Chapter 19

Resistive index for ovaries normally ranges from:

0.4-0.8

Pulsatility index for ovaries normally range from:

0.6-2.5

Ovarian size during menarche

2.5-5.0 X 1.5-3.0 X 0.6-2.2 (LWH)

What is created when the peritoneum is created?

A potential space or cul de sac

What is common to see in the retrouterine pouch?

A small amount of free fluid

body of uterus

Aka corpus. Largest portion of the uterus. Thick muscular segment. Located posterior to vesicouterine pouch, anterior to the retrouterine pouch & medial to the broad ligaments and uterine vessels

suspensory ligaments

Aka infundibulopelvic ligament. Extends from the lateral portion of the ovary to the pelvic sidewall.

iliopectineal line

An imaginary line from the superior border of the sacrum you the superior margin of the pubis symphysis that divides the true and false pelvis

Uterine arteries demonstrate as:

Anechoic tubular structures with a high resistance flow pattern.

Location of uterus

Anterior to rectum and piriformis muscles. Posterior to the urinary bladder, space of retzius, & symphysis pubis. Medial to ovaries, Fallopian tubes, obturator internus muscles, & external iliac vessels.

Space of Retzius. Retropubic space. Prevesicle space.

Anterior to the bladder. Posterior to the symphysis pubis.

Location of vagina

Anterior to the rectum and Anus. Posterior to the bladder, urethra, & peritoneum. Inferior (caudal) to the cervix. Medial to the levator ani muscles

retrouterine pouch. Posterior cul de sac. Pouch of douglass

Anterior to the rectum. Posterior to the uterus. Most inferior and dependent space. Most common site for fluid to accumulate

obturator internus

Anterolateral margins of the true pelvis. Surround the obturator foramen. Extend through the sciatic foramen to attach to the greater trochanter. Posterior and medial to the iliopsoas muscles. Level of the vagina. Lateral to the ovaries. Low level linear echoes abutting the lateral walls of the bladder

Pelvic Vasculature

Arcuate vessels, internal iliac arteries, ovarian arteries, ovarian veins, & uterine arteries.

Physiology of Fallopian tubes

Attract and transfer ova from the surface of the ovary to the endometrial cavity. Tubal peristalsis helps move the fertilized ovum into the endometrium.

Vagina

Collapsed tube consisting of an outer muscular layer and an inner mucosal layer. Extends from the vulva to the cervix. Sides of the vagina are enclosed between the levator ani muscles. Half of the vagina lies above and the other half below the pelvic brim. Supplies by the vaginal and uterine arteries (branches of the internal iliac arteries) and empties into the internal iliac veins.

Agenesis of ovaries

Congenital ovarian anomaly associated with an abnormal karyotype

endometrial cavity

Consists of a superficial functional layer and a deep basal layer. Functional layer sheds with menses. Basal layer regenerates new endometrium and remains intact during menses. Thickness is dependent on hormone levels.

adexa includes:

Fallopian tubes and ovaries

What can accumulate in these pelvic spaces?

Fluid, blood from an ectopic pregnancy ruptured Graafian follicle, or a hemorrhagic ovarian cyst.

Isthmus division of Fallopian tubes

Immediately adjacent to the uterine wall. Short straight narrow portion of tube.

The iliopectineal pelvis divides what?

Into true and false pelvis

Location of the ovaries

Intraperitoneal within the adnexa of the true pelvis. Uterine location influences the position of the ovaries. Generally located at the level of the uterine cornua. Medial to the external iliac vessels. Anterior to the internal iliac vessels and ureter. Lateral to the uterus. Posterior to the Fallopian tubes, external iliac vessels, and broad ligament

Anatomical ovarian variant

L-Shaped ovary: Normal variant giving the appearance of 2 arms. Lesions in one arm may appear exophtic or extrinsic to the ovary.

Cornua

Lateral funnel shaped horns of the uterus. Located between the fundus and the interstitial portion of the Fallopian tube

Each ovary is connected by:

Mesovarian ligament to the broad ligament. Uteroovarian ligament to the inferior portion of the uterus. Suspensory ligament to the pelvic sidewall. The medial, lateral & posterior borders of each ovary are not attached.

levator ani muscle

Name given to a group of muscles (puborectalis, iliococcygeus, & pubococcygeus). Forms pelvic floor along with the piriformis muscles. Supports and positions the pelvic organs. Most caudal structures within the cavity. Medial you're obturator internus muscles. Posterior to the vagina and cervix. Low-level, mildly curved linear echoes posterior to the vagina. Hypoechoic compared with normal uterus

Sonographic appearance of Fallopian tubes

Normal is not visualized. Interstitial segment may be visualized under normal conditions as a long echogenic tenuous structure extending laterally from the uterine wall.

Pelvic ligaments

Not routinely visualized. With intraperitoneal fluid collections, ligaments will appear as hyperechoic, moderately thin, linear structures. Broad, cardinal, ovarian, round, suspensory, & uterosacral

tunica albuginea

Outer layer is surrounded by a thin layer of germinal epithelium.

Endocervix

Portion of the cervix surrounding the cervical canal

Cervix

Posterior and inferior portion. Between vagina and isthmus. Projects into vaginal canal. More fibrous and less flexible. Anchored at the angle of the bladder by the parametrium. Divided into internal cervical os, external cervical os, endocervix, & exocervix. Peritoneal reflection is not demonstrated anterior to the cervix

Physiology of the ovaries

Produce ova and hormones (estrogen and progesterone)

arcuate vessels

Prominent vascular structures in the outer one third of the myometrium. Branch of the uterine artery. Radial arteries rise from the arcuate arteries.

Interstitial division of Fallopian tubes

Proximal portion of the tube that passes through the cornua of the uterus narrowest and the shortest portion.

Resistive index of the arcuate arteries

Range between 0.86 +\- 0.04 (reproductive) and 0.89 +/- 0.06 (postmenopause)

Unilateral ovary

Rare occurrence

Ampulla division of Fallopian tubes

Widest, longest, and most cooked portion. Region where fertilization most commonly occurs. Most common area of ectopic pregnancies.

Uterine arteries

branches from the internal iliac arteries. Medial in the levator ani muscles. Ascend in a tortuous course lateral to the uterus within the broad ligament. Supplies the cervix, vagina, uterus, ovaries and Fallopian tubes. Course lateral and terminate at the confluence with the ovarian artery

menopause

cessation of menstruation

Didelphys uterus

complete failure of the mullerian ducts to fuse. indications: asymptomatic, infertility, spontaneous abortion, vaginal septation. findings: wide separation between 2 disctinct uterine fundi (TRV plane). 2 separate cervix. possible septated vagina. differentials: pelvic muscles, pedunculated fibroid.

septated uterus

complete fusion of the mullerian ducts with failure to completely reabsorb the septum. 2 uterine cavities & 1 uterine fundus. most common type of mullerian duct anomaly. indications: asymptomatic, high incidence of infertility, recurrent 1st trimester miscarriage. findings: NL uterine contour. flat, convex, or small indentation (<1 cm) of the fundal contour (visualized best in coronal view). 2 closely separated endometrial cavities containing fibrous or myometrial tissue. endometrial cavities are usually symmetrica. differentials: fibroid, adenomyosis, endometrial polyp

medulla

composed of connective tissue and contains nerves, blood vessels, lymph vessels, & smooth muscle at the hilus region.

agensis of uterus

failure of the caudal mullerian ducts to develop. fallopian tubes are present. clinical indication: amenorrhea. sonographic findings: absent uterus differential: hysterectomy, unicornuate uterus

regions of the uterus

fundus, body, cervix, cornua, endometrial cavity, & isthmus

isthmus of uterus

narrowed region between the body and cervix. Aka lower uterine segment

perimetrium

outer layer of uterus. Serosal or external surface. Part of the parietal peritoneum. May be difficult to distinguish on ultrasound

cortex

outer layer that consists of follicles and is covered with the tunica albuginea.

ovaries

paired, elliptical-shaped endocrine glands located lateral to the uterus. smooth surface in early life, becoming markedly pitted after years of ovulation. without hormone replacement theory (HRT), ovaries decrease in size after menopause. attached to the posterior surface of the broad ligament by mesovarium. the only organs in the abdominopelvic cavity not lined with peritoneum. dual blood supply through the ovarian and uterine arteries

bicornuate uterus

partial fusion of the mullerian ducts. two uteri in the superior portion. two superior endometrial cavities. indications: asymptomatic, infertility, spontaneous abortion. findings: deep notch in fundus. two distinct endometriums separated by a small amount of myometrium. differentials: fibroid, septate uterus

Tissue layers of the uterus

perimetrium, myometrium, endometrium

reversion

refers to the relationship between the cervix and the vagina

congenital uterine anomalies

results from improper fusion of the mullerian ducts or incomplete absorption of the septum between them. coexisting renal anomalies occur in 20-30% of cases. agensis, arcuate, bicornuate, didelphys, septate, subseptus, & unicornuate

Progesterone

secreted by the corpus luteum

Fimbriae ovarica

the one fimbriae attached to the ovary

mesosalpinx

the upper portion of the broad ligament that encloses the Fallopian tubes

premenarche

time period in young girls before the onset of menstruation

unicornuate uterus

unilateral development of the paired mullerian ducts. indications: asymptomatic, hypomenorrhea, infertility. findings: small uterine size, lateral uterine position, rudimentary horn may be visualized. differential: uterine didelphysis

anteversion

uterine body and fundus are tipped anteriorly. cervix forms an angle less than or equal to 90 degrees with the vaginal canal. most common position

postpardum uterus stays enlarged for how long?

4-8 weeks following delivery

Fallopian tube size

7-12 cm cooked muscular tubes composed of smooth muscle and lined by a mucosa. 8-10 mm in diameter

true pelvis

Aka pelvic cavity, lesser pelvis. Most inferior portion of the body cavity. Located inferior to the pelvic brim. Muscles and ligaments form a pelvic floor. Anterior boundary: symphysis pubis. Posterior boundary: sacrum and coccyx. Posterolateral wall: piriformis and coccygeus muscles. Anterolateral wall: hip bone and obturator internus muscles. Lateral boundaries: fused ilium and ischium. Pelvic floor: levator ani and coccygeus muscles. Contains female reproductive system, bladder, distal ureters and bowel

Vesicouterine pouch. Anterior cul de sac

Anterior to the uterus. Posterior to the bladder. May contain bowel

Masses within the vesicouterine pouch will displace the bladder:

Anteriorly

Piriformis

Arise from the anterior sacrum. Form part of the pelvic floor. Course through the greater sciatic notch. Posterior to the uterus, ovaries, vagina and rectum. Anterior to the sacrum. Course diagonally to the obturator internus muscles. Low level linear echoes. Hypoechoic compared to the normal uterus

ovarian arteries

Arise from the lateral margins of the abdominal aorta, slightly inferior to the renal arteries. Course medially within the suspensory ligaments. Primary blood supply to the ovaries. Connect with the uterine arteries.

Radial artery branches.

Arises from arcuate arteries. Spiral arteries supply blood to the functional layer of the endometrium and respond to hormonal changes. Straight arteries supply to the basal layer of the endometrium. Construction of the spiral arteries cause menstruation to occur. Larger caliper vessels are typically arcuate veins.

psoas major

Arises from the lumbar spine. Descends into the false pelvis. Course laterally and anteriorly into the false pelvis. Exits posterior to the inguinal ligament. Low level echogenicity. Round in shape in the TRV plane. Imaged in the lower abdomen and upper pelvis lateral to the vertebrae

round ligament

Arises in the uterine cornua, anterior to the Fallopian tubes. Extends from the uterine fundus to the pelvic sidewalls. Helps to maintain anteflexion of the uterine body and fundus. Contracts during labor.

Where does the pelvis begin and end?

Begins at the iliac crests and ends at the symphysis pubis

Ovarian veins

Course within the suspensory ligaments. ROV empties directly into the inferior vena cava. LOV empties into the left renal vein.

Fundus

Dome shaped widest, most distal and superior portion. Position may vary with bladder filling. Located superior to the insertion of the Fallopian tubes.

Ovarian artery velocities

During menses and the early proliferative phases, the OV artery demonstrates high resistance with a low velocity.

ovarian ligament

Extends from the cornua of the uterus to the medial aspect of the ovary

uterosacral ligament

Extends from the upper cervix to the lateral margins of the sacrum. Firmly supports the cervix

Ligament

Extension of a double layer of peritoneum between visceral organs

Iliopsoas muscles

Formed by the psoas major and iliacus muscles. Lateral landmark of the true pelvis. Course anterior and lateral through the false pelvis. Descend until attaching to the lesser trochanter of the femur. Low level gray echoes with a distinct central hyperechoic focus. Abut the lateral walls of the urinary bladder

infundibulum division of Fallopian tubes

Funnel-shaped distal portion of the tube. Terminates at the fimbrial processes. One fimbriae is attached to the ovary (fimbriae ovarica). Opens into the peritoneal cavity adjacent to the ovary.

Uterus

Hollow, pear shaped organ. Derived from the fused caudal portion of the paired, hollow Müllerian ducts. Median septum of the fused ducts reabsorbs resulting in a single cavity. Muscular organ covered by peritoneum, except below the anterior cervical os. Supported by the levator ani muscles, cardinal ligaments, & uterosacral ligaments. Uterine growth begins at approximately 7-8 years, accelerates during puberty, & continues to grow until approx 20 years.

Normal sonographic appearance of the uterus

Homogeneous mid to low level echogenic structure surrounding a hyperechoic endometrial cavity. Slight difference in echogenicity of the uterine layers with the outer and inner layers slightly hypoechoic to the intermediate layer.

Measuring the uterus

Length: fundus to external cervical os. Height: (thickness) perpendicular to length of sides portion of the body. Width: at the widest portion of the body in short axis

false pelvis

Located superior to the pelvic brim. Anterior boundary: abdominal wall. Posterior boundary: flanged portions of the iliac bones and base of the sacrum. Lateral boundaries: abdominal wall. Contains loops of bowel

Normal sonographic appearance of the endometrium

Outer basal layer appears hypoechoic. Inner functional layer typically appears hyperechoic. Thickness varies with menstrual phase or status but shouldn't exceed 14 mm (1.4 cm)

Exocervix

Outer layer of the cervix continuous with the vagina

Normal sonographic appearance of the ovary.

Ovoid low to medium leaves echogenic structure. Isoechoic to hypoechoic compared with NL uterus. Hypoechoic periphery representing the tunica albuginea. Anechoic follicles demonstrating posterior enhancement may be present.

fallopian tube (oviduct)

Paired muscular tubes. Derived from the nonfused cranial portion of the Müllerian ducts. Contained in the superior portion of the broad ligament and covered by peritoneum. Composed of an outer layer of peritoneum (serosa), middle muscular layer, & an internal mucosal layer.

mesovarian

Posterior portion of the peritoneum that attaches to the ovary

internal iliac artery

Posterior to the uterus and ovaries. Follows a posterior course and enters the true pelvis near the sacral prominence. Aka hypogastric arteries. Supplies the bladder uterus vagina and rectum. Give rise to the uterine arteries.

Masses within the space of retzius will displace the urinary bladder:

Posteriorly.

Ovarian volumes

Premenarche: 1.0cm3 (0-5 years) 1.2cm3 (6-8 years) 2.1 cm3 (9-10 years) 2.5-3.0 cm3 ( 11-13 years) Menstruating: 9.8cm3 Postmenopause: 5.8 cm3 (LWH/2) or (LWH) x (0.523)

Estrogen

Secreted by the follicle

Location of Fallopian tubes

Situated in the superior free margin of the broad ligament. Superior to the uteroovarian, ovarian ligaments and blood vessels. Course posterior and lateral from the cornua of the uterus curving anterior and medial to the corresponding ovary. Open into peritoneal cavity.

Perineum

The surface region in both males and females between the pubic symphysis and the coccyx; are below the pelvic floor

What does the peritoneum drape over?

The uterus and Fallopian tubes, dividing the pelvis into anterior and posterior sections.

Myometrium

Thickest layer. Composed of three layer thick, smooth muscle supported by connective tissue containing large blood vessels. Outer layer: adjacent to serosa. Separated by the intermediate layer by the arcuate vessels. Intermediate layer: thickest of the 3 layers. Inner layer: junctional zone. Thin layer adjacent to the endometrium

Sonographic appearance of the vagina

Vaginal walls demonstrate low level homogeneous echoes. Vaginal canal demonstrates a central hyperechoic linear echo pattern

Ovarian volume

Varies with age, menstrual status, body habitus, pregnancy status, & phase of menstrual cycle. Lowest volume during luteal phase. Highest volume during the periovulatory phase. Larger volume at birth a result of maternal hormones. Stable volumes up to 5 years. Volume peaks in the 3rd decade. Begins to decline in the fifth decade

broad ligament

Wing-like double fold of peritoneum. Drapes over Fallopian tubes, uterus, ovaries and blood vessels. Extends from the lateral walls of the uterus to the sidewalls of the pelvis. Provides a small amount of support for the uterus. Creates the retrouterine and vesicouterine pouches. Divided into the mesometrium, mesosalpinx, & mesovarian segments.

measuring the endometrium

anterior-posterior thickness is measured in the sagittal plane. measured from echogenic interface to echogenic interface (functional layer) thin hypoechoic area (basal layer) is not included in this measurement. fluid within the cavity is not included in the measurement.

subseptus

complete fusion of the mullerian ducts with partial failure to completely reabsorb the septum. indications: asymptomatic, infertility, multiple spontaneous abortions. findings: NL uterine contour. may demonstrate a slight indentation of fundal contour. thin separation within endometrial cavity by fibrous or myometrial. differentials: fibroid, adenomyosis, endometrial polyp.

cardinal ligament

continuation of the broad ligament that extends across the pelvis floor to attach at the isthmus portion of the uterus provides rigid support for the cervix

endometrium

inner lining of the uterus. Highly vascular mucous membranes lining the uterine cavity. Thickness is related to hormone levels. Composed of the 2 layers: functional and basal. Contiguous with the vagina & Fallopian tubes

external cervical os

junction of the cervical canal with the vaginal canal

internal cervical os

junction of the endocervical canal and the endometrial canal at the uterine isthmus

menarche

onset of menstruation

the ovaries are composed of:

outer cortex & a central medulla

uterine sizes: premenarche, menarche, & postmenopausal

premenarche: 2.0-4.0 X 0.5-1.1 X 1.0-2.0 CX/corpus ratio: 2:1 menarche: nulliparous 6.0-8.0 X 3.0-5.0 X 3.0-5.0 C/C ration: 1-2 menarche: parous 8.0-10.0 X 3.0-5.0 X 5.0-6.0 C/C ration: 1:1

flexion

refers to the relationship between the body of the uterus and the internal cervical os.

true pelvis

region of the pelvis found below the pelvic brim

false pelvis

region of the pelvis located above the pelvic brim

arcuate

septum between the mullerian ducts is almost completely reabsorbed causing a slight indention of the superior endometrium by a thickened fundal myometrium. indication: asymptomatic, infertility, recurrent second trimester miscarriage. finding: NL external uterine contour. slight separation of the superior endo. heart shaped appearance of the superior endo. differentials: leiomyoma, synechiae, endometrial polyp

retroversion

uterine body and fundus are tipped posteriorly. cervix forms 90 degree angle with the vaginal canal. TV imaging is best to evaluate

anteflexion

uterine body and fundus bend significantly anterior until the fundus points inferior resting on the cervix

retroflexion

uterine body and fundus bend significantly posterior until the fundus is pointed inferior adjacent to the cervix. cervix and vagina are linear oriented. TV imaging is best to evaluate

levoflexion

uterine body is displaced or flexed to the left of the cervix. TRV plane is best to evaluate if levoflexed

Dextroflexion

uterine body is displaced or flexed to the right of the cervix. TRV plane is best to evaluate if dextroflexed