Radiological appearances of gynaecological emergencies

Abstract

Background: The role of various gynaecological imaging modalities is vital in aiding clinicians to diagnose acute gynaecological disease, and can help to direct medical and surgical treatment where appropriate. It is important to interpret the imaging findings in the context of the clinical signs and patient's pregnancy status.

Methods: Ultrasound and Doppler are readily available in the emergency department, and demonstrate features of haemorrhagic follicular cysts, ovarian cyst rupture, endometriotic cysts and pyosalpinx. Adnexal torsion may also be identified using ultrasound and Doppler, although the diagnosis cannot be safely excluded based on imaging alone. Computed tomography (CT) is not routinely employed in diagnosing acute gynaecological complications. However due to similar symptoms and signs with gastrointestinal and urinary tract pathologies, it is frequently used as the initial imaging modality and recognition of features of gynaecological complications on CT is important.

Results: Although MRI is not frequently used in the emergency setting, it is an important modality in characterising features that are unclear on ultrasound and CT.

Conclusion: MRI is particularly helpful in identifying the site of origin of large pelvic masses, such as haemorrhagic uterine fibroid degeneration and fibroid prolapse or torsion. In this article, we review the imaging appearances of gynaecological emergencies in non-pregnant patients.

Teaching points: • Ultrasonography is easily accessible and can identify life-threatening gynaecological complications. • Tomography scanners and computed radiography are not routinely used but are important to recognise key features. • MRI is used for the characterisation of acute gynaecological complications. • Recognition of the overlap in symptoms between gastrointestinal and gynaecological conditions is essential.

Fig. 1

Haemorrhagic cyst. Patient presented to the emergency department with acute onset of lower abdominal pain. The patient had a previous history of a right oophorectomy for an ovarian serous tumour. Transvaginal ultrasound of the left ovary demonstrates a cyst with typical lacelike reticular internal echoes (large white arrow). There is no internal blood flow but circumferential blood flow around the cyst wall is seen (small white arrow); this is a typical feature in a haemorrhagic corpus luteal cyst

Fig. 2

Rupture of a haemorrhagic cyst. Patient presented to the accident and emergency department with a 1-day history of acute right iliac fossa pain and diarrhoea. Initially the patient was diagnosed as having an appendicitis. a CT following iv contrast administration demonstrates bilateral low-density cystic lesions (white arrows). There is extensive hyperdense free pelvic fluid representing hemorrhagic ascites (black arrow). b Trans-abdominal ultrasound shows free fluid containing low level echoes in the pelvis (black arrow). There is an adnexal cyst in the pelvis representing the right haemorrhagic ovarian cyst (white arrow). The smaller right-sided cyst may be the site of rupture as the ruptured cyst may be small or difficult to visualize following rupture

Fig. 3

Acute presentation of endometriosis. Patient presented with intermenstrual vaginal bleeding and severe lower abdominal pain. a Transvaginal ultrasound demonstrates an ovarian cyst with an area of homogeneous internal echogenicity typical of an endometriotic cyst (black arrow). There is a focal area of clot retraction along the endometriotic cyst wall (white arrow). b Axial T1 image demonstrates bilateral complex adnexal cystic masses which contain high T1 material. c Axial T2 demonstrates intermediate signal intensity with ‘shading’ (black arrow), typical of endometriotic blood. The appearances are in keeping with bilateral haematosalpinges in a patient with endometriosis

Fig. 4

Torsion of an ovarian mass. Patient with a history of gastric cancer developed lower abdominal discomfort and attended for CT (a), which demonstrates bilateral solid/cystic complex adnexal masses consistent with ovarian metastases. Two months later she presented to the emergency department with acute onset of right iliac fossa pain with nausea and MRI of the pelvis was performed (b–d). b Sagittal T2-weighted image demonstrates marked enlargement of the right ovary with high T2 signal intensity in keeping with stromal oedema (white arrow). c Axial T1 image with fat saturation shows central low signal intensity (white arrow) surrounded a rim of high signal intensity in the enlarged right ovary consistent with peripheral haemorrhage (black arrow). d Axial T1 fat sat image following gadolinium administration confirms lack of enhancement of the right ovary (black arrow consistent with right ovarian torsion). The left ovarian metastasis enhances avidly (white arrow)

Fig. 5

Cystic fibroid degeneration. This patient presented to the emergency department with vaginal bleeding and lower abdominal pain. a CT following iv contrast administration shows demarcated regions of low density within the fibroid representing cystic degeneration (black arrow) with enhancing surrounding soft tissue (white arrow) . These features are in keeping with degenerative change of a uterine fibroid. The differential diagnosis includes a complex ovarian mass. b Sagittal T2 MRI demonstrates a large heterogenous mass (white arrow) arising from the fundus of the uterus (black arrow). Cystic areas of degeneration are demonstrated by areas of high signal intensity within the fibroid. Identifying a connection to the uterus is important in making the correct diagnosis

Fig. 6

Haemorrhagic fibroid degeneration. This patient, known to have uterine fibroids, presented to the accident and emergency department with low-grade pyrexia, tachycardia and acute lower abdominal pain. a Sagittal T2 image demonstrates a large uterine fibroid with high signal intensity centrally with a very low signal intensity rim suggestive of peripheral haemosiderin. b Axial T1 with fat-saturated image shows high signal intensity within the fibroid consistent with haemorrhage (black arrow). c Axial T1 with fat saturation following gadolinium administration demonstrates lack of enhancement within the fibroid (black arrow), consistent with infarction. The surrounding myometrium enhances normally (white arrow)

Fig. 7

Pedunculated submucosal fibroid with prolapse and torsion. The patient presented to the emergency department with acute abdominal pain and vaginal bleeding. a Sagittal T2 image demonstrates a fibroid arising on a stalk (white arrow) that originates in the lower endometrial cavity. The fibroid has prolapsed into the endocervical canal (black arrow) and demonstrates areas of low T2 suggestive of haemorrhage. These features are typical of a pedunculated fibroid or polyp. b Axial T2 image demonstrates the torted fibroid (white arrow) surrounded by the ring of cervical stroma (black arrow). c Axial T1 fat-saturated image demonstrates high signal intensity within the fibroid indicating haemorrhage (black arrow). d Axial T1 fat-saturated image following gadolinium administration demonstrates lack of enhancement consistent with torsion (white arrow)

Fig. 8

Pelvic inflammatory disease with pyosalpinx on ultrasound. This patient presented to the emergency department with lower abdominal pain, pyrexia and vomiting. a–b Transvaginal ultrasound of both adenexa. There are bilateral adenexal cysts that contain low-level echogenic material and have a tubular configuration (white arrows). The appearance is in keeping with bilateral pyosalpinges, a complication of pelvic inflammatory disease

Fig. 9

Pelvic inflammatory disease with pyosalpinx on CT. This patient presented to the accident and emergency department with abdominal pain and pyrexia. She had a raised white cell count and CRP. The clinicians suspected an intra-abdominal collection. a CT demonstrates bilateral adnexal complex fluid-filled and thick-walled cysts typical for tubo-ovarian abcess formation, a complication of pelvic inflammatory disease. b Coronal reformat of the CT demonstrates bilateral tubo-ovarian abcesses as well as distention of multiple bowel loops due to an associated ileus

Fig. 10

Pelvic inflammatory disease with pyosalpinx on MRI. This patient presented to the emergency department with pyrexia, lower abdominal pain and diarrhoea. a Sagittal T2 image of the pelvis demonstrates multiple fluid-filled cystic structures within the right adnexa (black arrows). The complex cyst is thick walled and there is adjacent fat stranding. b Axial T2 image demonstrates bilateral tubo-ovarian abcesses. c Axial T1 fat-saturated image following gadolinium administration demonstrates low signal intensity within the pus-filled cavities and marked enhancement of the inflammatory walls. The imaging appearances may overlap with ovarian malignancy but the clinical presentation is of sepsis