Spectrum of disease, including endometritis, salpingitis, tuboovarian abscess (TOA), and oophoritis

Transvaginal US is 1st-line modality

Early disease may be subtle

Pyosalpinx: Thickened, dilated fallopian tubes, walls often > 5 mm with internal echoes from pus

Thickened endosalpingeal folds: Cogwheel sign

Incomplete septa: Distended tube folding on itself

Oophoritis: Enlarged edematous ovary

TOA: Complex pelvic fluid collection engulfing ovary; may still see components of pyosalpinx

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  TOA often bilateral

  
  
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  Infection spreads from 1 side to other, often in posterior cul-de-sac

Tuboovarian complex (TOC): Abscess adherent to tube, distinguishable separate ovary

Complex peritoneal fluid

Increased color Doppler in tube, ovary, or abscess

CT useful for diffuse nonspecific symptoms, large abscesses, extensive infection

MR helpful if other modalities are equivocal

Endometrioma ± rupture

Hemorrhagic cyst ± rupture

Ovarian neoplasm

Complicated appendicitis

Paraovarian cyst

Ascending infection crosses endocervical canal and mucus barrier, ascends into upper genital tract, involves endometrium, tubes, and ovaries

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  Tubal occlusion results in hydrosalpinx/pyosalpinx

  
  
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  Oophoritis

  
  
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  Endometritis

Salpingitis can progress to hydrosalpinx or pyosalpinx if left untreated; late sequela is TOA

Advanced disease results in abscess collections

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  Complex pelvic fluid/collection

  
  
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  Complex peritoneal collections

Usually present with pain, fever, vaginal discharge

Pelvic pain and cervical motion tenderness, positive endocervical smear, elevated WBC, ESR, or CRP

Right upper quadrant pain rare, Fitz-Hugh-Curtis syndrome

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  Peritoneal spread of infection to perihepatic surfaces and right lobe of liver

Infertility, ectopic pregnancy, chronic pelvic pain

Risk factors: Exposure to STD, multiple sexual partners, use of illicit drugs or smoking, and young age

Early disease may have subtle findings

Check cul-de-sac and abdomen for associated findings

Transabdominal US may be required to image large/extensive abscesses

Evaluate for tenderness and mobility of adnexa

Evaluate abdomen with US when pelvic findings are extensive

Use probe pressure to diagnose TOC