Imaging in Acute Female Pelvic Conditions: A Focus on Diagnostic Precision and Clinical Evaluation

Abstract

Acute abdominal pain is a prevalent and often challenging presentation in emergency departments, accounting for a substantial number of admissions. The broad spectrum of underlying diseases makes accurate diagnosis complex, especially in women of childbearing age, where gynecological conditions frequently contribute to an acute abdomen. Given the potential for significant morbidity and mortality associated with diagnostic delays, a precise and timely evaluation is crucial. The cornerstone of correct diagnosis lies in a meticulous history and thorough clinical examination, which then guides the selection of appropriate imaging modalities. Ultrasound typically serves as the initial imaging modality of choice for most gynecological emergencies due to its accessibility, noninvasiveness, and ability to visualize pelvic organs. In cases where ultrasound findings are indeterminate or when further anatomical detail is required, MRI is often employed to establish a definitive diagnosis. This article aims to provide a comprehensive overview of the history, clinical examination findings, and imaging characteristics of a wide range of female pelvic emergencies concerning reproductive organs. A strong understanding of these interlinked elements is crucial for healthcare professionals to achieve accurate diagnosis, facilitate prompt management, and ultimately optimize patient outcomes.

Keywords

acute lower abdominal pain - gynecological imaging - pelvic emergencies

Introduction

Women with acute lower abdominal or pelvic pain frequently visit emergency rooms, presenting diagnostic challenges for gynecologists and surgeons. The causes can be gynecological, urological, or gastrointestinal, and management may range from conservative treatment to emergency surgery. Accurate diagnosis is crucial for effective treatment, often relying on imaging techniques.[1] [2] An ultrasonography (USG) is the initial investigation of choice, while CT is used for suspected urological or gastrointestinal issues. MRI is typically not performed in emergencies, but it serves as a valuable problem-solving tool for gynecological cases. This article offers a comprehensive review of female pelvic emergencies.

History and Clinical Examination

A thorough patient history is essential for diagnosing acute pelvic pain, beginning with confirmation or exclusion of pregnancy. Key details include the last menstrual period, cycle regularity, and symptoms such as bleeding or known fibroids. Assessing pain characteristics and risk factors, including a history of ectopic pregnancy, pelvic inflammatory disease (PID), or intrauterine device use, helps narrow down potential diagnoses.[3]

A structured clinical examination is crucial alongside the patient's history. Vital signs can indicate hemodynamic instability. Abdominal palpation assesses tenderness and guarding, while a speculum and bimanual exam visualize the cervix and vagina, allowing for detection of bleeding sources, uterine abnormalities, and adnexal masses. Findings may indicate conditions like PID or endometriosis.[3]

Investigations

Laboratory tests are vital for initial evaluation. A pregnancy test is mandatory for women of reproductive age with pelvic pain to rule out ectopic pregnancy. A complete blood count (CBC) assesses for anemia due to blood loss from conditions like ectopic pregnancy. In contrast, an elevated white blood cell count and C-reactive protein can suggest inflammatory or infectious issues.[3]

The Importance of a Multidisciplinary and Imaging-Guided Approach

In emergency settings, triaging patients with lower abdominal pain requires distinguishing between surgical and gynecologic causes. A thorough history, physical examination, and investigations are essential, but imaging is crucial for confirming or refining the differential diagnosis by providing precise localization or etiology.[3] [4]

Imaging Modalities: Choosing the Right Modality

USG is the primary imaging method for suspected gynecologic or obstetric causes of pelvic pain. Transvaginal ultrasound provides excellent visualization of the uterus and adnexa, is noninvasive, and uses no ionizing radiation. Color Doppler imaging enhances diagnostic accuracy for assessing blood flow, particularly in cases of ovarian torsion. Still, it can be limited in obese patients and when structures are outside the viewing field.[3]

Multidetector computed tomography (CT) is commonly used in emergency settings, especially for gastrointestinal or urinary tract issues, as it is fast, reliable, and readily available when ultrasound results are inconclusive.[3] [4]

Magnetic resonance imaging (MRI) is less frequently employed in emergencies but offers superior soft-tissue contrast and is valuable for cases involving pregnant women and young patients. It excels at diagnosing conditions such as endometriosis, adnexal torsion, complex hemorrhagic cysts, PID, or degenerating fibroids when ultrasound findings are inconclusive.[3] [4]

The differential diagnosis of causes of acute pelvic pain in women encompasses a range of conditions, from physiological processes to life-threatening emergencies, as detailed in [Table 1].

Table 1 Differential diagnosis of gynecological causes of acute pelvic pain

Adnexal pathologies:  1. Ectopic pregnancy  2. Adnexal torsion  3. Pelvic inflammatory disease  4. Ovarian hyperstimulation syndrome (OHSS)  5. Corpus luteal cyst/hemorrhagic cyst/dermoid cyst rupture  6. Endometriosis

Uterine conditions:  1. Fibroid  2. Hematometra and pyometra  3. Uterine rupture  4. Vascular lesions such as pseudoaneurysms or arteriovenous fistulas with bleeding

This review emphasizes key imaging features of acute gynecologic emergencies to enhance diagnostic accuracy and support timely clinical management. By integrating imaging with clinical findings, we aim to improve radiologists' confidence in identifying critical pelvic pathologies that may be initially missed. Our goal is to promote a comprehensive, patient-centered approach to imaging, thereby facilitating accurate diagnoses and timely interventions that lead to improved patient outcomes.

Ectopic Pregnancy

Ectopic pregnancy occurs when a blastocyst implants outside the endometrial cavity, accounting for 2% of pregnancies and 18% of first-trimester bleeding cases.[5] In India, the incidence ranges from 0.9 to 2.3%. The classic symptoms include missed period, abdominal pain, and per-vaginal bleeding, with risk factors including tubal surgery, PID, intrauterine contraceptive device (IUCD) use, in vitro fertilization, and congenital uterine anomalies.[6] The initial evaluation involves measuring serum β-hCG levels and performing an ultrasound, preferably transvaginal sonography (TVS). A β-hCG increase of less than 50% over 48 hours suggests a nonviable pregnancy, while plateauing levels indicate ectopic pregnancy.[7] [8]

The fallopian tube is the most common site, with 95% of cases occurring there, primarily in the ampulla.[9] Ultrasound findings typically show a heterogeneous adnexal mass without an identifiable gestational sac. Specific signs include the tubal ring sign, indicating a thick echogenic rim, and peripheral hypervascularity referred to as the “ring of fire.”[10] However, this can also be seen in a maturing ovarian follicle or corpus luteum cyst ([Table 2]). Early identification and management of ectopic pregnancies are essential to reduce maternal mortality. Signs of a ruptured ectopic pregnancy include free fluid in the pelvis and hematosalpinx.

Table 2 Differentiating features between ectopic pregnancy and corpus luteal cyst

Differentiating features	Ectopic pregnancy	Corpus luteum
Clinical scenario	A serious condition requiring immediate medical attention, especially in women of childbearing age	Common in women of childbearing age, especially during pregnancy
Serum hCG	Elevated	Normal
USG	Appears as a well-defined, extraovarian cystic structure, often with a “tubal ring” sign	Generally appears as a cystic structure within the ovary
Appearance	Presence of a distinct, extraovarian thick tubal ring. Hyperechoic (more than myometrium). May show a gestational sac within	Absence of a distinct, extra-ovarian tubal ring. May show a complex appearance with solid or cystic components and peripheral vascularity. If present, hypoechoic, and a thinner ring
Doppler	May show higher resistance index (RI) values (>0.7)	Low impedance flow (nonspecific feature)
Indirect signs	Hemoperitoneum ++	+
Follow-up	Does not reduce in size without management	Reduces in size at follow-up

MRI, while not commonly used, can help pinpoint anatomical locations in challenging diagnoses. A notable “three-ring sign” appears on T2W imaging, characterized by concentric rings: an inner hypointense extraembryonic coelom, a hyperintense layer of fetal capillaries, and an outer hypointense tubal wall, which displays restriction on DWI, indicating the ring of fire sign. A heterogeneous mass, detached from the ovary, may indicate a sealed ectopic pregnancy rupture ([Fig. 1]).

Fig. 1 A 31-year-old woman presented with acute abdominal pain, bleeding per vaginum after 8 weeks of amenorrhea. Urine pregnancy test shows a faintly positive result. (A) TAS shows a heterogeneously enhancing right adnexal mass (yellow arrow) without any identifiable gestational sac. (B–D) MRI coronal and sagittal T2W imaging showing a heterogeneous right adnexal mass with internal dark areas, separate from the uterus and both ovaries (yellow arrow). Blood collection within the endometrial cavity (blue star). (E) Both right and left ovaries are seen separately from the mass (blue arrow). (F) Axial T1WI showing hyperintense areas within the mass, again suggesting right adnexal mass with areas of variable stages of hemorrhage (yellow arrow and star). No evidence of free fluid. Chronic sealed ruptured right adnexal ectopic pregnancy.

Interstitial pregnancies, rare at 2 to 4% of cases, involve implantation 1 to 2 cm within the intramyometrial segment of the fallopian tube, with the gestational sac (GS) separated by more than 1 cm from the uterine cavity edge.[11] [12] The “interstitial line sign” is a thin bright line extending from the endometrium to the GS and indicates interstitial pregnancy.[13] Cornual pregnancies show an empty uterine cavity and an eccentrically located GS with minimal myometrial support(< 5 mm myometrial thickness), heightening rupture concerns ([Fig. 2A–C]). Lastly, a pregnancy in a rudimentary horn is extremely rare (1 in 76,000) and poses a significant risk of rupture and potential death[14] ([Fig. 2D–F]).

Fig. 2 (A–C) A 29-year-old woman presented with bleeding per vaginum after 7 weeks of amenorrhea. Urine pregnancy test shows a positive result. (A, B) Axial T2W imaging showing a well-defined heterogeneous mass with internal hemorrhage in the left uterine cornu (yellow arrow). The endometrial cavity shows only a thin streak of blood products. Both ovaries are seen separately (green arrow). (C) Axial GRE image showing blood products within the mass (blue star) and endometrial cavity (green star). Cornual ectopic pregnancy. (D–G) Another 33-year-old woman, 12 weeks of amenorrhea, with lower abdominal pain. UPT positive. (D) TAS revealed a gestational sac with a viable fetus, crown-rump length of 5.6 cm, over the left aspect of the uterus (yellow arrow). (E) MRI T2W imaging revealed that the sac was surrounded by a thin wall with the same signal intensity as that of the myometrium (red arrow). (F, G) An ectopic pregnancy was assumed (blue star) with an empty uterine cavity (yellow star). Laparotomy revealed a bicornuate uterus with a rudimentary horn pregnancy.

Implantation in the ovary accounts for 3% of cases,[15] detectable via USG, showing a GS with a “claw-sign” and a normal fallopian tube. Cervical pregnancy, less than 1% of cases,[11] shows a classic hour-glass appearance on USG, with an enlarged cervical canal and low-lying GS, distinguishable from threatened abortion through dynamic ultrasound.[16]

Blastocyst implantation over a previous caesarean section scar is very rare (< 1%) but poses a high rupture risk. USG reveals a GS in the anterior inferior uterus with myometrial thinning, while MRI helps in soft tissue evaluation[17] ([Fig. 3A–C]). This needs differentiation from cervical ectopic, low-implanted normal pregnancy, and evolving pregnancy loss. ([Table 3])

Table 3 Differentiating features between scar ectopic and cervical pregnancy

Differentiating features	CS scar ectopic	Cervical ectopic	Low implanted normal pregnancy	Evolving pregnancy loss
Implantation site	Implantation above the os in the anterior myometrium. Os closed	Implantation below the os in the cervical canal	Implantation above the os in the endometrium	Contents may lie in the cervical canal, os open
Scar niche	CS scar niche not seen	Normal scar niche	Normal	Normal
Uterine lower segment anterior myometrium	Residual myometrial thickness <5 mm	Normal	Normal	Normal

Fig. 3 (A, B) TVS showing a large heterogeneous gestational sac (yellow arrow) in the myometrium of the LUS with a developing embryo. The sac is abutting the anterior lip of the cervix with thinning of the myometrium (yellow arrow). Sagittal T2W imaging showing irregular heterogeneous GS embedded at the scar site with thinning of the overlying myometrium and indentation over the posterior bladder wall (blue arrow), growth toward the endometrial canal, and displacing the cervical canal posteriorly. (C) Follow-up USG after 1 week of medical management shows no significant vascularity at the scar site, with substantial resolution. Scar ectopic pregnancy. (D–F) A 36-year-old woman, 22 weeks of amenorrhea, with abdominal pain. UPT positive. T2W coronal and sagittal images show an empty uterine cavity (green arrow) with serosa rupture and intraperitoneal location of the placenta and fetus. The myometrial vessels are seen continuing with the extrauterine extension of the placenta (yellow arrow)—secondary intra-abdominal pregnancy.

Primary intra-abdominal pregnancy occurs in the peritoneal cavity (1.4% of cases) and typically goes undetected until the late second trimester. Secondary abdominal pregnancy arises from initial implantation in the fallopian tube or uterus, followed by rupture into the abdomen.[18] MRI provides better localization and assessment ([Fig. 3D–F]). Heterotopic pregnancy, a rare combination of intrauterine and ectopic pregnancy, occurs in 1 in 30,000 pregnancies, but the incidence significantly rises with the use of assisted reproduction techniques.[19] It may allow the continuation of the viable intrauterine pregnancy after careful removal of the extrauterine pregnancy.[9]

Adnexal Torsion

Adnexal torsion is defined as the twisting of the ovary, and often of the fallopian tube, on its vascular and ligamentous supports, resulting in venous followed by arterial blood flow compromise leading to infarction. Ovarian enlargement increases the tendency of the ovary to twist, and the presence of a benign ovarian lesion is the single most significant risk factor. Other risk factors include ovulation induction, polycystic ovaries, pregnancy, and prior pelvic surgery. Adhesions associated with malignancies and endometriosis are thought to be protective.[20]

It is one of the common causes of acute pelvic pain in females.[21] Patients commonly present with an acute onset of severe pelvic pain localizing to the side of torsion, nausea, and vomiting. Nausea and vomiting can be seen in up to 70% of patients with torsion. Early diagnosis of torsion is essential, along with characterization of the associated ovarian lesion, if any, to avoid ovarian infarction and subfertility and facilitate prompt and definitive surgical management.

Imaging Modalities

The initial imaging modality of choice is USG. In a systematic review, the diagnostic accuracy of ultrasound was 79% compared with 42% for CT.[22] In patients with nonspecific symptoms, indeterminate adnexal masses, or equivocal ultrasonographic findings, MRI is indicated, as it has the highest accuracy in diagnosing torsion and characterizing associated ovarian lesions. In unsuspected cases of torsion, CT may be performed to identify the cause of acute lower abdomen pain, which may raise the suspicion of adnexal torsion by identifying ancillary features such as unilateral ovarian enlargement, adnexal mass, free fluid, because only in a limited number of cases the twisting of the pedicle is visible in CT.[23]

Imaging Findings

Key imaging findings observed in all the modalities include displacement of the enlarged and edematous ovary towards the midline superior to the uterus, ovarian stromal oedema, peripherally displaced follicles, and twisting of the thickened pedicle(identified by “whirlpool” or “target” sign; [Fig. 4]).[20] [24] [25] Additional findings include the presence of a benign lead mass and pelvic free fluid. While an enlarged ovary with or without mass is the most common finding, the pathognomonic feature is twisting of the pedicle, and the latter can be assessed better with ultrasound and MRI.[26] Due to poor soft tissue resolution, it may be challenging to establish twisting, especially in noncontrast CTs.

Fig. 4 A 32-year-old woman presented with an acute onset of severe right-sided lower abdominal pain for 1 day. Transvaginal ultrasound images revealed an enlarged right ovary with diffuse stromal edema (measures with callipers in A and B). No internal vascularity is noted within the Doppler USG (C). Also, there is thickening and twisting of the right ovarian pedicle noted (white arrow in D). Features suggestive of right ovarian torsion.

Ovarian viability can be assessed by Doppler USG and with contrast in CT and MRI. The presence of arterial flow within the ovary does not exclude torsion, as the arterial perfusion may be maintained until late in the course of torsion.

Absence of color flow or contrast enhancement is suggestive of ovarian infarction. Additionally, a recent study suggested that even with a short MRI protocol featuring limited T2 sequences, it is possible to establish a diagnosis of torsion and predict ovarian viability by observing four T2 hypointensity signs: perifollicular, stromal, capsular, and pedicle hypointensity. The presence of hypointensity is predictive of necrosis ([Fig. 5]).[27]

Fig. 5 (A, B) A 40-year-old presented with an acute onset of severe right-sided lower abdominal pain for 1 day. T2-weighted coronal MR images show an enlarged right ovary (black star in A) with diffuse T2 hyperintensity—suggestive of stromal edema with thickening, twisting, and hyperintensity of right ovarian pedicle (white arrow in B)—Features suggestive of right ovarian torsion. The ovary was viable during the surgery, and laparoscopic oophoropexy was done. (C and D) A 39-year-old woman presented with an acute onset of severe left-sided abdominal pain for 4 days. T2 sagittal MR images show an enlarged left ovary (white star in C) with twisting of the pedicle (white arrow in D) and perifollicular, stromal, capsular, and pedicle T2 hypointensity. Laparoscopy revealed torsion of the left ovary with necrosis. In histopathology, hemorrhagic infarction was present.

Pelvic Inflammatory Disease

PID is a common gynecological issue that often brings women to the emergency department, with up to 70% of cases presenting there.[28] Symptoms can be mild and nonspecific, making diagnosis challenging. PID includes infections of the upper genital tract, such as endometritis, salpingitis, and tubo-ovarian abscess, typically caused by ascending infections from the lower tract, with Chlamydia trachomatis and Neisseria gonorrhoeae being common culprits.[29] Less frequently, PID ([Fig. 6]) can result from hematogenous spread, notably in cases of tuberculosis in developing countries. Common symptoms include pelvic pain, mild fever, vaginal discharge, and dyspareunia, with risk factors including gynecological procedures, the use of an IUCD, and multiple sexual partners.

Fig. 6 An 88-year-old woman with tuberculosis presented with fever and lower abdominal pain. CT of the chest (A) shows centrilobular nodules in bilateral lungs, suggestive of endobronchial spread. Contrast-enhanced axial CT image of pelvis (B) showing abnormal enhancement of the endometrium and hyperemia of the inner myometrium (thick white arrow), indicating endometritis. (C) Loculated collection with thick enhancing walls in both adnexa (thin white arrows), suggesting tubo-ovarian abscess.

Endometritis

Endometritis refers to the inflammation of the endometrial lining, often seen after gynecological procedures or in postpartum patients. Symptoms include pelvic pain and vaginal discharge. Ultrasound may reveal a thick, echogenic, heterogeneous endometrium. CT scans show a bulky uterus with heterogeneous enhancement at the endometrial-myometrial junction and mild fluid in the endometrial cavity ([Fig. 7]). Acute cases may present with fat stranding in surrounding structures.[30] For postmenopausal patients, an endometrial biopsy is necessary to rule out malignancy.

Fig. 7 Endometritis in a 38-year-old woman presented with pelvic pain and vaginal discharge. (A) Sagittal contrast-enhanced CT image shows a bulky uterus with hypodense thickened endometrium (thick white arrow) with heterogeneous enhancement of the junctional zone. (B) Axial CT image shows a dilated fallopian tube with thick-wall enhancement (star). (C) Transabdominal ultrasound of the pelvis shows a bulky uterus with thick echogenic endometrium (thin white arrow) and heterogeneous junctional zone. These findings are consistent with endometritis.

Salpingitis

Salpingitis is the inflammation of the fallopian tubes and is the most common acute form of PID. In acute suppurative salpingitis, the tubal lumen fills with pus, leading to pyosalpinx and possible surrounding peritoneal inflammation if untreated.[31] Chronic salpingitis involves persistent inflammation, resulting in adhesions, tubal blockage, and infertility, and is a common cause of ectopic pregnancy.[32] Diagnosis relies on clinical presentation, as ultrasound may not be practical early on, while CT scans can show thickened tubes (>5 mm) and fat stranding.[33] [34] In cases of pyosalpinx, the tubes appear fluid-filled with thickened, enhanced walls.

Oophoritis

Sometimes infection extends from the fallopian tubes to the ovaries, resulting in stromal swelling with surrounding oedema. On imaging, we can see enlarged ovaries (greater than 3 cm) with increased vascularity. On the grey scale, it gives the appearance of polycystic ovaries with multiple follicles and increased stromal vascularity.[35] On CT and MRI, it shows abnormal enhancement and mild free fluid in the cul-de-sac. If it is unilateral, it should be differentiated from ovarian torsion, where the ovary will be avascular. Isolated oophoritis is a rare condition that can be difficult to diagnose.

Tubo-ovarian Abscess

Tubo-ovarian abscess is a serious complication of fallopian tube infection, occurring in up to 15% of women with PID. It presents as a complex cystic solid mass.[36] On CT, it appears as a tubular cystic mass with septations and thick, uniform wall enhancement, along with loss of fat planes and fluid in the cul-de-sac.[37] On MRI, it appears hypointense on T1-weighted images and hyperintense on T2-weighted images, often exhibiting a hyperintense rim due to the presence of granulation tissue.[38] [39] Differentiation from other pelvic abscesses is essential; for instance, endometriosis can be distinguished on MR imaging due to its characteristic hyperintense signal on T1-weighted images ([Fig. 8]).

Fig. 8 A 24-year-old woman with fever and lower quadrant pain. (A) T2-weighted image shows cystic lesions in the bilateral adnexa (thick white arrow), intermediate signal contents. (B) T1-weighted fat-saturated image shows hypointense content with hyperintense rim in periphery (thin white arrow), suggestive of granulation tissue. (C, D) Contents show a prominent high signal on DWI with decreased ADC (white stars), indicating pus. (E, F) Fat-saturated contrast-enhanced T1-weighted coronal and axial images show thickening and enhancement of the cyst wall (thick black arrows), which are indicative of tubo-ovarian abscess.

Fitz Hugh Curtis Syndrome

It is a chronic complication of PID where there is spread of infection into the perihepatic space from the pelvis through peritoneal reflections. Imaging shows inflammatory changes in the perihepatic region and pelvis with pyosalpinx or tubo-ovarian abscess.

Vulvar Abscess

Vulvar abscess commonly occurs secondary to infection of the Bartholin gland cyst, and the less common causes include an infected epidermoid cyst. The Bartholin cyst or abscess is located at the posterior third of the labia majora, posterolateral to the vulva. When infected, it appears as a thick-walled cystic structure with internal debris and surrounding inflammatory changes.

Ovarian Hyperstimulation Syndrome

Ovarian hyperstimulation syndrome (OHSS) is a complication mainly associated with assisted reproductive technologies (ART), particularly in vitro fertilization (IVF). It occurs due to an exaggerated ovarian response to hormonal stimulation from exogenous gonadotropins.[40] [41]

OHSS is characterized by increased capillary permeability, triggered by vascular endothelial growth factor (VEGF), which leads to fluid leakage and complications such as ascites and pleural effusions. Risk factors include younger age, low BMI, polycystic ovarian syndrome (PCOS), and a history of OHSS, with anti-Müllerian hormone (AMH) levels helping to predict susceptibility.[41]

OHSS ranges from mild to severe, classified by the modified Golan system. USG is the primary imaging modality for assessing ovarian hyperstimulation syndrome (OHSS), which typically reveals enlarged ovaries with multiple peripheral follicles arranged in a “spoke-wheel” pattern ([Fig. 9]). The presence of ascitic fluid indicates moderate disease. At the same time, severe cases may present with pleural or pericardial effusions and ovarian diameters over 12 cm. Ultrasound also aids in guiding paracentesis for symptomatic ascites.[40] [42]

Fig. 9 A 28-year-old woman undergoing ovarian stimulation who presented with bloating, nausea, and mild abdominal pain. (A, B) Transvaginal grey-scale ultrasound shows the right and left ovarian enlargement, multiple enlarged follicles, consistent with ovarian hyperstimulation. (C, D) There is mild free fluid in the intraperitoneal cavity.

CT and MRI are used for complex cases or inconclusive sonography, especially when complications like pulmonary embolism are suspected. Complications may include ovarian torsion, hemorrhage, thromboembolism, and, occasionally, abdominal compartment syndrome.[40] [42]

While ovarian enlargement and multicystic morphology are common in ART cycles, differential diagnoses should include polycystic ovarian morphology, theca lutein cysts, and ovarian neoplasms, relying on imaging and clinical history for differentiation.

Spontaneous OHSS is very rare and linked to endogenous hormonal factors like β-hCG-secreting tumors, pituitary adenomas, or hypothyroidism. Its radiologic features resemble those of induced OHSS, including bilateral ovarian enlargement, multiple cysts, and ascites or pleural effusion. Diagnostic imaging, particularly ultrasound, is vital when there is no recent history of ovulation induction[43]

Hemorrhagic/Ruptured Corpus Luteum or Dermoid Cyst Rupture

Ruptured or hemorrhagic ovarian corpus luteal cysts are a common cause of acute pelvic pain in women of reproductive age.[1] The corpus luteum forms post-ovulation, secreting progesterone to support early pregnancy. Fluid or blood released during ovulation can cause mild mid-cycle pain known as Mittelschmerz, but larger amounts may lead women to seek emergency care.[44] A ruptured tubal ectopic gestation can mimic this condition, with elevated beta HCG levels aiding in the distinction.

Ultrasound is the preferred method for identifying the corpus luteum as a cystic structure, usually ≤3 cm, characterized by thick, crenated hypoechoic walls and internal echoes. Color Doppler imaging reveals the “Ring of Fire,” indicating intense peripheral vascularity ([Fig. 10]). Associated fluid or hemoperitoneum may present as low-level echoes in the pouch of Douglas and other areas. Occasionally, the corpus luteum can exceed 3 cm, exhibiting internal hemorrhage with a fishnet pattern.[45]

Fig. 10 A 20-year-old woman presented with an acute onset of severe right-sided lower abdominal pain. (A and B) Transvaginal ultrasound and Doppler images show a CL cyst in the right ovary (white arrow in A) with peripheral vascularity and hematoma in the right adnexa (white star in A). CT plain (C) and post-contrast (D) images reveal a hyperdense hematoma in the pelvis (black star) with mild hemoperitoneum. Also, CL cyst (white arrow in D) is redemonstrated in the right ovary. Her last menstrual period was 15 days ago, and beta-HCG was negative. These features are consistent with a ruptured right ovarian corpus luteal cyst with pelvic hematoma and hemoperitoneum.

CT scans can quickly identify the source of hemoperitoneum, showing hyperdense fluid in the pelvic or abdominal cavity, with potential active bleeding from the corpus luteum appearing as a hypodense structure with peripheral enhancement during the portal venous phase ([Fig. 10]).[46] MRI is less standard for acute pelvic pain, but can incidentally reveal a hemorrhagic corpus luteum as T1 hypointense and T2 hyperintense, with variable signal intensity depending on blood age. CEMRI can assess dehiscence or rupture in a corpus luteum cyst.[47]

Differentiating hemorrhagic corpus luteum from endometriotic cysts is essential, as the latter shows distinct imaging features.[48] Hemodynamically stable patients can be managed conservatively with pain relief and follow-up scans, while unstable patients may need laparoscopic drainage and cystectomy.[49]

Rupture of ovarian dermoid cyst is a rare(1-2%) but recognized complication. Patients present with sudden onset, severe abdominal pain, and distension due to spillage of cyst contents. On imaging, the presence of dermoid cysts in the adnexa, along with fat stranding, peritoneal thickening, free-floating fat, and calcifications, will be seen along with free fluid.[50]

Endometriosis

Endometriosis is an estrogen-dependent condition characterized by functional endometrial tissue outside the uterus, affecting mainly women in their reproductive years. It significantly contributes to pelvic pain and infertility. The exact cause is unclear, but theories include retrograde menstruation and immunologic dysfunction. Risk factors include early menarche, short and prolonged menstrual cycles, nulliparity, and a family history of the disease.[51] [52]

Transabdominal ultrasound is less sensitive than transvaginal ultrasound (TVS), which is commonly the first imaging choice in suspected cases due to its accessibility and ability to assess pelvic structures dynamically. MRI offers superior tissue contrast and is especially useful for identifying endometriomas, fibrosis, and complex anatomical distortions.

Endometriomas can present acutely, often in the context of PID, which is more severe and resistant to antibiotics in individuals with endometriosis. Many cases occur after assisted reproductive technologies (ART) within the first year. Imaging may reveal salpingitis, oophoritis, pyosalpinx, and tubo-ovarian abscesses.[53]

The development of acute hematosalpinx can cause acute abdominal pain in patients with endometriosis. On USG, it appears as a tubular cystic lesion in the adnexa with homogeneous ground glass internal echoes ([Fig. 11]).

Fig. 11 A 35-year-old woman presented with acute lower abdominal pain. (A) Ultrasound showing a tubular cyst lesion with homogeneous internal echoes and multiple small septae (marked by a white star)—suggestive of hematosalphinx. (B) Transvaginal ultrasound image shows heterogeneous myometrial echoes and cysts (annotated in B) in subserosal location consistent with a solid invasive form of deep pelvic endometriosis.

Endometriomas are also prone to infections due to their impaired local immunity and rich blood content. Infection routes include ascending infections from the genital tract, hematogenous spread, and direct inoculation during procedures. Signs of infection on imaging include increased wall thickness, low-attenuation cystic masses on CT scans, and diffusion restriction on MRI.[52] [53] [54]

Though rare, the rupture of endometriotic cysts can lead to acute abdominal symptoms similar to hemorrhagic ovarian cyst rupture. Imaging with ultrasound and CT may suggest rupture, while MRI is the most specific. It shows loss of signal characteristics, distorted cyst contours, and hemorrhagic ascites ([Fig. 12]).

Fig. 12 A 36-year-old female with a history of endometriosis cysts in the right ovary presented with the acute onset of lower abdominal pain. On MRI, the pelvis axial T2W imaging (A and B) and T1 FS (C) show an irregular, partially collapsed cyst (white arrow in A and C) with T2 hypointense and T1 hyperintense contents within. Free fluid with blood fluid levels and T1 hyperintense contents are noted within the pouch of Douglas and peritoneal cavity (black arrow in B and C). Also note the extensive inflammatory changes in the pelvis (white star in A and C). These features are consistent with rupture of an endometriotic cyst with hemoperitoneum and reactive pelvic inflammatory changes.

Torsion of endometriomas is uncommon but may occur in cases of hematosalpinx. MRI findings typically show high T1-weighted signals due to hemorrhagic content and a lack of typical T2 shading in other endometriotic lesions.[53]

Differential diagnoses include hemorrhagic ovarian cysts, dermoid cysts, and mucinous tumors. Hemorrhagic cysts typically have a lace-like internal pattern on ultrasound. Dermoids show fat suppression and chemical shift artefacts. If an infection is suspected, a tubo-ovarian abscess should be ruled out. In a ruptured corpus luteum cyst, hemoperitoneum may appear as an intermediate signal on T1-weighted sequences, with a high-signal clot present.

Acute Complications of Fibroids

Fibroids are benign lesions of the myometrium and are the most common gynecological neoplasms, with the incidence of up to 20 to 40% in women of reproductive age.[55] While many fibroids are asymptomatic and detected incidentally during pelvic imaging, approximately 20 to 50% of women with fibroids will have symptoms such as abnormal uterine bleeding and pelvic pain.[56] The pain due to fibroids is often chronic.

Very rarely, fibroids can cause acute symptoms and present as an acute abdomen. Acute complications of fibroids include torsion of pedunculated subserosal fibroids, prolapse of pedunculated submucosal fibroids, degeneration, spontaneous hemorrhage from fibroids, and pyomyoma.

Ultrasound is the initial investigation of choice in patients presenting with gynecological symptoms.[57] However, CT, although not an appropriate method for evaluating fibroids, is performed as the initial investigation in some patients due to the clinical symptoms of an acute abdomen.

In ultrasound, the fibroids appear as well-encapsulated heterogeneous masses with dense posterior shadowing and predominant peripheral vascularity. While ultrasound has high diagnostic accuracy in detecting fibroids, its role is limited in further characterizing them and identifying associated complications.

MRI is the most accurate investigation to diagnose complications associated with fibroids because of the better soft tissue contrast and ability to demonstrate enhancement characteristics.[57]

Torsion of Pedunculated Subserosal Fibroid

Pedunculated subserosal fibroids with a narrow pedicle are prone to torsion and present with the acute onset of lower abdominal pain, nausea, and vomiting. On imaging, the diagnostic feature is a pedunculated subserosal fibroid with twisting of its pedicle identified by a “whirlpool” or “swirl” sign. Due to a narrow pedicle, the diagnosis of torsion is often challenging with ultrasound, and further imaging with CT or MRI is required.[58] In the majority of cases, the fibroids show no blood flow on Doppler USG and no enhancement on post-contrast MR images ([Fig. 13]). The close differential is a solid ovarian lesion with torsion.

Fig. 13 A 30-year-old nulliparous woman presented with an acute onset of severe lower abdominal pain for 2 days. (A and B) Transabdominal ultrasonogram image shows a large subserosal fibroid with no internal vascularity (white star). T2 sagittal (C) and T2 axial (D) MR images show a pedunculated anterior subserosal fibroid (black star in C and D) with twisting of its narrow pedicle (marked by white arrow in D). On post-contrast images, it shows that the majority of the lesion is nonenhancing (white star in E). Also note the surrounding inflammatory changes (black star in E). The findings are consistent with torsion of a pedunculated subserosal fibroid with infarction.

Pedunculated subserosal fibroids with torsion are managed by emergency laparotomy and excision.

Degeneration of Fibroid

Degeneration of the fibroid occurs when the fibroid outgrows its blood supply. Depending on the degree of blood loss, the type of degeneration varies. The degeneration that most commonly presents with acute symptoms is red degeneration. It commonly occurs during pregnancy due to the thrombosis of the veins in the periphery of the lesion. Diagnosis is based on the clinical symptoms and imaging characteristics. MRI is the most accurate investigation to diagnose red degeneration. Fibroids with red degeneration will appear hyperintense on T1 and T2 with no enhancement on post-contrast images[59] ([Fig. 14]).

Fig. 14 A 40-year-old lady presented with severe lower abdominal pain for 4 days. (A) Transabdominal ultrasonography image shows an intramural fibroid (black star in A). MRI was done for further characterization. On MRI, the fibroid is predominantly hyperintense on T2 and T1 (black star in B and C, respectively). On post-contrast T1 fat-saturated images, the fibroid shows a large central nonenhancing area (black star in D) corresponding to T1 and T2 hyperintensity with minimal peripheral enhancement—suggestive of red degeneration of fibroid.

Prolapse of Pedunculated Submucosal Fibroid

Prolapse of the pedunculated submucosal fibroid can present with an acute onset of severe lower abdominal pain and heavy vaginal bleeding.

On ultrasound, the diagnostic feature is the presence of a heterogeneous polypoidal soft tissue lesion with the endometrial cavity extending to the cervical canal and into the vagina in some cases, with a vascular pedicle attached to the uterine wall extending to the myometrium with focal disruption of the endometrial–myometrial junction. Post-contrast MR images accurately demonstrate areas of necrosis if present. Treatment usually consists of myomectomy or hysterectomy.[60]

Spontaneous Intraperitoneal Hemorrhage from a Fibroid

Spontaneous intraperitoneal hemorrhage from a fibroid is an infrequent, life-threatening complication. It commonly occurs due to the spontaneous rupture of the subserosal vein overlying the fibroid. Sudden increase in intra-abdominal pressure, as happens during defecation or lifting heavy weights, is postulated to be a potential predisposing factor.[61] Patients commonly present with an acute onset of severe lower abdominal pain, dizziness, and features of hypovolemic shock. Imaging reveals a pelvic hematoma and a variable amount of hemoperitoneum. However, it is difficult to ascertain the source of bleeding in all cases.

The presence of hemoperitoneum and hemodynamic instability is an indication for emergency laparotomy.[62]

Pyomyoma

Pyomyoma is an infrequent, life-threatening complication of a fibroid that occurs due to infection of a necrotic focus within a fibroid. The predisposing factors include post-pregnancy, post abortion, curettage, cervical stenosis, and immunodeficiency.[63] Typical clinical features include sepsis, leiomyoma, and absence of any other source of infection. On USG, pyomyoma appears as a well-encapsulated lesion with echogenic foci suggestive of air within. CT confirms the presence of air within the fibroid, and MRI, it appears as a T2 hyperintense lesion with signal voids suggestive of air within and peripheral rim enhancement ([Fig. 15]). A serious complication of pyomyoma is spontaneous rupture leading to peritonitis. Early diagnosis and prompt management with antibiotics and myomectomy or hysterectomy are essential to avoid mortality.[64]

Fig. 15 A 40-year-old nonpregnant woman presented with an acute onset of severe lower abdominal pain for 4 days with no history of prior surgery/dilation or curettage. Transabdominal ultrasound showed an area of air pockets within the myometrium with dirty posterior shadowing (black star in A). Further evaluation with CT and MRI confirmed the intramural lesion with air pockets within (white star in B and C, respectively), with surrounding inflammatory changes. Diagnosis: Spontaneous pyomyoma of an intramural fibroid. Final HPE showed fibroid with infarction and multiple gram-positive bacteria within—suggestive of pyomyoma.

Pyometra and Hematometra

Pyometra is a rare condition characterized by pus accumulation in the endometrial cavity. It can result from obstructive cervical masses or cervical stenosis after radiation therapy, endometritis, and secondary infection of retained products of conception in postpartum patients.[65] Symptoms include whitish vaginal discharge, pelvic pain, and postmenopausal bleeding. In severe cases, it can lead to uterine rupture and peritonitis ([Fig. 16]).

Fig. 16 A 25-year-old woman post-lower segment caesarean section day 9 presented with severe abdominal pain. Reformatted contrast-enhanced CT scan sagittal image (A) shows an enlarged uterus with a thin imperceptible anterior uterine wall (thick white arrow). Coronal and axial images (B, C) show a distended uterine cavity filled with hypodense fluid (white stars) with a few air foci within. Hypodense ascitic fluid is also present (thin white arrow). Diagnosis of pyometra with uterine perforation was made, which was confirmed on laparotomy.

Diagnosis typically involves an ultrasound, revealing a distended uterine cavity with heterogeneous hyperechoic fluid. CT scans show hypodense fluid with parametrial fat stranding, while MRI can highlight restricted diffusion and better assess the cervical region.[66] [67] Management consists of drainage, either vaginally or percutaneously, and patients with ruptured pyometra require emergency surgery, including laparotomy and hysterectomy.

Hematometra is a rare cause of lower abdominal and pelvic pain due to blood accumulation in the uterine cavity. In young adults, it often results from obstructed Müllerian anomalies, while in older patients, it may be due to cervical stenosis from gynecological procedures or malignancy.[68] Patients with Müllerian anomalies typically present with primary amenorrhea and cyclical pain, while those with septate or bicornuate uteri may experience severe dysmenorrhea ([Fig. 17]).

Fig. 17 A 17-year-old girl presented with severe dysmenorrhea T2-weighted sagittal and coronal images. (A, B) Complete septate uterus with a distended left-sided uterine cavity due to obstruction by a transverse vaginal septum (thick white arrows). Right-sided uterine cavity is usually communicating to the vagina (thin white arrow). T1W fat-saturated axial images (C, D) show hyperintense contents in the distended left uterine cavity, suggestive of blood product (hematometra) (black star). Hyperintense contents are also seen in the dilated left fallopian tube, suggestive of hematosalpinx (black arrow). Screening of the upper abdomen revealed no renal anomalies.

Ultrasound reveals a homogeneous hypoechoic collection in the distended uterine cavity. MRI is the preferred imaging method, showing a distended cavity with hyperintense collections on T1-weighted images and detailed anatomy on T2-weighted images to assess the type of anomaly and other causes[69]

Uterine Rupture

Iatrogenic gynecological emergencies arise from procedures involving the reproductive system, such as dilatation and curettage or lower segment caesarean section. Early identification and management are crucial to reduce maternal mortality. When using ultrasound, a systematic outer-to-inner approach should be employed to assess the scar site with a high-frequency probe.[17] While a few air foci are typical, a heterogeneous collection may indicate a hematoma or abscess. Hematomas can appear hyperechoic in the acute phase and anechoic in the chronic phase, making it essential to locate them for effective management.

Subcutaneous plane hematoma occurs at the scar site above the rectus abdominis muscle, often involving the lower epigastric arteries. Rectus sheath hematoma forms within the rectus abdominis muscle, while subfascial hematoma (SFH) is located just deep to the rectus and superficial to the peritoneum. Bladder flap hematoma (BFH) occurs between the bladder and lower uterine segment and is extraperitoneal ([Fig. 18]). A BFH greater than 5 cm can increase the risk of uterine dehiscence and may require surgery, whereas one less than 4 cm is typically insignificant.[18] Long-standing hematomas can become infected, potentially leading to a loculated pelvic abscess, characterized by symptoms such as fever and discharge of pus.

Fig. 18 A 38-year-old woman, 7 days post-lower segment caesarean section, with local site pain and swelling. (A, B) Axial NCCT images show a hyperdense hematoma located in the space between the urinary bladder and lower uterine segment (blue star), along with rectus sheath hematoma (red star) (C, D). NCCT and (E) CECT sagittal images confirm the bladder flap (red arrow) and rectus sheath (yellow arrow) hematomas.

Uterine dehiscence is the separation of the endometrium and myometrium with an intact serosa. In contrast, uterine rupture involves a complete disruption of the wall, including the serosa, resulting in a connection between the endometrial and peritoneal cavities. Ultrasound shows a defect in the lower uterine segment (LUS) along with adjacent fluid and hemoperitoneum. A continuous pathway between the endometrium and the extrauterine collection, as seen on CT or MRI, is diagnostic ([Fig. 19]). The presence of gaps in the uterine defect suggests rupture. Dehiscence typically requires conservative management, whereas rupture necessitates urgent surgery.

Fig. 19 A 32-year-old woman, day 8 post-lower segment caesarean section, with lower abdominal pain, distension, and bleeding per vaginum. Axial and sagittal CECT images show a defect in the LUS at the scar site (arrow) and adjacent collection (asterisk). Anterior to the uterus and in the POD (blue arrow), uterine rupture.

Vascular Complications

Vascular complications in patients with vaginal bleeding may involve a uterine artery pseudoaneurysm (UAP). A color Doppler can identify UAP by showing a yin-yang sign (bidirectional flow). For anatomical details needed for urgent transcatheter angioembolization ([Fig. 20]), CT angiography is preferred. Rupture risk increases if the UAP diameter exceeds 2 cm.[70] Also, uterine arteriovenous fistula can occur after any intrauterine procedures, presents with heavy bleeding, and requires angioembolization. [Table 4] summarizes the key clinical and imaging pointers for diagnosing common gynecological emergencies.

Table 4 Key clinical and imaging pointers for diagnosing acute gynecological conditions

Acute gynecological emergency	Clinical presentation	Imaging findings	Key points for diagnosis
Ectopic pregnancy	Amenorrhea followed by irregular bleeding and acute abdominal pain	Heteroechoic adnexal lesion with pelvic hematoma, hemoperitoneum, and tubal ring sign	Elevated beta HCG levels Absent intrauterine pregnancy and adnexal lesion
Ruptured corpus luteal cyst	Acute lower abdominal pain in the midcycle (ovulatory phase)	USG showing cystic lesion with thick crenated margins, with Doppler showing “Ring of Fire” appearance, pelvic hematoma, and hemoperitoneum	Mid-cycle lower abdominal pain with imaging features of CL cyst and pelvic hematoma/hemoperitoneum
Adnexal torsion	Acute onset of unilateral lower abdominal pain is often associated with nausea and vomiting	Enlarged ovary with stromal edema and thickening and twisting of the pedicle. Often associated with benign lesions as a lead point. Absent vascularity	Acute unilateral lower abdominal pain with nausea and vomiting, with imaging showing features of torsion. Characterization of the associated lesion is crucial to plan the management
Pelvic inflammatory disease	Lower abdominal pain with systemic signs of infection	Diffuse smooth wall thickening of fallopian tubes with echogenic contents within - suggestive of pyosalpinx and surrounding inflammatory changes and collections. In MRI, smooth enhancement with wall thickening of the fallopian tubes with central restriction in diffusion	Abdominal pain with systemic signs of infection and imaging showing inflammatory changes in the pelvis with associated pyosalpinx and pelvic collections
Red degeneration of fibroids	Acute onset of lower abdominal pain in a patient with a fibroid. Commonly seen in pregnancy	MRI is the most accurate modality to diagnose degeneration. On MRI, the fibroid will appear hyperintense on T1 and T2 with no enhancement—suggestive of red degeneration	Common cause of lower abdominal pain in patients with fibroids complicating pregnancy. Classical features of MRI help to establish the diagnosis
Torsion of a pedunculated subserosal fibroid	Acute onset of severe lower abdominal pain	Pedunculated subserosal fibroid with no internal vascularity. MRI better demonstrates the twisting of the fibroid pedicle	Torsion of the fibroid should be suspected in patients with an acute onset of severe lower abdominal pain with pedunculated subserosal fibroids with a narrow pedicle
Ovarian hyperstimulation syndrome (OHSS)	Seen in patients undergoing assisted reproductive technologies (ART). Patients present with abdominal distension and bloating	USG revealed enlarged ovaries with multiple follicles arranged in a “spoke-wheel” pattern. Severe cases will have ascites and pleural effusion	High index of suspicion for OHSS in patients undergoing ART helps in the prompt initiation of treatment to avoid progression to severe disease

Fig. 20 A 26-year-old woman, 1.5 months post-lower segment caesarean section with vaginal bleeding and anemia. (A, B) CECT demonstrates a focal contrast-filled outpouching at the left lateral aspect of the uterus. The coronal MIP image illustrates the connection between this pseudoaneurysm (arrow) and the left uterine artery (C, D). Pre- and post-transcatheter angioembolization show significant improvement. Left uterine artery pseudoaneurysm.

Conclusion

When acute gynecological conditions are suspected, imaging findings must be interpreted alongside the patient's clinical presentation. Key information, like the date of the last menstrual period, is crucial for diagnosing many acute gynecological conditions. Ultrasound is the initial imaging modality of choice for most gynecologic emergencies, with MRI reserved for cases with inconclusive findings. Familiarity with clinical presentations and imaging is essential for accurate diagnosis and optimal patient care.

Conflict of Interest

None declared.

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Publication History

Article published online:
28 November 2025