The Use of Ultrasound-Based ???Soft Markers??? for the Prediction of Pelvic Pathology in Women With Chronic Pelvic Pain???Can We Reduce the Need for Laparoscopy?

The Use of Ultrasound-Based ‘Soft Markers’ for the Prediction of Pelvic Pathology in Women With Chronic Pelvic Pain—Can We Reduce the Need for Laparoscopy? - E Okaro - G Condous - A Khalid - D Timmerman - L Ameye - S V. Huffel - T Bourne An estimated one of every 10 gynecologic visits—and half of all diagnostic laparoscopies—are occasioned by chronic pelvic pain (CPP), a condition that often presents a difficult clinical problem. The most common disorders found at laparoscopy are pelvic endometriosis and adhesions, but no obvious cause of pain is identified in as many as 40% of women evaluated. Transvaginal sonography (TVS), in addition to disclosing ovarian cysts and hydrosalpinges, can provide more subtle information such as the degree of ovarian and uterine mobility and tenderness, findings characterized as “soft markers” of pelvic disease. This study sought soft markers in 120 consecutive premenopausal, nonpregnant women with CPP who were to have diagnostic or operative laparoscopy. They had experienced lower abdominal pain for at least 6 months, which was rated for intensity by visual analog scores. Pain was not associated exclusively with menses or intercourse. A single gynecologist experienced in TVS performed all the studies. Longitudinal and transverse views of the uterus and adnexa were obtained. All of the women subsequently had laparoscopy under general anesthesia. The patients, whose mean age was 31 years, had pain for 46 months on average. Seventy of the 120 participants (58%) had pelvic pathology: 51 of them, endometriosis alone; 7, endometriosis plus pelvic adhesions; 6, pelvic adhesions only; 5, hydrosalpinx plus adhesions; and one, hydrosalpinx with endometriosis. Hard markers were absent on TVS in 96 women. The most common such marker was a cyst consistent with endometrioma. Of 94 women lacking hard markers, 51 (53%) had soft markers. Laparoscopy confirmed abnormalities in 37 women having soft markers on TVS. Thirty of them had endometriosis; 6, adhesions; and one, endometriosis and adhesions. Nine women, most of them with low-grade endometriosis, had falsely negative TVS diagnoses. The likelihood ratio was infinity for hard markers (100% specificity); 1.9 (95% confidence interval [CI], 1.2–3.1) for soft markers; and 0.18 (95% CI, 0.09–0.34) for a “normal” sonogram. The pretest probability of pelvic disease was 58% overall, 100% when hard markers were present, and 73% with soft markers. With a normal sonogram, the figure fell to 20%. Seeking site-specific tenderness and ovarian mobility on TVS makes it easier to detect and exclude pelvic pathology in women with CPP. The investigators believe that taking both hard and soft markers into account may significantly lower the number of diagnostic laparoscopies required.