Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part II: uterine emergencies and pelvic inflammatory disease

Abstract

Due to the growing use of cross-sectional imaging in emergency departments, acute gynaecologic disorders are increasingly diagnosed on urgent multidetector computed tomography (CT) studies, often requested under alternative presumptive diagnoses in reproductive-age women. If clinical conditions and state-of-the-art scanner availability permit, magnetic resonance imaging (MRI) is superior to CT due to its more in-depth characterisationof abnormal or inconclusive gynaecological findings, owing to excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.This pictorial review aims to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their CT and MRI appearances, in order to provide a timely and correct imaging diagnosis. Specifically, this second instalment reviews with examples and emphasis on differential diagnosis the main non-pregnancy-related uterine emergencies (including endometrial polyps, degenerated leiomyomas and uterine inversion) and the spectrum of pelvic inflammatory disease.

Keywords: Computed tomography (CT); Gynaecologic emergencies; Magnetic resonance imaging (MRI); Pelvic inflammatory disease; Uterus.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Endometrial polyp in a 44-year-old woman with acute uterine bleeding and associated bilateral ovarian neoplasm. Sagittal (a) and oblique-coronal (d) T2-weighted images show a huge polypoid mass (arrowheads) arising from the uterine fundus that fills the endometrial cavity and protrudes into the cervical canal. Note the hypointense stromal axis of the polyp (arrows). Corresponding sagittal (b) and oblique-coronal (e) precontrast fat-suppressed T1-weighted images show hyperintense foci on the polyp edge (thin arrows), representing haemorrhage. On gadolinium-enhanced sagittal (c) and oblique-coronal (f) fat-suppressed T1-weighted images, the implant base (stromal axis) of the polyp shows intense enhancement (arrows). The patient underwent bilateral uterine artery embolisation in order to control bleeding

Fig. 2

Endometrial hyperplasia in a 43-year-old woman with acute abnormal uterine bleeding. Oblique-coronal (a), sagittal (b) T2-weighted images and gadolinium-enhanced sagittal (c) fat-suppressed T1-weighted image show marked endometrial thickening (arrowheads) without macroscopic signs of myometrial invasion. Hysteroscopy with endometrial biopsy demonstrated simple endometrial hyperplasia without atypia

Fig. 3

Surgically proven torsed uterine fibroma in a 64-year-old woman. Precontrast (a), arterial (b) and venous (c) phase CT images show a large, ovoid-shaped heterogeneous, mildly hyperattenuating and poorly enhancing mass (arrowheads) that displaces the uterus (plus sign) posterolaterally. Note the acute angle (thin arrow) indicating subserosal origin of the mass, and minimal effusion (asterisk) in the peritoneal cul-de-sac

Fig. 4

Leiomyoma with haemorrhagic degeneration in a 25-year-old woman suffering from acute pelvic pain. Oblique-coronal T2-weighted image (a) shows a subserosal leiomyoma, with predominant low signal intensity, arising from the left lateral wall of the uterus (arrowhead). On oblique-axial T1-weighted (b) and fat-suppressed T1-weighted (c) images, the mass demonstrates a central region of hyperintense signal (arrows) corresponding to haemorrhagic degeneration

Fig. 5

Leiomyoma with haemorrhagic degeneration in a 37-year-old woman with a palpable abdominal mass, pelvic pain and fever. Sagittal (a) and oblique-coronal (b) T2-weighted images show a huge subserosal leiomyoma arising from the posterior wall of the uterus, with heterogeneous signal intensity (arrowheads). On oblique-coronal fat-suppressed T1-weighted image (c), the mass demonstrates hyperintense signal (arrowhead) consistent with haemorrhagic degeneration, without contrast enhancement after gadolinium administration (d)

Fig. 6

Multiple leiomyomas in a 48-year-old woman with pelvic pain and fever after uterine fibroid embolisation (UFE). Pre-treatment oblique-coronal T2-weighted (a) and fat-suppressed T1-weighted (c) images show multiple intramural leiomyomas, with respectively low and intermediate signal intensity (arrowheads). After bilateral UFE, on oblique-coronal T2-weighted (b) and fat-suppressed T1-weighted (d) images, the leiomyomas (arrowheads) show low T2 signal intensity and peripheral or homogeneous high signal intensity on fat-suppressed T1-weighted image reflecting internal haemorrhagic necrosis

Fig. 7

Surgically confirmed, spontaneous uterine inversion without mass lesions in a 79-year-old woman experiencing muco-haemorrhagic vaginal discharge. Precontrast (a) and contrast-enhanced (b, c) CT images showed a solid, mass-like enhancing structure (plus sign) surrounded by air coursing through the dilated uterine cervix. Loss of the normally convex uterine fundus (thin arrows) was noted. Physically, the upper vagina was occupied by the inverted uterus. Sagittal (d) and axial (e) T2-weighted MRI images confirmed the diagnosis by showing lost convexity and depression of the uterine fundus (thin arrows), U-shaped inverted uterus (plus sign) with preserved zonal anatomy for age and normal homogeneous enhancement on post-gadolinium T1-weighted image (f), which coursed downwards through the hypointense uterine cervix walls (thin arrows) [adapted from Open Access ref. no [33]]

Fig. 8

Flow-chart showing the MRI algorithm that proposes diagnostic steps for characterisation and differential diagnosis of pelvic inflammatory disease (PID) forms, according to signal intensity features, diffusion restriction, mural thickness and contrast enhancement

Fig. 9

Cervicitis in a 24-year-old woman suffering from pelvic pain. Sagittal (a) and oblique-coronal (b) T2-weighted images show thickening of the mucosal layer at the cervical canal (arrowheads). The corresponding post-gadolinium sagittal (c) and oblique-coronal (d) fat-suppressed T1-weighted images show prominent enhancement along the cervical canal (arrowheads)

Fig. 10

Haematometra and endometritis at CT. Sagittal (a) and axial (b) postcontrast CT images show markedly dilated uterine cavity (plus sign) filled by heterogeneous fluid. Associated loculated effusion (asterisk) in the pelvic cul-de-sac with thin serosal hyperenhancement (thin arrow in b)

Fig. 11

MRI appearance of endometritis in a 38-year-old woman with pelvic pain. Sagittal gadolinium-enhanced fat-suppressed T1-weighted image shows contrast enhancement of the endometrium and inner myometrial layer (arrowheads)

Fig. 12

Acute salpingitis in a 25-year-old woman with pelvic pain and mild neutrophilic leukocytosis. Sagittal fat-suppressed (a), oblique-coronal (b) and oblique-axial (c) T2-weighted images show slightly dilated left fallopian tube with thickened walls (arrowheads). On axial diffusion-weighted imaging (DWI, b = 800 s/mm2) image (d), the tubal wall thickening demonstrates restricted diffusion (arrowheads), finding consistent with acute inflammation. Note pelvic peritoneal effusion (asterisk)

Fig. 13

CT appearances in three different patients with a clinical diagnosis of PID. a Heterogeneously enhancing, unilaterally enlarged right ovary (arrowhead). Note uterus (plus sign), mild cul-de-sac effusion (asterisk). b–d Multiplanar images of tubular-shaped left salpingitis (arrowheads), distended with prominent mural enhancement. e–f Enlarged, septated left ovary (arrowheads) with thickened walls consistent with early tubo-ovarian abscess (TOA)

Fig. 14

Acute pyosalpinx in the same patient as Fig. 11. Sagittal (a) and oblique-axial T2-weighted (b) images show distended fallopian tubes (arrowheads) with thickened walls and internal fluid-fluid levels. Axial DWI (b = 800 s/mm2) image (c) demonstrates high signal intensity indicating restricted diffusion of the tubal content (arrowheads) and of two fluid collections in the Douglas pouch (arrows), reflecting purulent content. Sagittal (d) and oblique-axial gadolinium-enhanced fat-suppressed (e, f) T1-weighted images show intense mural enhancement of the involved Fallopian tube (arrowheads) and of the fluid collections (arrows)

Fig. 15

Acute pyosalpinx in a 44-year-old woman with a history of surgically treated pelvic endometriosis 5 years earlier, suffering from abdominal pain, fever and diarrhoea. Sagittal (a), axial (b) T2-weighted images and axial fat-suppressed T1-weighted (c) image show a distended right fallopian tube (arrowheads) with thickened walls and internal fluid-fluid levels. On axial DWI (b = 800 s/mm2) image (d), the involved fallopian tube (arrowhead) demonstrates high signal intensity reflecting restricted diffusion from purulent content

Fig. 16

Acute onset of endometriosis in a 37-year-old woman with acute pelvic pain and fever for the last 4 days. Sagittal (a), oblique-coronal (b) T2-weighted images and sagittal (d), oblique-coronal (e) fat-suppressed T1-weighted images show a distended serpiginous right fallopian tube (arrows) with homogeneously high T2-weighted signal and low T1-signal intensity, consistent with hydrosalpinx. Additionally, oblique-coronal (b) and sagittal (c) T2-weighted images, oblique-coronal (e) and sagittal (f) fat-suppressed T1-weighted images demonstrate an endometriotic cyst of the left ovary (arrowheads) showing high T1 and low T2 signal (shading sign)

Fig. 17

In the same patient as Fig. 16, sagittal (a) and oblique-axial (c) T2-weighted images show a hypointense endometriotic plaque (arrowheads) that infiltrates the muscular layer of the anterior rectal wall. Sagittal T2-weighted (b) and sagittal fat-suppressed T1-weighted (d) images show additional endometriotic implants of the uterine serosa (arrows) demonstrating low T2-weighted, high T1-weighted signal intensity

Fig. 18

Haematosalpinx in a 34-year-old woman with endometriosis presenting with dysmenorrhea and pelvic pain. Sagittal (a) and oblique-coronal (b) T2-weighted images show a tortuous structure with homogeneously hypointense content in right adnexa (arrowheads). On sagittal (c) and oblique-coronal (d) fat-suppressed T1-weighted images the same structure (arrowheads) shows high signal intensity consistent with haemorrhagic content

Fig. 19

a–c Multiplanar CT images of a complex, septated left-sided TOA (arrowheads) in a 42-year-old woman, with characteristic irregular peripheral enhancement, that displaces the retroverted uterus (plus sign). Note metallic intrauterine contraceptive device (IUCD, thick arrows), minimal peritonitis of the cul-de-sac (thin arrows) and inflammatory stranding of the presacral fat (asterisk). The IUCD had to be removed

Fig. 20

TOA in a 57-year-old woman with right lower quadrant pain, fever, leukocytosis and acute diverticulitis. Sagittal (a) and axial (b) T2-weighted images show heterogeneous, multilocular collections at the right adnexa (arrowheads), containing air-fluid levels. Note diverticula of the sigmoid colon (thin arrows in b). Sagittal T2-weighted image (c) displays a fluid collection in the Douglas pouch (arrow). On axial DWI (b = 800 s/mm2) image (d), the fluid component of the adnexal masses demonstrates high signal intensity (arrowheads), consistent with restricted diffusion from purulent content

Fig. 21

a–c Multiplanar CT images of an extensive PID in a 27-year-old African woman, complicated by multiple, confluent abscesses (asterisk) occupying the entire pelvis, that compress the uterus (plus sing) on the midline. Note hydronephrosis (arrow in b). Clinical and radiological suspicion of actinomycosis was not supported by microbiology samples

Fig. 22

a–c Multiplanar CT images of genital involvement in a 58-year-old woman with respiratory tuberculosis, showing bilateral adnexal abscess-like enlargement (arrowheads) with peripheral enhancement, and dilated uterine cavity with thin endometrial enhancement (thin arrows) suggesting pyometra [adapted from Open Access ref. [50]]

Fig. 23

Two cases of vulvar abscesses (arrowheads) which required surgical incision. a Axial CT image of a small ovoid fluid collection with peripheral enhancement in the left-sided major labia. b Coronal CT image of an abscess with mixed fluid and gaseous content secondary to Bartholin gland infection