Transvaginal Ultrasonography for Detection of PID-Related Adhesions: A Case Report

Diagnosis of acute and chronic pelvic inflammatory disease continues to be a challenge despite advances in investigative procedures. Complications of PID include infertility, chronic pelvic pain and ectopic pregnancy. Currently, transvaginal ultrasonography is primarily used to detect tubo-ovarian abscesses (TOA) or pyosalpinx. We present a case where dynamic transvaginal ultrasound can detect filmy adhesions in the posterior the cul-de-sac corresponding to surgically confirmed PID.

A 19-year-old nulliparous female with chronic pelvic pain and presumed endometriosis underwent an advanced pelvic ultrasound demonstrating an anteverted uterus, a normal right ovary with mild thickening and erythema of the right fallopian tube, and a normal left ovary and fallopian tube. There were no signs of adhesions within the anterior compartment. A positive sliding sign was noted, suggesting a non-obliterated cul-de-sac. However, multiple filmy adhesions were detected along the right rectouterine pouch, aided by the presence of pelvic-free fluid. There were no findings of hydro/pyosalpinx or TOA. Using ultrasound, deep and ovarian endometriosis were also ruled out. During surgical evaluation, there were clear findings of PID, including filmy adhesions within the rectouterine pouch and Fitz-Hugh-Curtis adhesions in the right upper quadrant.

Given this unique finding, we propose using transvaginal ultrasonography to enhance the diagnosis of chronic PID for patients suffering from pelvic pain. While superficial endometriosis can also present with similar findings, we believe there is a quantification difference whereby PID presents with more diffuse adhesions in the absence of other features of endometriosis.