Ultrasound for Lower Pelvic Pain with Dyspareunia
Yes, ultrasound is necessary and should be ordered as the initial imaging study for a patient presenting with lower pelvic pain and dyspareunia (pain during sex). 1
Recommended Imaging Approach
Order a combined transvaginal and transabdominal pelvic ultrasound with Doppler as a single comprehensive examination. 2 These three modalities are complementary and should be performed together, not as separate studies. 2
Why Ultrasound is the Correct Choice
Transvaginal ultrasound provides superior spatial and contrast resolution for evaluating the uterus, endometrial canal, fallopian tubes, ovaries, and adnexal masses—all potential sources of pelvic pain and dyspareunia. 2
The combination of transabdominal and transvaginal approaches provides both an anatomic overview and detailed visualization of pelvic structures. 1
Doppler ultrasound is a standard component that evaluates uterine artery blood flow and assesses for pelvic venous disorders, with low-resistance waveforms being associated with chronic pelvic pain. 1, 2
Ultrasound can diagnose common gynecologic pathology involving the uterus, fallopian tubes, and ovaries with confidence, and can also identify non-gynecologic bowel pathology. 3
Clinical Context for This Patient
The presentation of lower pelvic pain with dyspareunia strongly suggests a gynecologic etiology, making ultrasound the appropriate first-line imaging modality. 4, 5
Dyspareunia (pain during sex) is a key symptom that points toward gynecologic causes such as ovarian cysts, endometriosis, pelvic inflammatory disease, or uterine pathology. 5
The American College of Radiology specifically recommends starting with ultrasound when gynecological etiology is suspected and pain is well-localized to the pelvis. 4
If the patient has no pelvic tenderness on examination and a normal ultrasound, significant pathology is very unlikely. 3
When to Consider Alternative Imaging
CT abdomen and pelvis has no established role as primary imaging for this presentation unless non-gynecologic causes are strongly suspected. 2
MRI pelvis with gadolinium should be reserved as a problem-solving examination if ultrasound findings are nondiagnostic or inconclusive, or when specific conditions like endometriosis or fistulizing disease are suspected. 1, 2
Common Pitfalls to Avoid
Do not order plain radiographs—they have very limited utility in evaluating pelvic pain. 4
Do not skip the transvaginal component—transabdominal ultrasound alone provides insufficient detail for gynecologic pathology. 1
Do not order CT as first-line imaging for well-localized pelvic pain with dyspareunia, as it exposes the patient to unnecessary radiation and is less sensitive for gynecologic pathology. 4, 2
Ensure Doppler is included—it is not optional but rather a standard component of comprehensive pelvic ultrasound evaluation. 1, 2