ABSTRACT
This research is aimed at assessing the common ultrasound findings in patient with pelvic pain. A retrospective study was done in Enugu scan centre, Ket, life chart and St.Michael diagnostic centres in Enugu. 1044 patients were scanned for pelvic pain from September 2010 to September 2011. The sonographic report showed that 442(42.34%) had uterine pathologies, 332(31.80%) had ovarian pathologies, 108(10.34%) had colon pathologies, 95(9.10%) had bladder problems and 67(6.42%) had prostate pathologies. It was also found that the incidence of pelvic pain was greater in females than in males.
TABLE OF CONTENT
Title page – – – – – – – – -i
Dedication – – – – – – – – -ii
Acknowledgement – – – – – – -iii
Abstract – – – – – – – – -iv
Table of content – – – – – – – -v
CHAPTER ONE
- Introduction – – – – – – – -1
1.1 Background of Study – – – – – – -1
1.2 Statement of Problem – – – – – – -2
1.3 Purpose of Study – – – – – – -3
1.4 Significance of Study – – – – – – -4
1.5 Scope of Study – – – – – – – -4
1.6 Literature Review – – – – – – -4
CHAPTER TWO: THEORETICAL BACKGROUND
2.0 Introduction – – – – – – – -13
2.1 Principal of Operation – – – – – -13
2.2 Type of Ultrasound used – – – – – -13
2.3 Indication to Pelvic Ultrasound – – – – -16
2.4 Anatomy of the Pelvis – – – – – -17
2.5 Functions of Pelvis – – – – – – -21
2.6 Pelvic Pain in women – – – – – – -23
2.7 Pelvic Pain in Men – – – – – – -24
CHAPTER THREE
- Research Methods – – – – – – -26
3.1 Research Design – – – – – – -26
3.2 Population Study – – – – – – -26
3.3 Source of data for the study – – – – – -26
3.4 Method of data Collection – – – – – -26
3.5 Data Analysis – – – – – – – -26
CHAPTER FOUR
Data Presentation and result – – – – – -27
CHAPTER FIVE
5.0 Discussion – – – – – – – -36
5.1 Summary of Findings – – – – – -38
5.2 Limitation of findings – – – – – -39
5.3 Recommendation – – – – – – -39
5.4 Conclusion – – – – – – – -40
5.5 Area for further study – – – – – – -40
Reference
CHAPTER ONE
1.0 INTRODUCTION
1.1 BACKGROUND OF SYUDY
Pelvic pain is defined as pain that occurs below the umbilicus (belly button) to the lower border of the symphysis pubis. [1] It is not a disease, rather, a symptom that can be caused by several different conditions. It can affect both women and men. The pain may indicate the existence of poorly-understood conditions that likely represent abnormal psychoneuromuscular function. When this pain persists for a period of 3 months or more, it is to be considered chronic while less than this duration is considered acute. Acute pain is most commonly experienced by patients after surgery or other soft tissue traumas. It tends to be immediate, severe and short lived. [2]Chronic pelvic pain (CPP) accounts for 10% of all visits to gynecologists. [3]
Pelvic pain can be a sign that there is a problem with one of the organs in the pelvic area, such as the uterus, prostate, ovaries, fallopian tubes, cervix or vagina etc. It could also be a symptom of infection, or a problem with the urinary tract, lower intestines, rectum, muscle or bone. [4]
Ultrasonography or ultrasound (US) is becoming increasingly used as the investigation of choice in many years for pelvic pain diagnosis.Ultrasound (US) is a medical imaging modality that uses high frequency sound waves and their echoes to obtain images of tissues, organs etc. [5] pelvic ultrasound is an important diagnostic tool for evaluation of many structures in the pelvis. Some of the indications for pelvic ultrasound includes: pelvic pain, abnormal vaginal bleeding, and suspicion of an abnormality on a manual gynecologic examination. Other diagnostic imaging modalities may also be helpful in identifying the cause(s) of pelvic pain such as magnetic resonance image (MRI), computerized tomography (CT), and Radionuclide image.US modality is relatively inexpensive and portable, especially when compared with other modalities, such as MRI, CT etc. [6] As currently applied in the medical field, properly performed ultrasound poses no known risks to the patient.[7] US is generally described as a “safe test” because it does not use mutagenic ionizing radiation, which can pose hazards such as chromosome breakage and cancer development, it also causes little or no discomfort to the patient. [8]
1.2 STATEMENT OF PROBLEM
- Following the increasing demand for ultrasound in the diagnosis of pelvic pain, the researcher observed that the common ultrasound findings in patients with pelvic pain in Enugu metropolis are yet to be ascertained and documented.
- The ultrasound findings of patient with pelvic pain have not yet been correlated with gender
- The main reasons for the referral for ultrasound pelvic scan have not been identified in this locality.
1.3 PURPOSE OF THE STUDY
1.3.1 GENERAL PURPOSE
- To analyze the common ultrasound findings in patients that present with pelvic pain
1.3.2 SPECIFIC OBJECTIVES
- To ascertain and document the commonest ultrasound findings in patient with pelvic pain.
- To correlate the ultrasound findings of patient with pelvic pain with gender.
- To determine the main reason for the referral for ultrasound pelvic scan
1.4 SIGNIFICANCE OF STUDY
- The outcome of this project will serve as a guide to sonographers while scanning for accurate and easy diagnosis
- This research aims at providing a databank (safe store) for further evaluation of pelvic pain.
- The result of this work will help to justify and strengthen the use of ultrasound in the diagnosis of patient with pelvic pain
- The result will aid in definitive management of patient with pelvic pain.
1.5 SCOPE OF STUDY
The study was carried out at Enugu scan center, Ket, Life chart and St. Michael diagnostic ultrasound centers all in Enugu metropolis.
1.6 LITERATURE REVIEW
Pelvic ultrasound is frequently performed everywhere in the world, especially in the western societies. [8] The frequency with which relatively inexpensive and non-invasive diagnostic test are performed clearly places a burden on health care. [8] Hence, it is important that their role on patient management is assessed.
The most frequent indications for pelvic ultrasound scanning were Pelvic pain (18%), Dysmenorrhea (2 %),Amenorrhea (2%),Menorrhagia (1%),Metrorrhagia(1%), Menometrorrhagia(1%), Follow-up of a previously detected abnormality (2%), Evaluation, monitoring, and/or treatment of infertility patients (6.5%),Delayed menses, precocious puberty, or vaginal bleeding in a prepubertal child (1.5%), Postmenopausal bleeding (0.5%), Abnormal or technically limited pelvic examination (2%),Signs or symptoms of pelvic infection (6%), Further characterization of a pelvic abnormality noted on another imaging study (3%), Evaluation of congenital anomalies (5%), Excessive bleeding (6%,) pains or signs of infection after pelvic surgery (5%,) delivery or abortion(5%),Localization of an intrauterine contraceptive device (3%), Screening for malignancy in patients at increased risk (6.5%), Urinary incontinence or pelvic organ prolapse(5%). Guidance for interventional or surgical procedures (2%), Prostate cancer (5%) BPH (7%), Prostatitis (4%) [9].
Liddle and Davies [10] opined that chronic pelvic pain is a common and disabling condition affecting women of childbearing age. A specific diagnosis for the condition is often difficult, and referred pain from the abdominal viscera, neurogenic and psychogenic factors has all been implicated. Pelvic congestion syndrome (PCS), the presence of varices of the pelvic veins, has been shown to be the underlying aetiology in a significant Proportion of patients with chronic pelvic pain; the development of these varices is caused by a combination of endocrine and mechanical factors.
Robert et al [11] found out that endometriosis (35%), pelvic varices (25%), adenomyosis (23%), or pelvic adhesions (17%) are the four commonly demonstrated clinically important diseases that cause pelvic pain in women of childbearing age.
Kaakaji et al [12] opined that Pelvic inflammatory disease,ovarian cyst mass, Tubo ovarian torsion, Gastroenteritis, diverticulitis, appendicitis, pyelonephritis, and renal calculi, are the causes of acute pelvic pain in women.
Liliane et al [13] in their research on “Ovarian and Uterine Sonography in Healthy Girls between 1 and 13 Years Old: Correlation of Findings with Age and Pubertal Status” concluded that Uterine and ovarian growth was associated with age and puberty [13].
Mawaldi et al [14] conducted a research on “Validity of Ultrasound in Patients with Acute Pelvic Pain Related to Suspected Ovarian Torsion” from their study; they concluded that the diagnosis of ovarian torsion cannot be exclusively based on ultrasound. Both clinical and sonographic evaluation of acute pelvic pain should be considered for the diagnosis.
Lem and Nolan[15] in their study on “complications of hip arthroplasty simulating pelvic or bladder pathology: sonographic and radiographic findings” discovered that Intrapelvic extrusion of cement or medial migration of prosthetic hardware caused extrinsic compression of the bladder and hence results in pelvic pain.
Bowen and Wyllie [16] reviewed that the causes of Lower abdominal pain in women are bladder or kidney problems, constipation and diarrhoea, problems in the uterus (womb), Fallopian tubes or ovaries, endometriosis, fibroids, pelvic inflammatory disease, ovarian cysts and problems related to the early stages of pregnancy such as a miscarriage or ectopic pregnancy.
Reuter [17] reviewed Chronic Pelvic Pain in Men and the result of his review were Anal fissure, Hemorrhoids, Mental or emotional problems, Nerve problems, Pelvic floor muscle problems, Side effect of past surgery, Prostatitis, Other changes in pelvic organs, cystitis.
The common ultrasound findings in female patients are palpable masses such as ovarian cysts(27) and uterine fibroids(29%), ovarian(23%) or uterine cancers(21%). [18]
Long et al [19] evaluated common Sonographic findings in the painful hip after hip arthroplasty and concluded that sequel to the fact that total hip replacement is one of the most common orthopedic surgeries with more than 120,000 primary arthroplasties performed in the United States annually however, pelvic pain after the procedure is a difficult problem for orthopedic surgeons to diagnose and treat.
Donald [20] reported that Corpus luteal cysts are the second most common type of functional ovarian cyst and arguably the most clinically significant. Patients with symptomatic luteal cysts present with complaints related to pelvic pain or mass or due to hormonal effects.
Kennedy [21] assessed the value of ultrasound in patients with acute onset of abdominal pain and opined that lower abdominal pain is a common cause of pelvic pain.
Ursu [22] evaluated the findings on pelvic pain ultrasound and concluded that the common finding on pelvic ultrasound is fibroid (30.3%), ovarian cyst (20.7%) and polyps (7.2%) and other conditions (40.8%).
Bau and Atri [23] reviewed that the ultrasound findings in acute pelvic pain in women is ectopic pregnancy, appendicitis, diverticulitis, and incarcerated hernia, which are important differential considerations.
Dee H[24] in his findings recorded that in 17 of 41 patient (41%) myomas were diagnosed, 5 patients had large myomas more than 10cm in diameter, 4 of which (80%) were diagnosed prior to ultrasound exam.
Douglas RG [25] in his research was able to correlate not only the size of myomas with the outcome of pregnancy but also the relationship between the placenta site and the myomas. The finding suggested that patients in whom the placenta is near a myoma form a special sub group which is at risk of complication such as premature rapture of membranes, anterpertum bleeding and post partum haemorrhage. He also indicated in his study that the location of myoma especially its relationship to the placenta site is more significant than its actual size in predicting pregnancy without harming the mother and foetus. Leiomyoma of the uterus are usually multiple and of various sizes. A solitary node is found in only 2% of patient, the number of tumours in the uterus ay reach hundreds. The size ranges from microscopic to massive with hundred pounds being the largest single fibroid reported as the tumours increase in size it may out grow the blood vessel and ischemia is followed by various stages of degeneration. It has been estimated that the usual clinical picture is a palpable mass but leiomyoma is associated with excessive menstrual bleeding and pelvic pain.
Ejeeka G.V [26] analyzed tumours of the genital tract. He found out that there were total of 556 gynaecological tumours in the reviewed period. This figure represents 20.11% of all registered tumours in the reviewed period. There were 319 malignant and 247 benign tumours. The commonest of all the benign was found to be uterine fibroid (53.4%) V.E Egwuatu [26] in his study recorded that fertility and pregnancy out come among 141 women with uterine fibroid and 270 married, gynaecological subject matched for age and parity were studied. The average among 68 women in the study group who have previously been pregnant were 5.3% and 56% microscopic evidence of pelvic repsis was found at operation in 36.2% of all women in the study group and in 57.7% those who complained additionally of infertility.
White and wrigth [27] opined that fibroids are usually multiple although up to 20% of small fibroids may no be demonstrated by ultrasound. They also asserted that distortion of the endometrial cavity echo is helpful in identifying smaller submucous fibroids and that associated Menorrhagia may cause a prominent endometrial echo. They also found out that in histerosalpingography (HSG) submucosal fibroids are especially likely to cause distortion of the uterine cavity while subserosal and small intramural fibroids are often associated with a normal histerosalpingographic appearance.
Jacobson [28] in his findings recovered that ultrasound is the commonest method of providing confirmation of the steno the diagnosis. Magnetic resonance imaging (MRI) and computed tomography (C.T) may provide further information and help in distinguishing uterine fibroid modification in ultrasound diagnosis of gynaecologic patient. Some of which an abdominal salpingography and high frequency intralunation ultrasound. However, transvaginal ultrasound is preferable especially in the examination of retroverted ultrasound in case like cervical cancer growing into the cervical canal, Stenosis fibroyomata fibroid endometrial cancer, tumour growth in to the endometrial cavity transabdominal sonography has been an advantage because the probe in transvaginal cannot reach the fundus of the uterus.
Louis Kreel [29] explained indication for sonography as well in the sonographic appearance of the uterus in pathological condition. As a result it became a routine to visualize the uterus first like any other organ.
There are in a nut shell, certain pit fall encountered in the sonographic scan of the pelvis, organs in the pelvic these include empty bladder foreign bodies in the pelvis gas shadow, the fundus of the retroverted uterus this is because, sometimes they may prevent as pathology.
Furthermore the origin of large pelvic mass may be difficult to determine or visualize, subseros and broad ligament fibroids may mimic ovine or the adnexal mass, a bicoruate ultras may appear to be a normal uterine body with an adject fibroid. Sometimes pedunculated fibroids may be hard to visualize besides the fact that the facility or equipment matters, expertise of the sonographer can not be left out there are also other technical limitation if all those limitation are noted and well taken care off ultrasonic findings would be very accurate.
However, there has been a rise in the incidence of uterine fibroids among woman of child bearing age in this locality as observed by the researcher during clinical posting hence the need to correct ultrasound findings with surgical findings in other to evaluate the accuracy of ultrasound in the diagnosis uterine fibroids.
Literatures on common ultrasound findings have not yet being published in this part of the world. The literatures found have conflicting idea, probably because of the location of the scan, the sonographers experience, visual acuity and level of education and the type of ultrasound machine used for the scan.
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