Diagnostic and Interventional Imaging (2015) 96, 1065—1075

CONTINUING EDUCATION PROGRAM: FOCUS. . .

Postoperative pelvic pain: An imagingapproach

H. Faraha,∗, N. Laurenta, J. Phalippoub, M. Bazotc,G. Giraudetd, T. Serba, E. Ponceleta

a Service d’imagerie de la femme, centre hospitalier de Valenciennes, avenue Désandrouin,59300 Valenciennes, Franceb Service de chirurgie gynécologique et mammaire, centre hospitalier de Valenciennes,avenue Désandrouin, 59300 Valenciennes, Francec Service d’imagerie, hôpital Tenon, AP—HP, 4, rue de la Chine, 75020 Paris, Franced Service de chirurgie gynécologique, université de Lille Nord-de-France, hôpitalJeanne-de-Flandre, CHRU de Lille, 59000 Lille, France

KEYWORDSPelvis;Pain;Postoperative;MRI;Scan

Abstract Postoperative pelvic pain after gynecological surgery is a readily detected butunspecific sign of complication. Imaging as a complement to physical examination helps estab-lish the etiological diagnosis. In the context of emergency surgery, vascular, urinary anddigestive injuries constitute the most frequent intraoperative complications. During the follow-up of patients who had undergone pelvic surgery, imaging should be performed to detectrecurrent disease, postoperative fibrosis, adhesions and more specific complications relatedto prosthetic material. Current guidelines recommend using pelvic ultrasonography as the firstline imaging modality whereas the use of pelvic computed tomography and/or magnetic res-onance imaging should be restricted to specific situations, depending on local availability ofequipment and suspected disease.

© 2015 Éditions francaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

One must differentiate between acute postoperative pelvic pain, which generally reflects

an urgent complication related to peritoneal irritation (bleeding, perforation of a holloworgan, collection, obstruction), and later postoperative pelvic pain secondary to surgery.Imaging usually makes it possible to make an etiological diagnosis of postoperative pain andcomplications. The advantages of ultrasound are its accessibility and its low cost, and it

∗ Corresponding author.E-mail address: hedifarah3@gmail.com (H. Farah).

http://dx.doi.org/10.1016/j.diii.2015.07.0082211-5684/© 2015 Éditions francaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

1 H. Farah et al.

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emains the first-line test in patient with pelvic pain [1].onversely, computed tomography (CT) and magnetic res-nance imaging (MRI) are often performed in second line2]. In the emergency context, CT may be indicated inrst line in case of acute hemorrhage, suspicion of a uri-ary/digestive wound or gastrointestinal obstruction. Inatient with chronic pelvic pain, the combination of ultra-ound and MRI is the most relevant in the etiological inquiry,articularly to screen for scar tissue fibrosis, adhesions,ecurrences, or complications specific to certain prostheticaterials, in treatment for disorders of pelvic stability [3].

cute complication

ematoma

emorrhagic complications after pelvic surgery are rareanging between 1.1% and 4.1% [4,5]. The complicationate is greater in case of laparotomy or cancer surgery.ascular injury is the most serious hemorrhagic situationnd requires emergency secondary surgery, often with-ut imaging in case of hemodynamic instability of theatient. For stable patients, CT makes it possible tocreen for active leakage of iodinated contrast material.anagement involves pelvic arterial embolization in theseatients.

Postoperative hematoma, however, is more commonlyepicted with ultrasound (Fig. 1) or CT (Fig. 2). Inase of hemodynamic stability, clinical monitoring withr without radiological monitoring is sufficient. Secondaryurgery is considered in case of complicated hematoma [2].ematomas have a tendency to become infected (Fig. 3),hich may require percutaneous radiological drainage or a

epeat surgery. In the presence of prosthetic material, theemoval of the material is recommended [6].

igure 2. Unenhanced CT scan shows hematoma after hysterectomy inn abdominal wall hematoma (arrow); b: CT in the sagittal plane confirm

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igure 1. Endovaginal ultrasound in sagittal plane shows intrav-ginal hematoma after surgery for prolapses (arrow).

nfection

nfections occur in less than 1% of cases of suburethral bandsn surgery for stress urinary incontinence [7]. In gynecolog-cal cancer surgery, the celioscopic route presents fewernfections than the laparotomy route [8]. Post-hysteroscopynfections are uncommon (0.2%) [9]. In case of clinical sus-icion of postoperative infection, ultrasound and CT areainly used to screen for signs of pelvic abscess or collection

Fig. 4).In the absence of diagnosis and treatment, postoperative

nfections may develop into pelvic peritonitis. Postoper-tive infections may be responsible for sequellae in theorm of uterine synechiae, hydrosalpinx, tubal stenosis,ith an increased risk of infertility or of secondary ectopicregnancy.

woman presenting with pelvic pain: a: in the axial plane, CT showss hematoma of Douglas pouch (arrow).

he rate of perforation is approximately 1% [9]. Perforationan be caused by a lack of visibility, fragility of the uterine

Postoperative pelvic pain: An imaging approach 1067

Figure 3. Superinfected hematoma (white arrow) complicated by ascites (black arrows) after oocyte puncture; axial view of transabdom-inal pelvic ultrasound (a); axial view of contrast-enhanced CT scan (b).

Figure 4. CT scan of salpingitis and painful ovarian cyst after hysteroscopy. Axial view (a) and coronal view (b) show hypoattenuatingoatte

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ovarian left cyst (white arrow) associated with an abnormal hypsalpingitis (black arrow).

walls or a surgical procedure. The proximity of digestive andurinary structures can cause injuries of these organs andentrapments [10].

On ultrasound as on MRI, in case of perforation, one cancontinuously visualize a solution transfixing the myometriumwith an adjacent intraperitoneal hematoma (Fig. 5). In caseof ultrasound-based suspicion of entrapment, MRI is partic-ularly helpful to confirm the fatty nature of the entrappedepiploic fringes (Fig. 6).

Injury to nearby organs

BladderUrological risks in the form of injuries of the urethra orbladder are more commonly encountered in cancer surgery,

endometriosis, and treatment of urinary incontinence or ofpelvic stability disorder. Bladder and urethral injuries arethe most common complication of suburethral bands; theprevalence is evaluated at 5% and may reach up to 24% [7].

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nuating visible fallopian tube with contrast uptake suggesting a

Urethrovaginal fistulas are rare. They may be secondaryo suburethral bands that are too tight, leading to erosion.his causes pain as well as major urinary functional signs11]. The clinical assessment orients toward this diagnosisnd should be confirmed by cystoscopy. CT (Fig. 7a) andystography (Fig. 7b) may help in making the diagnosis.

After hysterectomy, the risk of injury increases to 2.2%12]. When the diagnosis is made intraoperatively, the blad-er is sutured and a resting urinary catheter is set up for 8 to0 days. A cystography verifies the absence of urinary fistulaefore removal of the catheter. In a postoperative context,esting for a urinoma requires the conduct of a urinary scan.

igestiveigestive injuries and perforations are rare during gyneco-

ogical surgery (<1%) but serious. An intraoperative diagnosiss often made, but it is sometimes revealed later by a peri-onitis or an obstruction. CT is often necessary to confirmerforation. Direct signs of organ injury are presence of a

1068 H. Farah et al.

Figure 5. Uterine perforation with collected hematoma of Douglas pouch. Sagittal view (a) of an endovaginal ultrasound shows a hypere-choic continuity solution in the uterine fundus corresponding to the perforation (black arrow) associated with a posterior collected hematoma(white arrow), without Doppler signal on the axial view (b). Sagittal view of a T1-weighted (c) and a gadolinium-chelate enhanced T1-weighted fat suppressed MR image (d) confirm the perforation with a hyperintense path transfixing the myometrium until the serosa withoutuptake of contrast material.

Figure 6. Uterine perforation with incarcerated sigmoidal omental fat (black arrow) after hysteroscopy for retained placenta. T1-weighted(a) and T1-weighted fat suppressed MR image in the axial plane (b) confirming fat nature of the sigmoidal omental that shows hypersignalthen hyposignal after fat saturation.

Figure 7. CT scan of a post-operative uretro-vaginal fistula on delayed phase (a) and cystoscopy (b) showing extravasation of contrastmaterial in the vagina (white arrow).

Postoperative pelvic pain: An imaging approach 1069

Figure 8. Non-enhanced CT scan in a patient with rectal wound after bilateral adnexectomy. Sagittal view (a) and axial view (b): hydroaericcollection of Douglas pouch (white arrow) and aeric tone continuity solution (black arrow).

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Figure 9. Lymphoceles. a: CT scan showing bilateral lymphocelesplane shows hyperintense lymphocele under external iliac right vei

water-gas collection that indicates the presence of pneu-moperitoneum (Fig. 8) [2].

Lymphocele

Gynecological cancer surgery often requires pelvic and/orlumbo-aortic lymph curettage. Postoperative lymphocelesare symptomatic in 8 to 10% of cases [13]. The diagnosisis initially based on ultrasound, but requires CT or the MRI(Fig. 9) because it is important to determine their relation-ships with subperitoneal vessels, to avoid confusing themwith a collection of another nature, particularly intraperi-toneal.

Management is based on percutaneous drainage, whichis performed under ultrasound or CT guidance. In case ofrecurrence or failure, surgical drainage should be planned.

Postpartum deep thrombophlebitis

The right ovarian vein drains into the inferior vena cava,

whereas the left one drains into the left renal vein. Post-partum thrombophlebites of the ovarian vein — particularlyon the right due to this anatomical specificity — can belife-threatening through the occurrence of a pulmonary

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r external iliac veins (arrow); b: T2-weighted MR image in the axialtted arrow).

mbolism or septic shock with a mortality of approximately% [14,15].

In case of pelvic pain associated with fever post-partum,ne should know how to detect thrombophlebitis andnfectious pathology. An emergency CT examination usingntravenous administration of iodinated contrast material ishe key test for etiological diagnosis (Fig. 10). Treatment isased on antibiotics and anticoagulants.

extiloma

extiloma (also referred to gossypiboma or retained for-ign object) has an incidence ranging between 1/1000 and/15,000 [16]. Protocols for counting compresses, which areurrently radio-opaque, make it possible to minimize thisomplication. In patients with suspected textiloma, imagings helpful for the diagnosis (Fig. 11).

hronic complication

carring

cars can be collected with hemorrhagic, infectious ornflammatory contents. In patient with chronic pelvic pain,

1070 H. Farah et al.

Figure 10. a and b: axial view of an enhanced CT scan showing a leftvaricose veins thrombosis (white arrows).

Figure 11. Abdominal radiography on day 8 of a cesarean: tex-tiloma (black arrow) associated with reactive ileus (white arrow)and a pneumoperitoneum (dotted arrow).

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Figure 12. a and b: T2-hyposignal and T1 FAT SAT weighted on MRI heendometriosis lesion (white arrows).

ovarian vein thrombosis (black arrow) associated with left pelvic

uperficial scar lesions in the form of fibrosis, chronic serumr migration of an endometriosis lesion should be suspectedFig. 12) [17].

ventration

he incidence of eventration is less than 3% [3]. The majorisk of eventration is acute intestinal obstruction by strangu-ation of the viscera in the hernial orifice, generating a riskf intestinal necrosis. CT is the modality of choice, providinghe direct diagnosis of eventration and information regard-ng content, mechanism of obstruction and severity of theisease (Fig. 13). Eventration requires emergency surgery.

eritoneal adhesions and pseudocysts

he frequency of adhesions can reach up to 90%. The relationetween pelvic pain and adhesions remains uncertain. Sometudies demonstrate the efficacy of adhesiolysis for anal-esic purposes and others estimate that they are not totallynvolved in the pain process. Obstructions can appear sec-ndary to adhesions and are responsible for abdominal painyndrome [18]. The combination of ultrasound and MRI canelp detect adhesions. On ultrasound, one can dynamically

ssess, upon insertion of the catheter, the responsibility orot of pain adjacent to an image of adhesion.

Peritoneal pseudocysts are structures with cystic appear-nce detected by chronic pelvic pain grinding the peritoneal

terogeneous hemorrhagic spicule node corresponding to a parietal

Postoperative pelvic pain: An imaging approach 1071

Figure 13. Axial (a) and sagittal (b) view of a portal phase CT scan showing an eventration (filled arrow) with colic content (doted arrow).

Figure 14. T2-weighted MR images in sagittal (a) and axial planes (b) show hypersignal corresponding to a quadrangular anterior peritoneal

Figure 15. T2-weighted MR image shows tissue mass (whitear

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pseudo-cyst milling neighboring organs.

organs while being depressible, unlike other cysts. Theyare often associated with intraperitoneal effusion and dys-trophic ovaries in a context of a history of infection orsurgery (Fig. 14).

Pudendal neuralgia

The pudendal nerve is the central somatic nerve componentof the perineum. Pudendal neuralgia mainly affects womenover 60 years of age with history of pelvic or orthopedicsurgery. Seated posture is a contributing factor (cycling,occupational). Pudendal neuralgia manifested as chronicpain meeting the diagnostic criteria of Nantes (i.e., painin the pudendal nerve area, worsening in seated position,without nocturnal waking or objective sensory deficit andhaving a positive diagnostic block to infiltration of corticos-teroids and xylocaine in the nerve). These infiltrations areperformed under CT guidance.

A pelvic MRI is necessary to rule out a compressive lesion

such as hematoma, infection or tumor, particularly alongthe course of the nerve (Fig. 15) [19,20]. The managementof pudendal neuralgia is complex and requires an expertconsensus opinion.

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rrow) on left pudendal nerve path responsible for organic neu-algia.

ecurrence of initial disease

elvic pain may indicate recurrence of the initial disease.

RI plays a dominant role in the early detection of recur-

ence thanks to high degrees of sensitivity (Fig. 16) [21].or benign diseases, endometriosis in particular, the rate

1072 H. Farah et al.

Figure 16. Tumor recurrence under the right external iliac vein in a woman treated for cervical cancer. T2-weighted MRI: T2-hyposignaltissular lesion (a) uptakes toward the necrotic center under the external iliac right vein (filled arrow) on the FAT SAT enhanced withgadolinium MRI scan (b) associated with an external iliac vein thrombosis (dotted arrow) (c).

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igure 17. 3D reconstruction of endovaginal ultrasound shows re

f recurrence may reach up to 20% at two years [22]. It isuspected in case of recurrence of pain, then confirmed byhysical examination and imaging, particularly ultrasoundFig. 17) and MRI [23].

rosthetic surgery

ainful complications of prosthetic surgery for pelvic stabil-ty are mainly represented by erosions, organ perforations,

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nt endometriosis of sigmoid colon (central dot).

xposures, infections, and retractions of prostheses. Theseomplications are observed in up to 1.5% of patients [24].erineal ultrasound allows good visualization of suburethralands and pelvic-peritoneal prostheses [25]. Perineal ultra-ound should be performed as first line modality to screen

or a complication of prosthesis. MRI can be useful as andditional tool, in particular to better determine the extentf a prosthetic infection or to reveal organ compression sec-ndary to retraction of prosthesis (Fig. 18) [26].

Postoperative pelvic pain: An imaging approach 1073

Figure 18. Axial view of a perineal ultrasound shows hyperechoic nodule (arrow) corresponding to a painful prosthetic shrinking on thepath of the probe (a). T2-weighted MR image in sagittal plane; in rest (b), hypointense prosthesis (dotted arrow) involving feces stasis abovethe shrinking after thrust (c).

Clinical case

Description

A 65-year-old woman who was treated by promontofixationpresented with chronic pelvic pain, dyspareunia and fever afew months after surgery.

Questions

1. What imaging do you propose?The following tests are performed: endovaginal ultra-

sound (Fig. 19), T1- and T2-weighted MRI in sagittal plane(Fig. 20).

2. What does prosthetic material look like on imaging?3. What is your diagnosis?4. What is the conduct to be followed?

Conclusion

Postoperative pelvic pain in gynaecological surgery is oftena sign of a complication, although unspecific.

The physical examination rules out a surgical emergency,sometimes complemented by ultrasound and CT scan toscreen for an acute complication in the form of vascular,urinary or digestive injury or obstruction.

In the longer term, in case of pain, one must knowhow to test for recurrence of a tumoral pathology orendometriosis, scar tissue fibrosis, adhesions, or spe-cific complications of certain surgeries such as prostheticsurgery.

However, imaging does not currently make it possi-ble to make a diagnosis for all types of postoperativepain. One should therefore not hesitate to ask forassistance from multidisciplinary teams and pain cen-ters to best managed patients, particularly in case ofneuralgia.

Take-home messagesAcute pelvic pain:

• rule out a surgical emergency: a vascular, urologicalor digestive injury, an obstruction;

• role of CT scan with IV of contrast material;• ultrasound and CT are also useful to screen for signs

of infection (abscess, effusion), hematoma, deepthrombophlebitis, etc.Chronic pelvic pain:

• pelvic ultrasound to be performed in first line, oftensupplemented by an MRI;

• recurrence of pain (oncology, endometriosis);• scarring pathology (fibrosis, pseudocysts, adhesions,

etc.);• screen for a pathology specific to prosthetic surgery

(perforation, retraction, etc.);• know how to consider pudendal neuralgia (using the

Nantes criteria).Figure 19. Sagittal view of an endovaginal ultrasonography ofuterine fundus.

1074 H. Farah et al.

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nswers

. In the first place, a pelvic ultrasound by subpubic thenendovaginal route to study the prosthesis and to screenfor a pelvic collection. Secondly, an injected pelvic MRIto screen for a peri-prosthetic collection and to screenfor bone or disc anomalies that might suggest spondy-lodiscitis.

. On ultrasound: hyperechogenic linear stripes. On MRI:linear stripes with distinct low signal.

. Prosthetic infection post-promontofixation withperitoneal-vaginal fistula formation. On the ultra-sound, we visualise hyperechogenic prosthetic materialabove the vaginal fundus (dotted arrow). On MRI, a col-lection (solid arrow) is seen adjacent to the prostheticmaterial, forming a fistula into the vagina. The restof the prosthesis is still hypointense on T2-weightedimage and that there is no abnormality of the signal ofadjacent intervertebral discs. There is no sign suggestingspondylodiscitis.

. Surgical removal of the prosthesis and antibiotic treat-ment.

isclosure of interest

he authors declare that they have no conflicts of interestoncerning this article.

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