pathology of the adnexa Flashcards
What causes PID?
std
gonorrhea and chlamydia
IUD
complications of childbirth
post abortion
What is PID?
diffuse disease processes of the female pelvic cavity
PID is an inclusive term for all pelvic infections like:
endometritis
salpingitis
hydrosalpinx
pyosalpinx
periovarian inflammation
tubo-ovarian complex
tubo-ovarian abscess
Is PID unilateral or bilateral?
bilateral
what locations might you find PID?
endometrium (endometritis)
uterine wall (myometritis)
uterine serosa and broad ligaments (parametritis)
Ovary (oophoritis)
MOST COMMON LOCATION: oviducts or Fallopian tubes (salpingitis)
During acute PID can you sonographically see PID?
no…it hasn’t really begun to manifest the inflammatory changes yet
In chronic PID what can ultrasound identify?
dilated Fallopian tubes (hydrosalpinx or pyosalpinx)
abscess
complex intraperitoneal fluid
When does PID peak?
20-24 years of age
What are the risk factors for PID?
early sexual contact
multiple sexual partners
hx of std
previous hx of PID
intrauterine contraceptive device IUD
douching (may push bacteria into the upper genital tract)
How does PID appear sonographically?
large, palpable, bilateral complex mass
ovary may be seen separate from mass
free fluid in cul-de-sac
How does PID appear with Doppler?
increased vascularity and diastolic flow
What is PID associated with?
infertility and endometritis
Where does PID infrequently spread to?
may travel upward through right flank, causing perihepatic inflammation
what is perihepatic inflammation called?
Fitz-Hugh-Curtis syndrome
How is PID spread?
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 (oophoritis/peritonitis)
What are the clinical symptoms of PID?
intense pelvic pain and tenderness
constant vaginal discharge
fever
pain in RUQ
dyspareunia
irregular menstrual bleeding
hx of infertility
elevated WBC - chlamydia
fitz-hugh-curtis syndrome - gonorrhea
Can PID be asymptomatic?
yes but can seriously damage reproductive organs (because of scarring)
What are the differentials for PID?
hematoma
dermoid cyst
ovarian neoplasm
endometriosis
What are the three things you might find with acute PID?
1st finding: endometritis - small amount of fluid in endometrial cavity
2nd finding: small amount of free fluid in posterior cul-de-sac
increasing amount of fluid spreading superiorly
What is an indefinite uterus?
fibrosis of adhesions “merging” all pelvic structures
What is the thickening or fluid in endometrium called?
endometritis
What are the clinical and sonographic findings of salpingitis?
Clinical:
asymptomatic to pelvic fullness or discomfort
low-grade fever
Sonographically:
dilated tube
tortuous
What is a peritoneal inclusion cyst?
complex cystic adnexal masses consisting of a normal ovary entrapped in multiple fluid-filled adhesions
what is peritonitis?
inflammation of the peritoneum
serous membrane lining the abdominal cavity and covering the viscera
internal endometriosis is called?
andenomyosis (internal, direct)
what is the most common form of endometriosis?
external, indirect
outside of uterus and may be found in:
Pouch of Douglas
surface of ovary
Fallopian tube
uterus broad ligaments
rectovaginal septum
How many American women are affected by PID each year?
750,000
How can you Sonographically detect perihepatic inflammation?
by scanning along liver margin and identifying hypoechoic rim between liver and adjacent ribs
What do you most likely have if you have enlarged ovaries with multiple cysts, indistinct margins?
periovarian inflammation
What has nodular thickening, irregularity of tube with diverticula?
salpingitis
What are the two kinds of fluid-filled irregular Fallopian tube with or without echoes?
pyosalpinx
hydrosalpinx
What complex mass with septations, irregular margins, internal echoes and usually found in the cul-de-sac?
tubo-ovarian abscess
When does hydrosalpinx tend to occur?
secondary to PID, endometriosis, or postoperative adhesions
What are the clinical symptoms of hydrosalpinx?
asympotmatic to pelvic fullness or discomfort
low grade fever
what are sonographic findings of hydrosalpinx?
walls become thin secondary to dilation
appearance of mulicystic or fusiform mass
follow dilated tubes from fundus of uterus
look for pointed “beak” at swollen end of tube near isthmus
bilateral
ampullary portion more dilated than interstitial part of tube
what are the clinical symptoms of pyosalpinx?
asymptomatic
pelvic fullness or discomfort
low grade fever
What are the sonographic findings of pyosalpinx?
may appear as a complex mass
pus within dilated tube - very thick and echogenic
poor sound transmission
When you have tubo-ovarian abscess what happens to the ovary?
cannot be separated from inflamed dilated tube
Why does tubo-ovarian abscess distort anatomy?
adhesive, edematous, inflamed serosa may further adhere to ovary and/or other peritoneal surfaces
as infection worsens, periovarian adhesions may form
What usually responds well to antibiotic treatment without need for surgical drainage?
Tubo - ovarian abscess TOA
When does peritonitis become pelvic peritonitis?
if infectious process spreads to involve bladder, ureter, bowel, and adnexal area
How exactly is peritonitis aquired?
inflammation caused by infectious organisms that gain access by way of rupture or perforation of viscera or associated structures.
via the female genital track
piercing abd wall
via bloodstream or lymphatic vessels
via surgical incisions
by failure to practice antiseptic techniques during surgery
What does peritonitis look like sonographically?
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
Endometritis can be divided into what two cases?
obstetric and nonobstetric
What is nonobstetric endometritis?
infection associated with PID or gynecologic instrumentation
acute or chronic
What is obstetric endometritis?
occurs in immediate postpartum period
most common cause of fever in postpartum patient
How does endometritis look sonographically?
endometrium may appear thick, contain fluid, air or clot or appear normal (normal up to 20mm)
When the endometrium measures greater than 20mm, what should you be suspicious of?
endometritis
hemorrhage
retained products of conception
If you have premature rupture of membranes (PROM), retained clot, or POC’s or prolonged labor , what happens to your risk of endometritis?
it increases
What is the definition of endometriosis?
the presence of functioning endometrial tissue in abnormal locations
ectopic tissue can be found almost anywhere in the body
What are the clinical symptoms of endometriosis?
severe dysmenorrhea
chronic pelvic pain from peritoneal adhesions
bleeding
dyspareunia
What may cause endometriosis?
retrograde travel of endometrial cells through Fallopian tubes
metaplastic transformation of peritoneal epithelium into endometrial tissue
traumatic spread from uterine surgery or amniocentesis
What are the two forms of Endometriosis?
internal and external
What is the extent of endometriosis?
varies from small foci to widespread sheets of tissue to focal discrete masses
What kind of tissue cyclically bleeds and proliferates as stimulated by changes in hormonal influence?
endometrial tissue in endometriosis
With adenmyosis, where do the endometrial cells begin to grow
into the uterine body, invading junctional zone and myometrium
What are the clinical symptoms for adenomyosis?
heavy menstrual bleeding
painful menses
uterine enlargement
With whom is adenomyosis most common?
in women who have had uterine surgery
What are the sonographic findings of endometriosis?
bulbous uterus - with/without myometrial “cysts”
border becomes indistinct between endometrium and myometrium
“blurred border” appearance more common in posterior aspect of uterus
Which modality is more specific in the findings of endometriosis, ultrasound or MRI?
MRI
What are the localized endometriomas called?
endometrioma or chocolate cyst
When do endometriomas become a surgical emergency?
when they become moderately enlarged and rupture
by causing ovary to twist on vessels that supply it causing torsion
How do endometriomas appear sonographicallY?
appear as bilateral or unilateral ovarian masses
patterns ranging from anechoic (rare) to solid - depending on amount of blood and its state of organization
If you have endometriosis what can happen to the ovaries?
typically adhere to posterior surface of uterus or are stuck in cul-de-sac and my be difficult to define
What are obscured organ borders and multiple irregular cystic masses also suggestive of?
disseminating cancer or pelvic infection
What is stage 1 acute PID?
endometritis:
infection of endometrium
vaginal discharge
irregular vaginal bleeding
what is stage 2 of PID?
Salpingitis:
infection of Fallopian tubes
low grade fever
pelvic pain
rebound pain
pain with cervical manipulation
dyspareunia
what is stage 3 PID?
TOA:
Purulent material spill form Fallopian tube to ovary causing the tube and ovary to become adherent
severe pelvic pain
high fever and shaking/chills
nausea/vomiting
leukocytosis
What is stage 4 PID?
peritonitis:
Infectious spread to peritoneum
RUQ pain:
inflammation of the pericolic gutter causing perihepatic infammation (Fitz-Hugh-Curtis syndrome)
What is the sonographic sign for PID?
“Beads on a String”
seen with chronic PID
Hyperechoic mural nodules on the inner walls of the Fallopian tubes
