Where is adnexal tenderness

Color and spectral Doppler imaging may show an absence of both arterial and venous flow to the affected ovary. One may also see absence of venous flow with persistent high-resistance arterial flow. These are highly specific signs of adnexal torsion and may help clinch the diagnosis. However, the presence of normal color flow and spectral waveforms does not exclude the possibility of torsion.

The reason for persistent vascular flow despite torsion is not altogether known and likely multifactorial. The dual blood supply to the ovary via both the ovarian artery and the ovarian branch of the uterine artery is thought to be one source of continued blood flow in a torsed ovary.

Another hypothesis is that venous thrombosis and infarction produce symptoms before the arterial supply to the ovary is compromised. Torsion may also be incomplete or even intermittent, with transient restoration of blood flow in between episodes of torsion. Therefore, in the appropriate clinical setting, a unilaterally enlarged ovary should raise the possibility of ovarian torsion, even with the presence of Doppler flow.

For these reasons, it is important to make a careful comparison to the contralateral ovary for both the gray-scale appearance and Doppler findings in order to make the diagnosis, especially in subtler cases. Pelvic inflammatory disease PID refers to a spectrum of infectious processes in the pelvis, typically ascending from cervicitis to involve the upper reproductive organs: the uterus endometritis , fallopian tubes salpingitis , and ultimately, the ovaries.

Most cases are caused by Chlamydia trachomatis and Neisseria gonorrhoeae. However, there is a high incidence of co-infection with other organisms, such as Streptococcus species, Escherichia coli , and Bacteroides species. If left untreated, the infection can progress to form pyosalpinx and tubo-ovarian abscess. The initial diagnosis of PID is usually made on clinical grounds in patients with pelvic pain and cervical motion tenderness on physical exam. Patients may also have fever and leukocytosis, although symptoms are often vague, and the extent of disease is often not evident clinically.

Sonographic findings of early stage PID in patients without pyosalpinx or tubo-ovarian abscess are usually very subtle and not easily detectable with ultrasonography; enlargement of the uterus and ovaries, indistinct soft tissue margins, thickening of the broad ligament and tubes, and fluid within the endometrial cavity or cul-de-sac.

As the disease progresses and involvement of the fallopian tubes persists, tubal sonographic findings are some of the most specific hallmarks of PID.

The luminal fluid may be purely anechoic or complex with floating echoes. The inflamed ovary can acquire a reactive polycystic appearance, and eventually become adherent to the tube, often situated posteriorly and inferiorly in the region of the cul-de-sac.

This is termed a tubo-ovarian complex. Persistent untreated disease leads to disruption of the normal adnexal and ovarian architecture with leakage of pus from the tube and the formation of a tubo-ovarian abscess TOA , which appears as a complex, mixed solid and cystic mass in the pelvis Fig. Treatment for advanced PID involves the use of broad-spectrum antibiotics. Abscesses are drained using image guidance, either ultrasonography or CT, with catheters placed via a transgluteal, transvaginal, or transrectal route.

Gray-scale A and color B sonograms show a complex solid and cystic mass in the right adnexa with internal vascularity in this patient with tubo-ovarian abscess. This patient ultimately underwent percutaneous transgluteal drainage under computed tomography guidance.

Acute-onset pelvic pain in premenopausal nonpregnant women is a very common symptom in ED patients. Adnexal causes of pain are numerous, and accurate diagnosis is important in order to distinguish between emergency surgical conditions and those that can be managed expectantly or with medical therapy.

The prompt initiation of appropriate therapy is key for the successful management of patients with certain conditions, such as ovarian torsion or PID and TOA. As a radiation-free and relatively inexpensive imaging modality, ultrasonography plays a most important role in diagnosis and management of these patients. We would like to express our gratitude to Dr. No potential conflict of interest relevant to this article was reported.

National Center for Biotechnology Information , U. Journal List Ultrasonography v. Published online May 9. Carolyn S. Dupuis and Young H. Author information Article notes Copyright and License information Disclaimer.

Correspondence to: Young H. This article has been cited by other articles in PMC. Abstract Acute-onset pelvic pain is an extremely common symptom in premenopausal women presenting to the emergency department. Introduction Acute-onset pelvic pain is an extremely common symptom in premenopausal women presenting to the emergency department ED. Functional and Hemorrhagic Ovarian Cysts Normal premenopausal ovaries generally have a homogenous echotexture and several small follicles are often seen at the periphery of the ovarian parenchyma.

Open in a separate window. A year-old female with pelvic pain. A year-old female with intermittent pelvic pain. A year-old female with lower abdominal discomfort. A year-old female with right adnexal tenderness.

Varied appearance of hemorrhagic cysts. A year-old female with acute-onset pelvic pain. Endometriosis Endometriosis is defined as the presence of functional endometrial mucosa outside the uterus. A year-old female with left pelvic pain. Ovarian Torsion Ovarian or adnexal torsion is an acute surgical emergency whereby the ovary is partially or completely rotated along the axis of its pedicle, compromising its blood supply.

A year-old female with acute onset left lower quadrant pain. Ovarian torsion resulting from a large ovarian mass. A year-old female with acute onset pelvic pain. A year-old woman with right pelvic pain. Adnexal torsion is uncommon, occurring most often during reproductive years. It usually indicates an ovarian abnormality. Benign tumors are more likely to cause torsion than malignant ones. Torsion of normal adnexa, which is rare, is more common among children than adults.

Typically, one ovary is involved, but sometimes the fallopian tube is also involved. Adnexal torsion can cause peritonitis. Adnexal torsion causes sudden, severe pelvic pain and sometimes nausea and vomiting. For days or occasionally weeks before the sudden pain, women may have intermittent, colicky pain, presumably resulting from intermittent torsion that spontaneously resolves.

Cervical motion tenderness, a unilateral tender adnexal mass, and peritoneal signs are usually present. Adnexal torsion is suspected based on typical symptoms ie, intermittent, severe pelvic pain and unexplained peritoneal signs plus severe cervical motion tenderness or an adnexal mass. The pain may be unilateral. Other common causes of pelvic pain Pelvic Pain Pelvic pain is discomfort in the lower torso; it is a common complaint in women.

It is considered separately from perineal pain, which occurs in the external genitals and nearby perineal skin PID may be sexually transmitted Clinical diagnosis of adnexal torsion is supported by imaging with transvaginal ultrasonography that shows an enlarged ovary or an ovarian mass. Color Doppler ultrasonography that shows decreased or absent blood flow in the ovary provides further support for the diagnosis. Adolescents can be uniquely challenging; issues to consider include confidentiality, local laws pertaining to consent, and high-risk behavior.

Rapport must be established in this population to obtain a complete history. Consent from the patient and understanding of the laws pertaining to consent are essential. The differential diagnosis of pelvic pain in adolescents is similar to that for adults. Anatomic anomalies that prevent menstruation, such as imperforate hymen and transverse vaginal septum, must also be considered in adolescents.

Compared with older patients, adolescents are at higher risk of PID because of unsafe behaviors. In a study of 4, adolescents 15 to 19 years of age, A detailed discussion on pelvic pain in pregnant and postpartum women is beyond the scope of this article.

In addition to many of the same conditions as nonpregnant women, special considerations in pregnant women include corpus luteum hematoma and uterine impaction in the first trimester, and placental abruption and preterm labor in the third trimester. In the first trimester, there is an increased risk of ovarian torsion 25 percent of all cases of ovarian torsion.

Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. PAUL S. Public Health Service. Address correspondence to Paul S. Reprints are not available from the authors. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U. Coast Guard, the U.

Public Health Service, or the U. Department of Health and Human Services. Acute nonspecific abdominal pain: A randomized, controlled trial comparing early laparoscopy versus clinical observation.

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