1. GYN - normal

What is the range of normal measurements for the endometrium in the menstruating female?

*0.4 - 1.4 CM*

What is the most common uterine position?

*anteverted* & anteflexed

Which muscles make up the pelvic diaphragm? (2)

- *levator ani m.* (puboccocygeus & iliococcygeus) - coccygeous

What are the 2 vessels that provide the dual blood supply to the ovary? Which of these 2 arteries provides the *main blood supply to the ovaries*?

- *ovarian artery* - ovarian branch of the uterine artery

In adults, the *pelvic skeleton* is composed of what structures?

- *sacrum and coccyx* - *two innominate bones* (os coxae); consist of the *fused ilium, ischium and pubis*

What is the shape of the neonate/newborn uterus?

- *teardrop shaped uterus*, 1:2 fundus to cx ratio - prominent and thickened echogenic endometrial lining due to hormonal stimulation in utero

echogenic foci within ovary

- 1 - 3mm & non-shadowing - caused by specular reflection of tiny, unresolved cysts - insignificant, no F/U needed - focal calcifications (associated with shadowing) should f/u to evaluate for early neoplasm

sonographic appearance of iliopsoas m.

- 2 ovoid structures separated by the brightly echogenic tendon - anterior and lateral to the urinary bladder on transverse imaging

Where does the right ovarian vein drain? Left ovarian vein?

- R ovarian vein drains into IVC - L ovarian vein drains into L renal vein

urinary bladder

- SAG, *triangular* or *elongated* in shape - muscular sac - *detrusor muscle* - receives and stores urine produced by the kidneys

List the branches of the uterine artery from the serosa to the endometrium:

- arcuate arteries - radial arteries - straight arteries - spiral arteries

sonographic evaluation of urinary bladder

- bladder fullness - bladder walls - R/O possibility of a midline cystic mass which may be mistaken for the bladder (recognize the normal bladder appearance); post void images obtained to confirm the presence of a cystic mass

What are the regions of the uterus from inferior to superior?

- cervix - proximal/inferior - isthmus - internal os - body/corpus - cornua - lateral - fundus - distal/superior

What are 2 diagnoses that may demonstrate the "ring of fire"?

- corpus luteal cyst (functional cyst) - ectopic pregnancy

*in the presence of pathology in the female pelvis, what should be done?*

- document RUQ (Morison's pouch & subphrenic area/below diaphragm) & bilateral renal areas - eval for the presence or absence of free fluid - R/O hydronephrosis when a large pelvic mass is noted (compression of ureter/s) - anatomic variants related to pelvic findings

The ovaries are both exocrine & endocrine glands. What hormones are secreted by the ovaries?

- exocrine gland, producing ova (egg) - endocrine gland, secreting: *estrogen & progesterone* and androgens

position, shape, & size of the vagina

- extends from the vulva (external genitalia) to the cervix of the uterus - posterior to the base (inferior portion) of the bladder & anterior to rectum - lies at right angles (perpendicular) to the cervix - constricted at the introitus, dilated in the middle, narrowed at the uterus

functional ovarian cyts

- follicular cyst - corpus luteum cyst - corpus luteum cyst of pregnancy - theca lutean cyst - ovarian remnant syndrome

What is alternate names for the *false pelvis*?

- greater pelvis - major pelvis

What is associated with complex fluid in the peritoneal recesses?

- hemorrhage - infection

posterior relationship of vagina

- inferior ¾ of the posterior surface adjacent and connects to the anterior wall of rectum - superior ¼ of the posterior vagina is separated by the rectal vaginal pouch of the peritoneum (commonly called the pouch of Douglas, cul de sac of Douglas, or posterior cul de sac)

What is alternate names for the *true pelvis*?

- lesser pelvis - minor pelvis

sonographic appearance of obturator internus m.

- located laterally at the acetabulum, run parallel to the lateral walls of the bladder on TRV imaging - triangular sheet

FYI - ovary in relation to major vessels

- medial to external iliac vessels - anterior & medial to internal iliac vessels

ureters

- originates at the renal pelvis - descends *anterior to internal iliac arteries* - the ureters and iliac vessels are *posterior to the ovary* - insert at the inferior-posterior portion of the bladder

sonographic appearance of piriformis m.

- originates at the sacrum - most posterior aspect of the true pelvis

Which pelvic structures lie in the adnexa?

- ovaries - ligaments - vessels - fallopian tubes - lymphatics

FYI - PA view of posterior pelvic muscles

- piriformis, superior - obturator internus, inferior

What is the average volume of the adult female ovary?

- premenarchal = 3cm³ - menstruating = 10 cm³ (UL - 18cm³ - 22cm³) - postmenopausal = 5.8cm³ (*ABNL > 8cm³*)

size of UT

- prepubertal female, *1 - 3 cm in length* - nulliparous female, *6 - 8 cm in length* - multiparous female, *8 - 10 cm in length* - postpartum uterus - remains enlarged for 4 - 8 weeks after delivery - postmenopausal female, *3 - 5 cm in length*

What are the functions of the female pelvis? (3)

- provide a weight-bearing bridge between the spinal column and bones of the lower extremities - protect the organs of reproduction - directs the pathway of the fetal head during childbirth

sonographic appearance of nabothian cysts

- round anechoic structures, may contain internal echoes if hemorrhagic, or infected - usually less than 2 cm - best visualized with TV scanning

sonographic appearance of levator ani m.

- seen transversely on most inferior sections as hypoechoic areas posterior to the vagina

fluid accumulation

- small amount of fluid may be identified with ovulation - fluid in cul de sac may be identified with a ruptured cyst, pelvic infection, or ectopic pregnancy - fluid in cul de sac may be part of more extensive ascites as seen with malignancy

sonographic appearance of the uterine serosa

- smooth outermost layer - *NOT sonographically distinct*

Which ligament/s support the ovary? Which is lateral & which is medial to the ovary?

- suspensory/infundibulopelvic ligament, lateral - utero-ovarian ligament, medial - mesovarium of broad ligament

sonographic appearance of the myometrium

- thick middle layer composed of *3 layers* of smooth muscle - mid-level gray echogenicity, typically homogeneous - peripheral anechoic structures (arcuate vessels)

anterior to posterior TA urethral image

- urethra - A - vagina - rectum - P

echogenic foci within inner layer of myometrium

- usually non-shadowing - dystrophic calcification due to previous instrumentation

The internal iliac artery that branches at the level of the cx becomes the following:

- uterine artery - cervical branches of uterine artery - vaginal branches of the uterine artery

Which ligaments suspended the uterus?

- uterosacral - cardinal - round - broad

What structures in the true pelvis does the broad ligament drape over?

- uterus - fallopian tubes, *except for the lateral infundibulum & ampulla* - ovaries encloses: - vascular structures of the uterus & ovaries - nerves - utero-ovarian ligament - round ligament - cardinal and sacro-ureteral ligaments

What are the layers of the endometrium? Which layer *varies in echogenicity & thickness cyclically*?

- zona basalis - *zona functionalis*

Name the pelvic ligaments. (7)

1. *sacro-uterine*/uterosacral 2. *cardinal (lateral/trv cervical)* 3. *round* 4. *broad* 5. *mesovarium* 6. *ovarian*/utero-ovarian 7. *infundibulopelvic (suspensory)*

tissue layers of the UT

1. endometrium 2. myometrium 3. serosa/perimetrium

What are the 3 divisions of the broad ligament?

1. mesosalpinx 2. mesovarium 3. mesometrium ("SVM")

What are the layers of the myometrium? *Which layer is adjacent to the endometrium*?

1. outer 2. intermediate 3. *inner/junctional zone*

What are the 3 peritoneal spaces in the pelvic cavity that fluid may accumulate?

1. posterior CDS/pouch of Douglas/rectouterine pouch 2. anterior CDS/vesicouterine pouch 3. space of Retzius/prevesicle space/retropubic space

abdominopelvic muscles related to US

1. rectus abdominus m. - FP 2. psoas major m. - FP 3. iliacus m. - FP 4. iliopsoas m. - FP 5. obturator internus m. - TP 6. piriformis m. - TP 7. pelvic diaphragm - TP

How long is the normal cervix?

3 cm or >

How long does the postpartum uterus remain enlarged?

4 - 8 weeks after delivery

What is the average measurement of the adult ovary?

4 x 3 x 2 cm (SAG X TRV X AP)

What is the approximate difference in volume between the ovaries when you are trying to determine if one ovary is abnormal?

> 2 X the volume of the contra-lateral ovary

AIUM

American Institute of Ultrasound in Medicine

Which is located more superior, the true or the false pelvis?

FALSE

The pelvis has more colon on what side of the pelvis? This may make it more difficult to visualize the ovary on that side.

LLQ

What is another name for the isthmus?

LUS

What is another name for the cardinal (lateral/trv cervical) ligaments?

Mackenrodts's ligament

Which of the peritoneal spaces is the most common location for free fluid to accumulate?

PCDS

What is the best scan plane to determine version & flexion of the uterus?

SAG

Which US technique provides a global view of the pelvis? Which provides better detail in most situations?

TA; TV

Are the uterus, fallopian tubes & ovaries located in the true or false pelvis?

TRUE

The lateral fornices are visualized when imaging the _______________.

TRV CX

What projection do you scan the patient from to determine if the uterus is deviated to the right or left from midline (dextroverted/dextroposition/dextroflexed (RT) & levoverted/levoposition/levoflexed (LT))?

TRV midline

What is the best method of evaluating the retroverted or retroflexed uterus, TA or TV?

TV

What is the formula for ovarian volume?

Volume (cc/cm³) = L X W X H X 0.523

Why is it important to recognize the "junctional zone"?

YOU DO NOT INCLUDE THE "JUNCTIONAL ZONE"/INNER LAYER OF THE MYOMETRIUM WHEN MEASURING THE ENDOMETRIUM!

broad ligament

a sheet of peritoneum that extends from the lateral aspects of the uterus, and attaches to the lateral pelvic side wall

What is the range of normal measurements for the PM female on HRT (hormone replacement therapy)?

allowed a normal DL thickness up to 8 MM

What is the longest portion of the fallopian tube? This is the area where fertilization most frequently occurs.

ampulla

introitus

an entrance that goes into a canal or hollow organ; *vaginal introitus* is the opening that leads to the vaginal canal (external entry).

What is the position of the uterus when the bladder is empty?

anteflexed

When performing a pelvic ultrasound, what is a common artifact to see in the bladder?

anterior reverberation artifact

What are the 3 locations of the vaginal fornices?

anterior, posterior, & bilateral

Which arteries supply the myometrium?

arcuate arteries

Where does the psoas major m. originate in the body?

arises from the lumbar spine and descends into the false pelvis to join with the iliacus m.

In the pelvis, which vessel typically lies anterior on the patient, arteries or veins?

arteries

mesovarium ligaments

attaches the *ovary to* the posterior layer of the *broad ligament* on each side

ovarian ligaments

attaches the inferior ovary to the uterine cornu, posterior to the fallopian tube on each side

infundibulopelvic (suspensory) ligaments

attaches the lateral ovary to posterolateral pelvic wall and transmit the ovarian vessels and nerves

Where does the round ligament originate?

attaches the uterine *cornua* to the anterior pelvic wall

version

axis of the cervix relative to the vagina

flexion

axis of the uterine body relative to the cervix

What will happen to the retroverted uterus when a woman is pregnant?

become anteverted

nebothian cysts/cervical inclusion cysts

benign developmental cyst/s within the cervix, obstructed and dilated transcervical glands, NOT pathology

The inner layer of parenchymal ovarian tissue contains

blood vessels and connective tissue

Which segment of the uterus is the largest?

body/corpus

What ligament/s hold the uterus loosely in place? Uterine body is mobile, may lie obliquely on either side of midline.

broad

What is the normal aging process of the arcuate arteries?

calcification, post menopausal; may be accelerated in diabetic patients

Which 2 ligaments hold the cx in a fixed position? Which ligament is posterior & which is lateral?

cardinal (lateral) and sacro-uterine (posterior)

parturition

childbirth

The vagina is a _______________ tube that consists of ___ layers.

collapsible; 2 1. external layer - smooth muscular layer - hypoechoic 2. internal layer - mucosal layer - highly reflective canal

What type of anomalies are related to congenital uterine anomalies?

congenital renal anomalies

Which segment of the uterus is proximal/most inferior?

cx

What 2 portions of the uterus does the isthmus connect?

cx and body

Where are nebothian cysts located? Is their presence a cause for concern, are they clinically significant?

cx; no

When is surgery recommended for an ovarian cyst in a postmenopausal woman?

cysts > 5cm containing septations or solid nodules

Why can't you use shadowing to determine if you are at the level of the CX?

endometrium may have edge shadowing mimicking the appearance of the cx

sacro-uterine ligaments

extends posterolaterally from the cervix, encircles the rectum, and attaches to the sacrum

portion of the cx that protrudes into the vagina:

external os

Where is the thickness of the endometrium typically the greatest?

fundus

Which segment of the uterus is distal/most superior?

fundus/dome

Variations in the position of the uterus

https://www.sciencedirect.com/science/article/pii/S1472029908000039#fig3

What is the appearance of the vaginal mucosa: hypoechoic, anechoic, or hyperechoic?

hyperechoic

the endo is _________________(echotexture) compared to the myometrium

hyperechoic

outer layer of myometrium is slightly _______________ to intermediate layer

hypoechoic

sonographic appearance of muscles

hypoechoic bands of tissue, with low-level echoes and characteristic thin linear hyperechoic striations

What is another term for internal iliac artery?

hypogastric

What *muscle in the false pelvis may be mistaken for an ovary*?

iliopsoas m.

What muscle is created with the fusion of the psoas major m. & iliacus m.?

iliopsoas m; *most commonly visualized pelvic muscle*

What is the linea terminalis?

imaginary line dividing the pelvic cavity into the *true pelvis & false pelvis* (extending from sacral promontory to symphysis pubis)

In what position is the uterine endometrium measured?

in SAG at its greatest AP thickness

*most hypoechoic* of the 3 myometrial layers

inner/junctional zone

the *thickest* and *most echogenic* of the 3 myometrial layers

intermediate layer

portion of cx at the uterine isthmus:

internal os

Mucosal lining of the uterus (endometrium) is continuous with what layer of the fallopian tube?

internal/mucous layer

What is the first/proximal portion of the fallopian tube called that can be imaged?

interstitial

The fundus contains the cornua, housing the _________________ portion of the fallopian tubes

interstitual/intramural

Intraperitoneal or retroperitoneal: the ovaries

intraperitoneal

thin (hypoechoic) halo surrounding the endometrium

junctional zone

The external iliac vessels are located where in relation to the uterus? To the ovary?

lateral

When imaging the female pelvis, what 2 structures together give the classic appearance of the "moustache sign"?

lateral fornices of the vagina

The cornua is located in what segment of the uterus?

lateral fundus

The ovaries are _____________ to the uterus

lateral, posterior

Which muscles enclose the vaginal walls?

levator ani m.

cardinal (lateral/trv cervical) ligaments

located at the base of the broad ligament and arise from the side of the cervix and the lateral fornix of the vagina attaching to the lateral pelvic wall. houses the uterine artery and veins

Where are the ovaries located in the neonatal period?

located between the lower pole of the kidneys and the true pelvis, volume increases until puberty

OV vs EIA & IIA

located medial to external & internal iliac vessels and anterior to internal iliac vessels

Are normal fallopian tubes visualized sonographically?

no

Can the cervix length be measured on a non-pregnant woman during a routine ultrasound exam?

no

Can you visualize the internal and external cervical os on a "non-pregnant" woman?

no

Is the junctional zone of the myometrium included in the endometrium measurement?

no

FYI - cx vs LUS

no peritoneal reflection anterior to the cervix, but a pad of cellular tissue interposed between it and the bladder

urinary bladder wall

normally measures between 3-6 mm, depending on the amount of bladder distension

anatomy of ovary

outer layer - germinal epithelium inner structure - outer cortex (tunica albuginea) & inner medulla follicular development in cortex: 1. primordial 2. primary 3. secondary 4. graafian/dominant follicle 5. corpus luteum 6. corpus albicans

The _______________ layer of the myometrium is adjacent to serosa & separated from intermediate layer by the _______________ _______________.

outer; arcuate vessels

What is the shape of the ovaries?

oval/almond, may assume a more elongated or round appearance

If a patient has an oophorectomy, what is the term that is used to describe the residual tissue remaining after surgery?

ovarian remnant syndrome

arcuate vessels

peripheral anechoic structures

What is the most common muscle in the *true pelvis* to be mistaken for an ovary?

piriformis m.

What are the *muscles of the true pelvis*?

piriformis, obturator internus, muscles of the pelvic diaphragm

The ovaries are _____________ to the broad ligament

posterior

Where are the ovaries located in relation to the broad ligament?

posterior

What are the *muscles of the false pelvis*?

psoas major, iliacus, iliopsoas

What is an oophorectomy?

removal of the ovary

Is the uterus intraperitoneal or retroperitoneal?

retroperitoneal

What ligament/s maintain the cervix at a 90 degree angle to the posterior wall of the vagina?

round & sacro-uterine

What is the range of normal measurements for the PM (postmenopausal female)?

should have a double layer thickness *<5 MM*

Which arteries supply the functional layer of the endometrium?

spiral

At what level in the pelvis is the iliopsoas m. seen?

superior, anteriolateral false pelvis @ level of the iliac crest & UT fundus

The outer, functional layer of parenchymal ovarian tissue consists of

the bulk of ovarian substance containing primordial and developing follicles

The interstitial portion of the fallopian tube is associated with what part of the uterus?

the cornua

What section of the fallopian tube connects the fallopian tube to the ovary?

the fimbriae ovarica of the infundibulum

What is the main source of peritoneal fluid in women?

the ovaries

Why is the bladder considered to be an acoustic/sonic window or cystic reference?

the structures posterior to the bladder can be better visualized due to posterior enhancement

TAH/BSO

total abdominal hysterectomy, bilateral salpingo-oophorectomy

Are the ovaries located in the true or false pelvis?

true

Is the uterus located in the true or false pelvis?

true

What are the two compartments in the pelvic cavity?

true pelvis & false pelvis

sonographic appearance of pelvic ligaments

unless outlined by free peritoneal fluid, the ligaments are not visualized, with the exception of the broad ligament or when the uterus is retroverted

"flat" tubular structure in TRV

vagina

Protrusion of the cervix into the vagina forms the _______________ _______________.

vaginal fornices

What is the most accurate measurement to determine ovarian size?

volume

How do you know if the bladder is adequately filled for TA pelvic sonography?

when the dome of the bladder extends above the uterine fundus

Does the size of the uterus & ovaries change with menopause? How? What about if the patient is on HRT?

yes; uterine physical proportions atrophy, ovaries decrease in size; stays the same size as premenopausal female