sonographic eval of female pelvis Flashcards
Why do we need a full bladder to scan transabdominally?
Displaces Bowel/colon out of true pelvis
acoustic “window”
anatomic and “cystic” reference point
mobility of organs/masses (full decreases the mobility of organs)
contour reflects size/shape of surrounding organs
causes physiologic retroversion of uterus (enables you to see the full uterus better)
How do you prep a patient for a transvaginal scan?
No prep
Have patient urinate prior to exam
have them wait and go again
bladder should be as empty as possible
why is a bladder thats too full a problem? (over distended)
It compresses the uterus
pushes the ovaries far out of the picture
measurements are askew
What is an adequate history for a transabdominal scan?
First day of LMP
Gravid (no. of pregnancies G)
Parity (no. of live births P)
abortions (how many…miscarriages too A)
menstrual status
patients symptoms
Personal/family history of cancer
pelvic surgieris
previous pap/biopsy results
lab tests
findings on pelvic exam
previous US or other imaging tests
what is Peri/premenopausal?
2-10 years prior to cessation of menses
Explain the trans abdominal scan (TA)
are you allergic to latex!!!
gel
where the transducer goes
pictures
can go to bathroom
transvaginal/endovag scan next…explain (TV or EV)
2 part exam
insert just the tip with the patient
What four major organization cover the performance standards for transvaginal exams?
SDMS - society of diagnostic medical sonography
AIUM - american institute of ultrasound in medicine
ACOG - american college of obstetrics and gynecology
ACR* - american college of radiology
What are the guidelines from the ACR to do pelvic exams?
Must have a valid medical reason
lowest possible dose (100mW/cm squared)
All anatomy and pathology MUST BE DOCUMENTED and IDENTIFIED if it’s not documented it doesn’t exist (TA and TV)
When would you do a transperineal scan done?
prolapse uterus
PROM (premature rupture of membranes) pregnancy)
Guidelines from the ACR about pelvic exams are what?
Personal (registered)
documentation (if it’s not documented it didn’t happen)
protocols (for billing)
equipment (safe and up to date)
QA (quality assurance must be done)
quality improvement ( ways to fix problems)
must prove this process is done for accreditation for that facility
What is the technique for a TA pelvic exam?
TA - full bladder “Overview” of the entire pelvis
What transducer do you use for a TA exam?
Curvilinear or sector/vector up to 5 mHz
What is the technique for a TV exam?
Empty bladder
detail and characterization
What transducer do you use for a TV exam?
TV transducer - 7.5 MHz or higher
How must you identify anatomy and pathology?
In two planes
proves the existance
measure in three diameters
document in two planes
What help does the equipment have to help us get good pelvic images?
Built in presents (vascular, abdominal etc)
should “tweak” to improve (gain, focus, etc)
harmonics (takes away low level junk, delineates walls)
highest frequency to penetrate
What do we identify when we look at anatomy and pathology?
identify sonographic characteristics (hetero, cystic etc)
location (where the heck is it?)
size (measure it!! volume or cm or mm) Pay attention to what units the paper work requires
external contours (circumscribed, irregular etc)
internal consistency (solid, anechoic etc)
see slide 15 for pictures
What must you see if you call a mass a cyst?
Through transmission
When is a transabdominal scan very limited?
obese patients
patients unable to fill their bladder
What does a transabdominal scan give us?
Global view
done in long and transverse
very methodical and routine
What is uterus midline?
When you can see the canal all the way through from the fundus through to the vagina
how do you measure length of the uterus?
fundus to cervix
Where do you zoom and measure the endometrium?
at it’s thickest point
IF there is fluid in the endometrium do you include it in the measurement?
no…only the endometrium, not the fluid
outside wall to endo wall on each side
after midline uterus what do you scan next?
uterus –>lateral uterus –> adnexa long
How do you scan adnexa?
Out from uterus to the iliac vessels
What is the routine for transverse TA?
Vagina –> Cervix –> uterine body –>w and w/o measurement –>fundus –>adnexa –>ovaries
double check lecture to make sure all steps are here
How do you measure an ovary?
long and AP
Document in 2 plans, measure it in ____?
Three
What are the steps for TA scanning longitudinal?
Uterus midline - measure
RT uterus
Rt edge of uterus
RT adnexa - btw uterine edge and iliac vessels
Uterus Midline (no pic just for bearings)
Lt uterus
Lt edge of uterus
Lt adnexa
Endometrium
What is the pre exam protocol for TV scan?
explain proceedure
prep probe
have patient empty bladder
pt remove clothes from waist down
position patient
have patient guide probe…DONT LET GO!
What is the orientation for TV scanning?
LT side of screen: crainial / rt side of patient (Fundus of uterus)
RT side of screen: caudal/ LT side of patient (close to transducer)
What is the scanning plane for TV?
Top - caudal
Bottom - Crainal
RT - anterior
LT- posterior
to see the fundus of the uterus in TV, which direction does the handle go?
handle goes down so the face of the transducer goes up
How do you do a translabial scan?
use a 3.5 - 5 MHz or TV probe
cover with probe cover
place in perineal area oriented toward the vagina
what do muscles look like on US?
Hypoechoic structures with echogenic striations
What muscles will you see on TA and TV images?
obturator internus muscle
pelvic floor muscles
illiopsoas muscles
WHat is TV scanning considered?
Coronal Imaging
How do you tilt the transducer to visualize fundus?
anterior
How do you tilt the tv probe to visualize the cul-de-sac?
posterior
How do you distinguish vessels vs cyts?
Doppler…color or power doppler
When would you use doppler on an ovary?
if you suspect torsion
What would an ovary/testical with torsion look like?
larger
edematous
What are the different doppler ratios?
S/D ratio (peak systole/end diastole)
Resistive index (A-B/A)
Pulsatility Index (A-D/mean)
Are the arteries usually anterior or posterior to the veins in the pelvis?
anterior
Where do you find the iliac vessels?
lateral pelvis
Where are the uterine vessels when not pregnant?
RI 0.88
assess lateral to cervix/LUS at level of internal os
Where do you find the vascularity for the vagina?
2 sources of blood
anterior surface of
finish slide 37
When does ovarian doppler vary?
Throughout the menstrual cycle
In the follicular phase what does ovarian doppler look like?
high resistance/low velocity (diastolic)
When will you have the highest velocity in the ovaries?
during ovulation
What happens to the diastolic flow in post menopausal ovaries?
no diastolic flow evident after 5 yrs into menopause
RI 1.0
What does impedance mean?
resistance and visa versa
how many layers does the uterus have?
three
What is the serosa?
it is the outer layer of the uterus…not visualized
what is the myometrium?
Middle muscle layer
break up slide 40
What are the outer vessels you can see in the uterus?
arcuate arteries
Which arteries come right up into the endometrium?
spiral arteries and radial arteries
What is vascular congestion in the pelvis?
big hypoechoic circles around the outside of the uterus
larger iliac vessels
veins are dilated
What is the body of the cervix separated from the cervix by?
the ithmus level of the internal os
What is the consistency of the cervical canal?
homogeneous
What is a nebothian cysts?
a normal cyst 1-2 cm found in the cervical canal
How does the cervical canal appear?
homogeneous
echogenic central line
how do we visualize the true lie of the uterus?
endovaginally
with an anteverted uterus, which side of the screen is the fundus on?
to the left of the screen
Cervix to the right of the screen
how is the endometrium best visualized?
endovaginally
During menstruation, what days do you see a hypechoic line and what is it’s normal measurement?
days: 1-4
4-8mm
Do we see normal Fallopian tubes?
no
What do abnormal Fallopian tubes look like?
tortuous tubular structure
8-10mm wide
What is PID?
Pelvic Inflammatory Disease
What is hydrosalpinx?
Fluid in the Fallopian tubes.
Where do we find ovaries?
normally lateral to uterus
anteromedial to iliac vessels
follow the ligaments from the cornea out to the ovaries
What do normal ovaries look like?
ovoid or almond shaped
medium level echogenic structure with follicles
what are normal volumes
make these flash cards again
What is the scanning technique for TA transverse?
Vagina
cervix
LUS
Uterus body x2 - measure at body
Uterus fundus
TRV RT Adnexa
TRV LT adnexa
How do you scan the ovaries?
Find ovaries TRV - follow ligament
Multiple images of ovary
Measure Ovary
turn 90 degrees to elongate ovary
scan ovary completely
measure ovary - long and AP
evaluate pelvis for mass/cyst
Where is the notch on the transducer for a long picture?
facing up
Where is the notch of the transducer for TRV scanning for TV?
Towards the sonographer
What is the TV scanning protocol for sagittal images?
in this order:
cervix
cul-de-sac
uterus
endometrium
uterus RT/LT
adnexa
ovaries
What is the TV scanning protocol for transverse?
in this order:
vagina
cervix
cul - de - sac
uterus
adnexa
ovaries
What is the name of the posterior cul-de-sac?
pouch of douglas
What does abnormal fluid look like in the pouch of douglas
large amount of fluid or debris
septated fluid is abnormal
What does bowel look like?
may be seen with “dirty” shadow or fluid filled with peristalsis
if unsure put color on it
What is sonohysterograpy?
saline infused sonography
evaluate thickened endometrium to r/o polyp or mass
how is a sonohysterography performed?
physician insert sterile speculum
then the catheter is inserted
speculum removed
tv probe inserted
10-15 cc sterile saline inserted
What is 3-D imaging?
Volume imaging
What do you need in order to see the muscles with ultrasound in the pelvis?
usually a full bladder
sector or curved transducer
Where would you see the obturator internus muscle on ultrasound?
posterior lateral corners of the bladder at the vag/cervix level
Where would you see the pelvic floor muscles on US?
transverse inferior aspect of the bladder
Where would you see the Piriformis muscles on US?
posterior lateral to upper half of uterine body/fundus
What type of muscles can you see using the linear transducer?
rectus abdominus muscles - ant abd wall
illopsoas muscles
With a retroverted uterus what side of the screen is the cervix/uterus on?
Cervix: left side
Uterus: right side
During menstruation, on days 3-7 what does the endometrium look like and what is it’s measurement?
thin echogenic line
2-3mm
What days are the early proliferative phase and what is the endometrium measurement?
days: 5-9
6mm
During what phase is the endometrium 10mm and on what number days?
Late proliferative phase
days: 10-14
ovualtion is occuring
During the menstrual cycle, what is the phase occurring during days 15-28?
Secretory (luteal) phase
endo measures: 7-14mm
If you find fluid in the endometrium, do you measure it?
No, measure each side of the endo around the fluid.
What is the normal size of a postmenopausal endometrium?
<8mm
When is an endometrium that is up to 14mm still considered normal?
when the woman is postmenopausal and on HRT
What is the size of a Graafian follicle?
2-2.5cm
day 14 dominant follicle
When does the corpus luteum develop?
after ovualtion
If the ovary volume is 3-8cm cubed, what stage of life is the female in?
premenarchal
What is the volume of menarchal ovaries?
9.8-21.9cm cubed
a postmenopausal ovary volume is 5-7cm cubed…true or false?
false….5.8-8 cm cubed
What size to ovarian follicles need to be in order to be considered normal?
<3 cm
When should postmenopausal cysts be removed?
> 5cm
with septations or nodules
What are inclusion cysts in the ovaries?
echogenic nonshadowing foci 1-3mm
normal
What are focal calcifications?
stromal reaction
previous hemmorrhage or infection
need f/u to r/o early neoplasm
When is fluid in the pouch of douglas abnormal?
when it is a large amount
has debris/septated fluid
What would you use to evaluate the endometrium better?
3D/4D
provides a coronal image
