1. Pelvis Anatomy (add uterine and ovarian sizes; ratio sizes)

peritoneal

The pelvis is part of which cavity?

infundulopelvic/suspensory ligament

the ovarian arteries reach the ovarian hilum via what?

broad ligament vesicouterine pouch/anterior cul-de-sac rectouterine pouch/pouch of douglas/ posterior cul-de-sac

the periemtrium becomes the __________ laterally, forms the _____________ anteriorly, and forms the ___________ posteriorly.

cecum of colon - appendix - distal end of right ureter - right ovary

the right iliac region contains what?

levator ani and coccygeus muscles

which muscles make up the pelvic diaphragm/floor?

vagina

which organ is directed cephalad and posteriorly, forming a 90 degree angle witht he cervix?

Space of Retzius retropubic space previsical space

which peritoneal recess is located between the bladder and the pubic symphysis?

posterior cul-de-sac pouch of douglas recto/retrouterine pouch

which peritoneal recess is located between the rectum and uterus?

anterior cul-de-sac vesicouterine pouch retrovesical space

which peritoneal recess is located between the uterus and the bladder?

posterior cul-de-sac pouch of douglas recto/retrouterine pouch

which peritoneal recess is the most dependent?

follicular phase

which phase of the ovarian cycle gives low velocity flow to the ovarian artery?

uterine venous - frequently identified sonographically

which plexus of channels is larger? uterine arterial or uterine venous

body/corpus

which portion of the uterus is the largest part of the uterus; between the fundus and cervix?

cervix

which portion of the uterus is the lower cylindrical portion that projects into the vagina?

intrmural

what is interstitial also known as?

empty bladder

what is needed to determine the true uterine position?

uterine tube - fallopian tubes - oviducts

what is responsible for directing mature ovum to the uterus through peristalsis?

RI 0.88

what is the RI for uterine arteries in non-gravid patients during proliferative phase?

RI 0.44

what is the RI of the ovarian artery during the ovulatory phase and begins to rise 4-5 days later?

tunica albuginea

what is the dense connective tissue surrounding cortex of the ovary?

1-4mm

what is the diameter of the fallopian tube?

high velocity/high resistance flow

what is the flow of uterine arteries in non-gravid patients?

endometrium

what is the inner mucosal layer of the uterus called?

transabominal gives global view and assists in locating ovaries - transvaginal better resolution

what is the purpose of doing a transabdominal with a transvaginal pelvic exam?

mucosal layer

when the bladder is distended, which layer of the bladder wall is stretched and no longer recognized as a distinct layer?

spiral artery

which arteries blood supply is shed during menses?

piriformis muscle

which muscle connects from the sacrum to the femur?

labia

- folds of skin at the opening of the vagina

clitoris

- located anterior to the urethral opening and partially hidden

mons pubis

- pads of fatty tissue and thick skin that overlies the symphysis pubis

labia majora

- thick, external folds of skin at the opening of the vagina

labia minora

- thin folds of skin between the labia majora

parametrium

-refers to the tissues surrounding the uterus, and does not constitute a uterine layer?

secretory

During which phase of the menstrual cycle does the radial arteries have lower restive flow?

proliferative

During which phase of the mentrual cycle is the uterine arteries flow high velocity?

Aorta Bifurcations RT and LT common iliac arteries Internal and external iliac arteries Anterior and posterior internal iliac arteries Uterine artery (from anterior internal iliac) Arcuate artery Radial artery/Spiral artery

List the flow of blood from the aorta to the uterus

upper left corner of the screen

On a transvaginal sagittal image, where is the bladder seen?

iliacus muscles - the iliac crest - iliopsoas

Psoas muscles merge with __________ at the level of _________ to form __________ muscles.

vagina uterus uterine tubes ovaries urinary bladder portion of the ureters and intestinal tract pelvic musculature ligaments peritoneal spaces

The female pelvis consists of what?

iliac wings to the pelvic diaphragm

The pelvis extends from where superiorly to where inferiorly?

linea terminalis aka iliopectine

The pelvis is divided into 2 regions by what?

endometrium - myometrium - perimetrium

What are the 3 layers of the uterus?

RI 1.0

What is the RI of the ovarian artery in post menopausal patients?

first 10 days of cycle

When is it best to evaluate the pelvis arteries via Doppler?

postmenopausal patients

Which has higher velocity in uterine arteries? reproductive pts postmenopausal pts

sacroiliac ligament

Which ligament attaches the sacrum to the iliac bones?

long axis of the uterus may deviate to either side of midline as well

along with the positions of the uterus being more anterior or posterior, how might the uterus be positioned laterally?

uterine artery

at the region of the uterine conru, the ovarian arteries anastomose with what artery?

posterior cul-de-sac pouch of douglas recto/retrouterine pouch

blue arrow?

yes

can the walls of the bladder be demonstrated sonographically?

pelvic congestion syndrome

dilated toruous veins (>4-5mm) near the uterus and/or adnexa may be associated with what?

vulva - pudendum

external genitalia is also known as what?

Space of Retzius retropubic space previsical space

green arrow?

> 4-5mm

how do dilated uterine veins measure?

homogenous

how does the myometrium appear sonographically?

10-12 inches

how long are the ureters?

2-4cm long

how long is the cervix?

9cm long (7-10cm edelman)

how long is the vagina?

16-18 oz

how much urine can the bladder hold?

UTERUS, OVARIES, ADNEXA fallopian tubes bladder small bowel sigmoid rectum

in a non-gravid patient what is contained in the true pelvis?

measure each side of the endometrium and add together to avoid fluid measurement

in the presence of fluid in the endometrial cavity, how do you measure?

anterior and posterior branches

internal iliac arteries further bifurcates into what?

rectal gas and pubic symphysis

limitations of translabial exams?

anteroposterior (AP) dimension on a sagittal image

measurements of the endometrium are obtained sonographically in the _________ dimension on a (SAG/TRANS/COR) image.

anus

most posterior orifice of the external landmarks

sacroiliac - sacrosciatic - sacrococcygeal - pubic

name the osseous ligaments of the pelvis

cardinal (lateral cervical) - broad - uterosacral - round - ovarian - mesovarium - infundibulopelvic (suspensory)

name the suspensory ligaments of the pelvis

Perimetrium - myometrium - junctional zone of myometrium - endometrium - basalis layer of endo - functionalis layer of endo

name the uterine layers from outer to inner

internal os

opening at the isthmus/uterus end of the cervix

external os

opening at the vaginal end of the cervix

gonadal arteries

ovarian arteries are also known as what?

osseous (holds bone together) and suspensory (supports an organ)

pelvic ligaments can be classified as which two?

sacrum - coccyx - os coxae (two innominate bones)

pelvic skeleton is composed of what?

urethral opening

posterior to the clitoris

anterior cul-de-sac vesicouterine pouch retrovesical space

red arrow?

basal artery

straight arteries are also known as what?

infundibulopelvic ligament

suspensory ligament is also known as?

level of L4 into right and left COMMON ILIAC ARTERIES

the abdominal aorta bifurcates at the level of _______ into right and left ________.

external and internal iliac arteries

the common iliac arteries bifurcated into _________

functionalis and basalis

the endometrium is further divided into what 2 layers?

psoas muscles femoral canals

the external iliac artery courses through the false pelvis, adjacent to the _________ muscles, and exits the pelvis through the __________ to supply the lower extremities.

distal end of ilium - urinary bladder - uterus

the hypogastric region contains what?

sacral promontory to symphysis pubis

the iliopectineol line aka linea terminalis extends from _________ to _________

the bladder, uterus, vagina, and rectum

the internal iliac artery supplies which organs?

sigmoid colon - distal end of left ureter - left ovary

the left iliac region contains what?

straight/basal and spiral arteries

the radial arteries further branch into what arteries?

gutters known as the vaginal fornices

the upper portion of the vagina surrounds the cervix creating what?

fallopian tubes laterally - vaginal cavity inferiorly

the uterus' central cavity opens into a _________ laterally and into the __________ inferiorly.

perimetrium

thin membrane that completely covers the myometrium of the uterus

visualization of ureteral jets

ureters are not typically visualized but may be identified how?

anteflexed

uterine position?

anteverted

uterine position?

retroflexed

uterine position?

retroverted

uterine position?

uterine tube - fallopian tubes - oviducts

what are coiled, muscular tubes that open into the peritoneal cavity at their lateral ends?

limited field of view and penetration

what are disadvantages of transvaginal exams?

oviducts and uterine tubes

what are fallopian tubes also known as?

pt never been sexually active intact hymen narrow vaginal canal

what are limitations of transvaginal exams?

ureters

what are muscular tubes that convey urine to the bladder?

obese patients - patients unable to fill bladder - retroverted uterus

what are some limitations of transabdominal pelvic exams?

epithelial layer - muscular layer - mucosal layer

what are the 3 layers of the bladder wall?

mucosal - muscular - outer covering

what are the 3 layers of the vagina?

interstitial - isthmus - ampulla - infundibulum

what are the 4 segments of the fallopian tubes?

abdominal wall base of sacrum iliac wings

what are the boundaries of the false pelvis?

pubis and pubic rami sacrum and coccyx iluim and ischium pelvic diaphragm

what are the boundaries of the true pelvis?

fimbriae

what are the finger-like projections that direct the released ovum into the tube called?

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

what are the functions of the female pelvis skeleton?

resist increased intra-abdominal pressure and resist gravity; rectal and urinary continence

what are the functions of the pelvic diaphragm?

hypogastric arteries

what are the internal iliac arteries also known as?

rugae

what are the mucosal folds of the bladder (when empty) called?

fused ilium - ischium - pubis

what do the os coxae consist of?

uterine tube - fallopian tubes - oviducts

what emerges from the superolateral margins of the uterine cornua and curve over the ovary?

os coxae

what forms the anterior and lateral walls of the pelvis?

sacrum and coccyx

what forms the posterior wall of the pelvis?

estrogen and progestrerone

what hormones are secreted by the ovary ?

uterine tube - fallopian tubes - oviducts

what is contained in the upper margin of the broad ligament and run laterally to the ovaries?

provides an alkaline secretion favorable for sperm penetration and acts as a sphincter during pregnancy

what is the function of the cervix in relation to pregnancy?

10-12cm

what is the length of the fallopian tubes?

myometrium

what is the middle muscular layer of the uterus?

anteverted

what is the most common uterine position?

vagina

what is the muscular tube located in the mid-region of the true pelvis between the urinary bladder/urethra and rectum/anus?

uterus

what is the muscular, pear-shaped, hollow organ of the pelvis and is located between the bladder and rectum?

interstitial/intramural

what is the narrowest segment of the fallopian tube?

perimetrium

what is the outer peritoneal/serosal layer of the uterus?

the uterus may become incarcerated (wedged in the pelvis as it grows)

what may occur in a retroflexed pregnant women?

urethra - vagina - rectum

what orifices pass through the lavator ani muscles?

ovarian follicles

what part of the ovary secretes estrogen?

corpus luteum

what part of the ovary secretes progesterone?

curvilinear 3.5-5MHz

what transducer is used for translabial/transperineal ultrasound?

curvilinear 5 MHz

what transducer is used in transabdominal?

EV probe 7.5 MHz

what transducer is used in transvaginal?

only in the presence of ascites

when are pelvic ligaments visualized sonographicaly?

when the dome (superior portion) of the bladder extends above the uterine fundus

when is the bladder adequately full for a tranabdominal scan?

when it is empty or slightly filled

when is the bladder entirely in the true pelvis?

hilum of ovary

where are the ovarian nerves and vessels situated?

**Positions are variable - Adnexa; typically lie lateral to uterus - Medially to the external iliac artery and anterior to the internal iliac vessels and ureters

where are the ovaries located?

on the lesser trochanter of the femur

where do iliopsoas muscles insert?

superior surface

where do the suspensory ligaments and frimbriae of the fallopian tubes attach to the ovary?

posteriorly and inferiorly (trigone)

where do the ureters insert the bladder?

inferiorly in the true pelvis

where is the bladder base fixed?

anterior surface of each ovary

where is the hilum of the ovary?

gonadal/ovarian arteries

which arteries are lateral branches of the abdominal aorta and arise just below the level of the renal arteries?

uterine artery

which artery arises from the anterior internal iliac artery?

radial artery

which artery arises from the arcuate artery and supplies blood into the deeper myometrium/ junctional zone?

straight/basal artery

which artery arises from the radial artery and feeds the basalis layer of the endometrium?

spiral artery

which artery arises from the radial artery and feeds the functionalis layer of the endometirum?

arcuate artery

which artery arises from the uterine arteries to carry blood to the outer myometrium

uterine artery

which artery courses laterally from the uterine cornu to join the ovarian artery?

uterine artery

which artery crosses the ureter on each side, and at the cervix ascends the lateral portion of the uterus within the broad ligament?

arcuate artery

which artery encircles the uterus and supplies the outer myometrium?

radial arteries

which artery is more difficult to visualize in postmenopausal women?

right ovarian vein

which gonadal/ovarian vein empties directly into the IVC?

left ovarian vein

which gonadal/ovarian vein empties into the renal vein of the same side?

mucosal layer

which layer of the bladder is the inner layer?

muscular layer

which layer of the bladder is the middle layer?

epithelial layer

which layer of the bladder is the outer layer?

functionalis layer

which layer of the endometirum is the superficial layer that changes dynamically in response to the menstrual cycle and varies in sonographic appearance?

basalis layer

which layer of the endometrium is the deep layer composed of dense stroma and mucosal glands?

junctional zone

which layer of the myometrium is the inner most layer and sometimes appears hypoechoic?

medulla

which layer of the ovary is composed of connective tissue containing blood, nerves, lymphatic vessels, and smooth muscle?

medulla

which layer of the ovary is the central layer?

cortex

which layer of the ovary is the outer, functional layer containing developing follicles?

cortex

which layer of the ovary is the site of oogenesis?

myometrium- its the thickest layer

which layer of the uterus forms the bulk of the uterus?

myometrium

which layer of the uterus is composed of 3 layers that contract during parturition (childbirth)?

sacrococcygeal ligament

which ligament attaches the sacrum and coccyx to each other?

sacrosciatic ligament

which ligament attaches the sacrum, iliac and coccyx to each other?

pubic ligament

which ligament attaches the two pubic rami together?

uterosacral ligaments

which ligament connects the lateral uterine isthmus to the 3rd and 4th bones of the sacrum? (posterior support)

cardinal ligament

which ligament connects to the uterus at the level of the cervix?

round ligament

which ligament extends from the fundus (uterine cornu) to the anterior pelvic sidewall?

suspensory aka infundibulopelvic ligament

which ligament extends from the lateral aspect of the ovary to the pelvic sidewall?

broad ligament

which ligament extends from the lateral aspects of the uterus to the pelvic side wall?

round ligaments

which ligament holds the uterine fundus in a forward position?

round ligaments

which ligament is anterior and inferior to the fallopian tubes?

uterosacral ligaments

which ligaments form the lateral boundaries of the pouch of Douglas?

suspensory aka infundibulopelvic ligaments

which ligaments transmit the ovarian vessels and nerve?

iliopsoas muscles

which muscle can be mistaken for ovaries in a transverse, transabdominal pelvic scan?

Psoas Major Muscle

which muscle extends from the lateral aspects of the lumbar vertebrae and descends inferiorly through the false pelvis?

obturator internus muscle

which muscle extends posteriorly and medially along the side wall of the true pelvis and exits through the lesser sciatic foramen?

rectus abdominus muscle

which muscle forms much of the anterior body wall and extends from the xyphoid to the pubic symphysis?

iliacus muscle

which muscle forms part of the lateral margins of the pelvic basin?

coccygeus muscle

which muscle forms the posterior pelvic floor?

obturator internus muscle

which muscle inserts on the greater trochanter?

obturator internus muscle

which muscle is a triangular sheet anchored along the brim of the true pelvis?

iliopsoas muscle

which muscle is lateral to the uterus and anterior to the iliac crest?

rectus abdominus muscle

which muscle is responsible for the refractions/"ghosting" artifact occasionally seen while imaging the midline pelvis in a transverse plane?

piriformis muscles

which muscle is situated in the posterior region of the true pelvis behind the ureters?

iliacus muscle

which muscle rises from the iliac crest to merge with the psoas muscle?

levator ani muscles (like a hammock)

which muscles form the anterior and middle aspect of the pelvic floor?

punococcygeus - iliococcygeus - puberectalis muscles

which muscles form the levator ani muscles?

pubococcygeus msucle

which of the levator ani muscles extends from the pubis to the coccyx and is the most anterior and medial of the three?

puberectalis muscle (like a sling)

which of the levator ani muscles extends from the pubis to the rectum?

iliococcygeus muscle

which of the levator ani muscles is located lateral to the pubococcygeus?

ovary

which organ is paired, bilateral, almond shaped and is the location in which the ova are formed?

periovulatory and luteal phase

which ovarian phase gives the highest velocity flow to the ovarian artery?

fundus/dome

which part of the uterus is the widest and most superior segment?

vagina

which pelvic organ extends from the external genitalia and the external cervical os?

bladder

which pelvic organ is a symmetrical, hollow, muscular organ that serves as a reservoir for urine?

bladder

which pelvic organ is located between the symphysis pubis and the vagina?

isthmus/lower uterine segment

which portion of the uterus is the slightly constricted portion where the uterine body meets the cervix?

isthmus/lower uterine segment

which portion of the uterus the most flexible portion of the uterus and grows at the most rapid rate during pregnancy (point where the uterus bends)?

anteflexed and retroflexed

which position has the fundus pointing inferiorly and lying near the cervix?

true pelvis aka lesser pelvis aka minor pelvis

which region is inferior to the linea terminalis?

false pelvis aka greater pelvis aka major pelvis

which region is superior to the linea terminalis?

infundibulum

which segment of the fallopian tube is the lateral segment?

ampulla

which segment of the fallopian tube is the middle segment?

infundibulum

which segment of the fallopian tube is the wide, funnel-shaped end that opens into the peritoneal cavity?

ampulla

which segment of the oviduct is the coiled segment where fertilization usually occurs?

ampulla

which segment of the oviduct is the most distendable ?

isthmus

which segment of the oviduct is the short, narrow, and medial portion?

ampulla

which segment of the oviduct is the widest and longest?

interstitial/intramural

which segment of the uterine tube is enclosed by the uterus at the cornua?

retroverted

which uterine position is the most common in multiparity women?

anteflexed

which uterus position? - 90 degrees from cervix to vagina - corpus and fundus are bent forward

anteverted

which uterus position? - 90 degrees from cervix to vagina - corpus and fundus are tilted forward

retroflexed

which uterus position? - cervix and vagina are linearly oriented - corpus and fundus are bent posteriorly

retroverted

which uterus position? - cervix and vagina are linearly oriented - corpus and fundus are tilt posteriorly

posterior fornix

which vaginal fornix is the frequent site of vaginal fluid collection?

anterior fornix

which vaginal fornix surrounds the anterior aspect of the external cervix, and is smaller than the others?

paired lateral fornices

which vaginal fornix surrounds the lateral aspect of the external cervix on either side?

posterior fornix

which vaginal fornix surrounds the posterior aspect of the external cervix?