Normal Pelvis 2 (muscles, etc)

Describe Pelvic Arteries (3)

-ANTERIOR to veins in Pelvis -Aorta bifurcates slightly superior to IVC -Common Iliac Arteries (External Iliac and Internal Iliac -hypogastric)

Pelvis Muscles (2)

-All are bilateral -May be mistaken for ovary/mass

Ovarian Artery (3)

-Anastomoses (connect) with Uterine Artery (provides safety valve for ovarian blood supply from 2 different points) -Courses inferiorly along psoas muscles to ovary -Originates from aorta at level of lower renal pelvis

U/S Appearance of Urinary Bladder (Sagittal)

-Anterior wall parallels abdominal wall -Inferior aspect parallels vagina -Superior aspect extends obliquely bowing from superior vagina to umbilicus -Triangularly shaped

Primary blood supply of Internal Iliac Arteries (4)

-Bladder -Pelvic floor muscles -Uterus -Vagina

Obturator Internus (3)

-Found anterior to uterus -Inferior --Found along lower half of uterus (Uterine body to cervix) --Landmarks the Posterior-Lateral corners of the bladder -Occupies inner surface of anterior and lateral pelvic walls

Obstetrical history

-Gravity (G); # of pregnancies -Parity (P); # of live births ???????????????????????????

Pelvic Diaphragm Muscles made up of....

-Made up of several muscles --Levator Ani (Pubococcygeus, Iliococcygeus) --Coccygeus (Not able to identify each muscle separately)

Filling Techniques (3)

-Orally - Drink 24 -32 ounces 1 hour prior; preferred -Intravenous Hydration - Usually takes longer especially if patient if dehydrated -Foley Catheter Retrograde; 500 cc IV bag saline; IV tubing, Gravity (putting a foley increases chances of infection

Full Urinary bladder

-Rectum and vagina are not displaced, anchored by pelvic diaphragm -Small bowel and mesentary displaced superiorly -Uterus and Sigmoid displaced posteriorly

Transvaginal transducer preparation (6)

-Rinse scan head with water -Wipe dry -Apply gel to transducer face -Cover transducer with condom (check for latex allergy) -Lubricate condom (KY preferred, U.S. Gel but do not use for fertility studies, and water) -Rubber band to secure condom

Inserting transvaginal probe (2)

-have a chaperon present for exam, patient and sonographer - perform exam

Iliacus Muscle (2)

Arises posteriorly from iliac wing Short triangular muscle

Anterior Cul De Sac

Between bladder and anterior uterine surface

Pelvic Veins

Courses with accompanying arteries

Right Ovarian Vein

Drains directly into IVC

Left Ovarian Vein

Drains into left renal vein

U/S Appearance of Obturator Internus (3)

Homogenous Hypoechoic Hyperechoic boundary (Obturator Fascia)

Medications (2)

Hormone Replacement Therapy (Estrogen/Progesterone) Oral Contraceptives

U/S Appearance of Obturator Internus-Transverse (2)

Ovoid Seen Angling Superiorly from Symphysis Publis

Complaints/Symptoms (5)

Pain (location, duration, cyclic) Fever Chills Vaginal Discharge Previous History of Problems/Dx

Landmark for ovary

Seen posterior with ureter & IIV

What does Peritoneal Spaces cover?

Superior aspect of bladder, uterus & rectum

Uterine Artery

consist of Arcuate Artery (Edge of Uterus)

Urinary bladder (4)

-Anchored inferiorly by urethra & trigone -Capacity = 300-500 ml (or cc) -Most anterior in lesser pelvis (true pelvis) -Posterior & superior aspects greatly distend

U/S Appearance of Urinary Bladder (3)

-Anechoic -Smooth, thin walls -Transverse

Distended bladder creates 3 spaces

-Anterior Peritoneal Space -Anterior cul de sac -Posterior cul de sac

Rectus Abdominis (6)

-Anterior abdominal wall -Cause "Ghost Image" artifact in uterus (2 endometrial canals, Twin gestational sacs) -Extend from pubic symphysis and Iliac Crest to costal cartilages and xiphoid process -Ovoid or lens-shaped in cross-section -Separated in midline by Linea Alba tendon -Shape may refract beam

Location of Ureter (4)

-Anterior to Internal Iliac Artery & Vein -Courses medially to enter bladder trigone -Directly posterior to ovary -Often can visualize ureter insertion into posterior bladder (UVJ) off ML

Piriformis Muscles (4)

-Appear hypoechoic ovoid when seen -Most common muscle to be mistaken for ovary -Often not visualized due to overlying bowel gas -Triangular shaped

Pelvic Diaphragm Location (4)

-Appears hypoechoic -At level of cervix/vagina -Found inferiorly and posteriorly on either side of midline -Posterior to Rectum

External Iliac Arteries (3)

-Becomes the Common Femoral Artery -Course along anterior medial border of Iliopsoas muscle -Pass through inguinal ligament to enter thigh

Posterior Cul De Sac (6)

-Between posterior surface of uterus and rectum -Extends caudally to upper 1/4th of vagina -Largest of the three spaces -Most common pelvic area for intraperitoneal fluid collections to settle -Often contains bowel & mesentary -"Pouch of Douglas"

U/S Iliopsoas Muscle in Transverse (2)

-Bull's Eye Pattern (Hyperechoic Center) -Round to Ovoid

Cidex (5)

-Caustic to skin -Contains Gluteraldehyde (should be vented and fumes may cause sickness) -Do NOT leave transducer soaking for excessive time perios -Change every 2 weeks or if fails litmus test -Record tests & times used

Filling Difficulties (2)

-Check stomach; if full, don't force more drinking; if empty or partially full, drink more -Medications; Hydrated with no progression after 30-45 minutes (Water pills, hypertension)

Neurogenic bladders (Filling Difficulties)

-Chronic Indwelling Foley -Dialysis -Do not force through retrograde filling (Extremely painful and may cause shock) -May not be able to fill bladder -Mentally Incapacitated -Spinal Cord Injury

External Iliac Vein (2)

-Connects Common Femoral and Common Iliac Veins -Drain leg

Psoas Major Muscle (5)

-Courses caudally -*Enters Greater Pelvis over Iliac Crest* -Extends anterior and laterally -Long thick muscle -Originates in Paralumbar vertebra region

Iliopsoas Muscle (7)

-Courses caudally at an anterior-lateral direction -**Found more superiorly (upper half of uterus)** -Inserts on lesser trochanter of femur -**Landmarks the lateral extent of pelvis** -**Located along anterior-lateral corners of pelvis (bladder)** -Made from Psoas Major & Iliacus muscles -Size varies depending on patient musculature

Internal Iliac Arteries Appearance & Location (4)

-Courses inferiorly along lateral pelvic wall -Hypogastric -Several branches to pelvic organs & muscles -Smaller of the two iliac branches

Reasons for filling bladder for pelvic ultrasound (3)

-Creates window -Flattens uterus -Pushes bowel out of way

Location of Piriformis Muscles (2)

-Deep posterior and superior -Found posterior to the upper half of uterus

U/S Appearance of Obturator Internus-Sagitally (3)

-Difficult to visualize -Elongated -Seen angling from ML to Lateral side walls

Normal structures that may indent bladder (3)

-Enlarged uterus -Suspect pathology -Unusual for normal bowel to indent bladder except for fecal impaction

Transvaginal patient preparation (3)

-Explain procedure -Empty bladder -Remove underclothes

U/S Iliopsoas Muscle in Long Axis (Sagital Oblique) (2)

-External Iliac Vessels (Seen directly anterior to anterio-medial to muscle) -Muscle seen angling from medial to lateral

Pelvic Diaphragm Function (3)

-Failure causes prolapse of pelvic organs -Resist gravity -Resist increased abdominal pressure (coughing, straining)

Describe Pelvic Diaphragm (3)

-Forms floor of pelvis -Most caudal structure of abdomino-pelvic cavity -Stretches across pubis and coccyx like a hammock

Ultrasound appearance of Iliopsoas Muscles (4)

-Hypoechoic -Striated -VERY HYPERECHOIC CENTRAL ECHO (Femoral Nerve Sheath) -Well Marginated (Good Borders)

Pelvis Muscle Types (5)Ul

-Iliopsoas -Obturator internis -Pelvic Diaphragm -Piriformis -Rectus Abdominis

Transvaginal scanning advantages (5)

-Improved resolution (higher frequency, closer to pelvic structures, avoids bowel gas) -Delineate normal structures or masses -Fertility Studies (Monitor follicular growth, egg retrieval) -Sonohysterography (Evaluation of Endometrium; Tubal Patency or blockage) -Visualize Pregnancy earlier (1 week earlier than TA, normal development, ectopic pregnancy)

Clinical history (4)

-Patients age -Menstrual history (LMP, Changes, Change of pregnancy-pregnancy test) -Surgical history -Contraception -Physical exam findings by doctor; mass? tenderness?

U/S Appearance of Urinary Bladder (Angling Inferiorly)

-UVJ's (ureter jets) -- on either side of ML at level of cervix --Ureteral Jets (urine shooting into bladder; verifies ureteral patency -Urethra is also seen angling further inferiorly in ML

Cleaning transvaginal transducer (3)

-Wipe with towel -Test cleaning solution with litmus strip -Place transducer in cleaning solution (Cidex for at least 15 minutes) -Rinse transducer with water -Wipe dry

Completing transvaginal exam (5)

-remove probe -remove condom with gloved hand from transducer -wrap probe in towel and secure -remove bundle from under patient's hips -assist patient

Anterior Peritoneal Space

Between Anterior parietal peritoneum (posterior abdominal wall) and anterior surface of bladder

List of pelvic veins (3)

External Iliac Vein Right Ovarian Vein Left Ovarian Vein

U/S Appearance of Urinary Bladder (Transverse)

Inferiorly - Lateral walls squared due to iliopsoas muscle and acetabulum Superiorly - Becomes rounded

Performing exam transvaginal exam

Review procedure with patient Position patient --Supine with knee flexed --Maintain patient modesty (provide adequate draping) --Elevate hips with folded sheets, sponge padding or bed pan