The Contribution of Ultrasound in Exploring Women Pelvic Pathologies in Two Teaching University Hospitals Maternities in Cotonou

Objective: The aim of this piece of work is to study the contribution of pelvic ultrasound while exploring pelvic pathologies at Hubert Koutoukou Maga Teaching University Hospital “CNHU-HKM” and at the Teaching University Hospital of Mother and Child “CHU-MEL” of Cotonou. Patients and Methods: A descriptive, cross-sectional and analytical study with prospective collection was carried out at the University Clinic of Gynecology and Obstetrics “CUGO” at the CNHU-HKM and in the gynecology department of the CHU-MEL, over a period of 4 months (May to August 2018). We included in this study women over 12 years old who performed a pelvic ultrasound and were followed in the aforementioned health centers. Results: The population of the study consisted of 181 patients. The pelvic ultrasound request frequen-c y was 18.84% compared to all ultrasound examinations. The age group of 25 - 29 years old was the most represented (22.10%). Pelvic pain was the first motive for pelvic ultrasound request (39.8%).


Introduction
Ultrasound is the preferred modality for exploring female reproductive system.
It is the first choice examination considered as an extension of gynecological examination [1]. Introduced in the medical field in the 1960s, ultrasound has since found applications in almost all medical specialties [2]. It has the advantage of being reliable, repetitive, non-invasive, and available in our workplace.
According to Fethia et al. [3], the pelvic ultrasound performed by the endovaginal route is an innocuous and readily available means of investigation to explore the uterus and appendices.
It is the first choice examination in the vast majority of uterine and/or annex pelvic pathologies, "PIVOT" of pelvic exploration [4] [5].
In Benin, ultrasounds are performed in the management of multiple pathologies that have been subject to several publications. However, very few studies have been carried out on the pelvic condition. This is the reason for this study which aims at studying the contribution of ultrasound in exploring pelvic conditions in women.

Patients and Methods
It was a descriptive, cross-sectional, analytical and multicentric study with prospective collection, over a period of 04 months from May 1st 2018 to August 31st 2018. It took place at the University Clinic of Gynecology and Obstetrics "CUGO" of the Teaching University Hospital of Hubert Koutoukou Maga "CNHU-HKM" and in the gynecology department of the Teaching University Hospital of Mother and Child "CHU-MEL".
We involved in this study women over 12 years old who performed a pelvic ultrasound for a pelvic pathology and were followed in the aforementioned hospitals. Those with an intra-or ectopic pregnancy discovered during the ultrasound as well as those with incomplete clinical record were excluded.
The variables studied included age, medical, surgical and gynecological history, reason for admission, ultrasound data mainly the reasons for ultrasound requests and the pathologies found. All the women directed to the ultrasound unit of these hospitals, who present a confirmed or suspected pelvic pathology after the clinical examinations carried out by gynecologists, have been comprehen-sively counted. The ultrasound was performed by the suprapubic or endovaginal route either by the radiologist or the gynecologist. The information was collected using a previously prepared survey sheet.
The statistical analysis was done in SPSS 25 and EPI DATA 3.1 software. The Pearson Chi-square test was used to analyze the relationship between the qualitative variables. Quantitative variables were expressed on average with their standard deviation and confidence interval at 95%. The significance threshold chosen was p < 0.05.
From ethical point of view, we received the authorization of the heads of CUGO department, CNHU-HKM and of CHU-MEL, and the informed consent from the patients. The confidentiality of the data was guaranteed.

Results
Hospital Frequency of Pelvic Ultrasounds ( Figure 1).
During the period of study, 2032 ultrasounds were performed in the ultrasound units of the CNHU and CHU MEL, of which 383 pelvic ultrasounds; accounting for 18.84% of the ultrasound activity. Out of the three hundred and eighty-three (383) pelvic ultrasounds performed, only 181 patients were included in the study (47.25%). And of the 181 patients selected, 95 (52.5%) ultrasounds were performed at the CNHU-HKM and 86 (47.5%) at the CHU-MEL.

Epidemiological and Clinical Profile of Patients
The average age was 35.15 ± 10.39 with extremes of 13 and 67 years old. The most represented age group was 25 -29 years old.
Patient histories are listed in Table 1.
The menstrual cycle was regular in 57 cases accounting for 31.50% and irregular in 111 cases representing 61.30%. Among the patients with regular menstrual cycle the average duration of the cycle was 28.38 ± 1.50 days with extremes of 23 and 30 days.
There was as much appendicectomy as myomectomy (2.8%). Abortion was noted in 77 patients accounting for 42.5%, aged on average 37.19 ± 10.3 years old. MIUA was noted in 50 patients accounting for 27.6%, aged on average 37.18 ± 10.36 years old the various reasons for requesting pelvic ultrasound are shown in Table 2.   It appears that pelvic algia was the most common (39.80%) in most of our patients, followed by menorrhagia (19.33%).

Distribution of Ultrasound Lesions
Route of ultrasounds performed ( Figure 2).
Among the 181 ultrasound examinations performed, the endovaginal route was used exclusively in 52.50% of our patients, and the suprapubic in 26%.
The lesions detected by ultrasound were dominated by uterine pathology which represented 55.4%, with myomas leading in 44% followed by ovarian pathology in 38%.
There was a polymyomatous uterus in 62.3% of cases. In 46.8% of myoma Open Journal of Radiology  cases, interstitial and sub-serous localization occurred in 18.2% of cases. In patients with multiple myomas, there was an association of myomas (sub-serous, sub-mucous and interstitial) in 5.2% of cases. (Table 4) There was a statistically significant relationship in cases of dysmenorrhea, metrorrhagia, amenorrhea and leucorrhea. It appears that patients who consult for metrorrhagia had a pathological ultrasound result in 90.24% of cases and 9.75% had a normal result. Open Journal of Radiology

Hospital Frequency of Pelvic Ultrasounds
Pelvic ultrasound in this study accounted for 18.84% of all ultrasound activities. Koussema [4], in Togo, in his study of pelvic pain noted 4.50% rate of pelvic ul-trasound out of all ultrasound scans. This difference is understandable for his work dealt only with pelvic pain. However, this relatively low rate, compared to what we got, could be explained by the limited access of women to pelvic ultrasound due to financial constrain.

Age
The average age was 35.15 years old with extremes of 13 and 67 years old. We noticed an increase in pelvic ultrasound performance in the age group of 25 -29 years old with a frequency of 22.10%. Koussema [4] found that the age of the patients ranged from 10 to 65 years old with an average age of 37 years and 6 months old, close to our results. For AkoAhui [1], patients between 25 and 35 years old were the most numerous; this age group can be superimposed on that of our study.
These results can easily be explained since pelvic conditions most often concern patients in periods of genital activity.

Reasons for pelvic ultrasound request
In this study, pelvic pain was the main motive for pelvic ultrasound (39.8%), just as was in NGbessoand al's [5] in Ivory coast, who observed that pelvic pains were a frequent reason for consultation with 36.94% of rate. According to Genevois [6] et al., they accounted for 5% of gynaecological consultations. According to HAHN et al., pelvic pain has a prevalence of 15% in a female population aged from 18 to 50 years old [7]. Acute pelvic pain, isolated or associated with metrorrhagia or fever, is very common but non-specific core symptoms of patients who consult in emergency department by Balleyguier et al. [8].

Route used
The endovaginal route was the most used accounting for 52.50% and the suprapubic was 26%. Our results are different from those of Boco et al. [9] whose most patients had undergone suprapubic examination in 95.1%. Likewise in Koussema's [4] whose patients were examined only by the suprapubic route.
According to Ardeans et al. [10] the two routes are complementary; we must choose the best one for a given structure. The suprapubic scan retains all its indications and, except in special cases, still remains the first-line of the common exam. But the use of a vaginal probe brings major advantages: unnecessary bladder repair, better definition by the proximity and high frequency of the probes, no discomfort due to parietal adiposity. Its disadvantages include the reduction of the exploration field.
In this study, 31.50% of the ultrasounds were normal versus 68.50% pathological. Unlike Koussema [4] et al., who found in their study 48% of pathological examinations versus 52% normal. This difference could be linked to the population of study, which only consisted of pelvic pain in the Togolese studies. Boco [9] in Benin found a rate, significantly lower than ours in 9.9% in 2003. The in-crease in the number of specialists and the ultrasound scanners since then could explain this difference.
Our results are similar to those of Ako Ahui et al., who reported 25.5% normal versus 74.5% of pathological ultrasound [1].
Koussema et al. [4] and Ako Ahui [1] drew up more or less the same etiological catalogue on ultrasound, but in different proportions respectively 32.7% and 28.2% for uterine disease, 36.3% and 64.1% for ovarian disease, and 1.8% and 7.7% for tubal disease.
Uterine disease was dominated by myomas (79.3%) (Figure 3). This finding is widely reported in the literature [11]. N'gbesso [5] claimed that fibroids accounted for 92% of utero-vaginal masses, and Kouamé et al. [12] 52.2% of uterine conditions. Myoma is a common condition affecting 20% -30% of women during genital activity [13] [14]. Uterine myomas remain the prerogative of the young black woman [5] [13] [14]. These same authors evoke a genetic factor linked to the susceptibility of the black patient to develop more readily fibrous tissue abnormalities [5] [14]. Polymyomatous uterus was 62.3%, a frequency close to that of Koussema [4] of 52.27%. One might say that it is rare for uterine myoma to be unique. Ovarian pathologies ranked second in our study with 38% of cases.
Cystic dystrophies in 37.31% dominated by microcystic form (92%) ( Figure   4), and ovarian cysts in 34.33% dominated by functional cysts (69.5%), represented the most common ovarian abnormalities. Koussema, N'gbésso, and Kouamé [4] [5] [12] have also made the same observation in different proportions, with a predominance of functional cysts. These authors agree with the literature that asserts that these are the most common ovary lesions in women during genital activity, representing at least 2/3 of the ovarian cysts. Ultrasound is of a major contribution because it is more sensitive than the clinic as pointed out by Marret et al. [16], who assessed the sensitivity of ultrasound in ovarian masses at 80% on average.
Ultrasound helps to have a fairly perfect analysis of the organs forming the upper genital sphere of a woman. It should be the first choice examination in exploring female pelvis [4]. It specifies the site and nature of a possible causal lesion with the advantage of an extended exploration to the rest of the pelvic cavity or even the abdomen. Open Journal of Radiology

Correlation Ship between Reason for Consultation and Ultrasound Results
90.24% of patients with metrorrhagia had a pathological ultrasound scan versus 37.9% with a normal result. There was a statistically significant relationship (p = 0.002) between the presence of metrorrhagia and the ultrasound result. Furthermore, patients with metrorrhagia were about five times more likely to have a pathological ultrasound than one without this sign (OR = 5.63; 95% CI = 4.5 -6.7). A statistically significant relationship was also found between the ultrasound result and three other reasons for consultation, namely dysmenorrhea, amenorrhea and leucorrhoea, respectively with a p-value of 0.014; 0.009 and 0.002. This leads us to conclude that ultrasound scan plays an important role in the etiological investigation of amenorrhea, metrorrhagia, dysmenorrhea and leucorrhoea. This observation is corroborated by other authors such as Sétchéou et al. [17]; Fethia et al. [3] and Bidet [18], respectively for amenorrhea, metrorrhagia and dysmenorrhea.

Conclusion
The hospital frequency of pelvic ultrasound scan was relatively low at CUGO (CNHU-HKM) and (CHUMEL). Pelvic pain was the most frequent cause. Uterine pathologies were the most common, dominated by myomas. There was a statistically significant relationship between the presence of metrorrhagia, dys-menorrhoea, amenorrhoea and leucorrhoea (p < 5%) and the ultrasound result. Thus, ultrasound remains the first choice in exploring pelvic pathologies in women. It should therefore be desirable to improve accessibility to all women in the genital activity.

Limitations of the Study
The unavailability of complete ultrasound report logs in the units of those hospitals.
The reluctance of some patients to join the survey. The large number of patients excluded because some of them were not followed in the gynaecological units that were our study framework.
Failure to perform ultrasound after prescription due to financial cost.