Pitfalls in Gynecologic Ultrasound Disclaimer Outline Uterus


Pitfalls in Gynecologic Ultrasound Disclaimer Outline Uterus
• I have no disclosures.
Pitfalls in Gynecologic
Mindy M. Horrow, MD, FACR, FSRU, FAIUM
Director of Body Imaging
Albert Einstein Medical Center, Philadelphia, PA
Associate Professor of Radiology
Thomas Jefferson University
How we image the pelvis with
ultrasound at AEMC
• We do not require women to have a distended
• If no prior pelvic imaging, brief transabdominal
images are obtained
• Make decision about transabdominal versus
transvaginal imaging or combination of both
• Majority of women have only transvaginal
• Occasional wait to fill bladder
• Uterus
– Unusual fibroids and mistaken fibroids
– Adenomyosis
– Miscellaneous (including post surgical)
• Adnexa
– Fallopian tubes
– Vessels
– Bowel
• Ovaries
– Too big or too small without a focal abnormality
– Atypical appearances of common abnormalities
• Missed Cases
Benacerraf etal. JUM 2000;19:237-241
• Fibroids
• Adenomyosis
• Miscellaneous
Initial transabdominal measurements of uterus
Is this correct?
Further transvaginal imaging
Uterine or adnexal mass?
Repeat transabdominal view
Focal exophytic myoma, more normal
uterine body initially interpreted as cervix
Subserosal myoma with bridging
uterine vessels
Kim SH etal. JCAT. 2001;25:36-42
Cystic uterine or adnexal mass?
Is the endometrium too thick?
Cystic Myoma
*Claw sign
On TV imaging endometrial cavity
contains complex fluid
Atypical appearance of fibroids
T2 Fat Sat
• Degeneration secondary to outgrowing blood
• Red degeneration: may present acutely with
pain secondary to venous thrombosis and
• Common degeneration includes calcification,
hemorrhage and liquifaction and cystic changes
• Lipoleiomyoma: very rarely smooth muscle cells
undergo fatty change
Maizlin ZV etal. U Quarterly. 2007;23:55-62
Small hypoechoic “mass” initially measured
as fibroid, actually a prominent vein
64 year old diabetic
Does patient have fibroids?
Peripheral vascular calcifications
Is this a focal myoma?
Mönkeberg’s Sclerosis
• Common finding
with advancing age
• Accelerated process
in diabetics and
those with chronic
kidney disease
Focal Adenomyosis
thin shadows, tiny cysts, penetrating vessels, obscures endometrium
Atri M, etal. JCU 1992;20:211-216
McMullough PA, etal. CJASN 2008;
Adenomyosis with penetrating vessels
90 yo with post menopausal bleeding, incontinent, hip fracture:
Is there a uterus?
Fibroids with circumferential vessels
Color Doppler helps differentiate
fibroids and adenomyosis
Transrectal imaging demonstrates normal uterus
and endometrium with trace fluid
Patient gives history of hysterectomy
Post Surgical Imaging
Transvaginal view in transverse
Supracervical Hysterectomy
Patient gives history of hysterectomy
Initial interpretation: either uterus was not completely
removed, or there is a complex mass.
Two years earlier
Adjacent ovaries with follicles
Normal Fallopian Tubes
Tubular Structures in the
Beyond the Uterus and Ovaries
Two different patients with same diagnosis
Paratubal Cyst (Hydatid of Morgagni)
Normal fallopian tubes
Two different patients with pelvic inflammatory disease
Dilated thick walled fallopian tubes
small, round projections
Hematosalpinx with ectopic
History of endometriosis
incomplete waist sign: diametrically opposed indentations
Patel MD, etal AJR 2006;186:1033-1038
Post menopausal woman sent in for evaluation of
cystic tumor discovered on outside ultrasound exam
Dilated Fallopian Tubes
• Best markers for hydrosalpinx: waist sign or small
round projections
– incomplete septum (linear, echogenic protrusion arising from
one wall but not reaching the opposite) less discriminating
Chronic Hydrosalpinx: Incomplete septum
• Thick wall (≥ 5mm) and “cogwheel” sign are best
markers for acute disease
• Thin wall (< 5mm) and “beads on string” indicates
chronic disease
• Other findings: tubular, “solid” structure separate from
ovary, fluid/debris level, gas
Patel MD etal. AJR 2006;186:1033-1038
Benjaminov etal. AJR 2004;183:737-742
Timor-Tritsch etal. Ultra Obstet Gyn 1998; 12:56
Tessler FN etal. AJR 1989;153:523-525
History of pelvic pain: Ultrasound diagnosis of PID
History of chronic pelvic pain with multiple US and CT exams
Clinical findings do not coincide with US diagnosis, but
patient returns for follow up after course of antibiotics.
Dilated Veins: Very slow flow causes internal
echoes and requires sensitive Doppler settings
Pelvic Congestion Syndrome
Dilated R ovarian vein
Pelvic varices
Treated by embolization of pelvic varices
Pelvic Congestion Syndrome
Right pelvic pain, initially called pyosalpinx
• Pelvic varices develop because of incompetent valves
• Risk factors: multiparity, prior surgery, varicose veins
• Symptoms: dull, heavy pelvic pain that exacerbates with
standing. May be unilateral or bilateral pain.
• Clinical: bulky tender uterus, varicose veins in vulva,
buttocks, legs, 50% with cystic ovaries
• Imaging: dilated pelvic veins, ovarian veins, arcuate
veins in uterus and cystic ovaries.
• Analog to scrotal varicocele
Kuligowska E etal. Radiographics. 2005;25:3-20
Park SJ etal. AJR 2004;182:683-688
Ovary with follicle, Normal fallopian tube
Adjacent abnormal bowel
Right pelvic pain
Crohn’s Disease
16 year old with right pelvic pain, rule out ovarian torsion
Abnormal Ovaries
without a mass or cyst
Sag R
Are these ovaries too large or too
small, and why?
Acutely obstructing distal ureteral calculus
16 year old, amenorrhea
Turner Syndrome (mosaic)
• US, karyotype and gonadotropin levels have
prognostic value in predicting future sexual
• XO mosaicism showed much greater
percentage of ovaries and greater uterine
volume than XO. 50% had spontaneous breast
development, 38.5% with spontaneous
• As many as 1/3 have renal malformations:
horseshoe kidney, duplicated collecting system,
unilateral renal agenesis, crossed ectopia, pelvic
Small ovaries and small, juvenile type uterus
Haber HP. J Ultrasound Med. 1999;18(4):271-6
Mazzanti. J Pediatr. 1997;131:135
Infertility evaluation in a 35 year old
Premature Ovarian Failure
Cause of primary or secondary amenorrhea
Typically associated with elevated FSH levels
52.5% idiopathic, 45% immunologic, 2.5% chromosomal
2 sonographic groups
– Small ovaries without follicles (2/3)
– Normal sized ovaries with partial follicular maturation (1/3)
• Mean volume similar to post menopausal ovaries
Small ovaries, no follicles
Falsetti. Gynecol Endocrinol 1999;13: 189-95
75 year old with malignant pleural effusion
60 year old with history of breast carcinoma
Large right ovary with small amount adjacent
complex fluid: Ovarian Carcinoma
Large ovaries with metastases to liver, right
adrenal gland and spleen
Acute left pelvic pain
Metastatic Disease to Ovaries
• Generally difficult to distinguish primary from metastatic
• Some studies suggest that purely or predominantly solid
tumors are more likely metastases
• Vascular features and unilateral versus bilateral does not
help distinguish
• Most common primary tumors: colo-rectal and breast.
• Other primary tumors: endometrium, stomach,
Left ovarian volume: 78 cm3
Large ovary: ovarian torsion and detorsion
Alcazar etal. JUM 2003;22:243-247
Brown DL etal. Radiology 2001;217:213-218
Ovarian Torsion
• Most important finding is an enlarged ovary- may be
located in midline or above uterus
• Heterogeneous stroma secondary to hemorrhage
• Frequently with complex cyst or mass and multiplesmall
peripheral cysts secondary to vascular engorgement
• +/- arterial flow, ↓ venous flow
• Free fluid
• Twisted vascular pedicle: whirlpool sign
“M & M” cases
Large masses easily missed or
Shadinger LL, etal. JUM 2008;27:7-13
Vijayaraghavan SB. JUM 2004;23:1643-1649
Initial measurements of uterus
Is this a fibroid uterus?
Is this adenomyosis?
MR for problem solving: solid adnexal mass separate
from uterus and right ovary, no normal left ovary
Ovarian Fibroma
More TA and TV views of uterus
Interpreted as normal trans-abdominal study
Re-imaging TA and TV
Simple right ovarian cyst compresses
almost empty bladder
What is wrong with these labels?
Gas filled bowel superior to uterus?
Missed right dermoid
Measured vertebral body as ROV
35 year old with right pelvic pain
Interpreted as worrisome for
Large Dermoid
superior to uterus, mostly fat containing, easily missed
Peritoneal Inclusion Cyst
One year later with chronic pain
Forming an inclusion cyst:
Patient has documented PID and subsequent
development of right hydrosalpinx
adhesions trap fluid around ovary
Cystic lesion of lower uterus?
Peritoneal Inclusion Cyst
• Ovaries become encased by fluid that is entrapped by
peritoneal adhesions
• Appear as multiloculated cystic masses with identifiable
ovary in center or periphery
• Fluid is usually anechoic, but may be complex
• Must differentiate from ovarian neoplasm, hydrosalpinx,
paraovarian and paratubal cysts
• Patients typically present with pain and often have
history of pelvic inflammatory disease, prior surgery,
trauma or endometriosis
Retrograde filling of vagina
Kim etal Radiology 1997;204:481
Jain. AJR 2000;174:1559
Transperineal Imaging (sagittal)
Transperineal imaging (transverse)
History of Crohn’s disease and vaginal discharge
• Be familiar with uncommon variations of common entities, such as
cystic or fat containing myomata
• Consider ovarian size as well as any focal abnormality
• Always ask the patient if she has had a Cesarean section and be
familiar with the appearance of the scar and its associated
• Remember that there is more to the pelvis than the uterus and
ovaries. Consider bowel, fallopian tubes, ureters and the bladder
• Recognize the issues related to large abnormalities such as cysts
and dermoids that may extend out of the pelvis
• Appreciate the limitations of pelvic ultrasound and recommend
further imaging (usually MR) when things just do not make sense or
cannot be completely evaluated
Recto-vaginal fistula