Evaluarea ecografică a durerii pelviene acute: provocări diagnostice în diferențierea afecțiunilor ginecologice, chirurgicale și urologice

Introduction

Acute pelvic pain, defined as a newly developed symptom within the preceding three months, represents a common and clinically significant challenge in women’s health. It affects approximately 15-24% of women of reproductive age, and accounts for nearly 20% of laparoscopic procedures and 2-10% of outpatient gynecological consultations. Initial evaluation requires the determination of pregnancy status and careful correlation of symptoms with the clinical examination, both of which are critical for guiding subsequent diagnostic and therapeutic decisions.

Although most causes of acute pelvic pain are non-life-threatening, conditions that endanger life or fertility must be promptly recognized. In 2021, the global incidence of ectopic pregnancy was approximately 213 per 100,000 women. Adnexal torsion accounted for 2.5-7.4% of acute pelvic pain cases, while acute appendicitis remained the most common abdominal surgical emergency, with an incidence of 214 per 100,000 population worldwide⁽¹⁾.

Ultrasound has established itself as the first-line imaging modality in the assessment of acute pelvic pain due to its wide availability, absence of ionizing radiation, and ability to rapidly detect both gynecological and nongynecological causes, including intestinal and urogenital conditions. In situations where ultrasound is inconclusive, computed tomography (CT) provides a valuable complementary tool, particularly useful for identifying gastrointestinal and urinary tract pathologies, while magnetic resonance imaging (MRI) may be reserved for selected cases requiring further diagnostic clarification.

The etiological spectrum of acute pelvic pain is broad. Gynecological causes involve the uterus, fallopian tubes and ovaries, whereas nongynecological etiologies include intestinal conditions (such as appendicitis and diverticulitis), urological disorders (ureteral or bladder calculi, urinary tract infections) and, less frequently, vascular diseases. In many instances, ultrasound enables the rapid establishment of a precise diagnosis in emergencies that demand prompt medical or surgical intervention, such as ovarian torsion, ectopic pregnancy, or acute appendicitis.

Gynecological disorders are among the most frequent etiologies of acute pelvic pain in women of reproductive age. The main causes include ectopic pregnancy, adnexal torsion, ruptured or hemorrhagic ovarian cysts and pelvic inflammatory disease (PID). Ectopic pregnancy remains a critical diagnosis due to the risk of rupture and maternal morbidity, with an estimated global incidence of 342.44 per 100,000 women. Adnexal torsion accounts for 2.5-7.4% of cases of acute pelvic pain, and requires prompt surgical intervention to preserve ovarian function. Ruptured or hemorrhagic cysts typically cause sudden, unilateral pelvic pain, sometimes accompanied by mild intraperitoneal bleeding. PID, most often due to ascending bacterial infection, leads to bilateral pain, fever and cervical tenderness, with potential long-term consequences such as infertility⁽³⁾.

Ultrasound plays a central role in the rapid identification of these conditions, allowing distinction between gynecological and nongynecological causes, and guiding the appropriate management.

Surgical pathologies represent an important subset of acute pelvic pain and often require prompt intervention. Acute appendicitis is the most frequent, presenting with right lower quadrant pain, nausea, vomiting and low-grade fever; delayed diagnosis may lead to perforation or peritonitis. Diverticulitis can mimic gynecological pain, causing lower abdominal discomfort, fever and altered bowel habits, occasionally requiring surgical management for complications. Intestinal obstruction, due to adhesions, hernia or volvulus, presents with diffuse abdominal pain, distension and vomiting, and may progress to ischemia or perforation if untreated.

Ultrasound serves as a first-line imaging modality, aiding in the rapid detection of appendiceal inflammation, bowel wall thickening, fluid collections and other surgical abnormalities, thereby supporting early diagnosis and timely management.

Urological disorders represent an important component of the differential diagnosis of acute pelvic pain. The most frequent causes include urolithiasis and urinary tract infections (UTIs). Urolithiasis, particularly ureteral calculi, is a frequent cause of acute pelvic pain, with global incidence estimates ranging from 114 to over 700 cases per 100,000 population, according to recent multinational epidemiological data. UTIs afflict up to 30-40% of women of reproductive age, presenting with suprapubic pain, dysuria and urinary frequency. Less frequent etiologies include interstitial cystitis and urinary retention. Ultrasound remains the first-line imaging modality, allowing the rapid detection of hydronephrosis, bladder wall changes and intraluminal calculi⁽⁴⁾.

Therefore, ultrasound remains a cornerstone in the differential diagnosis of gynecological versus surgical causes of acute pelvic pain, supporting the timely identification of patients requiring urgent intervention and guiding optimal clinical management.

Aim of the study

The aim of this study is to analyze the challenges of differential diagnosis between gynecological and surgical pathologies in patients presenting with acute pelvic pain and to highlight the role of ultrasound as a first-line tool in the rapid identification of underlying causes, thereby facilitating appropriate therapeutic decision-making and optimizing clinical management.

Materials and method

The study was conducted through an analysis of the specialized literature on acute pelvic pain and the role of ultrasound in the differential diagnosis between gynecological and surgical pathology. Articles published between 2000 and 2025 were included, accessed from international databases such as PubMed, Scopus and Web of Science, using search terms such as “acute pelvic pain”, “gynecological causes”, “surgical causes”, “urological causes”, “ultrasound”, “differential diagnosis” and “imaging.”

A total of 14 relevant studies were selected, including reviews, international guidelines, clinical and observational studies, addressing the frequency, etiology and management of acute pelvic pain, with a focus on the usefulness of ultrasound in the early diagnosis of conditions requiring prompt intervention, such as ovarian torsion, ectopic pregnancy, or acute appendicitis.

For each included study, demographic parameters, type of imaging investigations used, diagnostic accuracy of ultrasound, intervention times and clinical outcomes were analyzed. The data were synthesized descriptively and comparatively, highlighting the role of ultrasound as a first-line method and its limitations in the context of the differential diagnosis between gynecological and surgical pathology.

Results

The analysis of the 14 included studies, presented in Table 2, demonstrated that ultrasound represents the first-line imaging method in the evaluation of acute pelvic pain, due to its high accessibility, absence of ionizing radiation and ability to rapidly provide essential clinical information for therapeutic decision-making. According to the data summarized in Table 3, the sensitivity of ultrasound ranged between 80% and 92%, while specificity ranged between 85% and 95%. These values were influenced by the type of pathology investigated, the imaging technique used (transabdominal or transvaginal) and the operator’s experience.

According to Table 3, ultrasound demonstrates particularly high diagnostic accuracy for gynecological emergencies such as ovarian torsion, ectopic pregnancy and ruptured ovarian cysts. Prompt identification of these conditions facilitates timely surgical or medical management, thereby reducing the risk of severe complications, including ovarian loss or life-threatening hemorrhage. Additionally, ultrasound provides valuable clinical information in the assessment of other acute gynecological conditions, including pelvic inflammatory disease, ovarian hematoma and intrauterine bleeding, supporting informed therapeutic decision-making.

In nongynecological pathologies, ultrasound has shown diagnostic utility in acute appendicitis, ureteral lithiasis, and urinary tract infections. Nevertheless, its accuracy may be affected by patient-related factors such as body habitus, anatomical variations, or the clinical setting, as well as by operator expertise. In diagnostically inconclusive cases, or when complex intestinal pathology is suspected, complementary imaging modalities such as computed tomography or magnetic resonance imaging are recommended. These modalities enhance both sensitivity and specificity, and play a pivotal role in guiding appropriate therapeutic strategies.

International guidelines and systematic reviews consistently highlight that a multimodal imaging approach – integrating ultrasound with CT or MRI – optimizes diagnostic accuracy, minimizes delays in diagnosis and reduces the incidence of complications, including the need for unplanned surgical interventions.

Across all reviewed studies, ultrasound was consistently recognized for its rapid applicability, widespread availability in emergency and gynecological settings, and the absence of ionizing radiation. These advantages reinforce its central role as the primary imaging modality in the differential diagnosis of acute pelvic pain, enabling prompt recognition of urgent cases and contributing to improved clinical outcomes and optimized patient management.

Discussion

The analysis of the specialized literature and the integration of data from Table 4 emphasize the essential role of ultrasound in the differential diagnosis of acute pelvic pain, both for gynecological and for surgical or gastrointestinal pathology. Ultrasound remains the first-line imaging modality owing to its accessibility, absence of ionizing radiation and rapid provision of clinically relevant information, thereby facilitating prompt therapeutic decision-making.

In the case of ovarian tumors and cysts, the use of IOTA (International Ovarian Tumor Analysis, 2016) cri­teria allows morphological characterization of adnexal lesions (simple, hemorrhagic, or complex cysts) and application of the ADNEX model, offering a clear distinction between benign and malignant lesions, and reducing diagnostic errors⁽²⁰⁾. For deep infiltrating endometriosis (DIE), the IDEA consensus (2016) and the #Enzian classification (2021) provide a systematic ultrasonographic evaluation of pelvic compartments, including the pouch of Douglas, uterosacral ligaments and bowel wall, thereby standardizing terminology and facilitating correlation with laparoscopic findings^(21,22).

In ectopic pregnancy, the Barnhart classification (2013) establishes standardized ultrasonographic criteria for visible gestational sac, nonspecific adnexal mass and pregnancy of unknown location (PUL), optimizing correlation with hCG values and supporting timely clinical decision-making⁽²³⁾. For acute appendicitis, the Rettenbacher classification (2002) defines specific ultrasonographic parameters, such as appendiceal diameter above 6 mm, non-compressibility, and the presence of complications (abscess, perforation), thereby facilitating the differential diagnosis between gynecological and nongynecological causes of acute pelvic pain⁽²⁴⁾.

In colonic pathology and diverticulitis, local ultrasonographic classifications (Mizuki et al., 2018) enable the identification of intestinal wall thickening above 5 mm, loss of stratification and pericolic inflammation, contributing to differentiation from endometriosis or pelvic masses⁽²⁵⁾. These consensuses and classifications demonstrate that the integration of standardized ultrasonographic approaches enhances diagnostic accuracy and allows clearer communication between radiologists and clinicians.

Overall, the reviewed studies confirm that when ultrasound is applied in accordance with international protocols and consensuses, it optimizes the differential diagnosis, reduces the risk of complications, and limits the need for additional imaging investigations. This has a direct impact on the management of patients presenting with acute pelvic pain.

Conclusions

Ultrasound is confirmed as the first-line imaging modality in the evaluation of acute pelvic pain, owing to its rapidity, accessibility and absence of ionizing radiation, providing essential clinical information for timely therapeutic decision-making. Sensitivity and specificity values, ranging from 80-92% and 85-95%, respectively, demonstrate the accuracy of ultrasound in diagnosing major gynecological causes, including ovarian torsion, ectopic pregnancy and ruptured ovarian cysts.

For nongynecological pathologies, ultrasound remains useful; however, computed tomography and magnetic resonance imaging are recommended in inconclusive cases or when patient anatomy is complex, highlighting the importance of a multimodal imaging approach. The application of standardized ultrasonographic consensuses and classifications – including IOTA, IDEA, #Enzian, Barnhart, Rettenbacher, and Mizuki et al. – enhances diagnostic accuracy, facilitates communication between clinicians and radiologists, and allows the precise correlation with surgical or laparoscopic findings.

Furthermore, ongoing operator training and adherence to standardized protocols are essential for optimizing ultrasound performance and minimizing diagnostic errors. Overall, ultrasound, integrated with clinical data and, when appropriate, complementary imaging, constitutes the primary tool in the management of patients with acute pelvic pain, providing an effective differential diagnosis and contributing to the prevention of complications.

Autor corespondent: Irina Burdeniuc E-mail: iburdeniuc1@gmail.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.