What type of Magnetic Resonance Imaging (MRI) is needed to evaluate pelvic pain during sexual intercourse?

MRI for Pelvic Pain During Sexual Intercourse

For evaluating pelvic pain during sexual intercourse, MRI pelvis with diffusion-weighted imaging (DWI) sequences is the most appropriate imaging modality when ultrasound findings are inconclusive or when endometriosis is suspected.

Initial Imaging Approach

• Transvaginal and transabdominal ultrasound with Doppler imaging should be the first-line imaging modalities for evaluating pelvic pain during sexual intercourse, as they provide complementary information and should be performed together 1
• Ultrasound is widely regarded as the initial imaging study of choice for pelvic pain, though there is limited high-quality evidence specifically supporting its use for pain during intercourse 1
• Color and spectral Doppler are considered standard components of pelvic sonography to evaluate internal vascularity and distinguish cysts from soft tissue 1

When to Consider MRI

• MRI should be considered as a second-line imaging study when:
  • Ultrasound findings are inconclusive 1, 2
  • Deep pelvic endometriosis is suspected 1, 2
  • Further characterization of abnormalities is needed 1, 2
  • Pelvic floor muscular anatomy and function need assessment 1

Recommended MRI Protocol

• MRI pelvis with diffusion-weighted imaging (DWI) sequences is the most appropriate protocol 1
• The protocol should include:
  • T2-weighted sequences (multiplanar) 3
  • T1-weighted sequences (pre-contrast and post-contrast) 3
  • Diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping 1

Clinical Value of MRI for Specific Conditions

• Endometriosis: MRI has excellent diagnostic performance for deep pelvic endometriosis with sensitivity of 90.3%, specificity of 91%, and accuracy of 90.8% 1

  • Deep pelvic endometriosis appears as T2 hypointense fibrosis, most commonly at the torus uterinus and uterosacral ligaments, which may contain T1 hyperintense hemorrhagic foci 1, 4
  • MRI can identify obliteration of fat planes and the pouch of Douglas 1

• Pelvic Floor Dysfunction: MRI enables accurate depiction of pelvic floor muscular anatomy, integrity, and function 1

  • Particularly useful for assessment of muscular hypertonicity in chronic pelvic pain syndromes 1

• Adenomyosis: MRI can identify adenomyosis, which is found in up to 22% of women with pelvic pain initially attributed to other conditions 3

• Pelvic Venous Disorders: MRI can identify dilated periprostatic/periuterine venous plexus, which has been significantly correlated with chronic pelvic pain syndrome 2, 5

Added Value of MRI

• MRI provides additional diagnostic information in approximately 44% of women with symptoms initially attributed to other conditions by ultrasound 3
• When DWI is added to MRI protocols for evaluating certain conditions like tubo-ovarian abscess, diagnostic accuracy increases significantly (from 69.6% to 98.6%) 1
• MRI findings frequently lead to changes in management strategy 6, 3

Important Considerations and Limitations

• MRI should not be used as the initial or primary imaging examination when physical examination is normal 1
• The correlation between anatomic abnormalities and symptoms can be weak, and anatomic abnormalities may actually be caused by underlying functional disorders 2
• Clinical utility of pelvic MRI for pain varies by specialty, with overall utility of 34% across all providers 6
• MRI is particularly useful for parous women with pelvic pain, poor quality of life scores, and/or multiple pelvic pathologies 3

Common Pitfalls to Avoid

• Ordering MRI without first performing ultrasound evaluation 1, 2
• Failing to include DWI sequences, which significantly improve diagnostic accuracy 1
• Attributing symptoms solely to incidental findings without comprehensive clinical correlation 2
• Proceeding to surgical intervention based on imaging findings alone without a rigorous trial of conservative therapy 2