Imaging Of The Female Pelvis Flashcards
Advantages of Ultrasound in assessment of the Female pelvis
First line of investigation
Easy access
Portable
No radiation used especially to radiosensitive ovaries.
Low cost
Contraindications:
TV ultrasound is not appropriate in young (Age below 16), virgin intacta or patients with vaginismus.
Disadvantages Ultrasound
TV scan is invasive
Additional staff i.e. a Chaperone maybe required depending on hospital protocol or if male sonographer performing the scan.
Limitations in visualising organs in obese patients or overlying bowel gas.
Full bladder required for TA scan, some elderly patients may struggle to maintain a full bladder as required. Unable to prepare very young children with a full bladder.
Patient’s with severe mobility issues may not tolerate TV scan.
MRI pros and cons
Advantages of MRI include superb spatial and tissue contrast resolution
No use of ionising radiation
Multiplanar capability and fast techniques.
However, optimisation of MRI sequences and clinical protocols is crucial to ensure best results.
Relatively expensive
Good modality if ultrasound is inconclusive.
Clinical indications of Ultrasound
Examination of the normal pelvic contents including the uterus, ovaries, and adnexal structures.
Masses palpated on physical examination can be further evaluated with US, e.g. large ovarian cysts, congenital abnormalities of uterine shape and uterine fibroids.
Patients who present with pelvic pain can be evaluated by US. Oftenthe diagnoses of pelvic inflammatory disease, ovarian torsion, ectopic pregnancy, and normal pregnancy are made. Less often during pelvic US, appendicitis is diagnosed.
Abnormal vaginal bleedingcan be related to possiblepregnancy, known pregnancy,menses,precocious puberty, and postmenopausal bleeding.
Evaluation for appropriate positioning of an intrauterine device.
Evaluation for polycystic ovarian syndrome and infertility.
US can be utilized for proof of ascites or other free fluid.
How does Ultrasound work
- High-frequency sound waves are transmitted from a transducer.
- These sound waves are then reflected by different tissue types in different ways.
- The reflected sound waves are then picked up by the ultrasound transducer.
- The sound waves are then transformed into an image by special software.
What is Colour Doppler?
Sonography allows the visualisation of flow direction and
velocity within a user defined area.
Flow that travels away from the transducer (negative Doppler shift) is depicted in blue, and flow that is travelling toward the transducer (positive Doppler shift) is depicted in red, with lighter shades of each colour denoting higher velocities. A third colour, usually green or yellow, is often used to denote areas of high flow turbulence.
Usefulness of Colour Doppler
Cyst determination- Haemorrhagic cysts have peripheral vascularity typically, simple cysts and endometrioma’s have no flow around them.
Ovarian carcinoma may show vascularity within the middle of the cysts sometimes on nodules or thickened septums.
Fibroids tend to have peripheral vascularity.
Adenomyosis demonstrates diffuse vascularity.
Endometrial carcinoma may or may not demonstrate vascularity.
Endometrial polyps, tend to demonstrate feeder vessels which are typically two vessels.
What is Adenomyosis?
Presents with pain and excessive bleeding or can be asymptomatic. Associated with subfertility
Caused by ectopic endometrial tissue with the myometrium
Can mimic other conditions such as early fibroid changes and is often missed. However it can be associated with fibroids and endometriosis
Ultrasound appearances:
Enlarged uterus
Heterogenous echotexture of myometrium
Uneven appearances of anterior and posterior myometrium
Diffuse vascularity
No treatment apart from hormone therapy or hysterectomy
Endometrial polyps
Abnormal growths within the uterine lining, typically present with abnormal bleeding, caused by excessive oestrogen
Removal using Hysteroscopy is considered based on severity of symptoms. Polyps can also affect fertility and cause miscarriage
3D ultrasound using saline infusion can readily demonstrate polyps
Endometrial hyperplasia
Thickened endometrium with cystic spaces noted throughout. Precursor for endometrial carcinoma.
Caused by excess oestrogen
Causes excess vaginal bleeding and will need hormone or surgery treatment
Pelvic inflammatory Disease
Pelvic inflammatory disease (PID)is a broad term that encompasses a spectrum of infection and inflammation of the upper female genital tract, resulting in a range of abnormalities.
75% of cases being under 25 years of age. In the United States, approximately 1 million females are thought to be afflicted with pelvic inflammatory disease per year.
Presentations includeacute pelvic pain(of variable intensity), cervical motion tenderness, vaginal discharge, fever, dyspareunia, and leucocytosis.
The infection generally ascends from thevaginaorcervix(cervicitis) to theendometrium(endometritis), then to thefallopian tubes(salpingitis,hydrosalpinx,pyosalpinx), and then to and/or contiguous structures (oophoritis,tubo-ovarian abscess, peritonitis).
Hydrosalpinx
Results from an accumulation of secretions when the tube is occluded
Thin- or thick-walled (in chronic cases)
Elongated or folded, tubular, C-shaped, or S-shaped fluid-filled structure
Distinct from the uterus and ovary.
Ovarian torsion
Patients typically present with sudden severe pelvic pain, either intermittent or sustained. Often patients report similar episodes during the previous month.
Nausea typically coincides with the onset of pain and vomiting may follow.
3% of women presenting to an emergency department with acute abdominal pain have ovarian torsion.
Ultrasound may demonstrate normal vascularity, however a partial torsion is still a possibility
Polycystic Ovarian Syndrome PCOS
PCOS is a confusing term as has multifollicular appearances using ultrasound
Caused by an imbalance of reproductive hormones.
Rotterdam Criteria for diagnosis includes at least 2 of the below criteria
- ovulatory dysfunction (oligo- and/or anovulation)
- clinical and/or biochemical signs of hyperandrogenism
- polycystic ovarian morphologyon ultrasound or elevated serum AMH23
Women with PCOS may haveirregular menstrual cycles, infertility, ovarian cysts, excessive hair growth, acne, and weight gain.
Long term risk of diabetes mellitis or
Endometrial carcinoma
Ovarian Cancer
Ultrasound characteristics of ovarian carcinoma include:
Solid tumor
Mass >10 cm with loculation
Mural nodule
Thick and irregular walled cyst
Cyst with thick septae (>3 mm)
Poorly defined margins
Adherent bowel loops
Ascites
Benign Ovarian cysts
Simple fluid filled cyst and larger than 2.5cm
Endometrioma- Can be small or large cysts with homogenous echoes.
Reticulated pattern typical of haemorrhagic cyst
Dermoid cyst=Solid, echogenic flecks,part fluid appears similar to bowel,
