form of endometriosis?
external/indirect form which varies from small foci to wide spread sheets of tissue to focal discrete masses
T/F: endometriosis is rarely diagnosed with US?
true
How does endometriosis present sonographically?
presents as adnexal mass or masses (endometriomas) of variable echogenicity, shape, and size
What are clinical findings of endometriosis?
not distinctive; complaints of dysmenorrhea with pelvic pain; premenstrual dyspareunia; sacral backache during menses; infertility
Endometriomas are usually
asymptomatic and can be multiple and have a unique son appearance
Endometriomas may occur in any _______ female
menstruating
What are clinical symptoms of endometriomas?
- painful periods
- painful intercourse
- lower abd. pain
- pelvic and back pain
- irregular bleeding and
- infertility secondary to adhesions and fibrosis
Differential diagnoses of endometriomas (5):
- hemorrhagic ovarian cysts
- TOA
- cystic ovarian neoplasm
- solid ovarian neoplasm
- ectopic pregancy
Endometriomas may range in size from
1-10cm
T/F: endometriomas may be unilateral or bilateral?
true
What is the most common presentation of endometriomas?
chocolate cyst with low intensity echoes and acoustic enhancement
T/F: some endometriomas can be multiloculated, often with varied internal echo patterns and interconnecting loculations?
True
Endometriomas can have a similar appearance to what three things?
- inflammation
- trophoblastic tissue
- dermoids
Pain and development of a pelvic mass after pelvic surgery can indicate complications such as
- post-op bleeding
- hematomas
- abscess formation
U/s can be used to distinguish a distended bladder from
a fluid collection
