From the Guidelines
For a female with left adnexal pain radiating up the left abdomen, a combined transabdominal and transvaginal ultrasound should be the initial imaging study. This approach is recommended by the American College of Radiology, as stated in the 2023 update of the ACR Appropriateness Criteria for acute pelvic pain in the reproductive age group 1. The combination of transabdominal and transvaginal ultrasound allows for a comprehensive evaluation of the ovaries, fallopian tubes, and surrounding structures, which is essential for identifying common causes of adnexal pain, such as ovarian cysts, torsion, ectopic pregnancy, or pelvic inflammatory disease.
Some key points to consider when performing ultrasound imaging for adnexal pain include:
- A transabdominal-only approach can be used as an alternative if the transvaginal approach is not feasible 1
- Transvaginal ultrasound is the most useful initial imaging modality in the assessment of adnexal pathology, with a sensitivity of over 90% 1
- The diagnostic performance of transvaginal ultrasound is likely improved when undertaken by experienced operators 1
If the ultrasound findings are inconclusive or if non-gynecologic causes are suspected, further imaging studies such as a CT scan with intravenous contrast of the abdomen and pelvis may be necessary. However, the initial imaging study should always be a combined transabdominal and transvaginal ultrasound, as it provides the most comprehensive evaluation of the adnexal region and surrounding structures 1.
From the Research
Imaging for Left Adnexal Pain
For a female with left adnexal pain that radiates up her left abdomen, the following imaging modalities can be considered:
- Ultrasonography, specifically transvaginal ultrasound (TVUS), is a useful initial imaging modality for evaluating adnexal masses and associated pelvic pain 2, 3, 4.
- Morphologic assessment with two-dimensional (2-D) ultrasound is the foundation for adnexal evaluation, and Doppler assessment can also be used to evaluate blood flow to the adnexa 2.
- Three-dimensional (3-D) sonography, 3-D vascular assessment, and contrast imaging may also be used to augment diagnostic accuracy 2.
- In cases where ultrasound is unclear or inconclusive, diagnostic laparoscopy may be indicated to confirm diagnoses and guide management 5, 4.
Specific Considerations
- Ovarian torsion is a potential cause of left adnexal pain, and ultrasonography can be used to evaluate for this condition 5, 3, 6.
- The presence of blood flow on Doppler ultrasonography of the adnexa has a poor negative predictive value for ovarian torsion, and a high clinical suspicion and early laparoscopic management are crucial for favorable outcomes 5.
- Other potential causes of left adnexal pain, such as hemorrhagic ovarian cysts, endometriosis, and tubo-ovarian abscess, can also be evaluated with ultrasonography 3.