ULTRASOUND OF THE OVARIES - Normal

Transabdominal pelic ultrasound scan plane transabdominal axial image
Use the full urinary bladder as an acoustic window to angle across to the ovary. Axial trans-abdominal image with the ovary lateral to the uterus.
Axial trans-vaginal scan plane Axial trans-vaginal image
Axial trans-vaginal scan plane. Axial trans-vaginal image.
Normal ovary TV flattened ovary
Normal transvaginal ovary demonstration normal peripheral follicles. The uterus may be oblique and squash the ovary giving it a flattened ovoid shape.

 

 

ULTRASOUND OF THE PELVIS PROTOCOL

ROLE OF ULTRASOUND

 

  • To examine the uterus, ovaries cervix vagina and adnexae.
  • Classification of a mass identified on other modalities eg solid, cystic, mixed.
  • Post surgical complications eg abscess, oedema.
  • Guidance of injections, aspiration or biopsy.
  • Assistance with IVF.
  • To identify the relationship of normal anatomy and pathology to each other.

INDICATIONS

  • P/V bleeding/discharge
  • Menorrhagia
  • Polymenorrhea
  • Amenorrhea
  • Irregular periods
  • Pelvic pain
  • F/H uterine or ovarian Cancer
  • Palpable lump
  • Infertility- primary or secondary
  • Anomalies

LIMITATIONS

  • Transvaginal scanning is contra-indicated if the patient is not yet sexually active,or cannot provide informed consent.
  • Large patient habitus will reduce detail, particularly via the transabdominal approach.
  • Excessive bowel gas can obscure the ovaries.

EQUIPMENT SELECTION AND TECHNIQUE

  • Use of a curvilinear 3-6Mhz probe and a 6-10Mhz endovaginal probe. Low dynamic range.

PATIENT PREPARATION

  • If possible, scan the patient in the first 10 days of the cycle. Preferably Day 5-10 for improved diagnostic accuracy in the assessment of the endometrium and ovaries.
  • A full bladder is required . Instruct the patient to drink 1 Litre of water to be finished 1 hour prior to their appointment. They cannot empty their bladder until after the scan.

 

SCANNING TECHNIQUE

 

TRANS-ABDOMINAL APPROACH

This is a generalised overview to identify the cervix, uterus and ovaries.

  1. Check for the orientation the uterus (anteverted V's retroverted)
  2. Assess the myometrium
  3. Assess the endometrial status and measure the thickness: <10mm pre menopausal; <4mm post menopause or ,<6mm if post menopausal on HRT
  4. Look for free fluid in the pouch of douglas
  5. Check the ovaries and adnexae
  6. Assess bladder

Scan sagitally in the midline immediately above the pubis. In this plane you should be able to assess the uterus, vagina and cervix. Zoom the image to assess and measure the endometrial thickness. Rotate into transverse and angle slightly cranially to be perpendicular to the uterus. Whilst in transverse and slightly right of midline, angle left laterally to identify the left ovary using the full bladder as an acoustic window. Examine this ovary in two planes. Now repeat this for the right ovary.

TRANS-VAGINAL (TV) APPROACH

INSERTING THE TV PROBE

  • Before letting the patient empty their bladder, show them the TV probe and explain the procedure. Indicate the length that is inserted which is approximately the length of a standard tampon. Explain there is no speculum used. Explain the importance of a TV scan because it is the gold standard in gynaecological ultrasound because of its superior accuracy and improved diagnostic resolution.
  • Cover the probe with a latex free Transvaginal sheath and lubricate with sterile gel on the outside.
  • Elevate the patients bottom on a thick sponge/pillow to assist the scan. A gynaecological ultrasound couch which drops down is ideal so that a better angulation is achieved for an anteverted uterus.
  • Ensure the patient is ready and get permission before inserting the probe.
  • If there is some resistance as the probe is being inserted, offer for the patient to help guide the probe in far enough to see the end of the fundus.
  • Keep asking the patient if they are okay.
  • When manouvering the probe to visualise the adnexae, withdraw slightly then angle the probe towards the fornix. This avoids unnecessary patient discomfort against the cervix.

COMMON PATHOLOGIES

VAGINAL

  • Gartners duct cyst
  • Vaginal carcinoma
  • Hydro/haematocolpos (secndary to imperforate hymen or vaginal stenosis)
  • Foreign body

CERVICAL

  • Nabothian (retention) cysts
  • Polyps
  • Cervical fibroids
  • Cervical carcinoma
  • Cervical stenosis

UTERINE

  • Fibroids (leiomyoma)
    • submucosal
    • intramural
    • subserosal
    • pedunculated
  • Leiomyosarcoma
  • Adenomyosis
  • Lipoleiomyoma

ENDOMETRIAL

  • Endometrial Polyps
  • Endometrial Carcinoma
  • Endomtrial hyperplasia
  • Endometritis
  • Cystic hyperplasia 2ndary to Tamoxifen
  • Adhesions- Ashermans Syndrome
  • Submucosal fibroids
  • Arterio-venous malformation (AVM)
  • Hydro/haematometra
  • blood/fluid/infection or retained produts of conception (RPOC)

OVARIAN

  • Ovarian cysts
    • simple Vs complex (haemorrhagic, corpus luteal, ruptured, septated).
    • any mural nodules
  • Dermoid
  • Ovarian tumours:
    • Cystadenoma (serous/mucinous)-Benign
    • Cystadenocarcinoma (serous/mucinous)-Malignant
  • Polycystic Ovarian Disease
  • Endometrioma
  • Torsion
  • Hyperstimulation syndrome
  • Ectopic pregnancy

POUCH OF DOUGLAS (POD) & ADNEXAE

  • Fluid
  • Pus
  • Blood
  • Pelvic inflammatory disease-PID (may be indicated by above conditions)
  • Cysts (Mesenteric)
  • Ectopic pregnancy
  • Endometriosis
  • Pelvic venous congestion

FALLOPIAN TUBES

  • PID
  • Pyosalpynx
  • Hydrosalpynx
  • Ecopic pregnancy
  • Cyst
  • Ectopic pregnancy
  • Endometriosis

Bladder and Bowel should also be examined.

 

BASIC HARD COPY IMAGING

An pelvic series should include the following minimum images;

  • Uterus - longitudinal, transverse (with measurements)
  • Endometrial thickness measured in the longitudinal plane
  • Cervix
  • Both ovaries- longitudinal, transverse
  • Both adnexae
  • Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity.


REFERENCES

  •  Garel L, Dubois J, Grignon A, Filiatrault D, Van Vliet G. US of

the pediatric female pelvis: a clinical perspective. Radiographics

2001; 21:1393–1407.

  •  Brown DL, Zou KH, Tempany CM, et al. Primary versus

secondary ovarian malignancy: imaging findings of adnexal

masses in the Radiology Diagnostic Oncology Group Study.

Radiology 2001; 219:213–218.

  • Jarvela IY, Sladkevicius P, Kelly S, Ojha K, Nargund G,

Campbell S. Three-dimensional sonographic and power

Doppler characterization of ovaries in late follicular phase.

Ultrasound Obstet Gynecol 2002; 20:281–285.

  •  Kinkel K, Hricak H, Lu Y, Tsuda K, Filly RA. US characterization

of ovarian masses: a meta-analysis. Radiology 2000;

217:803–811.

  • Sato S, Yokoyama Y, Sakamoto T, Futagami M, Saito Y.

Usefulness of mass screening for ovarian carcinoma using

transvaginal ultrasonography. Cancer 2000; 89:582–588.

Funt SA, Hann LE. Detection and characterization of adnexal

masses. Radiol Clin North Am 2002; 40:591–608.

  •  Kaakaji Y, Nghiem HV, Nodell C, Winter TC. Sonography of

obstetric and gynecologic emergencies, part II: gynecologic

emergencies. AJR Am J Roentgenol 2000; 174:651–656.

 Laing FC, Brown DL, DiSalvo DN. Gynecologic ultrasound.

Radiol Clin North Am 2001; 39:523–540.

 


 
 

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