{"paper_id":"eab1c873-4e14-44c7-bb42-e2f69314cbae","body_text":"Dick et al . European Radiology (2025) 35:6682 –6695\nhttps://doi.org/10.1007/s00330-025-11539-8\nINVITED REVIEW Open Access\nESR Essentials: Gynaecological causes of\nacute pelvic pain in women: a primer for\nemergent evaluation —practice\nrecommendations by the European Society of\nEmergency Radiology\nElizabeth A. Dick 1,2, Ana Blanco 3, Marcela De La Hoz Polo 4 and Raffaella Basilico 5*\nAbstract\nAcute pelvic pain (APP) is a common presentation in women of all ages and has both gynaecological and non-\ngynaecological causes. In the emergency department, the suspected differential diagnosis dictates the chosen\nimaging modality. For premenopausal patients with APP, transabdominal ultrasound (TAUS) and transvaginal\nultrasound (TVUS) are first-line investigations with high sensitivity and speci ficity for ectopic pregnancy, adnexal\ntorsion, and ovarian cysts and their complications. US may also be valuable in pelvic in flammatory disease. When a\nnon-gynaecological cause is suspected, contrast-enhanced CT (± transabdominal US) is indicated and has the\nadvantage of 24/7 availability and lack of operator dependence. CT, however, may reveal an unexpected\ngynaecological cause of APP. When available, MRI is an excellent second test to improve diagnostic certainty in\npregnant women when US is inconclusive —both for gynaecological and non-gynaecological conditions. MRI has a\nhigh diagnostic accuracy for pelvic in flammatory disease and tubo-ovarian abscesses. This article will enable readers to\nrefresh their knowledge of common causes of APP and understand the histopathological processes involved in\ngynaecological causes of APP and how the imaging findings correlate. It will outline why different modalities are\nuseful in different pathologies and help understand the limitations of each modality, including the requirement for\noperator expertise (US), relative lack of speci ficity/sensitivity (CT), and limited availability (MRI). This article excludes\npregnancy-related causes of APP (apart from ectopic pregnancy) and also excludes non-gynaecological causes of APP.\nKey Points\n●\nIn female patients with acute pelvic pain, ultrasound is the best first modality in suspected gynaecological pathology.\n●\nCT can be used when non-gynaecological causes of pain are suspected and when US is inconclusive.\n●\nMRI has limited availability in an emergency setting and may be used in pelvic in flammatory disease and in pregnancy when\nUS is inconclusive.\n© The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,\nsharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s)\nand the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material\nin this article are included in the article ’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not\nincluded in the article ’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted\nuse, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/\nlicenses/by/4.0/.\nAna Blanco and Marcela De La Hoz Polo contributed equally to this work.\nThis article belongs to the ESR Essentials series guest edited by Marc Dewey\n(Berlin/Germany).\n*Correspondence:\nRaffaella Basilico\nraffaella.basilico@gmail.com\nFull list of author information is available at the end of the article\n1234567890():,;1234567890():,;\n1234567890():,;\n1234567890():,;\n\nKeywords Pelvic pain, Gynaecological examination, Ultrasonography, Computed tomography, Magnetic resonance imaging\nKey recommendations\n●\nIn skilled hands, transabdominal and transvaginal\nultrasound is the best first modality in suspected\ngynaecological pathology. It will help identify\nectopic pregnancy, adnexal torsion, causes of\novarian cysts and their complications, and may be\nof value in pelvic in flammatory disease (Level of\nevidence high).\n●\nCT is a relatively non-speci fic test which is often the\nfirst imaging investigation due to its easy availability\n24/7. It can be used when non-gynaecological causes\nof pain are suspected and when US is non-conclusive\n(Level of evidence moderate).\n●\nMRI has high diagnostic accuracy and is very helpful\nin further characterisation after US ± CT. It has\nlimited availability in an emergency setting and may\nbe used in differentiating pelvic in flammatory disease\nand tubo-ovarian abscesses. MRI is useful in\npregnancy when US is inconclusive (Level of\nevidence moderate).\nIntroduction\nImaging modalities and protocols\nAcute Pelvic Pain (APP) is a common emergency com-\nplaint (Table 1) with gynaecological and non-\ngynaecological causes in women of all ages [ 1]. The\ndifferential diagnosis determines the choice of imaging\nmodality. Ultrasound (US) is indicated if a gynaecolo-\ngical cause is suspected and has many advantages, being\nnon-invasive, radiation-free, and with a high diagnostic\nyield. Transabdominal (TA) and transvaginal (TV) US\nare often performed together. TAUS allows visualisation\nof all pelvic contents, including free pelvic fluid. TVUS\nbetter depicts the uterus and adnexa. Colour and spec-\ntral Doppler are useful for vascularity assessment,\nespecially if torsion is suspected [ 2]( T a b l e2). However,\nCT is increasingly becoming the first emergency imaging\ntest due to 24/7 availability, especially if a non-\ngynaecological cause of APP is suspected (such as\nappendicitis or renal colic) and when US is unavailable\n[2, 3].\nCT and US in combination may improve diagnostic\ncertainty in some patients [ 4]. A single venous phase\nminimises radiation, with an additional arterial phase\nwarranted in suspected active bleeding [ 3, 5].\nIn dual-energy CT (DECT), iodine mapping can dif-\nferentiate haemorrhagic infarction from contrast\nenhancement in ovarian torsion. Virtual monochromatic\nimages increase the detection of ischaemia in adnexal\ntorsion or peritoneal in flammation. Finally, DECT can\nreplace a true nonenhanced scan with a virtual none-\nnhanced scan, reducing radiation exposure [ 6].\nOn CT, normal fallopian tubes are not visible, while\nnormal ovaries can be identi fied by location and follicular\nstructure [ 5].\nMRI, if available, enables excellent characterisation of\nabnormal gynaecological findings already identi fied on\nUS or CT without ionising radiation [ 5]. A full MRI\nprotocol includes fat-suppressed T2W images which\nTable 1 Causes of acute pain\nGynaecological Non-gynaecological\nNonpregnant Pregnant Genitourinary\n Ovarian functional cyst rupture/\nhaemorrhage\n Haemorrhagic corpus luteal cyst  Distal ureteral calculus\n Pelvic in flammatory disease (PID)  Ectopic pregnancy  Lower urinary tract infection\n Ovarian torsion  Uterine rupture Gastrointestinal\n Fibroid degeneration/torsion  Uterine torsion  Appendicitis\n Malpositioned IUD  Placental abnormalities  Diverticulitis\n Hematometra  Spontaneous/incomplete\nabortion\n Epiploic appendagitis/intraperitoneal focal fat\ninfarction\n Endometriosis/endometriosis cyst rupture  Ovarian hyperstimulation\nsyndrome\n Bowel in flammation, ischaemia, haemorrhage\n Ovarian hyperstimulation syndrome\n Gynaecological tumours\n Ovarian vein thrombophlebitis\nDick et al . European Radiology (2025) 35:6682 –6695 6683\n\nincrease the conspicuity of in flammation, oedema, and\nascites. Gradient echo T2* sequences and pre-contrast\nT1 fat-saturated sequences identify blood products.\nDWI detects hypercellular fluid/pus [ 7].\nIn APP, gadolinium-enhanced fat-suppressed T1W\ndemonstrates inflammatory peritoneal enhancement in PID\n(not visible in endometriosis). It can also characterise leio-\nmyomas, leiomyosarcomas and adnexal masses [ 5, 8]\n(Table 3, limited protocol).\nGynaecological causes of acute pelvic pain\nInfection/pelvic in flammatory disease (PID)\nPID refers to the in flammation of female reproductive\norgans, typically caused by b acterial infection ascend-\ning from the vagina, causing cervicitis, endometritis,\nsalpingitis, pyosalpinx, oop horitis, tubo-ovarian abscess\n(TOA) [ 9], peritonitis and occasionally pyometra and\novarian vein thrombophlebitis [ 10]. Risk factors\ninclude multiple sexual partners, intrauterine surgery,\nintrauterine devices (IUDs ), delivery, and endome-\ntriosis [ 7].\nFever, pelvic pain, vaginal discharge, cervical tenderness\nand dyspareunia are common presentations. PID requires\nearly antibiotic treatment to avoid complications such as\ninfertility and ectopic pregnancy [ 10, 11]. Imaging helps in\nclinical uncertainty. Ultrasound is the best modality with\nCT used if US is inconclusive or there are suspected\ncomplications. General CT findings include thickening of\nthe uterosacral ligaments, pelvic fat stranding (sensitivity\n60.4%), obscuration of fascial planes, reactive lymphade-\nnopathy, and pelvic free fluid [ 10, 11]. The most\nspecificC T finding is bilateral tubal thickening\n(95.1%, n = 190) [ 12].\nMRI has a greater sensitivity than CT (0.95 pooled sen-\nsitivity versus 0.79) [13]. However, MRI is rarely needed to\ndiagnose PID except in doubtful cases, the differential\ndiagnosis of unclear adnexal lesions, and distinguishing non-\ncomplex fluid from blood and pus [ 7, 14].\nTable 2 US findings of common causes of acute pelvic pain\nPelvic in flammatory disease (PID)  Free fluid in the pelvis with internal echoes indicating purulent content\n Endometritis/pyometra: thickened heterogenous endometrium, indistinct endometrium, fluid and/or gas\nwithin the cavity\n Salpingitis: swollen fallopian tube (> 5 mm diameter), thickened walls and endosalpingeal folds showing\nhyperaemia on Colour Doppler.\n Pyosalpinx: dilated fallopian tubes with echogenic fluid that may form levels due to purulent content\n Tubo-ovarian abscess: multilocular complex cystic mass in the adnexa with a thick wall and internal echoes,\nshowing hyperaemia on Colour Doppler. The ovary and the fallopian tube cannot be individually identi fied.\nGas may be seen as echogenic foci with posterior dirty shadowing.\nOvarian cysts  Follicular cyst: thin wall, posterior acoustic enhancement. No internal vascularity on Colour Doppler\n Corpus luteum: well-circumscribed cyst ≤ 3 cm with a thick wall showing prominent hyperaemia on Colour\nDoppler ( “ring of fire” sign), and no internal vascularity. Spectral Doppler: prominent diastolic flow with low-\nvelocity waveform throughout the luteal phase of the cycle.\n Haemorrhagic cyst: heterogeneous content, fluid levels, possible complex mass appearance. No internal\nvascularity. ± Hemoperitoneum\n Haemorrhagic corpus luteum: heterogeneous echogenic content, thickened hyperaemic walls. ±\nHemoperitoneum\nAdnexal torsion  Enlarged ovary with peripherally displaced follicles. Heterogeneous ovarian echotexture (echogenic areas =\nhaemorrhage; hypoechoic areas = oedema)\n Midline or superior displacement of the affected ovary. Uterine deviation to the side of the twist. Ascites\n Colour Doppler: Whirlpool sign indicating the twisted pedicle\n Spectral Doppler: absent venous flow, decreased/absent diastolic flow, absent arterial flow. Important:\npresence of arterial or venous flow does not exclude ovarian torsion.\nEctopic pregnancy (serum β-hCG +)  Absence of a normal intrauterine gestational sac (double decidual sac with two concentric hyperechoic rings\nthat surround an anechoic gestational sac)\n Tubal pregnancy:\n∘ Adnexal mass separate from the ovary ± presence of gestational sac or a living embryo\n∘ “Tubal ring sign ” + “ring of fire sign ”: decidual response in the fallopian tube with hypervascularity\n Extrauterine findings: pelvic free fluid, hematosalpinx, hemoperitoneum. Hemoperitoneum is highly suggestive\nof ruptured ectopic pregnancy\nDick et al . European Radiology (2025) 35:6682 –6695 6684\n\nCervicitis and endometritis Both represent early man-\nifestations of PID. In cervicitis, the cervix may be enlarged\nand hyperaemic on US, with an enhancing endocervical\ncanal and parametrial fat stranding and free fluid on\nCT/MRI. Endometritis can occur in PID, during the\nperipartum period, and after gynaecological procedures.\nFindings of a thickened heterogenous endometrium\non US, abnormal endometrial enhancement relative to\nthe inner myometrium on CT/MR, and fluid within\nthe cavity suggest endometritis. The uterine border may\nbe indistinct from parametrial tissue [ 2, 10].\nUterine empyema (pyometra) is characterised by complex\nfluid in the uterine cavity containing gas or air- fluid\nlevels [ 10].\nSalpingitis, tubal empyema (pyosalpinx) In salpingitis,\nthe fallopian tube is swollen (> 5 mm diameter) and\nthickened. In pyosalpinx, pus distends the lumen\n(echogenic on US) and the mural thickening is\nhyperaemic on Doppler US, enhancing on CT (Fig. 1).\nCT may show surrounding pelvic in flammation, includ-\ning uterosacral ligament thickening and para-aortic\nlymphadenopathy [ 2, 10, 15]. CT-multiplanar recon-\nstruction helps identify the tubular contour, while MRI\nadditionally differentiates pyosalpinx from haematosal-\npinx by the presence of intratubal blood products. In\npyosalpinx, there is tubal wall thickening, enhancement\nand in flammation. On DWI, restricted diffusion suggests\npyosalpinx, while unrestricted diffusion suggests hydro-\nsalpinx [ 7].\nTubo‑ovarian abscess Infection and destruction of\nadnexal structures result in a TOA. Imagingfindings typically\nreveal a multilocular complex cystic mass in the adnexa with\nthick walls, showing hyperaemia on US and uniform\nenhancement on both CT and MRI (Fig. 2). Associated free\nperitoneal fluid, surrounding pelvic in flammation, fat\nstranding and enhancement are common [ 10, 15]. The\ncomplex mass can be difficult to differentiate from an ovarian\nmalignancy, but a dilated fallopian tube and restricted\ndiffusion on DWI sequences suggest infection [11].\nPeritonitis Pyometra, pyosalpinx, and TOA can cause\nperitonitis when an abscess ruptures or pus leaks from the\ninfected organ [ 10, 15], but it can also be seen in the\nabsence of such complications.\nFitz-Hugh– Curtis syndrome (perihepatitis) In this rare\ncomplication, peritoneal spread to the liver capsule results\nin sharp right upper quadrant (RUQ) pain. CT findings\ninclude enhancement and thickening of the anterior liver\ncapsule, geographic areas of variable perfusion in\nsubcapsular and periportal areas, fluid and fat stranding\nextending from the pelvis into the RUQ, and gallbladder\nwall thickening [ 10, 15].\nAtypical PID forms PID can uncommonly progress to\ninvolve other pelvic organs such as the bladder, urethra,\nor bowel. In addition to typical organisms, two further\norganisms should be considered, especially in unusual or\nextensive cases: Actinomycosis is suggested when there is\nTable 3 Time-efficient non-contrast MRI protocol for urgent study of the female pelvis and non-cooperating patients\nMRI protocol Axial T2W\nSSFSE\nSagittal T2WFRFSE Oblique coronal/axial\nT2W FRSE\nAxial DWI SE EPI Sagittal, oblique coronal/axial\nT1W 3D GRE LAVA\nRepetition time/echo time\n(ms)\n765/59 4675/100 4675/100 3000/74 4.4/2.1\nFlip angle 90° 90° 90° 90° 12°\nSection thickness (mm) 6 4 4 8 3.4\nInterslice gap (mm) 0.6 0.4 0.4 2 −1.7\nBandwidth (kHz) 31.25 41.67 41.67 62.5\nField of view (cm) 38 32 32 42 40\nMatrix 320 × 288 320 × 224 320 × 224 160 × 160 370 × 192\nNo. of averages 0.54 2 2 2 0.75\nNo. of images 30 26 26 15\nFrequency direction Right to left Anterior to posterior Right to left Anterior to posterior Superior to inferior\nAcquisition time 24 s 2 min 15 s 2 min 15 s 27 s 22 s\nβ value (s/mm\n2)- - - 0 –800 -\nReproduced under the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/) from Tonolini et al [ 5]\nT2W T2-weighted, T1W T1-weighted, SSFSE single-shot fast spin-echo, FRFSE fast recovery fast spin-echo, DWI diffusion-weighted imaging, SE spin-echo,\nEPI echoplanar imaging, GRE gradient echo, LAVA liver acquisition with volume acceleration\nDick et al . European Radiology (2025) 35:6682 –6695 6685\n\nextension across tissue planes and fistula formation in the\npresence of an IUD. Tuberculosis can cause pyosalpinx,\nendometritis, and peritoneal thickening with deposits that\ncan mimic peritoneal carcinomatosis [ 15].\nVaginal infections Isolated vaginal abscesses (without\nascending infection) can occur in Bartholin ’s glands\n(posterolateral vagina) and in a Gartner cyst (anterolat-\nerally within the proximal vagina) [ 11].\nUterine emergencies: leiomyoma degeneration and uterine\ninversion\nUterine leiomyomas ( fibroids) are a common gynaecolo-\ngical neoplasm containing smooth muscle and fibrous\nconnective tissue, which can be submucosal, intramural,\nsubserosal, and/or pedunculated [ 11, 16]. In 30% of\npatients, acute degeneration or torsion can cause APP\n[16]. Ultrasound is helpful, but MRI is optimal in char-\nacterisation [ 16].\nIn acute degeneration, the leiomyoma outgrows its blood\nsupply. Speed of onset of degeneration in fluences pain\nexperienced, histopathological nature (hyaline, myxoid,\ncystic or haemorrhagic) and imaging findings [16]. Hyaline\ndegeneration is the most common and least painful, with\ndeposition of collagen fibres [11]. Haemorrhagic (so-called\n‘red’) degeneration occurs with rapid leiomyoma growth,\nsuch as in pregnancy or with oral contraceptive use [ 16]. In\nred degeneration, CT may show haemorrhage, loss of con-\ntrast enhancement, ± cystic contents [ 11]. On MRI, non-\ndegenerated leiomyomas are ty pically well-circumscribed,\nlow to intermediate signal intensity on T2. Degenerated\nleiomyomas do not enhance post gadolinium due to\ninfarction and, on T2W imaging, can be low (hyaline or\ncalcific degeneration) or high signal (cystic or myxoid\ndegeneration) [16]. Red degeneration may show peripheral\nT1 high signal intensity (repr esenting blood products and\npossibly thrombosed peripher al vessels) with variable\nT2 signal intensity (Fig. 3).\nOf patients who have undergone uterine artery embo-\nlisation of leiomyomas, 10% may require readmission for\npostembolisation syndrome, which includes pain, fever,\nand nausea. MRI will demonstrate haemorrhagic infarc-\ntion (high signal on T1) and lack of enhancement corre-\nlating with successful embolisation [ 16].\nInversion of the uterine fundus is rare, can extend\nthrough the cervix, and occurs either acutely postpartum\nFig. 1 Pelvic in flammatory disease (pyosalpinx) in two different patients presenting with acute pelvic pain and fever. a Transabdominal grey-scale US\nand ( b) transvaginal Doppler image show thick-walled dilated tubular adnexal structures (arrows in a), distended with echogenic fluid-debris levels\n(dashed arrows) with surrounding vascularity with Doppler ultrasound. c Transabdominal grey-scale US image in a different patient, shows bilateral cystic\nstructures (arrows) surrounding the uterus (U) containing hyperechoic material compatible with pyosalpinx. The ovaries show multiple follicles\n(arrowheads). d, e Coronal and axial post-contrast CT images, respectively, of the same patient, demonstrate both ovaries with multiple follicles\n(arrowheads) and bilateral thick-walled dilated tubular structures (arrows) representing the dilated fallopian tubes\nDick et al . European Radiology (2025) 35:6682 –6695 6686\n\nor in postmenopausal multiparous women, where it may\nbe associated with a leiomyoma acting as a lead point [ 11].\nWhile this is a challenging clinical diagnosis, sagittal MRI\n(and, to a lesser extent, CT) demonstrates inversion and\nindentation of the fundus [ 17].\nOvarian cyst complications, endometriomas, and ovarian\nhyperstimulation syndrome\nHaemorrhagic and ruptured ovarian cysts Ruptured or\nhaemorrhagic ovarian cysts are the most common\ngynaecological cause of APP in a nonpregnant, afebrile\npremenopausal woman [ 18]. This may be a physiologic,\nself-limited process involving a corpus luteum (CL) cyst\nor a follicular cyst [ 6] (Fig. 4). While ovarian endome-\ntriosis is common, rupture of an endometriotic cyst is\nuncommon [ 19].\nRuptured or haemorrhagic ovarian cysts present clini-\ncally with severe APP and, occasionally, hypotension due\nto large intraperitoneal bleed [ 18]. B-hCG levels help to\ndifferentiate from ruptured ectopic pregnancy [ 14].\nUS is the best modality to assess ovarian cyst rupture and\nhaemorrhage/haemoperitoneum. Ruptured ovarian cyst\nmay be sonographically normal if the cyst has completely\nruptured and the fluid reabsorbed. Clues to a leaking cyst\nare crenellated appearance and low-level echoes/clot.\nRuptured luteal cysts have a thick, echogenic, and\nirregular wall with increased peripheral blood flow on\nDoppler, the so-called “ring of fire” [14, 18].\nSonographic findings of haemorrhagic cysts depend on\nthe age of the haemorrhage. In the early stages, a\nhaemorrhagic cyst exhibits diffuse, low-level internal\nechoes, thin walls, posterior acoustic enhancement and\nno internal vascularity (Fig. 4)[ 18]. As the haemorrhage\nevolves, a lace-like reticular pattern of internal echoes\ndevelops. As echogenic thrombus coalesces within the\ncyst, a heterogeneous avascular mass forms with\nretractile angular or concave margins. Clots may be\nadherent or rounded but can be differentiated from\nmural nodules by lack of vascularity on Doppler US and,\nwhere needed, 6 –8 week US follow-up [ 18]. On CT,\nhigh-density cyst contents and thick enhancing walls can\nFig. 2 Surgically con firmed tubo-ovarian abscess in two different patients. a, b Middle-aged woman with lower abdominal pain, fever and vaginal\ndischarge. a Transabdominal grey-scale ultrasound shows a large cystic complex mass representing a tubo-ovarian complex with echogenic content\nconsistent with pus. b Microflow ultrasound imaging demonstrates peripheral vascularity in the walls of the cystic lesion without internal vascularity\nin keeping with the cystic nature of the mass. c–e Young woman with pelvic pain and raised in flammatory markers. Consecutive axial ( a, b) and coronal\n(c) CECT images, venous phase, show bilateral pyosalpinx (dotted arrows) and a right ovarian abscess (asterisk). Note the fat stranding around the\nfallopian tubes (arrows) and the markedly thickened uterosacral ligaments (arrowheads)\nDick et al . European Radiology (2025) 35:6682 –6695 6687\n\nbe seen. The MR appearance of haemorrhagic cysts is\ncomplex, with different signal characteristics at different\nstages [ 6].\nComplicated endometriomas Endometriosis is the\npresence of ectopic endometrial tissue outside of the\nuterus. In the ovary, ectopic endometrial tissue can\nform haemorrhagic cysts or endometriomas due to\nrepeated cyclic haemorrhage causing APP [ 5]. On\nUS, endometriomas are unilocular, homogeneously\nhypoechoic cysts with diffuse low-level echoes ( ‘choco-\nlate cysts ’)[ 18]. Spontaneous rupture of an\nendometriotic cyst is rare and torsion rarely occurs\nbecause of adhesions, however, these should still be\nconsidered in patients with endometriosis. CT can\ndemonstrate features suggestive of endometrioma\nrupture, including thick-walle d, multilocular or bilateral\novarian cysts, loculated pelvic ascites, and fat stranding\n[19].\nOther acute complications of endometriosis causing\nAPP include endometrioma superinfection, PID, hemo-\nperitoneum, and bowel and genitourinary complications\n[20].\nMRI is the best technique to diagnose endometrio-\nmas with ‘shading ’ on T2W due to dependant blood\nand repeated bleeding episodes (Fig. 4), with bilateral\nor multiple lesions being typical. In comparison, a\nnon-endometriotic haemorrhagic ovarian cyst is\nmore likely to be unilateral, unilocular, and without\nshading.\nFig. 3 A–C Red degeneration on an intramural fibroid in a postmenopausal patient with acute pelvic pain and known fibroids. Sagittal T2, T1-FS pre and\npost-gadolinium MRI images, respectively, show intramural fibroids (arrows) with ( A) central heterogeneous T2 signal, ( B) hyperintense on T1 fat sat\n(haemorrhage) and ( C) non-enhancement in the post-contrast images in keeping with infarction. D, E Myometrial abscess in a patient with pelvic pain\nand vaginal discharge. Axial and sagittal post-contrast CT images show pelvic fluid (asterisk), fat stranding and thickening and oedema of the uterosacral\nligaments (arrows). A uterine intramural hypodense abscess (arrowheads) was noted communicating with the endometrial cavity which is distended\nwith fluid\nDick et al . European Radiology (2025) 35:6682 –6695 6688\n\nOvarian hyperstimulation syndrome Ovarian hypersti-\nmulation syndrome (OHSS) is a condition that can occur\nafter ovarian stimulation, often in the context of fertility\ntreatments. Imaging plays a crucial role in diagnosing and\nassessing the severity of OHSS. Ultrasound is the primary\nimaging modality used to evaluate the ovaries, where\nfindings typically include enlarged ovaries with multiple\nthin-walled cysts, ranging from small to large, represent-\ning enlarged follicles or corpus luteum cysts (Fig. 5).\nIn severe cases, free fluid may be seen in the pelvis or\nabdomen due to capillary leakage. In more advanced\nstages, CT or MRI scans may be employed to assess\ncomplications such as ovarian torsion, ascites, pleural\neffusions or other signs of severe OHSS. Particularly, MRI\nis very helpful in differentiating OHSS from ovarian\ntumours, including choriocarcinoma, which can also\nproduce high hCG levels, by demonstrating markedly\nbilateral symmetrically enlarged ovaries with simple cysts\nof different size, separated by thin septa and lacking\ninhomogeneous solid tissue consistent with malignancy\n(Fig. 5)[ 5].\nAdnexal torsion\nAdnexal torsion can involve the ovary, fallopian tube, or\n(most commonly) both. Isolated fallopian tube torsion\nspares the ovary, is rare, usually occurs during repro-\nductive years and seldom post-menopause [ 6]. Clinically,\nFig. 4 Complicated ovarian cyst in a young woman in her late teens presenting with acute pelvic pain, nausea and vomiting. a, b Transabdominal grey-\nscale and Doppler US shows a complex cystic mass with hyperechoic content (arrow) without vascularisation in Doppler images. c–e Portal venous\nphase axial and coronal CT images demonstrate a large amount of hemoperitoneum (asterisk) in the abdomen and pelvis. The images through the pelvis\nshow a right para-uterine cystic mass (black arrows) with multiple hyperdense foci within related to active bleeding. Large hemoperitoneum with\nsentinel clot in the pelvis. Findings suspicious for ruptured ovarian cyst with active bleeding. Surgery con firmed ruptured corpus luteal cyst.\nf, g Endometrioma in a young woman with acute left quadrant pain. Axial T1-FS WI ( f) shows a large left ovarian cyst with high signal intensity and a\nfluid-fluid level (arrow). In the axial T2 WI ( g), the adnexal lesion shows marked signal loss due to cycling bleeding (shadowing sign). Note the right\novarian follicular cyst (arrowhead)\nDick et al . European Radiology (2025) 35:6682 –6695 6689\n\npatients present with nausea, vomiting and excruciating\nunilateral APP [ 18].\nA normal ovary rarely undergoes torsion, except\noccasionally in perimenarchal girls or pregnancy [ 6].\nIn up to 90% of cases, an underlying ovarian mass serves\nas the lead point for torsion, particularly if larger than\n5c m [ 14, 21]. Malignant ovarian tumours and endo-\nmetriotic cysts are less likely to cause ovarian torsion\ndue to adhesions [ 6]. Other risk factors include\novulation induction, pregnan cy, previous tubal ligation\nand hypermobility of adnexal structures [ 18].\nOvarian torsion is a surgical emergency. Delayed treat-\nment increases the risk of vascular compromise and hae-\nmorrhagic infarction. Torsion occurs when the ovary twists\non its vascular pedicle, resulting in partial to complete\nobstruction of arterial in flow and venous out flow [22].\nPelvic US and colour Doppler is thefirst imaging modality\nto rule in/out adnexal torsion. The US appearance of torsion\nFig. 5 Ovarian hyperstimulation syndrome in two different patients. a–d Women in her 30 ’s undergoing in vitro fertilisation presented with abdominal\ndistention, nausea and vomiting. TAUS ( a, b) and TVUS ( c, d) demonstrate ascites (arrow in a), enlarged ovaries (black arrows) with preserved central flow\n(b) and multiple follicles of varying sizes ( b–d) consistent with OHSS. e, f Different patient in her early 30 ’s and 15 weeks pregnant presented with\nabdominal pain. Sagittal T2WI at the level of the right and left adnexal regions show markedly enlarged bilateral ovaries (arrows) containing multip le\nlarge, thin-walled cysts consisted with OHSS. P (placenta). MRI can provide better characterisation of the ovarian process in the differential diag nosis of\novarian tumours\nDick et al . European Radiology (2025) 35:6682 –6695 6690\n\nis variable and depends on the chronicity and degree of\ntorsion, and whether there is some preservation of arterial\nflow to the ovary from its dual supply from the ovarian and\nuterine arteries [23, 24]. Findings greatly depend on factors\nsuch as duration and degree of vascular obstruction and\nwhether it is intermittent [23]. Classical sonographic signs of\novarian torsion include increased ovarian diameter (> 4 cm)\nand volume (> 20 cm\n3 premenopausal or > 10 cm 3 post-\nmenopausal); however, in 5% of p a t i e n t s ,n oo v a r i a ne n l a r -\ngement occurs [ 21]. Other signs of ovarian torsion are\nperipherally displaced folli cles, midline or superior dis-\nplacement of the affected ovary, heterogeneity of the central\nstroma with echogenic areas indicating haemorrhage and\nhypoechoic areas representing oedema, and uterine devia-\ntion to the side of the affected ovary and ascites [ 14, 18].\nDoppler ultrasound flow patterns reflect the degree of vas-\ncular compromise and duration of torsion with venousflow\naffected before the high-pressure arterial flow. Signs of\ncomplete torsion include absent venous flow, decreased or\nabsent diastolic flow and absent arterial flow. In partial\ntorsion, arterial flow with high resistive spectral signal may\nbe seen, In some cases of nonviable or complete torsion,\nperipheral arterialflo wc a nb ep r e s e r v e d ,w h i c hm a yb ed u e\nto the dual arterial supply and relative preservation of flow\nwithin the uterine artery [21, 23]. The ‘whirlpool’ sign refers\nto the twisted ovarian pedicle, and in association with an\nenlarged ovary, it is diagnostic of ovarian torsion [21]. Many\nof these findings can also be seen with contrast-enhanced\nCT and MRI, including the presence of a twisted vascular\npedicle or an underlying mass and abnormal enhancement\n(Fig. 6). Finally, abnormal morphology and cystic degen-\neration suggest infarction [21].\nFig. 6 Right adnexal torsion in a woman in her 40 ’s with intense right pelvic pain and vomiting. CT was requested to exclude appendicitis. a–c Post-\ncontrast coronal ( a) and axial CT images ( b, c) excluded appendicitis and showed an enlarged and hypodense right ovary (arrow) posteriorly displaced\nbehind the uterus in the axial images, compared to the normal size and located left ovary (arrowhead) and twisted right fallopian tube (dotted arrows) .\nd, e Subsequent transvaginal US performed preoperatively by the gynaecologist con firmed the CT findings with an enlarged and oedematous right\novary (arrow) measuring approximately 98 × 42 mm with distended peripheral follicles (curved arrows). f Intraoperative image con firmed right ovarian\nnecrosis\nTable 4 Factors which increase the risk of ectopic pregnancy\n[27]\nFactors which increase the risk of ectopic pregnancy [ 27]\nPrevious PID\nPrevious surgery\nEndometriosis\nUse of IUDs\nPrevious EP\nAssisted reproductive technology\nInfertility\nSmoking\nCongenital uterine anomalies\nAdvanced maternal age\nDick et al . European Radiology (2025) 35:6682 –6695 6691\n\nHaemoperitoneum due to gynaecological causes\nGynaecological causes of haemoperitoneum are many and\ninclude sexual intercourse, intense exercise, corpus\nluteum bleeding, ruptured haemorrhagic ovarian cyst,\nectopic pregnancy, and ruptured endometriotic cyst. On\nUS, peritoneal or pelvic fluid demonstrates low-level\nechoes, and US can also identify the cause. On CT, the\nfree peritoneal fluid has a relatively high attenuation. CT\ncan demonstrate the volume of haemoperitoneum, pre-\nsence of septations or loculation (which suggest endo-\nmetriosis), and active bleeding, which guides\ninterventional management. Active bleeding may be seen\non the arterial or, most usually, on the venous phase,\nreflecting intermittent or venous haemorrhage [ 5]. On\nFig. 7 Ectopic pregnancies in three different patients. a–c Teenager with intense abdominal pain and persistent vaginal bleeding. Grey-scale US images\nshow a large amount of partially echogenic abdominal fluid (asterisk) and a pelvic haematoma (star) surrounding the uterus (U). A round, thick-walled\npara-uterine cystic mass (arrow) with vascularised wall and a fetal pole was noted with Colour Doppler ( d). No gestational sac was identi fied within the\nendometrial cavity. Laparoscopic surgery con firmed a ruptured ectopic tubal pregnancy with extensive hemoperitoneum. e–g Axial post-contrast CT\nimages in a different patient with a ruptured tubal EP. Normal right adnexa is noted (black arrow), separate from a ring-enhancing right para-uterine\ncystic mass (dotted arrow) which increases the likelihood that the cystic mass represents an ectopic pregnancy. Active bleeding from the ruptured tu bal\npregnancy is visible during the arterial phase (arrowhead). h Woman in her 20 ’s presenting in the emergency department with acute pelvic pain and\nvaginal bleeding. Coronal T2 WI shows an eccentric gestational sac (arrow) with a fetal pole (arrowhead) located in the interstitial segment of the ri ght\nFallopian tube, next to the uterus (U). MRI is more helpful in evaluating ectopic interstitial pregnancy, which is a diagnostic challenge on ultrasou nd\nDick et al . European Radiology (2025) 35:6682 –6695 6692\n\nMRI, signal intensity of haemoperitoneum depends on\nage of the blood [ 25].\nEctopic pregnancy including ruptured ectopic pregnancy\nEctopic pregnancy (EP) is a common cause of pregnancy-\nrelated APP. Early diagnosis and treatment have\ndecreased the incidence of EP rupture, which is poten-\ntially life-threatening. In EP, the fertilised oocyte implants\noutside of the uterine endometrium, most commonly in\nthe fallopian tubes (93 –98% of all EP, of which 75% are\nampullary, 13% isthmic and 12% fimbrial) [ 26]. The dif-\nferential diagnosis includes non-gynaecological adnexal\nmasses [ 27]. Table 4 outlines factors which increase the\nrisk of EP.\nA serum β-hCG value > 2000 mlU/mL (IRP Interna-\ntional Reference Preparation ) without intrauterine preg-\nnancy but with an extraovarian mass is highly suggestive\nof an EP [ 28]. On TVUS, an adnexal mass separate from\nthe ovary is seen in most, but not all, tubal pregnancies\n[29]. Other signs include the “tubal ring sign ”: a thick\nechogenic ring surrounding an extrauterine gestational\nsac and the “ring of fire sign ” due to peripheral hyper-\nvascularity of the hyperechoic ring (Fig. 7). If the tro-\nphoblast invasively grows into the fallopian tube, EP\nrupture and hemoperitoneum occurs.\nHaemoperitoneum in EP is not necessarily indicative of\ntubal rupture but the larger the amount of fluid, the\nhigher the likelihood of such.\nCT is now increasingly performed on pregnant women\neither because pregnancy status is unknown, there is\nclinical deterioration before serum β-hCG is available, or\nthe early urine pregnancy test is false-negative. On CT, an\nadnexal area of low attenuation with a dramatic enhanced\nring adjacent to the ipsilateral ovary and associated hae-\nmoperitoneum suggests EP. In EP rupture, active bleeding\ncan be seen (Fig. 7). The main CT differential diagnosis of\nEP is a CL cyst because (1) the wall of a CL may show\nstrong enhancement, (2) a CL cyst may rupture in the\nperitoneum, and (3) a CL cyst may occur in the setting of\nearly pregnancy. If clinical symptoms and serum β-hCG\nlevels do not allow differentiation of these two entities, the\nsite of the adnexal cystic mass may be a clue: a CL cyst is\nintraovarian, unlike an EP.\nMRI is a second-line test in suspected EP, demon-\nstrating haemoperitoneum, a heterogeneous, partly hae-\nmorrhagic adnexal mass representing the gestational sac\nand haematosalpinx within a dilated tube and mural\nenhancement [5]. MRI is better than CT at demonstrating\ndirect signs (ectopic gestational sac —92% diagnostic\naccuracy) (Fig. 7) and indirect signs (haematosalpinx,\nadnexal haematoma, hemoperitoneum). 100% diagnostic\nINVESTIGATION OF FEMALE WITH ACUTE PELVIC PAIN\nHistory, examination, investigations\nDepending on local \nexpertise US or CT\nβ HCG + (POS)\nPost-menopausal\nMRI\nPre-menopausal \nCT\nβ HCG is essential in \npre-menopausal patients\nEctopic pregnancy\nOvarian hyperstimulation\nGynaecological \ncauses *\nNon-gynaecological \ncauses **\nCT\nCT\nβ HCG    (NEG) or not available\n(or clinical condition worsening)\nGynaecological \ncauses\nUterine & placenta \ncomplications\n*\nGynaecological \ncauses *\nUS +/ CT\nIf US \nnon-conclusive \nOR \nnon-gynaecological \ncauses ** ^\nGynaecological causes *\nPID \nMalignancy \nOvarian torsion\nCyst complications\nLeiomyoma torsion / degeneration \nCT \nor \nMRI (if available)\nNon-gynaecological \ncauses **\nAppendicitis ^\nDiverticulitis\nPerforation\nOmental infarct\nVascular disease\nBowel obstruction\nBowel inflammatory disease ^\nUrinary lithiasis / infection \n(when complicated)\nMRI / CT\nIf US \nnon-conclusive \nOR \nnon-gynaecological \ncauses ** ^\nEctopic pregnancy\nOvarian hyperstimulation\nUS\nMRI\nUS\nFig. 8 Flowchart of investigation of a female with acute pelvic pain. β HCG, beta humanchorionic gonadotropin; POS, positive; NEG, negative; US,\nultrasound; CT, computed tomography; MRI, magnetic resonance imaging; PID, pelvic in flammatory disease. *Gynaecological causes, **Non-\ngynaecological causes, and ^MRI: consider MRI in these clinical scenarios in pregnant or very young women\nDick et al . European Radiology (2025) 35:6682 –6695 6693\n\naccuracy is achieved if the gestational sac is visible along\nwith two indirect signs [ 30]. MRI protocol should include\nT2*W sequences in 3 planes to identify low signal fresh\nhaematoma within the adnexal mass with a sensitivity,\nspecificity and accuracy of 95%, 100% and 96%, respec-\ntively, in diagnosing EP [ 31].\nSummary statement\nBoth gynaecological and non-gynaecological pathologies\ncan cause acute pelvic pain, and both the clinician\nand radiologist have to bear this in mind when requesting\nand interpreting imaging. Pregnancy and pre- and post-\nmenopausal status will direct investigation pathways Fig. 8.\nCommon gynaecological causes include ovarian cyst hae-\nmorrhage, corpus luteum rupture, endometriomas, adnexal\ntorsion, ectopic pregnancy, uterine leiomyoma degenera-\ntion, and a spectrum of infective pelvic in flammatory dis-\nease. Although ultrasound followed by MRI is often the\npreferred imaging pathway, the ubiquity of CT and the\npossibility of non-gynaecological causes means that for\nmany patients with gynaecological causes of acute pelvic\npain, CT is the first imaging modality.\nPatient summary\nAcute pelvic pain in women can have both gynaecological\nand non-gynaecological causes. Gynaecological causes\ninclude corpus luteum rupture, ectopic pregnancy, twist-\ning/loss of blood supply to fibroids or ovary, and infection\nof the cervix, uterus, fallopian tubes, and ovary. Ultrasound\nis the best first test if there is high suspicion of a gynae-\ncological cause, whereas CT is often performedfirst if other\ncauses, such as appendicitis or kidney stones, are suspected.\nMRI is usually a second-line test which con firms the sus-\npected diagnoses seen on ultrasound or CT.\nAbbreviations\nAPP Acute pelvic pain\nCT Computed tomography\nDECT Dual-energy CT\nDWI Diffusion-weighted imaging\nEP Ectopic pregnancy\nIUD Intrauterine device\nMRI Magnetic resonance imaging\nRUQ Right upper quadrant\nTAUS Transabdominal ultrasound\nTOA Tubo-ovarian abscess\nTVUS Transvaginal ultrasound\nUS Ultrasound\nβ-hCG Beta human chorionic gonadotropin\nAcknowledgements\nThis paper was endorsed by the Executive Council of the European Society of\nRadiology (ESR) and the Executive Committee of the European Society of\nEmergency Radiology (ESER) in March 2025. The authors wish to thank Ms\nMiranda Leff and Ms Cordelia Leff for their help with manuscript preparation.\nFunding\nOpen access funding provided by Università degli Studi G. D ’Annunzio Chieti\nPescara within the CRUI-CARE Agreement.\nCompliance with ethical standards\nGuarantor\nThe scienti fic guarantor of this publication is Professor Raffaella Basilico.\nConflict of interest\nProfessor Elizabeth Dick has received funding and support for conferences and\nlectures from Everlight Radiology and GCG Global Healthcare. Marcela De La\nHoz Polo is an employee of Everlight Radiology. The authors of this manuscript\ndeclare no other relationships with any companies, whose products or services\nmay be related to the subject matter of the article.\nStatistics and biometry\nNo complex statistical methods were necessary for this study.\nInformed consent\nWritten informed consent was not required for this paper. Images included are\nanonymised.\nEthical approval\nInstitutional Review Board approval was not required.\nStudy subjects or cohorts overlap\nNot applicable.\nMethodology\n● Practice recommendations\nAuthor details\n1Imperial College NHS Trust, London, UK. 2Imperial College, London, UK.\n3Emergency Section, Department of Radiology, Hospital Universitario Morales\nMeseguer, Murcia, Spain. 4Everlight Radiology, London, UK. 5Raffaella Basilico,\nDepartment of Medical, Oral and Biotechnological Sciences, University G.\nD’Annunzio Chieti-Pescara, Chieti, Italy.\nReceived: 4 November 2024 Revised: 22 January 2025 Accepted: 11\nFebruary 2025\nPublished online: 21 May 2025\nReferences\n1. Andreotti RF, Lee SI, Choy G et al (2009) ACR Appropriateness Criteria on\nacute pelvic pain in the reproductive age group. J Am Coll Radiol\n6:235–241\n2. Shetty M (2023) Acute pelvic pain: role of imaging in the diagnosis and\nmanagement. Semin Ultrasound CT MR 44:491 –500\n3. 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