Role of ultrasound in the evaluation of patients with acute pelvic pain

Acute pelvic pain is a common clinical condition that can indicate a range of gynecological, gastrointestinal, urinary, and vascular pathologies. Early diagnosis is essential to manage these patients, particularly in emergency settings. Point-of-care ultrasound (PoCUS) can be used as a first-line diagnostic tool for acute pelvic pain, due to its diagnostic capacity in identifying key pathologies. PoCUS enables quick, real-time assessment of conditions such as gastrointestinal pathologies (e.g., appendicitis and diverticulitis) and gynecological issues (e.g., hemorrhagic ovarian cysts and torsions) without exposing patients to ionizing radiation. This narrative review aims to evaluate the specific ultrasound findings for each condition, thus underscoring PoCUS diagnostic accuracy and utility. PoCUS is a valuable tool in the clinical management of acute pelvic pain. PoCUS optimizes patient outcomes and streamlines therapeutic pathways in both emergency and routine clinical settings by facilitating timely diagnosis and appropriate treatment. Similar content being viewed by others Data availability The data can be requested from the corresponding author.

Basta Nikolic M, Spasic A, Hadnadjev Simonji D, Stojanović S, Nikolic O, Nikolic D (2021) Imaging of acute pelvic pain. Br J Radiol 94(1127):20210281 Dietrich CF, Goudie A, Chiorean L, Cui XW, Gilja OH, Dong Y et al (2017) Point of care ultrasound: a WFUMB position paper. Ultrasound Med Biol 43(1):49–58 Arnold MJ, Jonas CE, Carter RE (2020) Point-of-care ultrasonography. Am Fam Physician 101(5):275–285 Scheier E, Shapira Levy E, Fisher A (2024) POCUS for pediatric appendicitis in the pediatric emergency department: an 8-year retrospective review. J Clin Ultrasound 52(9):1355–1359 Cho SU, Oh SK (2023) Accuracy of ultrasound for the diagnosis of acute appendicitis in the emergency department: a systematic review. Medicine (Baltimore) 102(13):e33397 Dirks K, Calabrese E, Dietrich CF, Gilja OH, Hausken T, Higginson A et al (2019) EFSUMB position paper: recommendations for gastrointestinal ultrasound (GIUS) in acute appendicitis and diverticulitis. Ultraschall Med 40(2):163–175 Rettenbacher T, Hollerweger A, Macheiner P, Rettenbacher L, Tomaselli F, Schneider B et al (2001) Outer diameter of the vermiform appendix as a sign of acute appendicitis: evaluation at US. Radiology 218(3):757–762 Xu Y, Jeffrey RB, Shin LK, DiMaio MA, Olcott EW (2016) Color doppler imaging of the appendix: criteria to improve specificity for appendicitis in the borderline-size appendix. J Ultrasound Med 35(10):2129–2138 Balbo S, Pini CM, Raffaldi I, Delmonaco AG, Castagno E, Guanà R et al (2024) Accuracy of point-of-care ultrasound in the diagnosis of acute appendicitis in a pediatric emergency department. J Clin Ultrasound 52(5):485–490 Tsung JW, Firnberg M, Sosa P (2024) Interobserver agreement of an ED PoCUS video training dataset of normal appendix and appendicitis in children. Ultrasound J 16(1):38 King WC, Shuaib W, Vijayasarathi A, Fajardo CG, Cabrera WE, Costa JL (2015) Benefits of sonography in diagnosing suspected uncomplicated acute diverticulitis. J Ultrasound Med 34(1):53–58 Huang CH, Liu KL, Lim ZJ, Sung CW, Wang HP, Chen IC et al (2023) Colonic diverticulitis location affects the diagnostic accuracy of point-of-care ultrasound: a multicenter, 10-year study. Ultrasound Med Biol 49(7):1611–1615 Valentino M, Serra C, Ansaloni L, Mantovani G, Pavlica P, Barozzi L (2009) Sonographic features of acute colonic diverticulitis. J Clin Ultrasound 37(8):457–463 Dumbrava BD, Abdulla HS, Pereira J, Biloslavo A, Zago M, Hashem JH et al (2023) Surgeon-performed point-of-care ultrasound in the diagnosis of acute sigmoid diverticulitis: a pragmatic prospective multicenter cohort study. Cureus 15(1):e33292 Sartelli M, Catena F, Ansaloni L, Coccolini F, Griffiths EA, Abu-Zidan FM et al (2016) WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting. World J Emerg Surg 11:37 Abu-Zidan FM, Cevik AA (2018) Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced. World J Emerg Surg 13:47 Hasbahceci M, Erol C, Seker M (2012) Epiploic appendagitis: is there need for surgery to confirm diagnosis in spite of clinical and radiological findings? World J Surg 36(2):441–446 Goodsall TM, Nguyen TM, Parker CE, Ma C, Andrews JM, Jairath V et al (2021) Systematic review: gastrointestinal ultrasound scoring indices for inflammatory bowel disease. J Crohns Colitis 15(1):125–142 Smith RL, Taylor KM, Friedman AB, Gibson RN, Gibson PR (2020) Systematic review: clinical utility of gastrointestinal ultrasound in the diagnosis, assessment and management of patients with ulcerative colitis. J Crohns Colitis 14(4):465–479 Rivera K, Cabrera G, Kalivoda EJ (2021) Point-of-care ultrasound diagnosis of a crohn’s disease-related intraabdominal abscess in the emergency department. Cureus 13(4):e14290 Wright EK, Wang I, Wong D, Bell SJ, Connell WR, Thompson AJ et al (2020) Accuracy of point-of-care intestinal ultrasound for Crohn’s disease. Australas J Ultrasound Med 23(3):176–182 Allocca M, Furfaro F, Fiorino G, Peyrin-Biroulet L, Danese S (2021) Point-of-care ultrasound in inflammatory bowel disease. J Crohns Colitis 15(1):143–151 Dong J, Wang H, Zhao J, Zhu W, Zhang L, Gong J et al (2014) Ultrasound as a diagnostic tool in detecting active Crohn’s disease: a meta-analysis of prospective studies. Eur Radiol 24(1):26–33 Panés J, Bouzas R, Chaparro M, García-Sánchez V, Gisbert JP, Martínez de Guereñu B et al (2011) Systematic review: the use of ultrasonography, computed tomography and magnetic resonance imaging for the diagnosis, assessment of activity and abdominal complications of Crohn’s disease. Aliment Pharmacol Ther 34(2):125–145 Boccatonda A, D’Ardes D, Tallarico V, Vicari S, Bartoli E, Vidili G et al (2023) Gastrointestinal ultrasound in emergency setting. J Clin Med 12(3):799 Maconi G, Nylund K, Ripolles T, Calabrese E, Dirks K, Dietrich CF et al (2018) EFSUMB recommendations and clinical guidelines for intestinal ultrasound (GIUS) in inflammatory bowel diseases. Ultraschall Med 39(3):304–317 Maconi G, Bollani S, Bianchi PG (1996) Ultrasonographic detection of intestinal complications in Crohn’s disease. Dig Dis Sci 41(8):1643–1648 Rispo A, Calabrese G, Testa A, Imperatore N, Patturelli M, Allocca M et al (2023) Hocus pocus: the role of hand-held ultrasonography in predicting disease extension and endoscopic activity in ulcerative colitis. J Crohns Colitis 17(7):1089–1096 Bru C, Sans M, Defelitto MM, Gilabert R, Fuster D, Llach J et al (2001) Hydrocolonic sonography for evaluating inflammatory bowel disease. AJR Am J Roentgenol 177(1):99–105 Robinson A, Light D, Kasim A, Nice C (2013) A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc 27(1):11–18 Al Jalbout N, Liteplo A, Shokoohi H (2022) Point-of care ultrasound in stratifying clinically evolving inguinal and femoral hernias. J Emerg Med 63(2):257–264 Alfonzo M, von Reinhart A, Riera A (2017) Point-of-care ultrasound identification of an abdominal hernia. Pediatr Emerg Care 33(8):596–598 Robinson A, Light D, Nice C (2013) Meta-analysis of sonography in the diagnosis of inguinal hernias. J Ultrasound Med 32(2):339–346 Jacomino K, Frasure SE, Boniface KS, Shokoohi H (2021) Point-of-care ultrasound in the diagnosis of an incarcerated inguinal hernia. Cureus 13(7):e16281 Argintaru N, Al-Den A, Chenkin J (2015) Diagnosis of a strangulated laparoscopic incisional hernia with point-of-care ultrasonography. West J Emerg Med 16(3):450–452 Gottlieb M, Peksa GD, Pandurangadu AV, Nakitende D, Takhar S, Seethala RR (2018) Utilization of ultrasound for the evaluation of small bowel obstruction: a systematic review and meta-analysis. Am J Emerg Med 36(2):234–242 Krol K, Chen YR, Morales Sierra MO, Nasir R, Mahabir N, Iyeke L et al (2024) Integrating pre-test probability and point-of-care ultrasound (POCUS) in the emergency department (ED) diagnosis of small bowel obstruction (SBO). Cureus 16(3):e56397 Shokoohi H, Mayes KD, Peksa GD, Loesche MA, Becker BA, Boniface KS et al (2023) Multi-center analysis of point-of-care ultrasound for small bowel obstruction: a systematic review and individual patient-level meta-analysis. Am J Emerg Med 70:144–150 Hollerweger A, Wüstner M, Dirks K (2015) Bowel obstruction: sonographic evaluation. Ultraschall Med 36(3):216–235 Brower CH, Baugh CW, Shokoohi H, Liteplo AS, Duggan N, Havens J et al (2022) Point-of-care ultrasound-first for the evaluation of small bowel obstruction: national cost savings, length of stay reduction, and preventable radiation exposure. Acad Emerg Med 29(7):824–834 Shokoohi H, Al Jalbout N, Peksa GD, Mayes KD, Becker BA, Boniface KS et al (2024) Optimal bowel diameter thresholds for diagnosing small bowel obstruction and surgical intervention with point-of-care ultrasound. Am J Emerg Med 84:1–6 Hollerweger A, Maconi G, Ripolles T, Nylund K, Higginson A, Serra C et al (2020) Gastrointestinal ultrasound (GIUS) in Intestinal emergencies—an EFSUMB position paper. Ultraschall Med 41(6):646–657 Bergmann KR, Arroyo AC, Tessaro MO, Nielson J, Whitcomb V, Madhok M et al (2021) Diagnostic accuracy of point-of-care ultrasound for intussusception: a multicenter, noninferiority study of paired diagnostic tests. Ann Emerg Med 78(5):606–615 Huang D, Al-Bassam M, Leon LN, Ganti L (2022) Emergency department point-of-care ultrasound diagnosis of a large bowel obstruction due to metastatic rectal cancer: a case report. Cureus 14(9):e28817 Di Capua M, Tonani M, Paglia S (2022) Ultrasound detection of portomesenteric venous gas is an early sign of bowel ischaemia in non-traumatic abdominal pain: old dogs, new tricks-four cases report. Case Rep Crit Care 2022:1734612 Boccatonda A, Balletta M, Vicari S, Hoxha A, Simioni P, Campello E (2023) The journey through the pathogenesis and treatment of venous thromboembolism in inflammatory bowel diseases: a narrative review. Semin Thromb Hemost 49(7):744–755 Granat N, Gabrieli S, Alpert EA (2020) Point-of-care ultrasound to diagnose colitis in the emergency department: a case series and review of the literature. J Emerg Med 58(1):77–84 Wiesner W, Khurana B, Ji H, Ros PR (2003) CT of acute bowel ischemia. Radiology 226(3):635–650 Danse EM, Van Beers BE, Goffette P, Dardenne AN, Laterre PF, Pringot J (1996) Acute intestinal ischemia due to occlusion of the superior mesenteric artery: detection with Doppler sonography. J Ultrasound Med 15(4):323–326 Braccini G, Lamacchia M, Boraschi P, Bertellotti L, Marrucci A, Goletti O et al (1996) Ultrasound versus plain film in the detection of pneumoperitoneum. Abdom Imaging 21(5):404–412 Taylor MA, Merritt CH, Riddle PJ Jr, DeGennaro CJ, Barron KR (2020) Diagnosis at gut point: rapid identification of pneumoperitoneum via point-of-care ultrasound. Ultrasound J 12(1):52 Hefny AF, Abu-Zidan FM (2011) Sonographic diagnosis of intraperitoneal free air. J Emerg Trauma Shock 4(4):511–513 Karahan OI, Kurt A, Yikilmaz A, Kahriman G (2004) New method for the detection of intraperitoneal free air by sonography: scissors maneuver. J Clin Ultrasound 32(8):381–385 Chadha D, Kedar RP, Malde HM (1993) Sonographic detection of pneumoperitoneum: an experimental and clinical study. Australas Radiol 37(2):182–185 Boccatonda A, Venerato S, D’Ardes D, Cocco G, Schiavone C, Vicari S (2023) Contrast-enhanced ultrasound follow-up for acute pyelonephritis patients. Healthcare (Basel). 11(21):2899 Boccatonda A, Stupia R, Serra C (2024) Ultrasound, contrast-enhanced ultrasound and pyelonephritis: a narrative review. World J Nephrol 13(3):98300 Luyckx F (2015) Who wants to go further has to know the past: a comment upon: Ultrasonography versus computed tomography for suspected nephrolithiasis-R. Smith-Bindman et al. N Engl J Med. 2014 Sep 18;371(12):1100-1110. World J Urol 33(10):1371–1372 Dalziel PJ, Noble VE (2013) Bedside ultrasound and the assessment of renal colic: a review. Emerg Med J 30(1):3–8 Khan MAB, Abu-Zidan FM (2020) Point-of-care ultrasound for the acute abdomen in the primary health care. Turk J Emerg Med 20(1):1–11 Turk M, Catanese B, Lefler B, Sparks MA, Bronshteyn YS, Bowman A (2024) Point-of-care kidney and genitourinary ultrasound in adults: image acquisition. J Vis Exp 208:66802 Watanabe H (1991) Transrectal sonography. A personal review and recent advances. Scand J Urol Nephrol Suppl 137:75–83 Murray KJ, Koratala A, Perez-Sanchez A, Lund T, Andrade A, Gorbatkin SM et al (2024) Current use, training, and barriers in point-of-care ultrasound in nephrology: a national survey of VA medical centers. Clin Nephrol 102(5):257–263 Cook DL, Patel S, Nee R, Little DJ, Cohen SD, Yuan CM (2023) Point-of-care ultrasound use in nephrology: a survey of nephrology program directors, fellows, and fellowship graduates. Kidney Med 5(4):100601 Schull A, Monzani Q, Bour L, Barry-Delongchamps N, Beuvon F, Legmann P et al (2012) Imaging in lower urinary tract infections. Diagn Interv Imaging 93(6):500–508 Lessiani G, Boccatonda A, D’Ardes D, Cocco G, Di Marco G, Schiavone C (2020) Mondor’s disease in SARS-CoV-2 infection: a case of superficial vein thrombosis in the era of COVID-19. Eur J Case Rep Intern Med 7(10):001803 Weatherspoon K, Polansky S, Catanzano T (2017) Ultrasound emergencies of the male pelvis. Semin Ultrasound CT MR 38(4):327–344 Ibrahimi A, Ziani I, Bellouki O, El Sayegh H, Benslimane L, Nouini Y (2020) Epididymo-testicular ischemia without torsion. Urol Case Rep 33:101324 Shibata J, Liu YT (2024) Clinical ultrasound in obstetrics and gynecology. Emerg Med Clin North Am 42(4):839–862 Martins JG, Waller J, Horgan R, Kawakita T, Kanaan C, Abuhamad A et al (2024) Point-of-care ultrasound in critical care obstetrics: a scoping review of the current evidence. J Ultrasound Med 43(5):951–965 Wachira J, Matheka DM, Masheti SA, Githemo GK, Shah S, Haldeman MS et al (2023) A training program for obstetrics point-of-care ultrasound to 514 rural healthcare providers in Kenya. BMC Med Educ 23(1):922 Wong TW, Lau CC, Yeung A, Lo L, Tai CM (1998) Efficacy of transabdominal ultrasound examination in the diagnosis of early pregnancy complications in an emergency department. J Accid Emerg Med 15(3):155–158 Toscano M, Szlachetka K, Whaley N, Thornburg LL (2020) Evaluating sensitivity and specificity of handheld point-of-care ultrasound testing for gynecologic pathology: a pilot study for use in low resource settings. BMC Med Imaging 20(1):121 Recker F, Weber E, Strizek B, Gembruch U, Westerway SC, Dietrich CF (2021) Point-of-care ultrasound in obstetrics and gynecology. Arch Gynecol Obstet 303(4):871–876 Cocco G, Ricci V, Cocco N, Boccatonda A, D’Ardes D, Basilico R et al (2020) Sonography of abdominal wall vascular malformation: a case report and review of the literature. J Ultrasound 23(4):481–485 Yoffe N, Bronshtein M, Brandes J, Blumenfeld Z (1991) Hemorrhagic ovarian cyst detection by transvaginal sonography: the great imitator. Gynecol Endocrinol 5(2):123–129 Bourne TH, Hagström H, Hahlin M, Josefsson B, Granberg S, Hellberg P et al (1996) Ultrasound studies of vascular and morphological changes in the human corpus luteum during the menstrual cycle. Fertil Steril 65(4):753–758 Cacciatore B, Leminen A, Ingman-Friberg S, Ylöstalo P, Paavonen J (1992) Transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease. Obstet Gynecol 80(6):912–916 Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS (1998) Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound Obstet Gynecol 12(1):56–66 Levine D, Brown DL, Andreotti RF, Benacerraf B, Benson CB, Brewster WR et al (2010) Management of asymptomatic ovarian and other adnexal cysts imaged at US: society of radiologists in ultrasound consensus conference statement. Radiology 256(3):943–954 Haldorsen IS, Lura N, Blaakær J, Fischerova D, Werner HMJ (2019) What is the role of imaging at primary diagnostic work-up in uterine cervical cancer? Curr Oncol Rep 21(9):77 Raffone A, Raimondo D, Neola D, Travaglino A, Doglioli M, Ambrosio M et al (2024) Prevalence of sonographic signs in women with uterine sarcoma: a systematic review and meta-analysis. Ultraschall Med 45(3):293–304 Moro F, Bolomini G, Sibal M, Vijayaraghavan SB, Venkatesh P, Nardelli F et al (2020) Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion. Ultrasound Obstet Gynecol 56(6):934–943 Sibal M (2012) Follicular ring sign: a simple sonographic sign for early diagnosis of ovarian torsion. J Ultrasound Med 31(11):1803–1809 Valentin L (2009) Characterising acute gynaecological pathology with ultrasound: an overview and case examples. Best Pract Res Clin Obstet Gynaecol 23(5):577–593 Nyberg DA, Laing FC, Filly RA, Uri-Simmons M, Jeffrey RB Jr (1983) Ultrasonographic differentiation of the gestational sac of early intrauterine pregnancy from the pseudogestational sac of ectopic pregnancy. Radiology 146(3):755–759 Stein JC, Wang R, Adler N, Boscardin J, Jacoby VL, Won G et al (2010) Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med 56(6):674–683 Sun B, Ma Y, Li L, Hu L, Wang F, Zhang Y et al (2020) Factors associated with ovarian hyperstimulation syndrome (OHSS) severity in women with polycystic ovary syndrome undergoing IVF/ICSI. Front Endocrinol (Lausanne) 11:615957 Van Holsbeke C, Van Calster B, Guerriero S, Savelli L, Paladini D, Lissoni AA et al (2010) Endometriomas: their ultrasound characteristics. Ultrasound Obstet Gynecol 35(6):730–740 Cocco G, Delli Pizzi A, Scioscia M, Ricci V, Boccatonda A, Candeloro M et al (2021) Ultrasound imaging of abdominal wall endometriosis: a pictorial review. Diagnostics (Basel). 11(4):609 Guerriero S, Condous G, van den Bosch T, Valentin L, Leone FP, Van Schoubroeck D et al (2016) Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the international deep endometriosis analysis (IDEA) group. Ultrasound Obstet Gynecol 48(3):318–332 Cocco G, Ricci V, Boccatonda A, Schiavone C (2020) Focused ultrasound for the diagnosis of non-palpable endometriotic lesions of the abdominal wall: a not-uncommon surgical complication. J Ultrasound 23(2):183–187 Boccatonda A, Brighenti A, Tiraferri V, Loiacono R, Serra C 2025 Bedside CEUS: a feasible option to consider. Eur J Intern Med

The authors acknowledge Marisol Doglioli and Alice Brighenti for their editorial assistance. Funding This research received no external funding. Author information Authors and Affiliations Contributions Conceptualization and methodology, A.B.; software, L.D.; writing—original draft preparation, V.T.; writing—review and editing, G.F. and C.S. All authors have read and agreed to the published version of this manuscript. Corresponding author Ethics declarations Conflicts of interest The authors declare no conflicts of interest. Informed consent Not applicable. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Boccatonda, A., Tiraferri, V., De Meis, L. et al. Role of ultrasound in the evaluation of patients with acute pelvic pain. Intern Emerg Med 20, 1339–1351 (2025). https://doi.org/10.1007/s11739-025-03982-8 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s11739-025-03982-8