📄 SCRS
Pelvic inflammatory disease
Pelvic inflammatory disease ultrasound case study
USG
Pelvic Inflammatory Disease (PID) — Ultrasound Case Study
Case Study Record
| SN | Case Name | Report Line |
|---|---|---|
| 1 | Reactive PID | View Report Line |
| 2 | PID Associated with Tubo-Ovarian Complex | View Report Line |
| 3 | PID Associated with Tubo-Ovarian Abscess | View Report Line |
| 4 | PID Associated with Hydrosalpinx | View Report Line |
| 5 | PID Associated with Pyosalpinx | View Report Line |
| 6 | PID Associated with Peritonitis | View Report Line |
| 7 | PID Associated with Appendiceal Diverticular Perforation | View Report Line |
| 8 | PID Associated with Postsurgical Abscesses | View Report Line |
| 9 | PID Associated with Intrauterine Device (IUD) | View Report Line |
CASE–1
CASE–1
Reactive PID
Reactive PID
Clinical History
A 34-year-old female presented with lower abdominal pain, fever, abnormal vaginal discharge, and pelvic tenderness. She was referred for pelvic ultrasound to evaluate suspected pelvic inflammatory disease (PID). There was no history suggestive of uterine fibroids or adenomyosis.
Ultrasound Findings
Ultrasound examination demonstrates a mildly bulky anteverted uterus measuring approximately
12.7 × 5.9 × 5.0 cm (estimated uterine volume 197 mL).
The myometrium appears mildly heterogeneous without any focal myometrial mass or fibroid.
The endometrial thickness measures approximately 9.5 mm and appears regular.
Mild diffuse reactive enlargement of the uterus is noted. Mild inflammatory changes are present within the pelvis, with a small amount of free fluid in the pouch of Douglas. No retained products of conception or intrauterine collection is identified. Both ovaries are visualized with preserved morphology and vascularity.
|
| Transabdominal pelvic ultrasound. Mildly enlarged (bulky) uterus measuring approximately 12.7 × 5.9 × 5.0 cm with mildly heterogeneous myometrium. Endometrial thickness measures 9.5 mm. The findings are compatible with reactive uterine enlargement associated with pelvic inflammatory disease (PID). |
Report Line
Mild bulky uterus measuring approximately 12.7 × 5.9 × 5.0 cm (estimated uterine volume 197 mL) with mildly heterogeneous myometrial echotexture. Endometrial thickness measures 9.5 mm. No focal myometrial lesion is identified. Mild reactive inflammatory enlargement of the uterus is noted in association with pelvic inflammatory changes, consistent with PID-associated bulky uterus.
Impression
Reactive uterine enlargement associated with pelvic inflammatory disease (PID).
Go To Table
Recommendation
Clinical correlation with symptoms, pelvic examination, and inflammatory markers is recommended.
Appropriate antibiotic therapy should be considered according to institutional PID guidelines.
Follow-up pelvic ultrasound after completion of treatment may be performed to document resolution of the reactive uterine enlargement and associated inflammatory changes.
Key Learning Points
- A mildly bulky uterus is a non-specific ultrasound finding and may occur as a reactive change in PID.
- Reactive uterine enlargement is characterized by diffuse mild uterine enlargement without a focal myometrial mass.
- The myometrium may appear mildly heterogeneous due to inflammatory edema.
- The endometrium may be normal or mildly thickened depending on associated endometritis.
- Associated ultrasound findings of PID include pelvic free fluid, salpingitis, hydrosalpinx, pyosalpinx, tubo-ovarian complex, or tubo-ovarian abscess.
- Color Doppler may demonstrate increased myometrial vascularity in active inflammation.
- Correlation with clinical findings and laboratory investigations is essential, as ultrasound findings alone are not diagnostic of PID.
CASE–2
PID Associated with Tubo-Ovarian Complex
PID Associated with Tubo-Ovarian Complex
Clinical History
A 32-year-old female presented with lower abdominal and pelvic pain, fever, abnormal vaginal discharge, and marked pelvic tenderness. She was referred for pelvic ultrasound with clinical suspicion of pelvic inflammatory disease (PID) and possible tubo-ovarian involvement. There was no history suggestive of uterine fibroids or adenomyosis.
Report Line
A complex thick-walled tubo-ovarian collection is identified in the left/right adnexal region, measuring approximately ___ × ___ × ___ cm, with heterogeneous internal echoes, internal debris, and areas of complex fluid. The normal ovarian and tubal architecture is poorly delineated within the inflammatory mass. Surrounding pelvic inflammatory changes with adjacent fat stranding/echogenic pelvic tissues and mild to moderate free fluid are noted. Color Doppler demonstrates increased peripheral vascularity surrounding the collection, without significant internal vascularity. These findings are highly suggestive of a tubo-ovarian abscess associated with pelvic inflammatory disease (PID).
Impression
Complex thick-walled tubo-ovarian abscess in the left/right adnexa, associated with pelvic inflammatory disease (PID).
Associated pelvic inflammatory changes and free fluid are noted.
Go To Table
Associated pelvic inflammatory changes and free fluid are noted.
Recommendation
Urgent clinical and gynecological correlation is recommended.
Correlation with temperature, pelvic examination, complete blood count, inflammatory markers, and appropriate microbiological investigations is advised.
Prompt antibiotic therapy should be initiated according to institutional PID guidelines.
Gynecological consultation is recommended for assessment of treatment response and determination of the need for image-guided or surgical drainage, particularly in cases of large abscess, severe symptoms, sepsis, or failure to respond to medical therapy.
Follow-up pelvic ultrasound may be performed to assess interval reduction or resolution of the tubo-ovarian abscess.
Key Learning Points
- A tubo-ovarian abscess (TOA) is a serious complication of pelvic inflammatory disease involving the ovary and fallopian tube with formation of an infected inflammatory collection.
- Ultrasound typically demonstrates a complex thick-walled adnexal mass with heterogeneous internal echoes, debris, and complex fluid.
- The normal ovarian and fallopian tube anatomy may become indistinguishable because of extensive inflammatory involvement.
- Peripheral hypervascularity may be demonstrated on Color Doppler due to surrounding inflammatory hyperemia, while the abscess cavity itself generally shows little or no internal vascularity.
- Associated findings may include pelvic free fluid, hydrosalpinx, pyosalpinx, pelvic inflammatory changes, and bilateral adnexal involvement.
- A tubo-ovarian abscess should be distinguished from a tubo-ovarian complex, in which a definite organized purulent collection may not yet be present.
- Important differential diagnoses include hemorrhagic ovarian cyst, endometrioma, ovarian torsion with necrosis, infected endometrioma, and other complex adnexal masses.
- TOA can rupture and lead to pelvic or generalized peritonitis and sepsis, making prompt clinical assessment essential.
- Management generally requires appropriate broad-spectrum antimicrobial therapy, with drainage or surgical intervention considered when clinically indicated.
- Ultrasound findings should be interpreted in conjunction with symptoms, physical examination, laboratory investigations, and the overall clinical picture.
CASE–3
PID Associated with Tubo-Ovarian Abscess
PID Associated with Tubo-Ovarian Abscess
Clinical History
A 35-year-old female presented with severe lower abdominal and pelvic pain, fever, abnormal vaginal discharge, and marked pelvic tenderness. She was referred for pelvic ultrasound with clinical suspicion of pelvic inflammatory disease (PID) complicated by tubo-ovarian abscess. There was no history suggestive of uterine fibroids or adenomyosis.
Report Line
A complex thick-walled collection is identified in the left/right adnexal region, measuring approximately ___ × ___ × ___ cm, with heterogeneous internal echoes, echogenic debris, and complex fluid contents. The normal ovarian and fallopian tube architecture is poorly delineated and appears incorporated within the inflammatory mass. Marked surrounding inflammatory changes are present with associated pelvic free fluid. Color Doppler demonstrates prominent peripheral and surrounding vascularity with no significant internal vascularity within the collection. The overall sonographic appearance is highly suggestive of a tubo-ovarian abscess associated with pelvic inflammatory disease (PID).
Impression
Left/right tubo-ovarian abscess associated with pelvic inflammatory disease (PID).
Complex thick-walled adnexal collection with surrounding inflammatory changes and pelvic free fluid.
Go To Table
Complex thick-walled adnexal collection with surrounding inflammatory changes and pelvic free fluid.
Recommendation
Prompt clinical and gynecological evaluation is recommended.
Correlation with fever, pelvic pain, vaginal discharge, cervical motion tenderness, complete blood count, inflammatory markers, and relevant microbiological investigations is advised.
Appropriate broad-spectrum antimicrobial therapy should be considered according to institutional PID guidelines.
Gynecological consultation is recommended to assess the need for image-guided drainage or surgical intervention, particularly in cases of large abscess, severe systemic symptoms, sepsis, rupture, or failure to respond adequately to antibiotic therapy.
Contrast-enhanced CT or MRI may be considered when the extent of disease, rupture, additional collections, or alternative pathology cannot be adequately assessed by ultrasound.
Follow-up pelvic ultrasound may be performed to document interval reduction or resolution of the tubo-ovarian abscess.
Key Learning Points
- A tubo-ovarian abscess (TOA) is a serious complication of PID in which infection and inflammation involve the fallopian tube and ovary with formation of an organized purulent collection.
- Ultrasound typically demonstrates a complex thick-walled adnexal mass containing heterogeneous fluid, internal echoes, debris, and sometimes septations.
- The normal distinction between the ovary and fallopian tube may be lost because of extensive inflammatory involvement.
- Color Doppler may demonstrate increased peripheral vascularity within the inflamed tissues, while the abscess cavity generally demonstrates little or no internal vascularity.
- Associated findings may include pelvic free fluid, pyosalpinx, hydrosalpinx, salpingitis, pelvic peritonitis, and bilateral adnexal involvement.
- A tubo-ovarian abscess should be distinguished from a tubo-ovarian complex, where inflammatory involvement is present but a well-organized abscess cavity may not yet have developed.
- Important differential diagnoses include hemorrhagic ovarian cyst, endometrioma, infected endometrioma, ovarian torsion with necrosis, and other complex adnexal masses.
- Rupture of a tubo-ovarian abscess can result in pelvic peritonitis, generalized peritonitis, sepsis, and other serious complications.
- Large, persistent, or clinically complicated abscesses may require image-guided drainage or surgical management in addition to antimicrobial therapy.
- Ultrasound findings should be interpreted together with clinical examination and laboratory investigations because imaging alone cannot determine the clinical severity of PID.
CASE–4
PID Associated with Hydrosalpinx
PID Associated with Hydrosalpinx
Clinical History
A 27-year-old female presented with lower abdominal and pelvic pain, abnormal vaginal discharge, and pelvic tenderness. She was referred for pelvic ultrasound with clinical suspicion of pelvic inflammatory disease (PID) and possible tubal involvement with hydrosalpinx. There was no history suggestive of uterine fibroids or adenomyosis.
Report Line
A tubular, elongated cystic structure is identified in the left/right adnexal region, measuring approximately ___ × ___ cm, separate from the ipsilateral ovary and demonstrating fluid distension with incomplete septations and characteristic folded tubular configuration. The fallopian tube appears mildly to moderately dilated with thin walls and predominantly anechoic internal contents. Mild surrounding pelvic inflammatory changes and a small amount of pelvic free fluid are noted. These findings are consistent with a hydrosalpinx associated with pelvic inflammatory disease (PID).
Impression
Left/right hydrosalpinx associated with pelvic inflammatory disease (PID).
Mild associated pelvic inflammatory changes and free fluid are noted.
Go To Table
Mild associated pelvic inflammatory changes and free fluid are noted.
Recommendation
Clinical correlation with pelvic pain, fever, abnormal vaginal discharge, and other features of PID is recommended.
Correlation with inflammatory markers and relevant microbiological investigations may be performed as clinically indicated.
Appropriate antibiotic therapy should be considered according to institutional PID guidelines.
Gynecological consultation is recommended for persistent symptoms, significant adnexal disease, or suspected complications.
Follow-up pelvic ultrasound may be performed after treatment to assess the hydrosalpinx and associated inflammatory changes.
If internal echoes, thickening of the tubal wall, or complex fluid develops, evaluation for progression to pyosalpinx or tubo-ovarian abscess should be considered.
Key Learning Points
- Hydrosalpinx represents fluid distension of the fallopian tube, commonly resulting from previous or chronic pelvic inflammatory disease and tubal obstruction.
- On ultrasound, it typically appears as a thin-walled, elongated or serpiginous cystic adnexal structure separate from the ovary.
- Characteristic sonographic features include incomplete septations, folded tubular configuration, and small internal projections or folds representing the thickened tubal mucosa.
- The ovary is usually identifiable separately from the dilated fallopian tube, helping distinguish hydrosalpinx from an ovarian cystic lesion.
- Active PID may produce associated pelvic free fluid and inflammatory changes surrounding the affected tube.
- Hydrosalpinx containing complex fluid, internal echoes, or debris should raise suspicion for pyosalpinx rather than simple hydrosalpinx.
- Bilateral hydrosalpinx may occur, particularly in chronic or recurrent pelvic inflammatory disease.
- Important differential diagnoses include paraovarian cyst, ovarian cyst, peritoneal inclusion cyst, and dilated bowel loops.
- Chronic tubal damage from PID may result in tubal factor infertility and increased risk of ectopic pregnancy.
- Ultrasound findings should be interpreted together with clinical examination and laboratory findings, as hydrosalpinx alone does not establish active PID.
CASE–5
PID Associated with Pyosalpinx
PID Associated with Pyosalpinx
Clinical History
A 36-year-old female presented with lower abdominal and pelvic pain, fever, abnormal vaginal discharge, and marked pelvic tenderness. She was referred for pelvic ultrasound with clinical suspicion of pelvic inflammatory disease (PID) complicated by pyosalpinx. There was no history suggestive of uterine fibroids or adenomyosis.
Report Line
A dilated, tubular adnexal structure is identified in the left/right adnexal region, measuring approximately ___ × ___ cm, separate from the ipsilateral ovary and containing heterogeneous echogenic fluid with internal debris. The fallopian tube demonstrates wall thickening and increased surrounding vascularity on Color Doppler. Associated pelvic inflammatory changes and mild to moderate free fluid are noted. The sonographic appearance is consistent with an infected, pus-filled fallopian tube (pyosalpinx) associated with pelvic inflammatory disease (PID). No definite tubo-ovarian abscess is identified at present.
Impression
Left/right pyosalpinx associated with pelvic inflammatory disease (PID).
Associated pelvic inflammatory changes and pelvic free fluid are noted.
Go To Table
Associated pelvic inflammatory changes and pelvic free fluid are noted.
Recommendation
Prompt clinical and gynecological correlation is recommended.
Correlation with fever, pelvic pain, abnormal vaginal discharge, cervical motion tenderness, complete blood count, inflammatory markers, and relevant microbiological investigations is advised.
Appropriate broad-spectrum antibiotic therapy should be considered according to institutional PID guidelines.
Gynecological consultation is recommended, particularly in patients with severe symptoms, systemic infection, large or persistent pyosalpinx, or inadequate response to medical treatment.
Follow-up pelvic ultrasound may be performed after treatment to document resolution of the pyosalpinx and associated inflammatory changes.
Progression to tubo-ovarian complex or tubo-ovarian abscess should be considered if the inflammatory adnexal process persists or worsens.
Key Learning Points
- Pyosalpinx represents infection of a fallopian tube resulting in accumulation of pus within a dilated tubal lumen and is an important complication of PID.
- Ultrasound typically demonstrates a dilated tubular adnexal structure containing complex fluid, internal echoes, or echogenic debris.
- The affected fallopian tube may show thickened walls and increased peripheral vascularity due to active inflammation.
- Characteristic tubular or serpiginous morphology can help distinguish pyosalpinx from a complex ovarian cystic lesion.
- Associated findings may include pelvic free fluid, salpingitis, hydrosalpinx, pelvic inflammatory changes, and tubo-ovarian involvement.
- Compared with simple hydrosalpinx, pyosalpinx usually contains complex internal material rather than simple anechoic fluid.
- Pyosalpinx may progress to a tubo-ovarian complex or tubo-ovarian abscess if infection extends to the adjacent ovary.
- Important differential diagnoses include hydrosalpinx, hematosalpinx, complex ovarian cyst, endometrioma, and dilated bowel loops.
- Color Doppler may demonstrate increased vascularity in the inflamed tubal wall and surrounding tissues, while the intraluminal purulent material generally lacks internal vascularity.
- Ultrasound findings should be correlated with clinical examination and laboratory investigations because imaging findings alone cannot establish the presence or severity of PID.
CASE–6
PID Associated with Peritonitis
PID Associated with Peritonitis
Clinical History
A 34-year-old female presented with severe lower abdominal and pelvic pain, fever, abnormal vaginal discharge, and marked pelvic tenderness. She was referred for pelvic ultrasound with clinical suspicion of pelvic inflammatory disease (PID) complicated by pelvic peritonitis. There was no history suggestive of uterine fibroids or adenomyosis.
Report Line
Ultrasound demonstrates inflammatory changes within the pelvis with moderate free fluid extending into the dependent pelvic spaces and surrounding adnexal structures. The fluid demonstrates low-level internal echoes/debris, with associated inflammatory thickening of the pelvic tissues. The uterus and adnexa demonstrate surrounding inflammatory changes, with possible associated tubal/adnexal involvement. Increased vascularity is noted within the inflamed pelvic tissues on Color Doppler. The sonographic appearance is concerning for pelvic inflammatory disease complicated by pelvic peritonitis.
Impression
Pelvic inflammatory disease (PID) with associated pelvic peritonitis.
Moderate complex pelvic free fluid and surrounding inflammatory changes are noted.
Go To Table
Moderate complex pelvic free fluid and surrounding inflammatory changes are noted.
Recommendation
Prompt clinical and gynecological evaluation is recommended.
Correlation with fever, pelvic pain, abdominal tenderness, vaginal discharge, complete blood count, inflammatory markers, and relevant microbiological investigations is advised.
Appropriate antibiotic therapy should be considered according to institutional PID guidelines.
If there is severe abdominal pain, marked tenderness, fever, hemodynamic instability, or clinical concern for systemic infection, urgent hospital-based assessment is recommended.
Further imaging such as contrast-enhanced CT may be considered when there is concern for extensive intra-abdominal infection, abscess formation, bowel involvement, or another acute abdominal process.
Follow-up ultrasound may be performed to assess resolution of the pelvic inflammatory changes and free fluid following treatment.
Key Learning Points
- Pelvic peritonitis is a complication of PID in which infection and inflammation extend beyond the reproductive organs to involve the pelvic peritoneal surfaces.
- Ultrasound may demonstrate moderate or complex pelvic free fluid, sometimes containing low-level echoes or debris.
- Associated inflammatory changes may involve the uterus, fallopian tubes, ovaries, and surrounding pelvic tissues.
- Increased vascularity of the inflamed pelvic tissues may be demonstrated on Color Doppler.
- Associated adnexal complications may include salpingitis, hydrosalpinx, pyosalpinx, tubo-ovarian complex, or tubo-ovarian abscess.
- Complex pelvic fluid should be differentiated from physiologic free fluid, hemorrhage, ruptured cyst, endometriosis, and other causes of pelvic fluid collection.
- Extensive inflammatory fluid or a localized collection may indicate progression toward pelvic abscess formation.
- Clinical findings such as fever, pelvic or abdominal pain, cervical motion tenderness, and raised inflammatory markers are important in assessing the severity of PID.
- Ultrasound has limitations in assessing the full extent of peritoneal inflammation; CT or MRI may be required when complications or alternative diagnoses are suspected.
- Severe or untreated pelvic infection may progress to sepsis, abscess formation, adhesions, infertility, or chronic pelvic pain, making timely treatment important.
- Imaging findings should always be correlated with clinical examination and laboratory investigations, as ultrasound alone cannot reliably determine the severity of peritonitis.
CASE–7
PID Associated with Appendiceal Diverticular Perforation
PID Associated with Appendiceal Diverticular Perforation
Clinical History
A 34-year-old female presented with severe right lower abdominal and pelvic pain, fever, abnormal vaginal discharge, and marked pelvic tenderness. She was referred for pelvic ultrasound with clinical suspicion of pelvic inflammatory disease (PID) associated with appendiceal diverticular perforation and possible pelvic inflammatory complications. There was no history suggestive of uterine fibroids or adenomyosis.
Report Line
The appendix is visualized in the right lower quadrant and demonstrates focal mural thickening with an adjacent small outpouching/diverticulum. A focal discontinuity of the appendiceal wall is identified at the site of the diverticulum, with surrounding periappendiceal inflammatory fat changes and a small amount of adjacent complex fluid. The inflammatory changes extend toward the right adnexa/pelvic cavity, with associated pelvic inflammatory changes and free fluid. No definite drainable pelvic abscess is identified at present. The overall sonographic appearance is concerning for appendiceal diverticular perforation with secondary pelvic inflammatory changes mimicking or complicating PID.
Impression
Focal appendiceal diverticular perforation with surrounding inflammatory changes and extension into the pelvis.
Associated right adnexal/pelvic inflammatory changes may mimic or coexist with PID.
No definite drainable pelvic abscess identified on the present examination.
Go To Table
Associated right adnexal/pelvic inflammatory changes may mimic or coexist with PID.
No definite drainable pelvic abscess identified on the present examination.
Recommendation
Urgent surgical consultation is recommended.
Clinical correlation with right lower quadrant abdominal pain, fever, nausea/vomiting, abdominal or pelvic tenderness, and other features of acute appendiceal inflammation is advised.
Correlation with complete blood count, inflammatory markers, and other relevant laboratory investigations is recommended.
Contrast-enhanced CT of the abdomen and pelvis may be considered for confirmation of appendiceal perforation, assessment of the extent of inflammatory disease, and evaluation for abscess or other intra-abdominal complications.
Appropriate antibiotic therapy should be initiated according to institutional protocols, particularly when perforation is suspected.
Further gynecological evaluation may be considered when significant adnexal inflammatory changes are present or when PID remains a clinical consideration.
Key Learning Points
- Appendiceal diverticular perforation is an uncommon but potentially serious complication of appendiceal diverticulosis/diverticulum.
- Ultrasound may demonstrate a focal appendiceal outpouching with adjacent inflammatory changes and a possible focal wall defect.
- Periappendiceal fluid, echogenic inflammatory fat, appendiceal wall thickening, and localized collection may accompany perforation.
- Pelvic extension of appendiceal inflammation can produce adnexal inflammatory changes and pelvic free fluid that may mimic PID or tubo-ovarian disease.
- Right-sided pelvic inflammatory findings should therefore be interpreted in conjunction with careful assessment of the appendix.
- Important differential diagnoses include acute appendicitis, tubo-ovarian abscess, pyosalpinx, ruptured ovarian cyst, ovarian torsion, and other causes of acute pelvic inflammation.
- Identification of an appendiceal diverticulum with focal inflammatory change should raise suspicion for diverticular appendiceal disease, particularly when the inflammatory process is focal.
- Perforation may result in localized or generalized peritonitis, phlegmon, or abscess formation.
- Color Doppler may demonstrate increased vascularity in the inflamed appendiceal wall and surrounding tissues.
- Ultrasound may not reliably demonstrate the full extent of perforation; contrast-enhanced CT is often useful when perforation or another intra-abdominal complication is suspected.
- This condition is an important diagnostic mimic because pelvic inflammatory findings do not always originate from the female reproductive organs.
- Prompt recognition and appropriate surgical/medical management are important to reduce the risk of progressive intra-abdominal infection and sepsis.
CASE–8
PID Associated with Postsurgical Abscesses
PID Associated with Postsurgical Abscesses
Clinical History
A 34-year-old female presented with lower abdominal and pelvic pain, fever, abnormal vaginal discharge, and marked pelvic tenderness following previous pelvic or abdominal surgery. She was referred for pelvic ultrasound with clinical suspicion of pelvic inflammatory disease (PID) associated with postsurgical pelvic abscess formation. There was no history suggestive of uterine fibroids or adenomyosis.
Report Line
A complex, thick-walled fluid collection is identified within the pelvic/operative bed, measuring approximately ___ × ___ × ___ cm, demonstrating heterogeneous internal echoes, debris, and surrounding inflammatory changes. The collection is located adjacent to the previously operated pelvic structures, with associated surrounding echogenic inflammatory tissue and mild to moderate pelvic free fluid. Peripheral vascularity is demonstrated on Color Doppler, without significant internal vascularity. The findings are suggestive of a postsurgical pelvic abscess. In the appropriate clinical setting, associated pelvic inflammatory changes may mimic or coexist with PID.
Impression
Complex postsurgical pelvic abscess within the operative bed.
Associated pelvic inflammatory changes and free fluid are noted.
Findings may mimic or contribute to a PID-like inflammatory presentation; clinical correlation with the surgical history is essential.
Go To Table
Associated pelvic inflammatory changes and free fluid are noted.
Findings may mimic or contribute to a PID-like inflammatory presentation; clinical correlation with the surgical history is essential.
Recommendation
Prompt clinical and surgical/gynecological evaluation is recommended, particularly considering the history and timing of recent pelvic surgery.
Correlation with fever, pelvic pain, wound or vaginal discharge, leukocytosis, inflammatory markers, and other clinical features of postoperative infection is advised.
Appropriate antimicrobial therapy should be considered according to institutional postoperative infection guidelines.
Image-guided drainage or surgical drainage may be required depending on the size, location, accessibility, and clinical response to medical treatment.
Contrast-enhanced CT of the abdomen and pelvis may be considered for better assessment of the extent of the abscess, communication with adjacent structures, or additional intra-abdominal collections.
Follow-up imaging may be performed to document interval reduction or resolution of the collection following treatment.
Key Learning Points
- A postsurgical pelvic abscess is an infected postoperative fluid collection that may develop within or adjacent to the operative bed.
- Ultrasound typically demonstrates a complex thick-walled collection containing heterogeneous fluid, internal debris, or septations.
- Peripheral hypervascularity with relatively absent internal vascularity may support the presence of an abscess rather than a solid vascular mass.
- Surrounding echogenic inflammatory tissues and pelvic free fluid may accompany the collection.
- The location and appearance should always be interpreted in relation to the patient's previous surgical procedure and operative anatomy.
- Postsurgical abscesses may clinically and sonographically mimic PID, tubo-ovarian abscess, pyosalpinx, or other pelvic inflammatory conditions.
- Possible associated complications include fistula formation, wound infection, peritonitis, bowel or urinary tract involvement, and sepsis.
- Important differential diagnoses include postoperative seroma, hematoma, lymphocele, urinoma, infected endometriotic collection, and recurrent or residual disease.
- A simple postoperative fluid collection generally lacks thick irregular walls, significant internal debris, and marked surrounding inflammatory change; development of these features raises suspicion for infection.
- Contrast-enhanced CT can be valuable when ultrasound cannot fully define the extent of the collection or when multiple intra-abdominal complications are suspected.
- Management commonly involves antimicrobial therapy with consideration of image-guided or surgical drainage when clinically indicated.
- Ultrasound findings alone cannot establish whether a pelvic abscess is caused by PID or a postoperative complication; clinical history, examination, laboratory findings, and surgical history are essential.
CASE–9
PID Associated with Intrauterine Device (IUD)
PID Associated with Intrauterine Device (IUD)
Clinical History
A 25-year-old female with an intrauterine device (IUD) in situ presented with lower abdominal and pelvic pain, fever, abnormal vaginal discharge, and marked pelvic tenderness. She was referred for pelvic ultrasound with clinical suspicion of pelvic inflammatory disease (PID) associated with IUD use. There was no history suggestive of uterine fibroids or adenomyosis.
Report Line
An intrauterine device (IUD) is visualized within the uterine cavity, with the device appearing appropriately positioned within the endometrial cavity. The uterus demonstrates mild heterogeneous myometrial echotexture with associated pelvic inflammatory changes. The endometrium measures approximately ___ mm. Mild bilateral adnexal inflammatory changes are noted, with associated pelvic free fluid. The fallopian tubes may demonstrate mild thickening or dilatation. In the appropriate clinical setting, the findings are compatible with pelvic inflammatory disease (PID) in a patient with an IUD in situ. No definite tubo-ovarian abscess is identified at present.
Impression
Pelvic inflammatory changes consistent with PID in the presence of an intrauterine device (IUD).
IUD appears appropriately positioned within the uterine cavity.
No definite tubo-ovarian abscess identified on the present examination.
Go To Table
IUD appears appropriately positioned within the uterine cavity.
No definite tubo-ovarian abscess identified on the present examination.
Recommendation
Clinical correlation with pelvic pain, fever, abnormal vaginal discharge, cervical motion tenderness, and other features of PID is recommended.
Correlation with inflammatory markers and appropriate microbiological investigations may be performed as clinically indicated.
Appropriate antibiotic therapy should be considered according to institutional PID guidelines.
The presence of an IUD does not by itself establish the diagnosis of PID and does not necessarily require removal solely because PID is diagnosed.
Gynecological consultation is recommended if there is poor clinical response, suspected IUD malposition or perforation, or development of tubo-ovarian abscess or other complications.
Follow-up pelvic ultrasound may be performed when clinically indicated to assess resolution of inflammatory changes and confirm continued appropriate IUD position.
Key Learning Points
- An IUD in situ is an important finding to document when evaluating a patient with suspected PID.
- The presence of an IUD does not by itself indicate active pelvic infection; PID remains a clinical diagnosis supported by examination, laboratory findings, and imaging when complications are present.
- Ultrasound should assess the position of the IUD, including its relationship to the uterine cavity and fundus.
- Associated sonographic findings of PID may include pelvic free fluid, salpingitis, hydrosalpinx, pyosalpinx, tubo-ovarian complex, or tubo-ovarian abscess.
- Malpositioned or perforated IUDs may be associated with pelvic pain and require separate evaluation and appropriate gynecological management.
- Three-dimensional ultrasound can be useful when the position of an IUD is uncertain on routine two-dimensional imaging.
- Increased vascularity of inflamed pelvic tissues may be demonstrated on Color Doppler.
- The risk of PID associated with IUD insertion is generally greatest during the period shortly after insertion and is primarily related to pre-existing cervical infection or infection introduced at insertion rather than long-term IUD use itself.
- Important differential considerations include IUD malposition, uterine perforation, endometritis, tubo-ovarian abscess, ectopic pregnancy, and other causes of pelvic pain.
- Ultrasound findings should be correlated with clinical symptoms, pelvic examination, laboratory investigations, and the timing and type of IUD insertion.
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