Chapter 42: The Sonographic and Doppler Evaluation of the Female Pelvis

Patient Preparation and History. What are the 8 things you should ask a patient before beginning the exam?

1. LMP 2. Gravidity and Parity 3. Horome Regimen - If they are taking any hormones 4. Symptoms 5. Family History of Cancer 6. Past Pelvic Surgeries 7. Laboratory Tests - Previous Pap or Biopsy Results 8. Pelvic Examination Finding

If a mass is detected in the cul-de-sac, what four things should be documented? (5 things)

1. Size 2. Position 3. Shape 4. Echographic pattern (echogenicity and texture examples: cystic, solid or complex) in comparison with the ovaries and the uterus.

What are the two parts of a pelvic examination?

1. Transabdominal Approach 2.Transvaginal Approach

ratio of cervix size to uterine body size in prepubertal is ______.

2:1

sonohysterography or saline infused sonography (SIS) or hysterosonography is usually performed on premenopausal women between days _____-______ or soon after _______ of bleeding in women with irregular periods.

6-10 cessation

The endometrial complex measures ___ to ____ mm during the secretory phase (days 15-28) and will have posterior ________ (thought to be attributed to increased _________ of the endometrium).

7-14 mm enhancement vascularity

To view the pelvic cavity in the coronal view in a transvaginal scan, rotate the tranducer ____ degrees from the sagittal (longitudinal) plane.

90

Pourcelot Resistive Index (RI)

A-B/A)

In a transabdominal pelvic ultrasound when imaging in the longitudinal (sagittal) plane you should measure the length and the __________ of uterus.

AP dimension (depth)

Nabothian cysts are _________, smooth-walled, with ________ acoustic enhancement. Generally measure less than _____-______ cm in diameter.

Anechoic Posterior 1-2

How can the endometrial cavity look if menstruation is heavy?

Anechoic.

The AP depth of the uterus is measured in the long axis from the ________ to ________ walls, and is perpendicular to the _________.

Anterior Posterior Length measurement

The outer layer of the uterus is separated from the intermediate layer by ________ vessel.

Arcuate

Straight arteries mostly go to the _______ layer of the endometrium.

Basal

In the transverse plane of a transabdominal exam in a mid view, what should be seen? (4 things)

Bladder Body of the uterus Endometrium Look for ovaries

List the structures required in the protocol of a transvaginal scan in the sagittal plane. (7 things)

Cervix Endocervical Canal Posterior cul-de-sac Uterus (midline, right and left) Endometrium Right ovary and adnexa Left ovary and adnexa

During a pelvic ultrasound exam you must document the following: (4 things)

Cervix Uterine size, shape and orientation Myometrium Endometrium

Define contour changes.

Changes in shape.

The endometrial layer is thin, _______ and relatively ___________. It is ________ and surrounds the relatively echogenic endometrial _______, creating a subendometrial ______.

Compact Hypovascular hypoechoic stripe halo

The myometrium and cervix is evaluated for ________ changes, ________ and __________.

Contour Echogenicity Masses

When imaging the ovaries you must document the size, shape, _________, __________ and their _________ relative to the uterus.

Contour Echogenicity Position

Transvaginally, the ovaries are easiest to locate in the _______ plane lateral to the ________.

Coronal Cornua

The coccygeus and piriformus muscles are located _______, ________ and ___________.

Deep Cranially and Posteriorly

The __________ (length and width) of the cervix are usually measured when a woman is __________.

Diameter Pregnant.

In the transverse plane of a transabdominal exam in a low/inferior view, what should be seen? (3 things)

Distended bladder Vagina Cervix

In a transabdominal pelvic ultrasound when imaging in a longitudinal (sagittal) plane at the midline what structures should you document? (5 things)

Distended urinary bladder Uterus Endometrium Cervix Vagina

When imaging the posterior cul de sac (Pouch of _________) you must differentiate normal loops of bowel from _________.

Douglas a mass

Ovaries are _______ in shape, with the long axis oriented _______.

Elliptical Vertically

For a transvaginal examination the bladder needs to be completely ___________ and is done after a ________________ examination.

Empty Transabdominal

When referring to waveforms D or B refers to what?

End diastolic velocity

In the coronal plane of a transvaginal exam you should evaluate for _________ in the endometrial/uterine cavity and the ____________.

Free Fluid posterior cul de sac (pouch of douglas)

During a transabdominal examination the bladder needs to be ___________.

Full/Distended

Spiral arteries mostly go to the _______ layer of the endometrium. This is the layer that is shed during menses.

Functional

The uterus is measured in long axis from its ________ to the _______, which is best done with the __________ approach.

Fundus Cervix Transabdominal

In the transverse view of a transabdominal exam in the high/superior view, what should be seen?

Fundus of uterus, Endometrium Look for ovaries lateral to cornua of uterus ***(most common location of ovaries)***

The tissue echogenicity around the cervical canal should appear ___________.

Homogenous

During the proliferative phase the functionalis layer appears as a _______ halo encompassing the ________ of the endometrial canal.

Hypoechoic Stripe

The levator ani is a ________, ______ shaped area that is _______, _____, and _______ to the obturator internus.

Hypoechoic Hammock Medial Caudal Posterior.

Where is the iliopsoas muscle located?

In the greater/false pelvis.

In the sagittal plane during a transvaginal exam, when looking at the ovaries, what landmark should you see posterior to the ovaries? Color doppler can be used to separate/differentiate __________ structures from the ovaries.

Internal iliac vessels Vascular

During the secretory phase the functionalis layer becomes _______ with the basalis layer.

Isoechoic

The body of the uterus is separated from the cervix by the _______ at the level of the _______ os. and is identified by the ______ of the endometrial canal.

Isthmus Internal narrowing

On a sonogram what features demonstrate that a structure is a muscle?

It has a symmetrical bilateral appearance.

Ellipsoid (prolate ellipse) Formula: Used to calculate the _________ of an ovary

L x W x H (thickness) x 0.523 volume

The three-line sign occurs during what part of the proliferative phase? At this point the endometrium will measure ___ - ___ mm thick and will continue to thicken to ____-____ mm thick periovulatory (right before ovulation)

Late (days 10-14) 4-8 mm 6-10 mm

What should you not mistake a mass for in the cul-de-sac?

Loops of bowel.

The middle layer of the uterus is known as the ______________. This layer should have _________ echotexture with ________ walled borders.

Myometrium Homogenous Smooth

If you angle the transducer to the right or left of the midline during a transabdominal pelvic ultrasound exam in the longitudinal plane, what structures should you see? (2 things)

Myometrium Area of the right or left ovary.

Frequently visualized cervical inclusion cyst (__________ cyst) are located near the _________ canal. These are not clinically significant.

Nabothian endocervial

Normal arcuate vessels should not be mistaken for _______. These are usually seen between _____ - ______ weeks after the onset of menses.

Pathology 1-3

When referring to waveforms S or A refers to what?

Peak systolic velocity

Sonographically, sections of obturator internus muscle are seen at _________ ________ borders/corners of the ________ at the level of the ________ and _________.

Posterior Lateral Bladder Vagina Cervix

The orientation of the transvaginal probe is controlled by _____ ____________ and __________.

Probe Rotation Angulation

In the sagittal plane of a transvaginal exam you should do what to the probe to image the cervix?

Pull it out slightly

The ______ arteries arise as multiple branches from the arcuate arteries and travel _______ to supply rich capillary network in the deep layers of the __________ and _____________.

Radial Centrally Myometrium Endometrium

The ________ _______ separates the rectus adominus muscle from surrounding _____ and _____. It appears as a bright _______, echogenic reflector.

Rectus Sheath Fat Bowel Linear

The AP thickness of the endometrium are measured in the ________ view of the uterus.

Sagittal/longitudinal

Define pourcelot resistive index (RI)

Systolic peak minus end diastolic peak divided by systolic peak (A - B/A or S - D/S)

TV scanning is superior for characterizing the ________ of the ovary.

Texture.

The ovaries are positioned _________ in relation to the internal iliac vessels?

Th ovaries are ANTERIOR to the internal iliac vessels.

The vagina is a landmark for what two structures on a sonogram?

The Cervix and the Lower Uterine Segment

What four structures are located in the lesser, or true pelvis?

The Urinary Bladder Reproductive Organs Levator Ani Obturator Internus

What layer represents the thin hyperechoic outermost layer surrounding the endometrium in the proliferative phase?

The basalis layer.

When imaging the adnexa you would evaluate the ___________ for free fluid or mass?

The cul-de-sac.

Define S/D or A/B ratio

The difference between the peak systolic velocity and end diastolic velocity.

The iliopsoas muscle is a combination of what two muscles?

The iliacus muscle and the psoas major muscle.

Define Parity.

The number of deliveries greater than 20 weeks.

Define Gravida.

The number of pregnancy's.

Which layer of the uterine muscle is not visualized sonographically?

The outer serosa/perimetrium

What are the two structures making up the adnexa (area on the lateral sides of the uterus) of the pelvis?

The ovaries and fallopian tubes.

During what phase can the endometrial canal appear as a single thin stripe?

The proliferative phase. (days 5 to 9)

After you have viewed the midline, right of the midline, and left of the midline, what is the last thing to do in a transabdominal exam? What should be seen along the lateral border?

The right and left adnexal areas in the true pelvis. The iliacus muscle.

At what phase is the endometrium at its thickest? The endometrial thickness is measured from the highly ______ interface of the basalis layer of the endometrium and _______ in the ________ view.

The secretory phase reflective myometrium sagittal (longitudinal)

Which vessel directly supply the endometrium?

The straight and spiral arteries.

The endometrium of the uterus is analyzed in an ultrasound exam for __________ and ___________.

Thickness Echogenicity

How many layers does the uterine muscle consist of? Name the layers:

Three perimetrium/outer serosa myometrium (middle layer) endometrium (inner layer)

The combination of the endometrial canal, the functionalis layer and the basalis layer creates what?

Three-line sign.

The width of the uterus can be measured from the _________ (transverse) or ________ views?

Transaxial Coronal

The width of an ovary is always measured in the _______ or ______ view.

Transaxial (transverse) Coronal

The levator ani muscle is best visualized sonographically in the __________ plane with _______ angulation at the most _______ part of the bladder.

Transverse Caudal Inferior

The obturator interns muscles located in the ________ pelvis. On sonogram it appears _____________ and is _______ to elongated.

True Hypoechoic Ovoid

Name all of the vessels that supply the uterus.

Uterine Artery Arcuate Artery Radial Artery Peripheral Artery Straight Arteries Spiral Arteries

What structures should be seen in a coronal view of the pelvic cavity during a transvaginal exam?

Uterine Fundus Uterine Body (with the endometrial canal) Cervix

In the sagittal plane of a transvaginal exam the long axis of the ________ should be measured along with the ____ dimension.

Uterus AP (anteroposterior)

The ________ and ________ are anatomic landmarks.

Vagina uterus

List the structures required in the protocol of a transvaginal scan in the coronal plane.

Vagina Cervix Posterior cul-de-sac Uterus Corpus (Body) Uterine Fundus Endometrium Right ovary and adnexa Left ovary and adnexa

The ________ of the ovary may also be calculated during the adnexa exam.

Volume.

Define uterine prolapse

abnormal protrusion/dropping of the uterus into the vagina due to weak levator ahi muscles and weak supporting ligaments.

During early menses, posterior ________ enhancement to the endometrium may appear in the presence of of endometrial ________ or ________.

acoustic fluid blood

The average ovarian volume in a women of menstrual age is ______ cm cubed.

approx 9.8

An empty bowel can look like an irregular _________ with thin, sharp, _______ outline on a cross section.

bull's eye hypoechoic

The cervix is anchored in the midline by the ______ and _______ ligaments

cardinal uterosacral

In the sagittal plane of a transvaginal exam, images should be taken from the ______ to the _______ of the uterus, including the ____________ cavity. Angle slowly to the right and left of the uterus.

cervix fundus endometrial

Flexion refers to the axis of the uterine body relative to the ______. Version refers to the axis of the cervix relative to the _______.

cervix vagina

Which muscle are not routinely visulized?

coccygeous and piriformus

In the sagittal plane during a transvaginal exam you need to follow the fundus of the uterus to the area of the _______ and angle slowly lateral to image the ______. What should you see posterior to the ovaries? Color imaging can be used to do what? What should be measured?

cornua ovaries The internal iliac vessel. To separate vascular structures from ovary. The long axis of the ovary.

As menses progresses (days 3 to 7) onto late menses the endometrial stripe becomes a _______ thin hyperechoic line usually measuring _______ mm.

discrete 2-3 mm.

Gas and fluid filled bowel loops are poorly defined, ______ free mobile structures that usually demonstrate _______ under observation.

echo perstalsis

The sonographic appearance of the endometrial canal is seen as a thin ________ line as a result of specular ______ from the interface between the opposing ________ of the endometrium. This consist of the _________ functional layer and the _______ basal layer.

echogenic reflection surfaces superfiscial deep

The zona functional is varies in _______ and _______ throughout the endometrial cycle.

echogenicity thickness

Normal fallopian tube is difficult to identify by TA or TV sonography unless they are surrounded by ________ or _______ with fluid (dilated).

fluid filled

For transvaginal exam a _______ frequency transducer is used for good image __________.

high quality

Solid material in the bowel is ______ and produces _____ posteriorly, as does ______.

hyperechoic shadowing gas

With endometrial measurement exclude the ______ halo around the basal is endometrium and _______ if present.

hypoechoic fluid

On sonogram the rectus abdominal muscles appear ________ with echogenic _________.

hypoechoic striations

During menstruation (days 1 to 4 or 1 to 5) the endometrial canal appears as a _________ central line representing blood and tissue, and reaching ________ mm, including the ______ layer . This is surrounded by a __________ basal endometrial echo.

hypoechoic 4-8 mm. Basal hyperechoic

Define sonohysterography or saline infused sonography (SIS) or hysterosonography

instillation of sterile saline solution or contrast media into the endometrial cavity and/or fallopian tubes

Ovaries are typical located _______ to the uterus and _______ to the internal iliac vessels.

lateral anteromedial

If a mass is found in an area other than the posterior cul de sac you must document its _________ (intrauterine or extrauterine), size, ________ contour (well-defined, ill-defined or irregular borders), and the internal __________ (cystic, complex, predominantly cystic, predominantly solid or solid)

location external consistency

To determine the size of the ovaries you must measure the length of the ________ axis with the AP (anteroposterior) dimension (depth) measured perpendicular to the ________ measurement.

long length

For transabdonimal exam a _______ frequency transducer is used for ________ penetration.

low increased/more

Sonographically the ovaries appear as ovoid _______-level echogenic structures. Follicular cyst may be seen peripherally in the ______. The appearance of the ovaries may change with _____ and ________.

medium cortex age menstrual cycle

Ovaries are very _____ and can move considerably in the pelvis, depending on ________ volume, ________ location and whether or not the women has had previous ________.

mobile bladder uterus pregnancies

Areas of increased or decreased echo texture in the myometrium should be ________ and _______.

noted/documented measured

The uterine body is mobile and may lie _______ on either side of the midline.

obliquely

The echogenic endometrial stripe represents _________ ________ of the endometrium.

opposing sides

The iliopsoas muscle is _______ to round in shape in the ______ image near the level of the uterine ________.

oval transverse (transaxial) fundus

Define Pulsatility Index (PI)

peak systolic velocity minus diastolic velocity divided by average/mean velocity (A - B/mean or S - D/mean)

In a neonate, the uterus is _____ shaped and the cervix is ________ the size of the entire uterus. ______ ratio of cervix to uterine body

pear 2 to 3 x's 2:1

Normal arcuate vessels should be seen near the _______ of the uterus in the outer _______ of the myometrium.

periphery 1/3

***The _______ muscle is most commonly mistaken for the ovaries. ***

piriformis

The rectouterine recess or posterior cul de sac is the most ________ and _______ reflection of the peritoneal cavity. Also know as the ________.

posterior inferior Pouch of Douglas

The rectus abdominal muscles insert on the _________ and are paired _________ straps in the abdominal wall.

pubic rami parasagittal

How to see certain structures during a transvaginal exam: (what you do with the probe) To image the right ovary you should...... To image the left ovary you should......

push the handle toward the left leg push the handle toward the right leg

How to see certain structures during a transvaginal exam: (what you do with the probe) To image the uterine fundus you should...... To image the cervix you should...... To image the posterior cul de sac you should......

push the handle towards the exam table pull the handle up and you may need to pull it out a little pull the handle higher than when imaging the cervix

The rectouterine recess is located between the _____ and the ______ and is frequently the initial site for ________ fluid collections.

rectum vagina intraperitoneal

Ovaries are measured in the ________ plane at the longest length and _____ dimension. In transverse or coronal planes ______ is measured at the _______ point.

sagittal (long) AP width widest

When measuring the ovaries, during the transvaginal approach, the long axis (length) should be measured in the ________ view. Rotate the handle 90 degrees from sagittal plane and measure the ________ and _______ in the coronal view.

sagittal (longitudinal) width depth

Radial arteries give rise to the _________ and ________ arteries.

straight spiral

Define hysterectomy

surgical removal of uterus

Define hysterosalpingo-oophorectomy

surgical removal of uterus, fallopian tubes and ovaries.

sonohysterography or saline infused sonography (SIS) or hysterosonography is used to further evaluate the endometrium when it exceeds normal _______ or shows ________ areas of thickening or if ________ are suspected. Also used to evaluate the ________ of fallopian tubes.

thickness focal polyps patency

Give the order of artery branches in uterus from outer to inner.

uterine artery > arcuate arteries > radial arteries > straight and spiral arteries

It is not uncommon to find the ovaries above the ________ or posterior in the rectouterine ________ area?

uterus cul-de-sac

When doing a endovaginal (transvaginal) ultrasound of someone who is s/p (status post) hysterectomy you will image the __________.

vaginal cuff