ULTRASOUND - Female Pelvis

Alternative Names:  pelvic ultrasound, pelvic sonography, ultrasound of the pelvic

ROLE OF THE PELVIC 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.

PELVIC

• P/V bleeding/discharge

• Menorrhagia

• Polymenorrhea

• Amenorrhea

• Oligomenorrhea (Irregular periods)

• Pelvic pain

• F/H uterine or ovarian Cancer

• Palpable lump

• Infertility- primary or secondary

• Anomalies

PELVIC 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.

• Patients who are unsuitable for transvaginal scanning but canot adequately fill their bladder for an acoustic transabdominal window.

EQUIPMENT SELECTION AND TECHNIQUE

Transabdominal

• Use the highest frequency probe to gain adequate penetration.

• This will be between a 2-7MHz range curved linear array or sector probe with Colour Doppler capabilities.

Transvaginal

• Probe 4-7MHz.

• A curved linear array probe can be used via the perineum to assess the vagina.Cover the probe.

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 before and they cannot empty their bladder before the scan.

• The patient empties their bladder before the transvaginal scan is started.

SCANNING TECHNIQUE OF THE PELVIC ULTRASOUND

TRANS-ABDOMINAL APPROACH

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

• Check for the orientation the uterus (anteverted V's retroverted)

• Assess the myometrium

• Assess the endometrial status and measure the thickness: <10mm pre menopausal; <4mm post menopause or ,<6mm if post menopausal on HRT

• Look for free fluid in the pouch of douglas

• Check the ovaries and adnexae

• Assess bladder

• Scan sagitally in the midline immediately above the pubis. Heel the probe to get the bladder over the fundus of the uterus. 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.

• While in transverse and slightly right of midline, angle left laterally to identify the left ovary using the full bladder as an acoustic window.

• Examine the ovary in two planes.

• 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 TV sheath and lubricate with sterile gel on the outside.

• Elevate the patients bottom on a thick sponge/pillow to assist the scan. A gynae 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 unecessary patient discomfort aginst the cervix.

COMMON PATHOLOGIES OF THE PELVIC

VAGINAL

• Gartners duct cyst

• Vaginal carcinoma

• Hydro/haematocolpos (2ndary 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 products 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

• Bowel pathology may be seen (but cannot be excluded)

FALLOPIAN TUBES

• PID

• Pyosalpynx

• Hydrosalpynx

• Ectopic pregnancy

• Cyst

• Endometriosis

• Bladder and Bowel should also be examined.

PELVIC (FEMALE) ULTRASOUND SAMPLE PROTOCOL (TYPICALLY)

This sample protocol is meant for educational purposes and the exact technique will depend on the patient's clinical indication for the examination and the radiologist's guidance.

An pelvic series should include the following minimum images;

1. Uterus - longitudinal with measurements

2. Uterus - transverse with measurements

3. Endometrial thickness measured in the longitudinal plane

4. Cervix

5. Right adnexae

6. Right ovary longitudinal

7. Right ovary transverse

8. Left adnexae

9. Left ovary longitudinal

10. Left ovary transverse

Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity.

Schedule Your Pelvic (Female) Ultrasound Today! 

• If you are looking for professional radiology services at your imaging site/center, call us at 1-800-626-8315 or contact us for a consultation. 

• If you live in Los Angeles, Century City, Glendale, Mid-Wilshire and need to schedule a radiology examination such as a MRI, CT Scan, Ultrasound, X ray, or PET scan, contact us to schedule an appointment. 

• If you are in search of other things, we're surprisingly resourceful!  Call us 1-800-626-8315 or contact us via our contact form.

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