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Comprehensive MR Imaging of Acute Gynecologic Diseases¹

¹ From the Department of Radiology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki 710-8602, Japan. Presented as a scientific exhibit at the 1999 RSNA scientific assembly. Received March 2, 2000; revision requested March 29 and received May 22; accepted May 26. Address correspondence to Y.W. (e-mail: yw5904@kchnet.or.jp).

View larger version (120K): [in a new window]   Figure 1a.   Rupture of ovarian endometrioma in a 35-year-old woman with sudden pelvic pain. Axial fat-suppressed T1-weighted (a, b) and fat-suppressed T2-weighted (c) MR images show massive hyperintense fluid contents (solid arrows) that have flowed out of a right ovarian endometrioma (arrowheads). The T1-weighted images (a, b) allow differentiation of the hyperintense fluid contents outside the endometrioma from fat. The endometrioma is seen as a hyperintense mass with a distorted shape and hypointense areas on both the T1-weighted (a, b) and T2-weighted (c) images. The posterior part of the wall, which is thinner than the other parts, was considered to be the rupture site (open arrow). * = uterus.

View larger version (123K): [in a new window]   Figure 1b.   Rupture of ovarian endometrioma in a 35-year-old woman with sudden pelvic pain. Axial fat-suppressed T1-weighted (a, b) and fat-suppressed T2-weighted (c) MR images show massive hyperintense fluid contents (solid arrows) that have flowed out of a right ovarian endometrioma (arrowheads). The T1-weighted images (a, b) allow differentiation of the hyperintense fluid contents outside the endometrioma from fat. The endometrioma is seen as a hyperintense mass with a distorted shape and hypointense areas on both the T1-weighted (a, b) and T2-weighted (c) images. The posterior part of the wall, which is thinner than the other parts, was considered to be the rupture site (open arrow). * = uterus.

View larger version (100K): [in a new window]   Figure 1c.   Rupture of ovarian endometrioma in a 35-year-old woman with sudden pelvic pain. Axial fat-suppressed T1-weighted (a, b) and fat-suppressed T2-weighted (c) MR images show massive hyperintense fluid contents (solid arrows) that have flowed out of a right ovarian endometrioma (arrowheads). The T1-weighted images (a, b) allow differentiation of the hyperintense fluid contents outside the endometrioma from fat. The endometrioma is seen as a hyperintense mass with a distorted shape and hypointense areas on both the T1-weighted (a, b) and T2-weighted (c) images. The posterior part of the wall, which is thinner than the other parts, was considered to be the rupture site (open arrow). * = uterus.

View larger version (95K): [in a new window]   Figure 2a.   Hemorrhagic ovarian cyst with hemoperitoneum in a 20-year-old woman with pelvic pain. Axial fat-suppressed T2-weighted (a) and fat-suppressed T1-weighted (b) MR images show a complex left adnexal mass (solid arrows). The mass is mostly hypointense with a small hyperintense portion on the T2-weighted image (a); it is hyperintense and isointense on the T1-weighted image (b). There is a fluid collection (open arrow), which is hyperintense on the T2-weighted image (a) and slightly hyperintense relative to urine (±) on the T1-weighted image (b), an appearance suggestive of bloody ascites. Note the layering low signal intensity (arrowhead) on the T2-weighted image (a); this finding is considered to represent fibrin debris or clots. large * = right ovary, small * = uterus.

View larger version (102K): [in a new window]   Figure 2b.   Hemorrhagic ovarian cyst with hemoperitoneum in a 20-year-old woman with pelvic pain. Axial fat-suppressed T2-weighted (a) and fat-suppressed T1-weighted (b) MR images show a complex left adnexal mass (solid arrows). The mass is mostly hypointense with a small hyperintense portion on the T2-weighted image (a); it is hyperintense and isointense on the T1-weighted image (b). There is a fluid collection (open arrow), which is hyperintense on the T2-weighted image (a) and slightly hyperintense relative to urine (±) on the T1-weighted image (b), an appearance suggestive of bloody ascites. Note the layering low signal intensity (arrowhead) on the T2-weighted image (a); this finding is considered to represent fibrin debris or clots. large * = right ovary, small * = uterus.

View larger version (162K): [in a new window]   Figure 3a.   Rupture of ovarian cystic teratoma in a 64-year-old woman with pelvic pain and abdominal distention. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic teratoma (arrows) with a fat-fluid level. The signal intensity of the fat (small *) floating within the tumor is suppressed on the fat-suppressed image (b). Note the massive ascites (large *). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image clearly shows thickened peritoneum (arrowheads), which suggests chemical peritonitis due to rupture of the tumor.

View larger version (130K): [in a new window]   Figure 3b.   Rupture of ovarian cystic teratoma in a 64-year-old woman with pelvic pain and abdominal distention. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic teratoma (arrows) with a fat-fluid level. The signal intensity of the fat (small *) floating within the tumor is suppressed on the fat-suppressed image (b). Note the massive ascites (large *). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image clearly shows thickened peritoneum (arrowheads), which suggests chemical peritonitis due to rupture of the tumor.

View larger version (160K): [in a new window]   Figure 3c.   Rupture of ovarian cystic teratoma in a 64-year-old woman with pelvic pain and abdominal distention. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic teratoma (arrows) with a fat-fluid level. The signal intensity of the fat (small *) floating within the tumor is suppressed on the fat-suppressed image (b). Note the massive ascites (large *). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image clearly shows thickened peritoneum (arrowheads), which suggests chemical peritonitis due to rupture of the tumor.

View larger version (137K): [in a new window]   Figure 4a.   Twisted left ovarian cystic teratoma with hemorrhagic necrosis in a 10-year-old girl with pelvic pain and nausea. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic tumor (solid arrows) with a markedly thickened wall, which is slightly hyperintense. A small fat component (open arrow) within the tumor is hyperintense on the T1-weighted image (a) and hypointense on the fat-suppressed T1-weighted image (b). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the wall is not enhanced, a finding indicative of hemorrhagic necrosis due to torsion. (d) Photograph of the cut surface of the resected tumor shows that the wall is thick and dark red (arrowheads), an appearance suggestive of hemorrhagic necrosis. Scale is in millimeters.

View larger version (133K): [in a new window]   Figure 4b.   Twisted left ovarian cystic teratoma with hemorrhagic necrosis in a 10-year-old girl with pelvic pain and nausea. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic tumor (solid arrows) with a markedly thickened wall, which is slightly hyperintense. A small fat component (open arrow) within the tumor is hyperintense on the T1-weighted image (a) and hypointense on the fat-suppressed T1-weighted image (b). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the wall is not enhanced, a finding indicative of hemorrhagic necrosis due to torsion. (d) Photograph of the cut surface of the resected tumor shows that the wall is thick and dark red (arrowheads), an appearance suggestive of hemorrhagic necrosis. Scale is in millimeters.

View larger version (121K): [in a new window]   Figure 4c.   Twisted left ovarian cystic teratoma with hemorrhagic necrosis in a 10-year-old girl with pelvic pain and nausea. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic tumor (solid arrows) with a markedly thickened wall, which is slightly hyperintense. A small fat component (open arrow) within the tumor is hyperintense on the T1-weighted image (a) and hypointense on the fat-suppressed T1-weighted image (b). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the wall is not enhanced, a finding indicative of hemorrhagic necrosis due to torsion. (d) Photograph of the cut surface of the resected tumor shows that the wall is thick and dark red (arrowheads), an appearance suggestive of hemorrhagic necrosis. Scale is in millimeters.

View larger version (142K): [in a new window]   Figure 4d.   Twisted left ovarian cystic teratoma with hemorrhagic necrosis in a 10-year-old girl with pelvic pain and nausea. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic tumor (solid arrows) with a markedly thickened wall, which is slightly hyperintense. A small fat component (open arrow) within the tumor is hyperintense on the T1-weighted image (a) and hypointense on the fat-suppressed T1-weighted image (b). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the wall is not enhanced, a finding indicative of hemorrhagic necrosis due to torsion. (d) Photograph of the cut surface of the resected tumor shows that the wall is thick and dark red (arrowheads), an appearance suggestive of hemorrhagic necrosis. Scale is in millimeters.

View larger version (122K): [in a new window]   Figure 5a.   Twisted left ovarian fibroma with hemorrhagic necrosis in a 60-year-old woman with sudden pelvic pain and vomiting. (a) Sagittal dynamic MR image (nonenhanced) shows a tumor with a slightly hyperintense portion at the posterior margin (arrows) due to the T1-weighted nature of the sequence. This appearance is suggestive of congestion or hemorrhagic necrosis. (b) Sagittal contrast-enhanced dynamic MR image (late phase) shows no enhancement of most of the tumor. The posterior margin of the tumor demonstrates moderate enhancement (arrows). However, it is difficult to determine the degree and extent of the enhancement because of the superimposed high signal intensity. (c) Sagittal contrast-enhanced dynamic subtraction MR image (late phase) shows that most of the tumor is not enhanced, a finding indicative of interruption of blood flow and strongly suggestive of necrosis of the tumor. Moderate enhancement of the posterior margin of the tumor (arrows) is more clearly identified because of exclusion of the superimposed high signal intensity.

View larger version (127K): [in a new window]   Figure 5b.   Twisted left ovarian fibroma with hemorrhagic necrosis in a 60-year-old woman with sudden pelvic pain and vomiting. (a) Sagittal dynamic MR image (nonenhanced) shows a tumor with a slightly hyperintense portion at the posterior margin (arrows) due to the T1-weighted nature of the sequence. This appearance is suggestive of congestion or hemorrhagic necrosis. (b) Sagittal contrast-enhanced dynamic MR image (late phase) shows no enhancement of most of the tumor. The posterior margin of the tumor demonstrates moderate enhancement (arrows). However, it is difficult to determine the degree and extent of the enhancement because of the superimposed high signal intensity. (c) Sagittal contrast-enhanced dynamic subtraction MR image (late phase) shows that most of the tumor is not enhanced, a finding indicative of interruption of blood flow and strongly suggestive of necrosis of the tumor. Moderate enhancement of the posterior margin of the tumor (arrows) is more clearly identified because of exclusion of the superimposed high signal intensity.

View larger version (132K): [in a new window]   Figure 5c.   Twisted left ovarian fibroma with hemorrhagic necrosis in a 60-year-old woman with sudden pelvic pain and vomiting. (a) Sagittal dynamic MR image (nonenhanced) shows a tumor with a slightly hyperintense portion at the posterior margin (arrows) due to the T1-weighted nature of the sequence. This appearance is suggestive of congestion or hemorrhagic necrosis. (b) Sagittal contrast-enhanced dynamic MR image (late phase) shows no enhancement of most of the tumor. The posterior margin of the tumor demonstrates moderate enhancement (arrows). However, it is difficult to determine the degree and extent of the enhancement because of the superimposed high signal intensity. (c) Sagittal contrast-enhanced dynamic subtraction MR image (late phase) shows that most of the tumor is not enhanced, a finding indicative of interruption of blood flow and strongly suggestive of necrosis of the tumor. Moderate enhancement of the posterior margin of the tumor (arrows) is more clearly identified because of exclusion of the superimposed high signal intensity.

View larger version (112K): [in a new window]   Figure 6a.   Histologically proved ovarian pregnancy in a 22-year-old woman with pelvic pain. (a, b) Axial fat-suppressed T1-weighted (a) and T2-weighted (b) MR images show a heterogeneous, hyperintense mass (long arrows) on the right side of the uterus (*). The margin of the mass has irregular low signal intensity (short arrows) on the T2-weighted image (b). Note the small amount of bloody ascites, which appears as a slightly hyperintense area (arrowheads) on both images. (c) Axial T2*-weighted MR image shows that the hypointense rim on the fat-suppressed T2-weighted image (b) is more enhanced (short arrows). This finding suggests that the effect is due to susceptibility artifact and that the mass (long arrows) is a hemorrhagic lesion. (d) Coronal contrast-enhanced dynamic subtraction MR image (late arterial phase) clearly shows extravasation of contrast material (open arrow) within the hemorrhagic mass (solid arrows). This finding indicates persistence of bleeding. * = uterus.

View larger version (96K): [in a new window]   Figure 6b.   Histologically proved ovarian pregnancy in a 22-year-old woman with pelvic pain. (a, b) Axial fat-suppressed T1-weighted (a) and T2-weighted (b) MR images show a heterogeneous, hyperintense mass (long arrows) on the right side of the uterus (*). The margin of the mass has irregular low signal intensity (short arrows) on the T2-weighted image (b). Note the small amount of bloody ascites, which appears as a slightly hyperintense area (arrowheads) on both images. (c) Axial T2*-weighted MR image shows that the hypointense rim on the fat-suppressed T2-weighted image (b) is more enhanced (short arrows). This finding suggests that the effect is due to susceptibility artifact and that the mass (long arrows) is a hemorrhagic lesion. (d) Coronal contrast-enhanced dynamic subtraction MR image (late arterial phase) clearly shows extravasation of contrast material (open arrow) within the hemorrhagic mass (solid arrows). This finding indicates persistence of bleeding. * = uterus.

View larger version (104K): [in a new window]   Figure 6c.   Histologically proved ovarian pregnancy in a 22-year-old woman with pelvic pain. (a, b) Axial fat-suppressed T1-weighted (a) and T2-weighted (b) MR images show a heterogeneous, hyperintense mass (long arrows) on the right side of the uterus (*). The margin of the mass has irregular low signal intensity (short arrows) on the T2-weighted image (b). Note the small amount of bloody ascites, which appears as a slightly hyperintense area (arrowheads) on both images. (c) Axial T2*-weighted MR image shows that the hypointense rim on the fat-suppressed T2-weighted image (b) is more enhanced (short arrows). This finding suggests that the effect is due to susceptibility artifact and that the mass (long arrows) is a hemorrhagic lesion. (d) Coronal contrast-enhanced dynamic subtraction MR image (late arterial phase) clearly shows extravasation of contrast material (open arrow) within the hemorrhagic mass (solid arrows). This finding indicates persistence of bleeding. * = uterus.

View larger version (171K): [in a new window]   Figure 6d.   Histologically proved ovarian pregnancy in a 22-year-old woman with pelvic pain. (a, b) Axial fat-suppressed T1-weighted (a) and T2-weighted (b) MR images show a heterogeneous, hyperintense mass (long arrows) on the right side of the uterus (*). The margin of the mass has irregular low signal intensity (short arrows) on the T2-weighted image (b). Note the small amount of bloody ascites, which appears as a slightly hyperintense area (arrowheads) on both images. (c) Axial T2*-weighted MR image shows that the hypointense rim on the fat-suppressed T2-weighted image (b) is more enhanced (short arrows). This finding suggests that the effect is due to susceptibility artifact and that the mass (long arrows) is a hemorrhagic lesion. (d) Coronal contrast-enhanced dynamic subtraction MR image (late arterial phase) clearly shows extravasation of contrast material (open arrow) within the hemorrhagic mass (solid arrows). This finding indicates persistence of bleeding. * = uterus.

View larger version (140K): [in a new window]   Figure 7a.   Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 2 months after dilation and curettage. (a) Sagittal fat-suppressed T2-weighted MR image shows tangled signal voids protruding into the endometrial cavity (arrows). (b) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal voids (arrows) enhance as intensely as the abdominal aorta (*), a finding indicative of a vascular lesion.

View larger version (115K): [in a new window]   Figure 7b.   Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 2 months after dilation and curettage. (a) Sagittal fat-suppressed T2-weighted MR image shows tangled signal voids protruding into the endometrial cavity (arrows). (b) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal voids (arrows) enhance as intensely as the abdominal aorta (*), a finding indicative of a vascular lesion.

View larger version (167K): [in a new window]   Figure 8a.   Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 1 week after dilation and curettage. (a) Axial T1-weighted MR image shows multiple signal voids (arrows) in the myometrium and parametrium. (b) Sagittal fat-suppressed T2-weighted MR image shows a hyperintense mass (arrow) protruding into the endometrial cavity, mimicking a polypoid tumor. (c) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal intensity of the mass (arrow) is identical with that of the abdominal aorta (*), a finding suggestive of a vascular lesion. (d) Coronal dynamic subtraction MR angiogram shows a uterine vascular lesion with dilated left uterine vessels and early venous return (arrows). Note the massive hemorrhage in the vaginal and endometrial cavities, which is seen as moderate high signal intensity on the T2-weighted image (* in b) and a nonenhanced area on the contrast-enhanced dynamic subtraction image (c). The findings of dynamic subtraction MR angiography were confirmed with conventional angiography, and transarterial embolization was performed. (Fig 8d reprinted, with permission, from reference 1.)

View larger version (124K): [in a new window]   Figure 8b.   Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 1 week after dilation and curettage. (a) Axial T1-weighted MR image shows multiple signal voids (arrows) in the myometrium and parametrium. (b) Sagittal fat-suppressed T2-weighted MR image shows a hyperintense mass (arrow) protruding into the endometrial cavity, mimicking a polypoid tumor. (c) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal intensity of the mass (arrow) is identical with that of the abdominal aorta (*), a finding suggestive of a vascular lesion. (d) Coronal dynamic subtraction MR angiogram shows a uterine vascular lesion with dilated left uterine vessels and early venous return (arrows). Note the massive hemorrhage in the vaginal and endometrial cavities, which is seen as moderate high signal intensity on the T2-weighted image (* in b) and a nonenhanced area on the contrast-enhanced dynamic subtraction image (c). The findings of dynamic subtraction MR angiography were confirmed with conventional angiography, and transarterial embolization was performed. (Fig 8d reprinted, with permission, from reference 1.)

View larger version (99K): [in a new window]   Figure 8c.   Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 1 week after dilation and curettage. (a) Axial T1-weighted MR image shows multiple signal voids (arrows) in the myometrium and parametrium. (b) Sagittal fat-suppressed T2-weighted MR image shows a hyperintense mass (arrow) protruding into the endometrial cavity, mimicking a polypoid tumor. (c) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal intensity of the mass (arrow) is identical with that of the abdominal aorta (*), a finding suggestive of a vascular lesion. (d) Coronal dynamic subtraction MR angiogram shows a uterine vascular lesion with dilated left uterine vessels and early venous return (arrows). Note the massive hemorrhage in the vaginal and endometrial cavities, which is seen as moderate high signal intensity on the T2-weighted image (* in b) and a nonenhanced area on the contrast-enhanced dynamic subtraction image (c). The findings of dynamic subtraction MR angiography were confirmed with conventional angiography, and transarterial embolization was performed. (Fig 8d reprinted, with permission, from reference 1.)

View larger version (123K): [in a new window]   Figure 8d.   Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 1 week after dilation and curettage. (a) Axial T1-weighted MR image shows multiple signal voids (arrows) in the myometrium and parametrium. (b) Sagittal fat-suppressed T2-weighted MR image shows a hyperintense mass (arrow) protruding into the endometrial cavity, mimicking a polypoid tumor. (c) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal intensity of the mass (arrow) is identical with that of the abdominal aorta (*), a finding suggestive of a vascular lesion. (d) Coronal dynamic subtraction MR angiogram shows a uterine vascular lesion with dilated left uterine vessels and early venous return (arrows). Note the massive hemorrhage in the vaginal and endometrial cavities, which is seen as moderate high signal intensity on the T2-weighted image (* in b) and a nonenhanced area on the contrast-enhanced dynamic subtraction image (c). The findings of dynamic subtraction MR angiography were confirmed with conventional angiography, and transarterial embolization was performed. (Fig 8d reprinted, with permission, from reference 1.)

View larger version (136K): [in a new window]   Figure 9a.   Retained products of conception in a 29-year-old woman with massive genital bleeding 1 month after delivery. (a) Sagittal fat-suppressed T2-weighted MR image shows hyperintense retained placenta (straight arrows) protruding into the dilated uterine lumen and multiple signal voids (arrowheads) in the myometrium. (b) Sagittal contrast-enhanced dynamic subtraction MR image shows that the retained placenta (straight solid arrows) is strongly hypervascular and attached to the posterior wall with deep invasion into the myometrium (open arrows). Note the massive clots (curved arrows) superimposed on the retained placenta, which are hypointense on the T2-weighted image (a) and nonenhanced on the contrast-enhanced dynamic subtraction image (b). Total hysterectomy was performed instead of dilation and curettage, which increases the risk of massive hemorrhage.

View larger version (136K): [in a new window]   Figure 9b.   Retained products of conception in a 29-year-old woman with massive genital bleeding 1 month after delivery. (a) Sagittal fat-suppressed T2-weighted MR image shows hyperintense retained placenta (straight arrows) protruding into the dilated uterine lumen and multiple signal voids (arrowheads) in the myometrium. (b) Sagittal contrast-enhanced dynamic subtraction MR image shows that the retained placenta (straight solid arrows) is strongly hypervascular and attached to the posterior wall with deep invasion into the myometrium (open arrows). Note the massive clots (curved arrows) superimposed on the retained placenta, which are hypointense on the T2-weighted image (a) and nonenhanced on the contrast-enhanced dynamic subtraction image (b). Total hysterectomy was performed instead of dilation and curettage, which increases the risk of massive hemorrhage.

View larger version (111K): [in a new window]   Figure 10a.   Pyosalpinx in a 48-year-old woman with pelvic pain and an elevated blood level of C-reactive protein. (a) Axial fat-suppressed T2-weighted MR image shows a pyosalpinx as a hyperintense, fluid-filled, dilated tube (arrows) with a thick wall. (b) Axial heavily T2-weighted MR image shows that the fluid (large *) within the pyosalpinx (arrows) is hypointense relative to urine (small *), an appearance suggestive of debris or hemorrhage. (c, d) Axial (c) and sagittal (d) contrast-enhanced fat-suppressed T1-weighted MR images clearly show intense enhancement of the wall of the pyosalpinx and adjacent soft tissue (arrows). The sagittal image is useful for recognition of a dilated, tortuous salpinx.

View larger version (152K): [in a new window]   Figure 10b.   Pyosalpinx in a 48-year-old woman with pelvic pain and an elevated blood level of C-reactive protein. (a) Axial fat-suppressed T2-weighted MR image shows a pyosalpinx as a hyperintense, fluid-filled, dilated tube (arrows) with a thick wall. (b) Axial heavily T2-weighted MR image shows that the fluid (large *) within the pyosalpinx (arrows) is hypointense relative to urine (small *), an appearance suggestive of debris or hemorrhage. (c, d) Axial (c) and sagittal (d) contrast-enhanced fat-suppressed T1-weighted MR images clearly show intense enhancement of the wall of the pyosalpinx and adjacent soft tissue (arrows). The sagittal image is useful for recognition of a dilated, tortuous salpinx.

View larger version (130K): [in a new window]   Figure 10c.   Pyosalpinx in a 48-year-old woman with pelvic pain and an elevated blood level of C-reactive protein. (a) Axial fat-suppressed T2-weighted MR image shows a pyosalpinx as a hyperintense, fluid-filled, dilated tube (arrows) with a thick wall. (b) Axial heavily T2-weighted MR image shows that the fluid (large *) within the pyosalpinx (arrows) is hypointense relative to urine (small *), an appearance suggestive of debris or hemorrhage. (c, d) Axial (c) and sagittal (d) contrast-enhanced fat-suppressed T1-weighted MR images clearly show intense enhancement of the wall of the pyosalpinx and adjacent soft tissue (arrows). The sagittal image is useful for recognition of a dilated, tortuous salpinx.

View larger version (144K): [in a new window]   Figure 10d.   Pyosalpinx in a 48-year-old woman with pelvic pain and an elevated blood level of C-reactive protein. (a) Axial fat-suppressed T2-weighted MR image shows a pyosalpinx as a hyperintense, fluid-filled, dilated tube (arrows) with a thick wall. (b) Axial heavily T2-weighted MR image shows that the fluid (large *) within the pyosalpinx (arrows) is hypointense relative to urine (small *), an appearance suggestive of debris or hemorrhage. (c, d) Axial (c) and sagittal (d) contrast-enhanced fat-suppressed T1-weighted MR images clearly show intense enhancement of the wall of the pyosalpinx and adjacent soft tissue (arrows). The sagittal image is useful for recognition of a dilated, tortuous salpinx.

View larger version (110K): [in a new window]   Figure 11a.   Postpartum myometritis and pelvic abscesses in a 30-year-old woman with a high fever. (a, b) Axial fat-suppressed T2-weighted MR images obtained at the level of the fundus of the uterus (a) and the body of the uterus (b) show multiple small, markedly hyperintense areas (arrows) surrounded by slightly hyperintense regions adjacent to the uterus. (c, d) Axial contrast-enhanced fat-suppressed T1-weighted MR images obtained at the same levels as a and b, respectively, show ill-defined intense enhancement of the myometrium and parametrium (large arrows) surrounding small abscesses (small arrows). Note the peritoneal enhancement (large *) and the small amount of ascites (small *) due to peritonitis.

View larger version (93K): [in a new window]   Figure 11b.   Postpartum myometritis and pelvic abscesses in a 30-year-old woman with a high fever. (a, b) Axial fat-suppressed T2-weighted MR images obtained at the level of the fundus of the uterus (a) and the body of the uterus (b) show multiple small, markedly hyperintense areas (arrows) surrounded by slightly hyperintense regions adjacent to the uterus. (c, d) Axial contrast-enhanced fat-suppressed T1-weighted MR images obtained at the same levels as a and b, respectively, show ill-defined intense enhancement of the myometrium and parametrium (large arrows) surrounding small abscesses (small arrows). Note the peritoneal enhancement (large *) and the small amount of ascites (small *) due to peritonitis.

View larger version (119K): [in a new window]   Figure 11c.   Postpartum myometritis and pelvic abscesses in a 30-year-old woman with a high fever. (a, b) Axial fat-suppressed T2-weighted MR images obtained at the level of the fundus of the uterus (a) and the body of the uterus (b) show multiple small, markedly hyperintense areas (arrows) surrounded by slightly hyperintense regions adjacent to the uterus. (c, d) Axial contrast-enhanced fat-suppressed T1-weighted MR images obtained at the same levels as a and b, respectively, show ill-defined intense enhancement of the myometrium and parametrium (large arrows) surrounding small abscesses (small arrows). Note the peritoneal enhancement (large *) and the small amount of ascites (small *) due to peritonitis.

View larger version (126K): [in a new window]   Figure 11d.   Postpartum myometritis and pelvic abscesses in a 30-year-old woman with a high fever. (a, b) Axial fat-suppressed T2-weighted MR images obtained at the level of the fundus of the uterus (a) and the body of the uterus (b) show multiple small, markedly hyperintense areas (arrows) surrounded by slightly hyperintense regions adjacent to the uterus. (c, d) Axial contrast-enhanced fat-suppressed T1-weighted MR images obtained at the same levels as a and b, respectively, show ill-defined intense enhancement of the myometrium and parametrium (large arrows) surrounding small abscesses (small arrows). Note the peritoneal enhancement (large *) and the small amount of ascites (small *) due to peritonitis.

View larger version (138K): [in a new window]   Figure 12a.   Pelvic actinomycosis associated with long-term use of an intrauterine contraceptive device in a 48-year-old woman with symptoms of ileus. (a) Image from a barium enema examination (lateral view) shows marked narrowing of the rectosigmoid (arrows) with irregularity of the mucosal margin. (b, c) Axial fat-suppressed T2-weighted MR images show a markedly thickened rectosigmoid wall (arrowheads) and an ill-defined mass (open arrows). Solid arrow = uterus. (d, e) Axial contrast-enhanced fat-suppressed T1-weighted MR images show intense enhancement of the rectosigmoid (arrowheads) and the mass (open arrows). Solid arrow = uterus.

View larger version (131K): [in a new window]   Figure 12b.   Pelvic actinomycosis associated with long-term use of an intrauterine contraceptive device in a 48-year-old woman with symptoms of ileus. (a) Image from a barium enema examination (lateral view) shows marked narrowing of the rectosigmoid (arrows) with irregularity of the mucosal margin. (b, c) Axial fat-suppressed T2-weighted MR images show a markedly thickened rectosigmoid wall (arrowheads) and an ill-defined mass (open arrows). Solid arrow = uterus. (d, e) Axial contrast-enhanced fat-suppressed T1-weighted MR images show intense enhancement of the rectosigmoid (arrowheads) and the mass (open arrows). Solid arrow = uterus.

View larger version (123K): [in a new window]   Figure 12c.   Pelvic actinomycosis associated with long-term use of an intrauterine contraceptive device in a 48-year-old woman with symptoms of ileus. (a) Image from a barium enema examination (lateral view) shows marked narrowing of the rectosigmoid (arrows) with irregularity of the mucosal margin. (b, c) Axial fat-suppressed T2-weighted MR images show a markedly thickened rectosigmoid wall (arrowheads) and an ill-defined mass (open arrows). Solid arrow = uterus. (d, e) Axial contrast-enhanced fat-suppressed T1-weighted MR images show intense enhancement of the rectosigmoid (arrowheads) and the mass (open arrows). Solid arrow = uterus.

View larger version (141K): [in a new window]   Figure 12d.   Pelvic actinomycosis associated with long-term use of an intrauterine contraceptive device in a 48-year-old woman with symptoms of ileus. (a) Image from a barium enema examination (lateral view) shows marked narrowing of the rectosigmoid (arrows) with irregularity of the mucosal margin. (b, c) Axial fat-suppressed T2-weighted MR images show a markedly thickened rectosigmoid wall (arrowheads) and an ill-defined mass (open arrows). Solid arrow = uterus. (d, e) Axial contrast-enhanced fat-suppressed T1-weighted MR images show intense enhancement of the rectosigmoid (arrowheads) and the mass (open arrows). Solid arrow = uterus.

View larger version (137K): [in a new window]   Figure 12e.   Pelvic actinomycosis associated with long-term use of an intrauterine contraceptive device in a 48-year-old woman with symptoms of ileus. (a) Image from a barium enema examination (lateral view) shows marked narrowing of the rectosigmoid (arrows) with irregularity of the mucosal margin. (b, c) Axial fat-suppressed T2-weighted MR images show a markedly thickened rectosigmoid wall (arrowheads) and an ill-defined mass (open arrows). Solid arrow = uterus. (d, e) Axial contrast-enhanced fat-suppressed T1-weighted MR images show intense enhancement of the rectosigmoid (arrowheads) and the mass (open arrows). Solid arrow = uterus.