🔥 PID on Ultrasound — When the Pelvis Turns into Chaos

Intro — Welcome to the Pelvic War Zone

You know that moment when you put the probe in, and instead of clean anatomy,
you see… smoke. Not literal smoke, but sonographic smoke.
The uterus looks blurry, ovaries are hiding,
and everything seems to be sticking to everything else.

Congratulations.
You’ve just met Pelvic Inflammatory Disease — the pelvic version of a group project where no one did their job, and everyone’s angry.

💬 OBGYNX humor:
It’s like scanning a battlefield where the fallopian tubes called in backup.

🔹 Step 1: What We’re Actually Talking About

Pelvic Inflammatory Disease (PID) = infection of the upper genital tract —
the uterus, tubes, ovaries, and adjacent structures.

Usually caused by:

• Chlamydia trachomatis

• Neisseria gonorrhoeae

• and their less famous friends: Mycoplasma, anaerobes, E. coli

💡 OBGYNX summary:
If bacteria ever held a music festival, PID would be the afterparty.

🔹 Step 2: How It Starts — The “Creeping Infection”

It begins as endometritis.
Then, like gossip, it spreads upward — tubes, ovaries, peritoneum.
Soon, the pelvis is one large inflammatory group chat.

Mnemonic: “E-T-O” → Endometritis → Tubo-ovarian inflammation → Obsession (adhesions).

🔹 Step 3: The Ultrasound Signs — “Find the Chaos”

Early PID can be subtle,
but advanced PID looks like your screen gave up trying to show anatomy.

Here’s your visual survival guide 👇

A. Uterus — The Inflamed Fortress

• Enlarged and tender on scan

• Thickened, heterogeneous endometrium

• Possible fluid or debris in the cavity

• Gas bubbles = endometritis gone wild

💬 OBGYNX humor:
If the endometrium looks like cappuccino foam, it’s not romantic — it’s infection.

B. Tubes — The Sausage Factory

Mnemonic: “TOO HOT” → Tubes: Obstructed, Opaque, Thick.

Classic findings:

• Dilated tubes (>5 mm) with thickened, echogenic walls

• Cogwheel sign: cross-section looks like gears

• Incomplete septae inside tube = chronic inflammation

• Debris-filled fluid = pyosalpinx

💡 OBGYNX tip:
If you see a tube pretending to be an ovary, it’s PID’s favorite trick.

C. Ovaries — The Innocent Victims

• Enlarged, hypervascular, blurred margins

• May fuse with tubes = tubo-ovarian complex

• Add fluid + debris → tubo-ovarian abscess (TOA)

💬 OBGYNX humor:
When the ovary and tube fuse, it’s not teamwork — it’s trauma.

D. Pelvic Fluid — The Swamp Zone

• Free fluid with echoes, septations, or debris

• Sometimes gas bubbles → ominous

• Fluid may extend to Morrison’s pouch (Fitz-Hugh–Curtis)

Mnemonic: “Smoke, Swirl, Sticky.”
If you see those three, it’s PID until proven otherwise.

🔹 Step 4: The Tubo-Ovarian Abscess (TOA) — The Grand Finale

When the pelvis says, “Enough,”
everything melts into one giant, angry, fluid-filled mass.

Sonographically:

• Complex, multiloculated mass with thick walls

• Mixed echoes (pus + necrosis = “infectious latte”)

• Peripheral vascularity on color Doppler

• Loss of normal anatomy — ovary? tube? who knows.

💬 OBGYNX humor:
If your scan looks like modern art, it’s a TOA.

🔹 Step 5: The Doppler Drama

Hypervascular everywhere — uterus, tubes, abscess wall.
Resistive index (RI) ↓
It’s red chaos on color Doppler.

💡 OBGYNX pearl:
If the pelvis looks like it’s on fire, don’t overthink — call it infection and step away from the probe.

🔹 Step 6: The Differential Diagnosis — Everyone’s Favorite Confusion

Mnemonic: “TOFAS.”
T – TOA (infection)
O – Ovarian neoplasm (esp. cystadenoma)
F – Functional cysts
A – Appendicitis (right-sided mimic)
S – Simple abscess (non-gynecologic)

💬 OBGYNX humor:
If you’re scanning the right adnexa and thinking, “This could be an appendix…”
It probably is. Call surgery before you name it.

🔹 Step 7: Management — Calm the Fire

Mild–moderate PID:

• Broad-spectrum antibiotics (covering anaerobes + chlamydia)

• Hydration, pain control

• Follow-up scan in 48–72h

Tubo-ovarian abscess:

• Admit.

• IV antibiotics ± drainage (image-guided if stable)

• Surgical intervention if ruptured or unresponsive.

💬 OBGYNX truth:
If your abscess starts looking more echogenic than your ego — time for drainage.

🔹 Step 8: The Mnemonic Recap — “PELVIS”

P – Pain & pelvic tenderness
E – Echogenic tubes & endometrium
L – Loss of anatomy (tubo-ovarian complex)
V – Vascular chaos (hyperemia)
I – Infected fluid collections
S – Surgery if abscess or sepsis

Resident version:
“If it’s messy, smelly, and merging — it’s PID.”

⚡️ OBGYNX Final Thought

Pelvic Inflammatory Disease is what happens when infection meets anatomy and both lose control.
Ultrasound won’t always show you clean structures — it’ll show you how anatomy falls apart.

Your job?
Find the chaos, label it with grace, and treat before it explodes.

“Infection doesn’t whisper. It screams in grayscale.” — OBGYNX 2025