Pain Imaging pp 451-469 | Cite as

Imaging of Ovarian Disease-Related Pain

  • Kirsi HärmäEmail author
  • Philippe Vollmar


A number of different conditions in the ovaries, including the adnexa, can cause ovarian or pelvic pain. Sometimes the pain character, chronic or acute, or the time point of the appearance of the symptoms within menstrual cycle can give us diagnostic clues for the accurate imaging interpretation. Woman’s fertility and life-threatening conditions, such as rupture of ectopic pregnancy or tubo-ovarian torsion, should be rapidly diagnosed and treated. As ovarian cancer, even in advanced stage, rarely causes specific symptoms or pain, indications to imaging by unspecific pelvic or urinary symptoms of the women should be closely proved. Often the first-line imaging technique is gynecologic sonography with power Doppler examination. MRI possess a high spatial and temporal resolution, functional imaging sequences being easily incorporated and being a valuable and safe tool in the diagnostic of ovarian and adnexal masses of the female patients in any age. The choice of the imaging modality must be made individually, criterion such as age of the patient, experience of the sonologist, access to MRI, and indication to emergency CT contributing. In order to reach an accurate diagnosis, combining the radiological findings with clinical and laboratory findings is warmly recommended.


Pelvic pain Adnexal torsion Pelvic inflammatory disease Ovarian neoplasms Ultrasonography Computed tomography Magnetic resonance 



Apparent diffusion coefficient


C-reactive protein


Computed tomography


Dynamic contrast enhanced


Default mode network


Diffusion-weighted imaging


Diffusion-weighted whole-body MRI


Ectopic pregnancy


European Society of Urogenital Radiology


Extrauterine gravidity


Fitz-Hugh-Curtis syndrome


The International Federation of Gynecology and Obstetrics


Field of view


Follicle Stimulating Hormone Receptor


Human chorionic gonadotropin


Isolated tubal torsion


Intrauterine device


Cell proliferation-associated Ki-67 antigen


Magnetic resonance imaging


Nutcracker syndrome


Ovarian cancer


Ovarian hyperstimulation syndrome


Ovarian pregnancy


Ovarian torsion


Primary dysmenorrhea


Positron-emission tomography


Pelvic inflammatory disease


Systemic lupus erythematosus

SRY Gene

Sex-determining region Y


T1 weighted, T2 weighted




Tubo-ovarian abscess


Transvaginal ultrasonography






Vascular endothelial growth factor


World Health Organization

Supplementary material

Video 22.1a

Normal ovaries on MRI (T2W). Normal anatomical location of the bilateral ovaries para uterine. Notice also endometrial hyperplasia. (AVI 33432 kb)

Video 22.1b

Ectopic ovary. “Ectopic ovary on the upper pelvic side wall left after ovariopexy proceeded before radiation in a patient with cervical cancer”. (AVI 39692 kb)

Video 22.2a

Axial T2-weighted series shows a central hyperintense cystic lesion with thickened wall of the right ovary. The imaging was proceeded because of uterine fibroids. (AVI 35120 kb)

Video 22.2b

DWI: corpus luteum cyst wall shows an Intermediate diffusion restriction in DWI. (AVI 113492 kb)

Video 22.2c

ADC map: corpus luteum cyst wall shows an Intermediate diffusion restriction in DWI and in ADC map. (AVI 41860 kb)

Video 22.3

Axial T1w fatsat post contrast series: left renal vein is compressed between the aorta and the superior mesenteric artery with a distension of the hilar part of the vein. Note the thickened left ovarian vein indicating nutcracker syndrome. (AVI 98608 kb)

Video 22.4a

Axial T2w series: twisted ovarian pedicle with enlarged, cystic left ovary. (AVI 27976 kb)

Video 22.4b

Sagittal T2w series: twisted ovarian pedicle with enlarged, cystic left ovary. (AVI 27156 kb)

Video 22.5a

DWI: bilateral tubo-ovarian abscess, clearly diffusion restricted in DWI. (AVI 11864 kb)

Video 22.5b

ADC map: bilateral tubo-ovarian abscess, clearly diffusion restricted in ADC map. (AVI 14040 kb)

Video 22.5c

Axial T2w series: thickened fallopian tube on the right side. Free fluid in fossa Douglas. (AVI 15180 kb)

Video 22.5d

Correlating findings in PET/CT. (AVI 3711 kb)

Video 22.6

Axial T2w series: Hydrosalpinx. Notice the so called “waist sign”. (AVI 14112 kb)

Video 22.7

CECT series: massive haematoperitoneum an inhomogenous mass in fossa ovarica showed a contrast extravasation indicating an active bleeding component. (AVI 57231 kb)

Video 22.8a

Coronal T2w series: large hyperintense cystic tumor with small amount of free fluid and a normal contralateral ovary. (AVI 12671 kb)

Video 22.8b

Axial T2w series: large hyperintense cystic tumor with small amount of free fluid and a normal contralateral ovary. (AVI 35531 kb)

Video 22.8c

DWI: no diffusion restriction. (AVI 10936 kb)

Video 22.8d

ADC map: no diffusion restriction, ADC value 3.0 × 10−3 mm2/s. (AVI 5604 kb)

Video 22.9a

Coronal T2w series: multilocular, cystic tumor in a pregnant woman. (AVI 12902 kb)

Video 22.9b

DWI: hyperintense restricted cystic wall. (AVI 17086 kb)

Video 22.9c

Axial T2w series: multilocular, cystic tumor in a pregnant woman. (AVI 19359 kb)

Video 22.10

Axial T2w series: ovarian dysgerminoma with “beak-sign”. (AVI 11249 kb)


  1. 1.
    Watkins BP, Kothari SN. True ectopic ovary: a case and review. Arch Gynecol Obstet. 2004;269(2):145–6.PubMedGoogle Scholar
  2. 2.
    Allen JW, Cardall S, Kittijarukhajorn M, Siegel CL. Incidence of ovarian maldescent in women with mullerian duct anomalies: evaluation by MRI. AJR Am J Roentgenol. 2012;198(4):W381–5.PubMedGoogle Scholar
  3. 3.
    Moawad NS, Santamaria E, Rhoton-Vlasak A, Lightsey JL. Laparoscopic ovarian transposition before pelvic cancer treatment: ovarian function and fertility preservation. J Minim Invasive Gynecol. 2017;24(1):28–35.PubMedGoogle Scholar
  4. 4.
    Poncelet C, Ducarme G, Yazbeck C, Madelenat P, Carbonnel M. Safety of transient abdominal ovariopexy in patients with severe endometriosis. Int J Gynaecol Obstet. 2012;118(2):120–2.PubMedGoogle Scholar
  5. 5.
    Darai E, Touboul C, Ballester M, Poncelet C. Can ovariopexy at the end of surgery for endometriosis be recommended? A case report. J Reprod Med. 2012;57(1–2):81–4.PubMedGoogle Scholar
  6. 6.
    Janig W, Habler HJ. Physiology and pathophysiology of visceral pain. Schmerz. 2002;16(6):429–46.PubMedGoogle Scholar
  7. 7.
    Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2–15.PubMedGoogle Scholar
  8. 8.
    Mui J, Allaire C, Williams C, Yong PJ. Abdominal wall pain in women with chronic pelvic pain. J Obstet Gynaecol Can. 2016;38(2):154–9.PubMedGoogle Scholar
  9. 9.
    Sala E, Rockall AG, Freeman SJ, Mitchell DG, Reinhold C. The added role of MR imaging in treatment stratification of patients with gynecologic malignancies: what the radiologist needs to know. Radiology. 2013;266(3):717–40.PubMedGoogle Scholar
  10. 10.
    Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015;21(6):762–78.PubMedGoogle Scholar
  11. 11.
    Liu J, Liu H, Mu J, Xu Q, Chen T, Dun W, et al. Altered white matter microarchitecture in the cingulum bundle in women with primary dysmenorrhea: a tract-based analysis study. Hum Brain Mapping. 2017;38(9):4430–43.Google Scholar
  12. 12.
    Liu P, Liu Y, Wang G, Li R, Wei Y, Fan Y, et al. Changes of functional connectivity of the anterior cingulate cortex in women with primary dysmenorrhea. Brain Imaging Behav. 2017;12(3):710–7.Google Scholar
  13. 13.
    Velasquez CA, Saeyeldin A, Zafar MA, Brownstein AJ, Erben Y. A systematic review on management of nutcracker syndrome. J Vasc Surg Venous Lymphat Disord. 2018;6(2):271–8.PubMedGoogle Scholar
  14. 14.
    Hibbard LT. Adnexal torsion. Am J Obstet Gynecol. 1985;152(4):456–61.PubMedGoogle Scholar
  15. 15.
    Huang C, Hong MK, Ding DC. A review of ovary torsion. Ci Ji Yi Xue Za Zhi. 2017;29(3):143–7.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005;159(6):532–5.PubMedGoogle Scholar
  17. 17.
    Robertson JJ, Long B, Koyfman A. Myths in the evaluation and management of ovarian torsion. J Emerg Med. 2017;52(4):449–56.PubMedGoogle Scholar
  18. 18.
    Melcer Y, Maymon R, Pekar-Zlotin M, Pansky M, Smorgick N. Clinical and sonographic predictors of adnexal torsion in pediatric and adolescent patients. J Pediatr Surg. 2017;53(7):1396–8.Google Scholar
  19. 19.
    Wilkinson C, Sanderson A. Adnexal torsion -- a multimodality imaging review. Clin Radiol. 2012;67(5):476–83.PubMedGoogle Scholar
  20. 20.
    Beranger-Gibert S, Sakly H, Ballester M, Rockall A, Bornes M, Bazot M, et al. Diagnostic value of MR imaging in the diagnosis of adnexal torsion. Radiology. 2016;279(2):461–70.PubMedGoogle Scholar
  21. 21.
    Mandoul C, Verheyden C, Curros-Doyon F, Rathat G, Taourel P, Millet I. Diagnostic performance of CT signs for predicting adnexal torsion in women presenting with an adnexal mass and abdominal pain: a case-control study. Eur J Radiol. 2018;98:75–81.PubMedGoogle Scholar
  22. 22.
    Ding DC, Chen SS. Conservative laparoscopic management of ovarian teratoma torsion in a young woman. J Chin Med Assoc. 2005;68(1):37–9.PubMedGoogle Scholar
  23. 23.
    Yen CF, Lin SL, Murk W, Wang CJ, Lee CL, Soong YK, et al. Risk analysis of torsion and malignancy for adnexal masses during pregnancy. Fertil Steril. 2009;91(5):1895–902.PubMedGoogle Scholar
  24. 24.
    Asch E, Wei J, Mortele KJ, Humm K, Thornton K, Levine D. Magnetic resonance imaging performance for diagnosis of ovarian torsion in pregnant women with stimulated ovaries. Fertil Res Pract. 2017;3:13-017-0040-2. eCollection 2017.Google Scholar
  25. 25.
    Gil Navarro N, Garcia Grau E, Pina Perez S, Ribot Luna L. Ovarian torsion and spontaneous ovarian hyperstimulation syndrome in a twin pregnancy: a case report. Int J Surg Case Rep. 2017;34:66–8.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Breech LL, Hillard PJ. Adnexal torsion in pediatric and adolescent girls. Curr Opin Obstet Gynecol. 2005;17(5):483–9.PubMedGoogle Scholar
  27. 27.
    Bolli P, Schadelin S, Holland-Cunz S, Zimmermann P. Ovarian torsion in children: development of a predictive score. Medicine (Baltimore). 2017;96(43):e8299.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Webster KW, Scott SM, Huguelet PS. Clinical predictors of isolated tubal torsion: a case series. J Pediatr Adolesc Gynecol. 2017;30(5):578–81.PubMedGoogle Scholar
  29. 29.
    Gross M, Blumstein SL, Chow LC. Isolated fallopian tube torsion: a rare twist on a common theme. AJR Am J Roentgenol. 2005;185(6):1590–2.PubMedGoogle Scholar
  30. 30.
    Krissi H, Shalev J, Bar-Hava I, Langer R, Herman A, Kaplan B. Fallopian tube torsion: laparoscopic evaluation and treatment of a rare gynecological entity. J Am Board Fam Pract. 2001;14(4):274–7.PubMedGoogle Scholar
  31. 31.
    Rotoli JM. Abdominal pain in the post-menopausal female: is ovarian torsion in the differential? J Emerg Med. 2017;52(5):749–52.PubMedGoogle Scholar
  32. 32.
    Hubacher D. Intrauterine devices & infection: review of the literature. Indian J Med Res. 2014;140(1):S53–7.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Rueda DA, Aballay L, Orbea L, Carrozza DA, Finocchietto P, Hernandez SB, et al. Fitz-Hugh-Curtis syndrome caused by gonococcal infection in a patient with systemic lupus erythematous: a case report and literature review. Am J Case Rep. 2017;18:1396–400.PubMedPubMedCentralGoogle Scholar
  34. 34.
    Chayachinda C, Rekhawasin T. Reproductive outcomes of patients being hospitalised with pelvic inflammatory disease. J Obstet Gynaecol. 2017;37(2):228–32.PubMedGoogle Scholar
  35. 35.
    Spain J, Rheinboldt M. MDCT of pelvic inflammatory disease: a review of the pathophysiology, gamut of imaging findings, and treatment. Emerg Radiol. 2017;24(1):87–93.PubMedGoogle Scholar
  36. 36.
    Taran FA, Kagan KO, Hubner M, Hoopmann M, Wallwiener D, Brucker S. The diagnosis and treatment of ectopic pregnancy. Dtsch Arztebl Int. 2015;112(41):693–703.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Lin EP, Bhatt S, Dogra VS. Diagnostic clues to ectopic pregnancy. Radiographics. 2008;28(6):1661–71.PubMedGoogle Scholar
  38. 38.
    Srisajjakul S, Prapaisilp P, Bangchokdee S. Magnetic resonance imaging in tubal and non-tubal ectopic pregnancy. Eur J Radiol. 2017;93:76–89.PubMedGoogle Scholar
  39. 39.
    Tamai K, Koyama T, Togashi K. MR features of ectopic pregnancy. Eur Radiol. 2007;17(12):3236–46.PubMedGoogle Scholar
  40. 40.
    Deng MX, Zou Y. Evaluating a magnetic resonance imaging of the third-trimester abdominal pregnancy: what the radiologist needs to know. Medicine (Baltimore). 2017;96(48):e8986.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Forstner R, Thomassin-Naggara I, Cunha TM, Kinkel K, Masselli G, Kubik-Huch R, et al. ESUR recommendations for MR imaging of the sonographically indeterminate adnexal mass: an update. Eur Radiol. 2017;27(6):2248–57.PubMedGoogle Scholar
  42. 42.
    Meinhold-Heerlein I, Fotopoulou C, Harter P, Kurzeder C, Mustea A, Wimberger P, et al. Erratum to: the new WHO classification of ovarian, fallopian tube, and primary peritoneal cancer and its clinical implications. Arch Gynecol Obstet. 2016;293(6):1367.PubMedGoogle Scholar
  43. 43.
    Michielsen K, Dresen R, Vanslembrouck R, De Keyzer F, Amant F, Mussen E, et al. Diagnostic value of whole body diffusion-weighted MRI compared to computed tomography for pre-operative assessment of patients suspected for ovarian cancer. Eur J cancer. 2017;83:88–98.PubMedGoogle Scholar
  44. 44.
    Lindgren A, Anttila M, Rautiainen S, Arponen O, Kivela A, Makinen P, et al. Primary and metastatic ovarian cancer: characterization by 3.0T diffusion-weighted MRI. Eur Radiol. 2017;27(9):4002–12.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Diagnostic, Interventional and Pediatric RadiologyInselspital, Bern University Hospital, University of BernBernSwitzerland

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