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Acute pelvic pain in the nonpregnant woman is one of the most common conditions requiring emergent medical evaluation in routine clinical practice. Although clinical evaluation and laboratory testing are essential, imaging plays a central role. Although various adnexal and uterine disorders may result in acute pelvic pain of gynecologic origin, other nongynecologic disorders of the gastrointestinal and genitourinary systems may likewise result in acute pelvic pain. Ultrasound is first choice for initial evaluation of acute pelvic pain of gynecologic origin. Computed tomography is performed if pelvic sonography is inconclusive, or if a suspected disorder is nongynecologic in origin.

The pelvic floor is a complex structure that supports the pelvic organs and provides resting tone and voluntary control of the urethral and anal sphincters. Dysfunction of or injury to the pelvic floor can lead to gastrointestinal, urinary, and sexual dysfunction. The prevalence of pelvic floor disorders is much lower in men than in women, and because of this, the majority of the published literature pertaining to MRI of the pelvic floor is oriented toward evaluation of the female pelvic floor. The male pelvic floor has sex-specific differences in anatomy and pathophysiologic disorders. Despite these differences, static and dynamic MRI features of these disorders, specifically gastrointestinal disorders, are similar in both sexes. MRI and MR defecography can be used to evaluate anorectal disorders related to the pelvic floor. MRI can also be used after prostatectomy to help predict the risk of postsurgical incontinence, to evaluate postsurgical function by using dynamic voiding MR cystourethrography, and subsequently, to assess causes of incontinence treatment failure. Increased tone of the pelvic musculature in men secondary to chronic pain can lead to sexual dysfunction. This article reviews normal male pelvic floor anatomy and how it differs from the female pelvis; MRI techniques for imaging the male pelvis; and urinary, gastrointestinal, and sexual conditions related to abnormalities of pelvic floor structures in men.Online supplemental material is available for this article.©RSNA, 2019.

Gastrointestinal neuroendocrine tumors (NETs) are a diverse group of neoplasms that arise from cells of the diffuse neuroendocrine system. Neuroendocrine tumors occur throughout the gastrointestinal tract. These tumors can produce a variety of hormones resulting in specific symptoms that may aid in their detection and classification. While all NETs have malignant potential, these tumors vary in their biologic characteristics and potential for metastatic disease. Although several classification schemes for neuroendocrine tumors have been proposed, the World Health Organization classification is currently the most widely accepted that will be reviewed in this paper. Various imaging modalities and techniques have evolved in recent years, including both morphologic and functional imaging techniques that will be explored in this paper. A thorough knowledge of the most recent classification schemes greatly aids radiologists in the assessment of gastrointestinal neuroendocrine tumors. Appropriate application of both morphologic and functional techniques is likewise essential for proper diagnosis and surveillance of gastrointestinal neuroendocrine tumors.

Acute pelvic pain in the nonpregnant woman is one of the most common conditions requiring emergent medical evaluation in routine clinical practice. Although clinical evaluation and laboratory testing are essential, imaging plays a central role. Although various adnexal and uterine disorders may result in acute pelvic pain of gynecologic origin, other nongynecologic disorders of the gastrointestinal and genitourinary systems may likewise result in acute pelvic pain. Ultrasound is first choice for initial evaluation of acute pelvic pain of gynecologic origin. Computed tomography is performed if pelvic sonography is inconclusive, or if a suspected disorder is nongynecologic in origin.

Additional file 2. Costs of EDDIE implementation.

Additional file 1. Characteristics of the RACF population in the immediate geographic region.

Additional file 3. Cost-effectiveness model structure. Figure A: Health states and transitions within usual care. Figure B: Health states and transitions within the EDDIE intervention.

Additional file 4. Figure A: Density of the fitted Normal distribution for the annual number of hospital admissions. Figure B: Density of the fitted Gamma distribution for length of stay.

Ultrasonography (US) is frequently the first imaging modality used to examine women with symptoms involving the pelvis. It is widely available and involves no exposure to ionizing radiation. Images can be acquired with a transabdominal, endovaginal, or translabial approach, and the use of video clips and three-dimensional reconstructions can be helpful. US is excellent for assessment of the uterus, ovaries, and adnexa. Occasionally, nongynecologic pelvic diseases arising from the gastrointestinal, genitourinary, and musculoskeletal systems and the pelvic peritoneal and extraperitoneal spaces may be detected and can be a source of diagnostic dilemma. US can be helpful not only in the detection but also occasionally in the characterization of such entities. Computed tomography and magnetic resonance imaging are useful in complicated cases. In this article, the normal US appearance of the bowel and US signs of bowel disease and specific entities, including appendicitis, diverticular disease, bowel obstruction, appendiceal mucocele, and intestinal tumors, are reviewed. The lower urinary tract is included in the field of view in every pelvic US examination; commonly encountered entities related to the urinary bladder, distal ureter, and urethra are illustrated. In addition to arising in the gastrointestinal and genitourinary tracts, pathologic conditions in the pelvis can arise in the peritoneal or extraperitoneal space. Although conditions of the pelvic peritoneal and extraperitoneal spaces are rare, it is important to recognize these entities and distinguish them from the more common gynecologic diseases. Owing to the implications for diagnosis and management, radiologists and other physicians who perform pelvic US should be aware of the spectrum of nongynecologic pathologic entities that can be detected. ©RSNA, 2017.

Gestational trophoblastic disease (GTD) is a spectrum of both benign and malignant gestational tumors, including hydatidiform mole (complete and partial), invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. The latter four entities are referred to as gestational trophoblastic neoplasia (GTN). These conditions are aggressive with a propensity to widely metastasize. GTN can result in significant morbidity and mortality if left untreated. Early diagnosis of GTD is essential for prompt and successful management while preserving fertility. Initial diagnosis of GTD is based on a multifactorial approach consisting of clinical features, serial quantitative human chorionic gonadotropin (β-hCG) titers, and imaging findings. Ultrasonography (US) is the modality of choice for initial diagnosis of complete hydatidiform mole and can provide an invaluable means of local surveillance after treatment. The performance of US in diagnosing all molar pregnancies is surprisingly poor, predominantly due to the difficulty in differentiating partial hydatidiform mole from nonmolar abortion and retained products of conception. While GTN after a molar pregnancy is usually diagnosed with serial β-hCG titers, imaging plays an important role in evaluation of local extent of disease and systemic surveillance. Imaging also plays a crucial role in detection and management of complications, such as uterine and pulmonary arteriovenous fistulas. Familiarity with the pathogenesis, classification, imaging features, and treatment of these tumors can aid in radiologic diagnosis and guide appropriate management. ©RSNA, 2017.

Radiologic imaging is a crucial part of the evaluation of women presenting with infertility. Imaging techniques that provide insight into causes and factors contributing to infertility include ultrasound, hysterosalpingography, hysterosalpingo-contrast sonography, and magnetic resonance imaging. In this chapter, we discuss imaging technologies for disorders of the uterus, fallopian tubes, and ovaries which may impact fertility and pregnancy outcomes, with consideration of test sensitivity and specificity, cost, discomfort, utilization of contrast media, and ionizing radiation. Hysterosalpingo-contrast sonography is an efficient modality for multiple aspects of female reproductive anatomy and is advocated as a first-line test for most infertile women. The specific questions and concerns for each patient should be considered to select the most appropriate test or sequence of tests.

Mullerian duct anomalies, also called congenital uterine anomalies, are developmental structural disorders of the female genital tract. These anomalies are clinically relevant in patients with a history of infertility and pregnancy-related complications. The American Society for Reproductive Medicine classification system is the most well known, although newer systems, such as from the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy, are becoming more widely accepted. MR imaging remains the optimal imaging modality due to its superior multiplanar capability and spatial resolution. This review article describes the typical MR appearance of congenital uterine anomalies.

Inflammatory bowel disease (IBD) is a chronic, relapsing immune-mediated inflammation of the gastrointestinal tract. IBD includes two major disease entities: Crohn disease and ulcerative colitis. Imaging plays an important role in the diagnosis and surveillance of these complex disorders. Computed tomographic and magnetic resonance enterographic techniques have been refined in recent years to provide a superb means of evaluating the gastrointestinal tract for suspected IBD. Although the intestinal imaging manifestations of IBD have been extensively discussed in the radiology literature, extraintestinal imaging manifestations of IBD have received less attention. Multiple extraintestinal manifestations may be seen in IBD, including those of gastrointestinal (hepatobiliary and pancreatic), genitourinary, musculoskeletal, pulmonary, cardiac, ocular, and dermatologic disorders. Although many associations between IBD and extraintestinal organ systems have been well established, other associations have not been fully elucidated. Some extraintestinal disorders may share a common pathogenesis with IBD. Other extraintestinal disorders may occur as a result of unintended treatment-related complications of IBD. Although extraintestinal disorders within the abdomen and pelvis may be well depicted with cross-sectional enterography, other musculoskeletal and thoracic disorders may be less evident with such examinations and may warrant further investigation with additional imaging examinations or may be readily apparent from the findings at physical examination. Radiologists involved in the interpretation of IBD imaging examinations must be aware of potential extraintestinal manifestations, to provide referring clinicians with an accurate and comprehensive profile of patients with these complex disorders.

Focal lesions of the spleen are being detected at an ever-increasing rate given the constant improvement in temporal and spatial resolution of computed tomography (CT) and magnetic resonance (MR) imaging. Many commonly encountered benign “incidentalomas” of the spleen present as non-specific lesions that are hypoattenuating relative to the background normal splenic parenchyma on CT. Incidentally detected lesions can lead to increased patient anxiety, while posing challenges in patient management for practicing radiologists and clinicians. While the literature regarding incidentally detected splenic lesions has previously been relatively scarce, recent consensus criteria have emerged in recent years that greatly aid in the characterization and management of such lesions. This article discusses the diagnosis and management of incidentally detected splenic lesions based on recently consensus criteria. This review is intended to aid clinical radiologists in the characterization, differentiation and management of incidentally detected splenic lesions.

The purpose of this article is to discuss the clinical and imaging findings of primary sclerosing cholangitis and its cholestatic mimickers, with a focus on MR cholangiopancreatography (MRCP) utilization and other characteristic MRI imaging findings. Primary sclerosing cholangitis is a rare idiopathic disease of the liver associated with inflammatory bowel disease which results in damage to the bile ducts and liver parenchyma. Although the etiology of primary sclerosing cholangitis is not completely understood, the disorder is thought to be a result of multiple environmental factors. Genetic factors are likewise important given that multiple genes have been linked to primary sclerosing cholangitis. While primary sclerosing cholangitis shares many clinical and imaging characteristics with other cholestatic diseases, the disorder demonstrates unique and distinguishing features. Discriminating between the similarities and differences on MRI with MRCP allows accurate clinical and radiologic diagnosis, facilitating appropriate management with improved patient outcomes.

Heterotopic pancreas is a congenital anomaly in which pancreatic tissue is anatomically separate from the main gland. The most common locations of this displacement include the upper gastrointestinal tract-specifically, the stomach, duodenum, and proximal jejunum. Less common sites are the esophagus, ileum, Meckel diverticulum, biliary tree, mesentery, and spleen. Uncomplicated heterotopic pancreas is typically asymptomatic, with the lesion being discovered incidentally during an unrelated surgery, during an imaging examination, or at autopsy. The most common computed tomographic appearance of heterotopic pancreas is that of a small oval intramural mass with microlobulated margins and an endoluminal growth pattern. The attenuation and enhancement characteristics of these lesions parallel their histologic composition. Acinus-dominant lesions demonstrate avid homogeneous enhancement after intravenous contrast material administration, whereas duct-dominant lesions are hypovascular and heterogeneous. At magnetic resonance imaging, the heterotopic pancreas is isointense to the orthotopic pancreas, with characteristic T1 hyperintensity and early avid enhancement after intravenous gadolinium-based contrast material administration. Heterotopic pancreatic tissue has a rudimentary ductal system in which an orifice is sometimes visible at imaging as a central umbilication of the lesion. Complications of heterotopic pancreas include pancreatitis, pseudocyst formation, malignant degeneration, gastrointestinal bleeding, bowel obstruction, and intussusception. Certain complications may be erroneously diagnosed as malignancy. Paraduodenal pancreatitis is thought to be due to cystic degeneration of heterotopic pancreatic tissue in the medial wall of the duodenum. Recognizing the characteristic imaging features of heterotopic pancreas aids in differentiating it from cancer and thus in avoiding unnecessary surgery.

Cystic lesions of the pancreas are presently receiving increased attention, both in the clinical setting and in the literature. Such lesions are being detected with ever increasing frequency given the continually improving spatial resolution of computed tomography. The presence of a cystic pancreatic lesion often represents a diagnostic dilemma; while most lesions are generally incidental in nature, a minority of these lesions may be potentially malignant. Aside from neoplastic lesions, post-inflammatory lesions can further complicate the differential diagnosis. The combination of medical history, demographic factors, and imaging characteristics can aid the radiologist when providing management recommendations. Most importantly, state-of-the-art magnetic resonance techniques currently offer unparalleled characterization of these lesions.

IgG4-related disease is a recently recognized systemic disorder involving multiple organs throughout the body. The multi-organ involvement of this disease was previously thought to occur as isolated, unrelated autoimmune disorders. Although virtually any part of the body may be involved in IgG4-related disease, abdominal manifestations tend to predominate in most affected individuals. While autoimmune pancreatitis is the most commonly encountered abdominal disorder in the setting of IgG4-related disease, the liver, kidneys, gastrointestinal tract, retroperitoneum, and mesentery may likewise be involved. Various diagnostic criteria for IgG4-related disease have been proposed based on physical exam, serology, and histopathologic confirmation. However, imaging plays an essential role in the diagnosis of this disorder, not only to establish the presence of IgG4-related disease, but to assess the severity and extent of systemic disease involvement.

Infertility is defined as failure to achieve pregnancy during 1 year of unprotected intercourse. The clinical evaluation of infertility has become increasingly sophisticated over the past several decades. Significant advancements in reproductive medicine yield much higher fertility rates among couples with infertility issues. The evaluation of an infertile couple demands a systematic approach in order to pinpoint a specific infertility disorder. Imaging plays a fundamental role in the evaluation of the infertile couple. Clinicians and radiologists involved in reproductive medicine must have a fundamental understanding of the strengths and weaknesses of various imaging modalities in order to be effective members of the reproductive healthcare community. In particular, knowing why a particular imaging modality is employed for a suspected infertility disorder and knowing when a particular imaging study should be performed is essential in the assessment of the infertile couple.