Pelvic inflammatory disease is a major public health concern with significant medical and socioeconomic consequences. It is the most frequent cause of hospitalization among reproductive-age women and leads to infertility in about 30% of cases and ectopic pregnancies in 50% [1–3]. PID includes all the acute or chronic inflammations of the salpinx, ovaries, and, often, the nearby organs. It is a spectrum of upper genital tract inflammatory disorders that may include endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis . The risk factors for PID include multiple sexual partners, a history of previous sexually transmitted infections/PID , lack of consistent condom use, and the use of intrauterine devices for contraception.
The principal symptom of PID is lower abdominal pain. Its intensity may vary. Usually it is continuous and bilateral with crampy exacerbations, often starting with the onset of menses and following it. Other symptoms include prolonged or increased menstrual bleeding, dysmenorrhea, dysuria, dyspareunia, and vaginal discharge. The patient may complain of right upper quadrant pain, which may be acute or severe as a result of perihepatitis (Fitz-Hugh-Curtis syndrome). Nausea and vomiting develop with severe PID, as does a corresponding peritonitis. Adnexal tenderness, uterine tenderness, and cervical motion tenderness may be noted during physical examination [4–7].
PID is sometimes difficult to diagnose. Its symptoms and signs are common for different diseases and vary from case to case. It can be overdiagnosed, leading to misdiagnosis of PID in healthy women, or underdiagnosed or misdiagnosed when women have other diseases, resulting in delayed appropriate treatment for the other conditions, including appendicitis. The differential diagnosis includes irritable bowel disease, diverticulitis, inflammatory bowel disease, adhesions after laparoscopy, endometriosis, and acute appendicitis .
Acute appendicitis is often misdiagnosed as PID and vice versa. Acute appendicitis usually presents with diffuse abdominal pain around the navel, which thereafter is located in the right lower quadrant. It is usually accompanied by nausea, vomiting, and a slightly elevated erythrocyte sedimentation rate, C-reactive protein, and leukocytes. Women with appendicitis more frequently have isolated right lower abdominal pain than do those with PID. On average, women with PID have pain twice as long as those with appendicitis. Compared with those with appendicitis, patients with PID are significantly less likely to report vomiting [9, 10].
Physicians face a common diagnostic dilemma when female patients present with lower abdominal pain. Early diagnosis is very important in order to provide the best treatment for the patient. Transabdominal and transvaginal ultrasound is a helpful diagnostic examination. It is possible to view the internal organs of the pelvic area to see whether the fallopian tubes are enlarged or whether an abscess is present. Laparoscopy may confirm the diagnosis [11, 12].
Color Doppler ultrasound is widely used nowadays for assessing differences in blood flow of the ovarian arteries. It has been used for the diagnosis of luteal phase defect, for hemodynamic assessment of PID, and for assessment of women with hypoestrogenic amenorrhea. It has also been used for the differential diagnosis of appendicitis and PID [13–16].
In our study, the pulsatility index of the ovarian artery was measured and compared with values obtained from healthy women. One of the major signs of inflammation is a change in vascular flow. It is possible to detect these changes with the help of transvaginal color Doppler velocimetry. We detected decreased vascular resistance in acute infection. Doppler velocity waveforms were quantitated by the pulsatility index. A low-resistance blood flow was found at the margin of the infectious complex. The severity of the infection as determined by C-reactive protein values was inversely correlated to the pulsatility index. Angiogenesis is responsible for the increased flow.
We conclude that transvaginal color Doppler is a useful additional tool in diagnosing and treating patients with PID. Color Doppler ultrasound of the ovarian artery seems to be a reliable, easy, and quick method when a prompt acute diagnosis is needed.
The sonographic criteria consistent with acute appendicitis were clearly different from those of acute inflammatory disease. More prospective trials are needed to evaluate the impact of transvaginal color Doppler ultrasound in the differential diagnosis between appendicitis and pelvic inflammatory disease.