Pelvic Pathology Review

What are the 3 peritoneal spaces in the pelvic cavity?

Anterior cul-de-sac, posterior cul-de-sac, prevesical space

Which of the following cannot be included in the category or cystic masses of the vagina? A. Gartner's duct cyst B. nabothian cyst C. Hematocolpos D. Bartholin cyst E. All of the above

B. Nabothian cyst They are located in the cervix, not the vagina

Endometrioma may appear sonographically similar to: A. benign cystic teratoma B. Polycystic ovaries C. hemorrhagic cyst D. hydrosalpinx E. Follicular cysts

C. hemorrhagic cyst

Ovaries that have been overstimulated by infertility medication are at risk for which of the following: A. producing grossly enlarged cysts B. Torsion C. Endometriosis D. Both A and B E. All of the above

D. Both A and B

What is the most common cause for hematocolpos? A. Bicornuate uterus B. endometritis C. PID D. imperforate hymen E. Ectopic pregnancy

D. Imperforate hymen

On US you view bilateral hypoechoic regions visualized posterior and lateral to the vagina most likely represent_____________________

Levator ani muscle group

What causes ovarian hyperstimulation syndrome?

Ovulation induction hormone changes/ increases (HCG)

Patient presents with: Heavy irregular periods, obesity, hirsutuism, and when viewed on U/S ovary appears with many follicles in the periphery. What is your diagnosis?

PCOS (Polycystic ovarian syndrome)

What is dyspareunia?

Painful intercourse

What is another name for Mullerian ducts?

Paramesonephric ducts

Patient presents with: Pain in lower abdomen, pelvis, and back, fever, painful intercourse, and irregular menstrual bleeding. What is the most likely differential diagnosis?

Pelvic Inflammatory Disease (PID)

What are the medial and lateral borders of the ovaries?

Lateral: Iliac a. and v. Medial: Uterus

What is the most common neoplasm of the uterus?

Leiomyoma

What is a normal endometrial measurement for Postmenopausal women?

Less than 5mm

What is a normal endometrial measurement for postmenopausal women on HRT?

Less than 8mm

What is the proper patient position for transvaginal examination?

Lithotomy position

The onset of menstruation is also termed:

Menarche

Term for irregular/ acyclic bleeding

Metrorrhea

How does a patient with a molar pregnancy present?

Most present with the same symptoms as a normal pregnancy. Increased abdominal girth, but will have VERY VERY High levels of HCG, and patient will normally have nausea.

What is Endometrial Hyperplasia?

Overgrowth of Endometrium. When noted in geriatric patients most often this is a sign of endometrial carcinoma

How might you differentiate a polyp from a fibroid?

Polyps typically have a vascular stalk

In what stage of the menstrual cycle would be an ideal time to evaluate the endometrium for a polyp?

Proliferative phase The lining is thick, but the internal component is hypoechoic. this allows for the echogenic polyp to be seen. In the secretory phase, the entire endometrial lining is echogenic and will mask a polyp

What position best describes the position of the uterus shown on the image:

Retroverted Uterus

What abnormality does the image best represent.

Septate Uterus -->The outline of a septate uterus is relatively normal and contains two endometrial cavities *A bicornate uterus contains two endometrial cavities but there is a deep indentation on the fundal contour

What is another name for PCOS?

Stein-Leventhal Syndrome

Which arteries supply the endometrium?

Straight and spiral arteries which arise from the arcuate arteries which course wihtin the outer myometrium

What fibroid location disrupts the endometrium?

Submucosal

What is the most common anatomical location for a dermoid cyst

Superior to the uterine fundus

What two ligaments are not "True ligaments"

Suspensory ligament Broad ligament

A complex adnexal mass is identified in a patient with tenderness and elevated fever and wbc. What is the most likely diagnosis?

TOA

What is Amenorrhea?

The absence of menstruation

The trigone refers to:

The base of the bladder containing the orifices of the ureters and urethra

What is Meig's syndrome?

The triad of pleural effusion, ascites, and ovarian tumor.

True or False: Dermoid tumors are generally asymptomatic

True

Is a Tubo-ovarian-abscess normally unilateral or bilateral?

Unilateral

What is a molar pregnancy?

a noncancerous tumor that develops in the uterus as a result of a nonviable pregnancy. also called gestational trophoblastic disease (GTD), hydatidiform mole or simply referred to as a "mole."

Sonographically appears as diffuse uterine enlargement without focal mass. Indistinct border between endometrium and myometrium. Myometrial cysts. Clinically present with abnormal bleeding and dysmenorrhea

adenomyosis

What is Pelvic congestion syndrome?

condition in women caused by varicose veins in the pelvis/ lower abdomen. it is a painful condition caused by the dilation of pelvic/ ovarian veins

Which muscle is the most commonly visualized during pelvic ultrasound

iliopsoas muscle Transverse appears as hypoechoic with echogenic center

What is a Theca- lutein cyst?

largest of the functional cysts and appear as very large, bilateral, multiloculated cystic masses (Associated with high levels of HCG--> GTD)

What is an inclusion cyst?

occurs when fluid produced by the ovaries is not absorbed and becomes trapped between the adhesions. *This occurs more frequently in patients with history of PID or previous surgery*

The date of the last menstrual period is counted from________

the date when menstrual bleeding began

Which uterine ligament is responsible for uterine orientation?

uterosacral ligament

An Endometrioma is otherwise referred to as a ______________________ cyst

"Chocolate Cyst" due to low level internal echoes due to blood.

Name some contraindications to transvaginal scans

-Virgins -Infants and children -elderly patients -unconscious patients -mentally insane

What is the mean diameter of a dominant follicular cyst at the time of ovulation?

25mm

What is the measurement of normal adult ovaries?

3x2x2

A rapidly growing fibroid in a postmenopausal woman not on HRT is suggestive of which of the following: A. leiomyosarcoma B. fibrous degeneration C. hermorrhagic infiltration D. Calcific changes E. Pregnancy

A. Leiomyosarcoma

During the early proliferative phase, the endometrium appears: A. thin, echogenic line 4-8mm B. Thin, hypoechoic line, 4-8mm C. Thickened and hypoechoic medially with an echogenic basal layer D. thickened and echogenic throughout E. Thin, echogenic line, 4-8cm

A. Thin, echogenic line 4-8mm

A Uterovesical junction (UVJ) obstruction is associated with what other findings: A. ureterocele B. unilateral hydronephrosis C. Pelvic Kidney D.Both A and C E. None of the above

A. Ureterocele

Which of the following is not part of the adnexa: A. urinary baldder B. Fimbria C. follicular cyst D. broad ligaments E. Internal iliac arteries

A. Urinary Bladder

Clinical symptoms of _____________are heavy menstrual bleeding, painful menses and uterine enlargement

Adenomyosis

How would you describe the appearance of Adenomyosis?

Adenomyosis is the invasion of endometrial tissue into the myometrium. Sonographic findings: uterus is large with small cysts visible in the inner myometrium. Will appear heterogeneous with salt and pepper like appearance.

Where is the most common sight for an ectopic pregnancy?

Ampulla of Fallopian tube

What is the difference between Anteverted and Anteflexed?

Anteversion--> tilted forward at the cervix Anteflexed--> Bent forward at the fundus

Which site of ectopic pregnancy has the highest maternal morbidity or mortality? A. abdominal pregnancy B. cornual C. Ampullary D. ovarian E. Isthmic

B. Cornual

Congenital abnormalities of the uterus result from improper fusion of which of the following structures? A. mesonephric ducts B. paramesonephric ducts C. Gartner's duct D. Wolffian ducts E. Bartholin duct

B. Paramesonephric ducts

What other organ system has a strong correlation with renal abnormalities? A. cardiac B. Uterine C. Ovarian D. muscular E. Brain

B. Uterine

Which of the following ligaments does not provide structural support for the uterus and cervix? A. round B. cardinal and uterosacral C. Infundibulopelvic D. uterosacral E. Cardinal

C. Infundibulopelvic

Which of the following statements regarding leiomyomas is false? A. calcifies and attenuates the ultrasound beam B. may mimic a myometrial contraction C. normally increases in size after menopause D. distorts the endometrial cavity E. derives from the muscle of the uterus

C. Normally increases in size after menopause

During the periovulatory phase, the endometrium appears A. thin, echogenic line 4-8mm B. Thin, hypoechoic line, 4-8mm C. Thickened and hypoechoic medially with an echogenic basal layer D. thickened and echogenic throughout E. Thin, echogenic line, 4-8cm

C. Thickened and hypoechoic medially with an echogenic basal layer

What is the sonographic appearance of arcuate artery calcification?

Calcification was manifest as symmetric, hyperechoic foci with acoustic shadowing in the periphery of the uterine myometrium

What is precocious puberty?

Child who goes through puberty much earlier than normal

Which cyst is associated with the "ring of fire" appearance?

Corpus Luteal cyst. This cyst has a rich blood supply, and occurs once ovulation has occurred

Which of the following muscles is not located within the true pelvis? A. obturator internus B. levator ani C. pirirformis D. iliopsoas E. Coccygeus

D. The iliopsoas m.

During the secretory phase, the endometrium appears: A. thin, echogenic line, 4-8mm B. Thin, hypoechoic lin, 4-8mm C. thickened and hypoechoic medially with an echogenic basal layer D. Thickened and echogenic E. Less than 2mm

D. Thickened and echogenic

Fluid in the endometrial cavity in post-menopausal paitent may be associated with which of the following: A. increased estrogen B. Vaginal Atrophy C.Endometriosis D. Ectopic pregnancy E. Cervical stenosis

E. Cervical stenosis

Which of the following is a least likely cause for abdominal and pelvic abscess? A. heart failure B. nephrotic syndrome C. pancreatitits D. cancer E. Fibroid uterus

E. Fibroid uterus

What may be a cause of hematosalpinx?

Ectopic pregnancy Blood from peritoneal cavity Endometriosis Tubal Cancer

precursor to endometrial cancer. Presenting as endometrial thickening in peri/postmenopausal patients

Endometrial Hyperplasia

32 year-old woman presents with abnormal vaginal bleeding. Ultrasound shows echogenic mass within the endometrium, what is your diagnosis.

Endometrial Polyp

29 year old patient presents with a history of chronic pelvic pain especially during menses, back pain, and dyspareunia. Sonographic appearance show cystic structure with low level echoes. What is the most likely diagnosis?

Endometrioma

An ovarian mass identified on sonogram is complex, predominately hypoechoic with septations. The patient complains of severe pain during menses. What is the most likely diagnosis?

Endometrioma

Functional endometrial tissue outside the uterine cavity is termed__________________

Endometriosis

What is sonohysterography?

Evaluation of the endometrium using saline infusion into the endometrial lumen during transvaginal sonography.

What is the main cause of endometrial hyperplasia?

Excess of estrogen

The anterior pituitary gland is responsible of the production of which of the following: A. FSH B. GnRH C. LH D. Oxytocin E. both B and D F both A and C

F. Both A and C (FSH and LH)

True or False: Serous cystadenoma's can have thick septations?

False Serous cystadenoma's typically show thin walled septations

What is the most common gynecologic tumor?

Fibroid, leiomyoma, myoma, fibroid

What may cause a patient to have Menorrhagia? (Heavy or prolonged bleeding?)

Fibroids Hormone changes (Contraception, ovary dysfunction) Polyps Medications Cancer Adenomyosis Pregnancy complications

What does this number represent: G4P2

G4= 4 pregnancies P2= 2 live births

What might be a cause for Hematometra in a geriatric patient? In a young female patient?

Geriatric: Cervical stenosis Young: Imperforate hymen

What disease are theca lutein cysts associated with?

Gestational Trophoblastic disease

What is Hematometra? Hematocolpos?

Hematometra: Blood in the uterus Hematocolpos: Blood in the vagina

What is Hydrosalpinx? What is it often associated with?

Hydrosalpinx- collection of fluid in the fallopian tube. Usually associated with Pelvic Inflammatory Disease

What is a classic sonographic sign of a dermoid tumor?

Iceberg sign, with posterior shadowing

Where do Nabothian cysts occur?

In the cervix

Where are Gartner duct cysts located?

In the vagina

What is the most common location for fibroid to occur?

Intramural

What is the main clinical presentation of cervical polyps?

Irregular menstrual bleeding

When congenital uterine abnormalities are present, the __________ should also be evaluated.

Kidneys

Name some pertinent patient history questions prior to a pelvic exam:

- menstrual history - any abnormal bleeding -Pain -Previous surgery -Review of Blood work (Particularly WBC and HCG)

The current methods to prevent transmission of infection with transvaginal transducers are:

-chemical disinfectant -disposable probe cover

What are some advantages of transvaginal ultrasound?

-higher resolution -earlier and more definitive diagnosis -does not require a full bladder

What are some disadvantages to transvaginal scans?

-limited field of view -unable to see both ovaries on the same image -The confined space of the vagina limits the mobility of the transducer

Which uterine ligament is responsible for uterine orientation? A. transversali ligament B. broad ligament C. uterosacral ligament D. round ligament E. Ovarian Ligament

c. Uterosacral ligament

What is the normal size of an adult uterus?

6-8 cm in length 3-5 cm in width 2-4 cm

What is a follicular cyst?

A functional cyst of the ovary that occurs when a mature follicle fails to ovulate

Abnormal accumulation of intraperitoneal fluid that becomes trapped by adhesions in a patient with a history of previous surgery is most likely caused by which of the following? A. inclusion cyst B. Ovarian torsion C. dermoid cyst D. follicular cyst E. Leiomyosarcoma

A. Inclusion cysts *inclusion cyst is when fluid produced by the ovaries is not absorbed and becomes trapped between the adhesions. This occurs more frequently in patients with a history of previous surgery or PID

What is the most common cause for ovarian torsion? A. ovarian tumors B. hyperstimulation of the ovary C. Adhesions D. hypervascularity to the ovary E. PID

A. Ovarian tumors

Which of the following is an early sign/symptom of endometrial cancer? A. Postmenopausal vaginal bleeding B. abdominal and pelvic pain C. ascites seen on ultrasound D. Massive weight loss E. headache

A. Postmenopausal vaginal bleeding

95% of cases of ovarian torsion are associated with _____________

Adnexal mass The most common adnexal mass associated with ovarian torsion is the dermoid cyst The right adnexa are more commonly involved

Which of the following is true of mucinous cystadenocarcinoma? A. composed of germ layers, ectoderm, mesoderm, and endoderm B. when ruptured can result in pseudomyxoma C. occurs more frequently in women 40-70 years old D. contains fatty, sebaceous material, bone, teeth, and hair E. Gives a sonographic appearance called "tip-of-the-iceberg"

B. When ruptured can result in pseudomyxoma

A 60-year-old woman with primary adenocarcinoma of the stomach now presents with a large complex right ovarian mass and ascites. What is the most likely diagnosis? A. neurofibromatosis B. Sertoli-Leydig tumor C. Krukenberg's Tumor D. Meigs' syndrome E. Cystadenofibroma

C. Krukenberg's tumor --> malignant tumor of the ovary that metastasizes from a primary in the GI tract

Name the parts of the uterus from inferior to superior

Cervix, isthmus, body, fundus

Women with Endometriosis may have: A. dyspareunia B. Metromenorrhagia C. Dysmenorrhea D. All of the above E. Both D and C

D. All of the above

What is the most common cause for requesting pelvic ultrasound in the pediatric age-group? A. fibroid uterus B. Vaginal foreign Body C. ovarian cancer and ascites D. Precocious puberty and sexual ambiquity

D. Precocious puberty and sexual ambiquity

Female infertility may be caused by which of the following: A. uterine synechia B. PCOS C. Asherman's syndrome D. adenomyosis E. all of the above

E. all of the above

What is Synchiae?

Endometrial adhesions Found in women with posttraumatic or postsurgical histories (Includes uterine curettage and may be cause of infertility or recurrent pregnancy loss) AKA: Asherman's syndrome

What is a normal endometrial size during: Menses, proliferative phase, secretory phase?

Menses: 2-4mm Proliferative: 5-11mm Secretory:7-16mm

What is the sonographic appearance of an endometrial polyp?

Typically echogenic Project into the endometrial lumen best seen just before ovulation Typically cause diffuse or focal endometrial thickening