A Delphi Consensus-Based Chronic Pelvic Pain

Standardized Ultrasound Approach

Autores: Sharon Cristine Paroneto MD

Mathew Leonardi MD
Fabricio da Silva Costa MBBS, MD PhD
Helmer Herren MD
George Condous MBBS, MD
Omero Benedicto Poli-Neto MBBS, MD PhD

2022
 OBJECTIVE

 To develop a standardized, consensus-based international ultrasound approach on

the elements that should be included in the initial ultrasound assessment of women
with chronic pelvic pain, that can be, in future, applied in clinical practice.
 METHODS

 A Delphi survey was conducted with an international panel of experts in CPP and

ultrasound, selected for their clinical and scientific experience in the subject.

 Three rounds of questions were carried out to assess the main parameters that

should be included in the ultrasound approach..

 METHODS

 Five variables were evaluated during the study:

 experts' profile;

 assessment of the quality of the examination by operators;

 regions to be systematically evaluated;

 elements that must be included in the exam;

 probes and imaging modes.

 A priori consensus criteria were used to reach agreement:

 items > 70% consensus would be maintained;/ those between 50% and 70% would be restructured for retrial and those

below 50% would be suggested for exclusion.

 Still controversial issues after 2 rounds were asked again based on binary choices (yes/no) and approved when there

was a minimum agreement of more than 50%.

 RESULTS

1. experts profile

Countries’experts
Number of experts

81
3%
3% 3%

3%
3% 3% 31%

7%

3%
29
21 BRAZIL
7%
CANADA 10% ENGLAND
BELGIUM NORWAY ITALY
AUSTRIA
21%
SPAIN FRANCE
EUA AUSTRALIA SWEDEN
INVITED ROUND 1 ROUND 2
 RESULTS

1. experts profile

Experts experience Specific training in gynecological US

60.00% 40.00%

51.70% 34.50%
35.00%
50.00% 31.00%
44.80%
30.00% 27.60%
40.00%
25.00%
30.00%
20.00%
20.69% 20.70% 17.40%
20.00% 17.25% 15.00%
10.35% 10.30%
10.00% 6.90% 6.90% 10.00% 6.90%
3.40% 3.45% 3.45%
3.40%
0.00% 5.00%
> 20 years 15 - 20 years 10 - 15 years 5 - 10 years 0 - 5 years no experience
0.00%

Experience with caring for women with CPP

Experience with gynecological ultrasound
 RESULTS

2. assessment of the quality of the examination by operators

93% 90% 76%

QUALITY DIFFICU LTY R E A SO N O F D I F F I C U L T Y

 RESULTS

3. regions to be systematically evaluated

Tabela 1.
REGIÃO RODADA 1 RODADA 2 RODADA 3 CONSENSO

Compartimentos pélvicos (A / M / P ) 82,1% 95,2% C C

Quadrantes abdominais inferiores D e E 75,0% 80,9% C C

66,7 % (excluir)
14,3 % (neutro) 81,0%
Abdome superior 42,8%
(excluir)
E
19,0 % (manter)

23,9% (excluir)
57,0%
Parede abdominal e região inguinal 53,6% 28,0 % (neutro)
(manter)
C
47,6 % (manter)

57,1 % (excluir)
95,0%
Assoalho pélvico 42,8% 38,1 % (neutro)
(excluir)
E
4,7% (manter)

52,4 % (excluir)
57,0%
Sistema venoso pélvico 39,3% 19,0 % (neutro)
(excluir)
E
28,6 % (manter)

C (consenso) / E (excluir)
 RESULTS

4. elements that must be included in the exam

Tabela 2.
ELEMENTOS RODADA 1 RODADA 2 RODADA 3 CONSENSO
Consenso IDEA
88,0% 100,0% C C

Consenso IOTA
84,0% 80,9% C C

Consenso MUSA
64,0% 76,2% ** C C
**apenas miométrio e zona juncional

Bexiga.
(lesão focal; tamanho da lesão; grau de envolvimento
da lesão na parede vesical; distância da lesão ao 87,0% 92,8% C C
óstio ureteral e envolvimento da lesão com o trígono
vesical)

71,4% (excluir)
71,0%
Ileo e Ceco 46,0% 14,3% (neutro)
(excluir)
E
14,3% (manter)

14,3% (excluir)
67,0%
Apêndice 56,0% 38,1% (neutro)
(manter)
C
47,6% (manter)

Parede abdominal e região inguinal 67,0% umbilical

30,2% (excluir).
67,0% infraumbilical
37,0%% 44,4% (neutro). C
92,0% inguinal.
(região umbilical, infraumbilical e inguinal) 23,8% (manter)
(manter)
C (consenso) / E (excluir)
 RESULTS

5. probes and imaging modes

PROBES ROUND 1 ROUND 2 ROUND 3 CONSENSUS

2D transvaginal (first option) 95,2% 94,0% C C

3D transvaginal (complement pelvic

41,0% 41,7% 67,0% C
evaluation)

Doppler (venous system) 52,0% 20,0% 76,0% C

2D linear (abdominal wall) 50,0% 40,0% 76,0% C

2D convex (complement pelvic posterior

64,0% 62,0% 92,0% C
compartment evaluation)
2D convex (complement intraperitoneal part
35,7% 20,0% 19,0% E
of bladder evaluation)
2D convex (complement appendix and/or
60,0% 47,6% 43,0% E
rectosigmoid evaluation)

C (consenssus) / E (exclluded)
Final model
Assessment of the quality of the examination by operators

General quality
Perception of difficulties
Description of difficulties, if any

Regions to be systematically evaluated

Pelvic compartments (anterior / middle / posterior)

Right and lLeft lower quadrants
Abdominal wall and Inguinal ring 

Elements that must be included in the exam

IDEA consensus
IOTA consensus
MUSA consensus (only myometrium and junctional zone)
Bladder
Appendix
Umbilical region of the abdominal wall
Infraumbilical region of the abdominal wall
Inguinal region of the abdominal wall
Probes and imaging modes
2D transvaginal (main probe)
2D linear (abdominal wall)

2D convex (supplementary bladder, posterior compartment and appendix/rectosigmoid assessment)

 STRENGTHS AND LIMITATIONS

 Técnica Delphi em si (método qualitativo e não quantitativo).

 O baixo número de profissionais mundiais com expertise em dor pélvica crônica e ultrassonografia / a falta
de consenso sobre o número ideal de especialistas neste tipo de estudo podem limitar a
representatividade da proposta.  

 Condições funcionais e neurológicas associadas à DPC, como as síndromes miofasciais, a bexiga

dolorosa e a síndrome do intestino irritável , não possuem parâmetros ultrassonográficos de avaliação e
são, portanto, um “hiato” neste exame de rastreamento proposto. 
 CONCLUSION

 Based on consensus methodology, we propose a standardized international

ultrasound approach on the elements that should be included in the initial
ultrasound assessment of women with CPP.

 Whilst it requires validation, this tool may serve to standardize the performance of
the ultrasound for the indication of CPP, enhancing the evaluation of the broad
differential diagnostic and the clinical applicability.
 REFERENCES
 ABRAO, M. S. et al. Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis. Human Reproduction
(Oxford, England), v. 22, n. 12, p. 3092–3097, dez. 2007.
 ACCETTA, I. et al. Endometrioma de parede abdominal. ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo), v. 24, p. 26–29, mar. 2011.
 ACOG COMMITTEE ON PRACTICE BULLETINS--GYNECOLOGY. ACOG Practice Bulletin No. 51. Chronic pelvic pain. Obstetrics and Gynecology, v. 103, n. 3, p. 589–605, mar. 2004.
 AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE (AIUM) et al. AIUM practice guideline for the performance of ultrasound of the female pelvis. Journal of Ultrasound in Medicine:
Official Journal of the American Institute of Ultrasound in Medicine, v. 33, n. 6, p. 1122–1130, jun. 2014.
 BENACERRAF, B. R. et al. Consider ultrasound first for imaging the female pelvis. American Journal of Obstetrics and Gynecology, v. 212, n. 4, p. 450–455, abr. 2015.
 DIAMOND, I. R. et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. Journal of Clinical Epidemiology, v. 67, n. 4, p. 401–409,
abr. 2014.
 EXPERT PANEL ON GASTROINTESTINAL IMAGING: et al. ACR Appropriateness Criteria® Right Lower Quadrant Pain-Suspected Appendicitis. Journal of the American College of
Radiology: JACR, v. 15, n. 11S, p. S373–S387, nov. 2018.
 GONCALVES, M. O. DA C. et al. Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep
endometriosis, defining surgical strategy. Human Reproduction (Oxford, England), v. 25, n. 3, p. 665–671, mar. 2010.
 GUERRIERO, S. et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus
opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound in Obstetrics & Gynecology, v. 48, n. 3, p. 318–332, 2016.
 MATHUR, M.; SCOUTT, L. M. Nongynecologic Causes of Pelvic Pain: Ultrasound First. Obstetrics and Gynecology Clinics of North America, v. 46, n. 4, p. 733–753, dez. 2019a.
 PRATHER, H.; SPITZNAGLE, T. M.; DUGAN, S. A. Recognizing and treating pelvic pain and pelvic floor dysfunction. Physical Medicine and Rehabilitation Clinics of North America, v. 18,
n. 3, p. 477–496, ix, ago. 2007.
 RIDING, D. M. et al. Seeking consensus amongst UK-based interventional radiologists on the imaging diagnosis of pelvic vein incompetence in women with chronic pelvic pain: A modified
Delphi study. Phlebology, v. 34, n. 7, p. 486–495, ago. 2019.
 TIMMERMAN, D. et al. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis
(IOTA) Group. Ultrasound in Obstetrics & Gynecology: The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology, v. 16, n. 5, p. 500–505, out.
2000.
 TIMOR-TRITSCH, I. E. et al. Three-Dimensional Coronal Plane of the Uterus: A Critical View for Diagnostic Accuracy. Journal of Ultrasound in Medicine: Official Journal of the American
Institute of Ultrasound in Medicine, v. 40, n. 3, p. 607–619, mar. 2021.
 VAN DEN BOSCH, T. et al. Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus
Sonographic Assessment (MUSA) group. Ultrasound in Obstetrics & Gynecology: The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology, v. 46,
n. 3, p. 284–298, set. 2015.