Swiss Gynaecologic Ultrasound Guideline

Transcription

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Swiss Gynaecologic
Ultrasound Guideline
Swiss Society for Ultrasound in Medicine
Gynaecology and Obstetrics Section
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2nd Version
Schweizerische Gesellschaft für Ultraschall in der Medizin
Sektion Gynäkologie und Geburtshilfe (SGUMGG)
We are grateful to the following companies for their support in compiling this manual:
FUJIFILM (Switzerland) AG
Mindray Ultraschall-Diagnosesysteme
Siemens (Schweiz) AG
GE Medical Systems
Hitachi - Aloka Medical Systems
Bayer (Schweiz) AG
Hygis AG
Publisher:
Schweizerische Gesellschaft für Ultraschall in der Medizin (SGUM)
Sektion Gynäkologie und Geburtshilfe (SGUMGG)
Chairman: Dr. René Carlo Müller, Winterthur
www.sgumgg.ch
Manuscript and diagrams:
PD Dr. Michael Bajka, Zürich, Editor
PD Dr. Gilles Berclaz, Bern
Dr. René Carlo Müller, Winterthur
Professor Dr. Gabriel Schär, Aarau
Professor Dr. Sevgi Tercanli, Basel
Contents
1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
2
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
3
The principles of Diagnostic Ultrasound in Gynaecology......................... 1
Legal basis ............................................................................................. 1
The objectives of diagnostic ultrasound procedures .............................. 1
Potential benefits ................................................................................... 1
Potential injuries.................................................................................... 2
Practitioners’ qualifications ................................................................... 2
Equipment requirements........................................................................ 3
Equipping the workplace ....................................................................... 3
Hygiene ................................................................................................. 4
Examination procedure.......................................................................... 4
Findings ................................................................................................. 5
Documentation ...................................................................................... 7
References ............................................................................................. 8
The internal Genitalia .................................................................................. 9
Examination techniques ........................................................................ 9
Anatomy, biometry and physiological changes ................................... 13
Diseases of the internal genitalia ......................................................... 23
Early pregnancy................................................................................... 40
Anticonception .................................................................................... 43
Extragenital diseases ........................................................................... 46
The most common differential diagnoses... ......................................... 46
General recommendations and consequences...................................... 48
References ........................................................................................... 48
Urogynaecological sonography ................................................................... 52
3.1
The objectives of urogynaecological sonography .............................................. 52
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
Advantages .......................................................................................... 52
The quality of urogynaecological sonography..................................... 52
Examination procedure........................................................................ 53
Documentation .................................................................................... 54
Evaluation ........................................................................................... 55
Examples with interpretation ............................................................... 57
Further options and future developments ............................................ 62
References ........................................................................................... 63
4
4.1
4.2
4.3
4.4
4.5
4.6
4.7
5
Mammasonography ..................................................................................... 64
Indications for mammasonography ..................................................... 64
Examination technique and documentation ......................................... 64
Normal anatomy of the breast glands and axilla.................................. 65
Disease ................................................................................................ 65
BI-RADS (Breast Imaging Reporting and Data System) .................... 67
Recommendations and consequences .................................................. 68
References ........................................................................................... 68
Report sheets (PDF @ www.sgumgg.ch) .................................................... 69
1 The principles of Diagnostic Ultrasound in
Gynaecology
Michael Bajka, René Müller
1.1
Legal basis
According to the KVG (Swiss compulsory health care system), ultrasound scanning
is to be carried out appropriately and economically in terms of the indication,
preparation, implementation and conclusions to be drawn from the examination.
There are no clear-cut conditions governing gynaecological ultrasound scans unlike
the requirements stipulated in Article 13 of the Krankenpflege-Leistungsverordnung
(KLV) (Health Care Benefits Ordinance) for ultrasound screening during pregnancy.
According to Art. 20 of the Medizinprodukteverordnung (MepV) (Ordinance on
Medical Devices), health care professionals who use medical devices are responsible
for organising the servicing and testing of the equipment as directed. Maintenance
must be carried out in accordance with Quality Assurance principles and should be
planned, organised and documented efficiently in-house.
1.2
The objectives of diagnostic ultrasound procedures
• To shed light on symptoms and (unclear) clinical findings
• To record findings as comprehensively as possible with minimal stress to the
patient ("ALARA" principle, "as low as reasonably achievable") and with the
emphasis on evaluation and the procedure.
• To ensure process differentiation by…
• Organ identification
• Allocation to the relevant pathological spectrum (functional, inflammatory,
neoplastic, degenerative, pregnancy-related, etc.)
• Type of diagnosis (benign/malignant, chronic/acute, etc.)
• Corroborating the clinical evaluation
• Supporting an appropriate procedure (expectative, conservative treatment,
puncture, endoscopic therapy, open procedure, etc.)
• Guidance with invasive procedures (puncture, biopsy, endoscopy, etc.)
1.3
•
•
•
•
1
Potential benefits
Avoidance of unnecessary check-ups
Avoidance of unnecessary procedures
Alleviating anxiety and uncertainty
Early recognition of changes and thus the opportunity to intervene from the
outset
• Cutting costs.
Since ultrasound scanning is primarily a diagnostic function, a benefit can only be
anticipated if the right consequences are actually drawn on the basis of the medical
finding.
1.4
1.4.1
Potential injuries
Technical safety aspects
When performing an ultrasound scan of the internal genitalia in particular, the
examination should only be carried out in women of child-bearing age in accordance
with the safety parameters for ultrasound scanning during pregnancy, i.e. the sound
power should be limited to a maximum of 100 mW/cm2. It should be noted that
sound power can increase to a maximum of 720 mW/cm2 when the Doppler
technique is used. The thermal and mechanical effect of the sound power currently
used is indicated via the thermal index (TI) or the mechanical index (MI). If
possible, the index should be < 11. This will preclude any short- or long-term
harmful effects on the patient or the pregnancy. The ALARA principle is basically
followed.
1.4.2
Psychological consequences
Possible psychological consequences can include:
• Anxiety due to an assumed change (abnormality)
• Anxiety because of an actual change (true positive)
• Anger and disappointment because of a change that has been overlooked (false
negative)
• Anger and disappointment because of an incorrectly diagnosed change (false
positive)
Ultrasound scanning must be aimed at preventing negative effects as much as
possible. Good communication is extremely important. Anxiety can be alleviated
during the examination by pointing out the key anatomical structures (bladder,
ovaries, uterus).
1.5
Practitioners’ qualifications
The quality of the ultrasound scan essentially depends on the skill of the practitioner.
In Switzerland, basic training in gynaecological ultrasound scanning is a key
component of continuous professional training in gynaecology and obstetrics.
Anyone who has not undergone specialist gynaecological training must take a basic
course and a final course in gynaecological ultrasonography. In addition, a certain
number of ultrasound examinations must be carried out under supervision,
preferably in a gynaecological clinic as part of a regular training programme.
Current information on the number of ultrasound examinations to be performed
under supervision can be found in the proficiency programme offered by the
2
Schweizerische Gesellschaft für Ultraschall in der Medizin (www.sgum.ch) (Swiss
Society for Ultrasound in Medicine), under the Gynaecology module.
Gynaecological-obstetric ultrasound scans should only be carried out in practices
that perform at least 50 examinations themselves each year (sonographic fitness).
Regular attendance at continuing training events focusing on gynaecologicalobstetric ultrasound techniques is a pre-requisite.
Examining practitioners must acknowledge the fact that gynaecological-obstetric
diseases that slip through the net lead to increasingly complex rights of recourse
confirmed by a court of Final Appeal.
1.6
Equipment requirements
A vaginal probe (≥ 5 MHz) and an abdominal probe (≥ 3.5 MHz) must be
permanently attached to the ultrasound device in order to perform a differentiated
examination of the urogenital system. The transvaginal probe or transducer should
have an angle of at least 1200 and a frequency exceeding 5 MHz. Special highfrequency probes (≥ 7.5 MHz) are required for mammasonography. Preference is
given to linear ultrasonic probes. Ultrasound devices that allow three or more probes
to be connected at the same time are extremely useful if all three probes are used
frequently.
The devices must comply with IEC standard 1157 especially if they are used
concomitantly in obstetric diagnostics: The sound speed must be 1540 m/s, distance
(B-mode) or time (M-mode) errors must not exceed 3%; for measuring distances <
17 mm, an absolute error of 1.0 mm is permissible. The device should be able to
display at least 256 grey scales. It should also be possible to record appropriate
imaging documentation with every device. Obtain these conditions in writing from
the manufacturer prior to purchase. Make sure that the manufacturer provides you
with the essential servicing documents for the device, explaining how the equipment
is to be serviced.
1.7
Equipping the workplace
Gynaecological ultrasound scans can be performed in any room fitted with a dimmer
switch and equipped for gynaecological examinations.
Several studies stress the fact that an optimal examination technique is extremely
important for patients. The relevant precautions should be taken with regard to the
structural and processing quality of the examination. Ideally, the ultrasound
practitioner should outline the procedure to the patient beforehand, emphasising that,
in principle, the examination is carried out via the vagina, like a gynaecological
examination (transvaginal sonography – TVS) and possibly via the abdominal wall
(transabdominal sonography – TAS).
3
In an ideal situation, a second monitor should be installed so that the patient can
follow the examination on screen. Alternatively, the monitor can be turned towards
the ultrasound device.
It is advisable to have available standard references on gynaecological sonography.
1.8
Hygiene
Particular attention should be paid to hygiene when carrying out TVS. The
ultrasound practitioner should wear gloves.
The TVS probe is covered with a uniform gel-filled rubber sleeve. A sterile
lubricant is applied to the outside (N.B.: allergies to rubber components, e.g. latex
allergy and lubricants). Condoms are preferably used since they are more resistant
than standard ultrasound sleeves. In terms of infection, the vaginal mucosa can be
likened to abraded skin and is thus prone to an increased risk of infection. Thorough
decontamination after every examination is essential to prevent infection via
bacterial spores, mycobacteria and fungi. The most effective procedure is to wash
the probe with soap and water, rinse with water and dry2,3,4. 99% of bacterial
colonisation is already eliminated by using soap. In addition, the probe should be
immersed in glutaraldehyde for 20 minutes and subsequently rinsed and dried. This
is recommended because 2 % of condoms are not leak-proof. In 66 % of cases, the
non-leak-proof area is in the region of the probe tip and can easily be identified by
wiping with a dry paper towel.
The TAS probe and the mammary probe should always be disinfected after use. In
17.5 % of cases, bacterial contamination persists if the probe is just wiped. If a
disinfectant is used, a 2 % level of contamination persists5.
Ultrasound gel is another source of contamination. Gel should only be used with
small bottles that are changed/disinfected daily.
1.9
Examination procedure
An ultrasound examination, especially of the internal genitalia, should only be
initiated after obtaining a certain amount of background knowledge. It is also
advisable to record this information in the ultrasound documentation. It should
include at least the menopause status, day of the cycle, the intake of hormonal active
substances, procedures carried out to date, symptoms and/or clinical findings
together with a clearly formulated statement. The last two points are crucial quality
factors, especially when the ultrasound scan is carried out as a separate service,
independently of the clinical examination or patient treatment.
Diagnostic evaluation of the internal genitalia and perineal sonography should be
carried out with the patient lying in the supine position on a gynaecological
examination couch with leg rests. Alternatively a high cushion placed beneath the
buttocks will suffice. The mammasonography should ideally be carried out on a
narrow couch, again in the supine position, and possibly with the patient’s arms
elevated.
4
The examination should be structured in such a way so as to ensure that the
atmosphere is relaxed for practitioner and patient alike6. An easy to operate room
dimmer switch should also be close at hand. Right-handed practitioners generally
prefer to guide the probe with their dominant right hand, using the left hand to
operate the device. The equipment is thus positioned on the patient’s right side.
All practitioners should plan the procedure to ensure that they cannot be criticised
for inappropriate action. A male practitioner performing a genital examination on an
unaccompanied female patient of a different culture or who has difficulty in
understanding the local language should ideally ask for another female person to be
present in the examination room.
The practitioner should personally greet the patient before the examination and
outline the examination procedure.
Practitioners should have their own examination procedure and consequently work
to plan whenever possible, e.g. diagnostic procedures on the internal genitalia can be
conducted as follows: initially by examination of the uterus with its myometrium
and endometrium followed by the right adnexa with the right ovary, then the left
adnexa with the left ovary, the intestine and pouch of Douglas, completing the
examination with the urinary bladder and rectum. A TAS can be included if
required. This routine approach guarantees that no findings are overlooked and that
there is no confusion between right and left.
The patient should be able to make out the most important easily recognisable
structures on the monitor with the aid of the marker (e.g. uterus, ovaries and urinary
bladder).
The documentation should be prepared during the examination with images and/or
film sequences being stored digitally on the ultrasound device or via the network, or
else printed out immediately. The mandatory written examination report is drafted at
the end of the procedure.
The findings should always be documented with an ultrasound evaluation and
possibly also with recommendations especially if the ultrasound scan is carried out
by other practitioners who are not treating the patient.
To conclude, patients should always be given a brief account of the outcome and the
next stage following the examination, even in the case of inconspicuous findings,
e.g. "It looks fine", "I didn’t find anything in particular", "We will send your doctor
a report. Please make an appointment to see him/her in 1 week’s time".
1.10 Findings
1.10.1
A descriptive account of the findings
A purely descriptive account warrants the use of targeted terminology without preempting a pathological or histological diagnosis. It provides an important basis for
any objective description of imaging techniques so that the right conclusions can
finally be drawn, and the same applies to sonography.
5
The following aspects should be covered in the event of conspicuous findings
observed during the ultrasound scan:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Visibility/presentability: good, partial, unsatisfactory, cannot be shown/portrayed
Organ identification, at least the assumed organ
Size (on at least 2 perpendicular levels: length, breadth, height)
Shape (round, oval, oblong, polycyclic)
Structure [simple (uniform), complex (non-uniform)]
External margins
Delineation
Deformability
Cystic finding or cystic segment:
Internal echoes: Position (parietal, central, ubiquitous), size (fine, moderately
coarse, coarse), intensity (mild, moderate, strong, extremely strong), distance
(loose, moderately tight, tight), distribution (uneven, even)
Number of chambers
Wall thickness
Septum thickness
Solid finding or solid segment:
Internal echo(es): Detection (empty, parietal, central, ubiquitous), size (fine,
moderately coarse, coarse), intensity (mild, moderate, strong, extremely strong),
distance (loose, moderately tight, tight), distribution (uneven, even)
Percentage of the overall finding
Mobility/relocatability in the region of / towards the surrounding organs
Attenuation and intensification of sound behind the medical finding
Evidence of movement within a medical finding
Pain elicited on pressure (“Sonopalpation”).
1.10.2
Interpretation of ultrasound findings
When evaluating ultrasound findings, practitioners are aware of the fact that a
relatively small number of sonomorphological criteria can be indicative of numerous
pathological diagnoses. Unfortunately, these are mostly pathognomonic ultrasound
criteria. A single ultrasound criterion seldom points conclusively to one
histopathological diagnosis, e.g. heart action in the adnexal region is clearly
indicative of extrauterine pregnancy (EUP). Conversely, virtually every
histopathological diagnosis can be reflected in more than just one single
sonomorphology (typical example of multiplicity: the dermoid).
Where possible, it is advisable to interpret and draw conclusions from ultrasound
findings only in conjunction with the clinical findings, menstrual cycle, medical
history, laboratory test results and, above all, additional imaging techniques.
Pathological changes should only be discussed with the patient after the examination
with reference to the recorded images.
6
If the ultrasound examination is an isolated procedure where the practitioner is
responsible only for the imaging, he/she is strongly urged to provide a purely
descriptive account of the images recorded during the ultrasound examination if
possible. Consequently, the ultrasound practitioner must and should assess the
ultrasound findings from a differential diagnostic perspective and comment on the
clinical relevance.
1.11 Documentation
There are no legal regulations governing the scope of the documentation in
Switzerland. However, the standard requirement to file documentation for at least
ten years obviously also applies to medical ultrasound examinations.
The current fee schedule in Switzerland used to calculate the cost of medical
services (Tarmed) requires mandatory organs/structures and pathological processes
to be displayed on two planes and non-essential, optional organs, without the
opportunity to charge, to be documented on film / as a hard copy or in an appropriate
electronic format. The following procedure can be followed for documenting images
in the small pelvis: uterus with myometrium and endometrium, right adnexa with
right ovary, left adnexa with left ovary (a total of at least 3 images), followed by the
urinary bladder and pouch of Douglas. The urogynaecological examination should
comprise a total of at least 4 images recorded at rest, on straining, during coughing
and, to conclude, on contraction of the pelvic floor. When examining the breast, the
right breast is initially examined (pathology including the axilla) followed by the left
breast (pathology including the axilla) with an image of each of the upper external
quadrants (a total of at least 2 images). A written examination report (structured
evaluation, description, procedure, etc.) is mandatory and a component of the
respective examination / position regarding fees.
The documentation should always be managed purposefully in order to avoid, where
possible, any stressful situations for practitioners in the event of a right to recourse.
A report and images of the examined organs should always be filed even if no
abnormal findings are observed.
Pathological images should, if possible, always be recorded on two planes,
including the area surrounding the medical finding, dividing the image into a left
half and a right half where possible. There is no ceiling as to the number of images
that should be recorded for each case given current storage facilities.
The structure of the written documentation should follow the routine examination
procedure. The report can be sub-divided into various sections such as medical
history, findings, evaluation and recommendations. It can be written on a special
form such as one of the SGUMGG reporting forms (see appendix or visit the
website at www.sgumgg.ch), or as an entry in the patient’s medical record. Ideally,
the documentation should be stored on a PC-based system in the form of text and
images with the option of displaying the data graphically in addition to the
comprehensive, uniform and structured report.
7
1.12 References
1
2
3
4
5
6
SGUMGG: Empfehlungen zur Ultraschalluntersuchung in der Schwangerschaft, 3. Auflage, 2011.
AIUM 2003. Report for cleaning and preparing endocavitary ultrasound transducers between patients, American
Institute of Ultrasound in Medicine, AIUM Reporter 1995, 11,7.
CDC 2004. Information supplied to ultrasonographers on the safe decontamination and disinfection of ultrasound
probes. CDC Operational Circular OP 1891/04.
ASUM Transvaginal transducers hygiene – what is the big deal? ASUM Ultrasound Bulletin 2005 May, 8(2).
Mullaney PJ, Munthali P, Vlachou P, Jenkins D, Rathod A, Entwisle J: How clean is your probe? Microbiological
assessment of ultrasound transducers in routine clinical use, and cost-effective ways to reduce contamination.
Clinical Radiology 2007;62:694-698.
Jeager KA, Imfeld S. Schädigende Wirkung des Ultraschall – auf den Untersucher. Ultraschall in Med
2006;27:131-133.
8
2 The internal Genitalia
Michael Bajka, René Müller
2.1
2.1.1
Examination techniques
Preparations
Both transabdominal and transvaginal access with the appropriate probe (and, in
exceptional cases, also transrectal access with a vaginal probe) can be chosen to
highlight the female internal pelvic organs. On numerous occasions, transvaginal
examination of the uterus and adnexa has proved superior to the transabdominal
procedure in many ways,2,3,4,5. The initial approach usually comprises transvaginal
sonography (TVS) but if a process protrudes from the small pelvis (e.g. an adnexal
tumour of over 10 cm in size, a large Uterus myomatosus), or other abdominal
organs have to be examined, practitioners tend to opt for transabdominal
sonography (TAS).
TVS should be carried out with an empty urinary bladder and TAS with a full
bladder. The challenge is to make the most of this situation or to control it.
2.1.2
Examination aids
Occasionally, TVS does not grant sufficient access to the small pelvic organs from
the outset. Then greater clarity is often achieved by slowly applying increasingly
more pressure in the direction of the structure under examination. The patient should
be told in advance to inform the practitioner if she experiences any pain. Obviously,
targeted searches for painful processes can also be carried out (sonopalpation). If
this does not suffice, the free hand can also be used to exert slight pressure from the
abdominal wall in the direction of the small pelvis. If necessary, the patient can do
this herself.
Regular echodense, ribbon-like reflexes, a few millimetres to centimetres apart, can
severely impair the image (so-called reverberation artefacts). This is mostly due to
the filling of the urinary bladder, which should be emptied.
Ultrasound blurring on sector scanning is often caused by inadequate contact gel
application, which should be corrected accordingly.
Larger myomas as well as gas-filled intestinal loops often are often highly "soundabsorbent". If these cannot be removed from the field of vision, the procedure is
switched to TAS. If the structure to be examined is still not visible, it is more likely
that a larger cystic space-occupying lesion can at least be ruled out.
2.1.3
Monitor displays
Image displays are shown on the monitor in a number of different ways. This
manual focuses on the image displays mainly used in German-speaking
countries6,7,8,9.
9
With TVS, the image is generally displayed from the bottom to the top, with the
ventral region to the right of the image and the dorsal region to the left in the sagittal
section (Fig. 1). The images are structured in such a way as though they were
recorded in a woman in the standing position, facing right, with the practitioner
examining the internal organs as if the pelvis were transparent. The fundus of the
anteflexed uterus lies on the bladder and is always pointing to the right (Fig. 1a)
whilst the fundus of the retroflexed uterus is always pointing to the left in the image
(Fig. 1c). In transverse sections (Fig. 1b, 1d), the right side of the body is displayed
on the left of the image and the left side of the body on the right. It should be noted
that the external iliac vessels in this arrangement always run from cranial left to
caudal right whereas the internal iliac vessels always run towards the dorsal left
(Fig. 16). Lateral sections of the median sagittal plane should be labelled with “left”
or “right”, respectively as this information is not evident from the images.
Fig. 1
Standard TVS display of the uterus with an empty bladder, image build-up from below
cranial
ventral
dorsal
left
right
caudal
a) anteflexed uterus in the median sagittal section (organrelated)
b)
anteflexed
uterus
in
a
transverse
section
cranial
ventral
dorsal
right
left
caudal
c) Retroflexed uterus distinctly close to the inner surface
of the sacrum
d) Retroflexed uterus in a transverse section
The TVS probe is guided according to the organs and structures to be examined in
order to generate optimal image displays. The direction and overview in the small
pelvis should never be lost, especially when using rotation symmetrical probes.
10
With TAS, cranial left and caudal right areas are displayed in the sagittal sections
(Fig. 2a) with right to left imaging and left to right imaging with transverse sections
(Fig. 2b).
Fig. 2 TAS: Standard display of the uterus with a full urinary bladder, image build-up from above
cranial
caudal
a) Anteflexed uterus in the median sagittal section
2.1.4
right
left
b) Anteflexed uterus in a transverse section
Hystero Contrast (Agent) Sonography (HyCoSy)
HyCoSy is used to scan the uterine cavity and to check tubal patency.
Basically, a fine catheter is introduced through the cervical canal under sterile
conditions and sealed against backflow (Fig. 3a). To keep discomfort to a minimum,
it is advisable to block the balloon catheter, if used, in the cervical canal if
technically feasible (Fig. 3b). Prepared hyperechogenic ultrasound contrast agent
(e.g. ExEm® Foam) is then inserted into the cavity with minimal pressure. The
contrast agent is initially expected to reach one and then the other interstitial portion
of the tube (Fig. 4a) and is then tracked distally along the isthmic, meandering path
as far as possible (Fig. 4b, 4c), often reaching the end of the fimbria. Eventually, the
contrast agent can be seen as a hypoechogenic film around the ovaries (Fig. 4e). The
cavity can then be assessed in contrast with 0.9%-NaCl solution (Fig. 4e).
Space occupying lesions in the uterus present as a gap per se in the presence of an
echogenic contrast agent (Fig. 5), and are mostly displayed as echogenic and clearly
delineated in an echo-free NaCl solution (Fig. 6).
The use of HyCoSy in the evaluation of tubal patency with over 90% approval for
use in chromo-laparoscopy has been documented since the mid-nineties10. HyCoSy
carries the same diagnostic significance as a hysterosalpingogram but without
exposing the patient to irradiation or anasesthesia11. It is well tolerated with a very
low incidence of adverse events12. Promising 3D techniques have recently been
tested in order to make the procedure more objective and feasible regardless of
ultrasound practitioner experience13.
11
Fig. 3 Starting phase for HyCoSy
a) Application catheter in the
cervical canal
b) Block with balloon catheter in
the cervical canal (white dot)
b) Block with balloon catheter in
the uterine cavity (white dot)
Fig. 4 HyCoSy with ExEm® Foam to track passage through the tubes
a) Tube exits right and left
b) Right isthmic tube path
d) Periovariell contrast agent (arrow)
Abb. 5 HyCoSy: Negative imprint of a
spherical finding protruding in the uterine
cavity to the right on the posterior wall
c) Left isthmic tube path
e) Wash-out phase with NaCl
Fig. 6 NaCl hydrosonography with echodense
polyp (marked with white crosses)
12
2.2
2.2.1
Anatomy, biometry and physiological changes
IETA criteria
In a consensus statement, the IETA (International Endometrial Tumour Analysis
Group) stipulated terms, definitions and measurements to describe sonographical
findings in the endometrium and intrauterine lesions14. An overview is given below.
B image portrayal:
Thickness of the endometrium
• … mm
• Not measurable
Endometrial echogenicity and pattern:
• Uniform
• 3-layer pattern
• Hyper-echoic
• Hypo-echoic
• Iso-echoic
• Non-uniform
• Homogeneous
• With regular cystic areas
• With irregular cystic areas
• Heterogeneous
• Without cystic areas
• With regular cystic areas
• With irregular cystic areas
Endometrial midline
• Linear
• Non-linear
• Irregular
• Not defined
“Bright edge“
• No
• Yes
Endo-myometrial junction
• Regular
• Irregular
• Interrupted
• Not defined
Synechiae
• No
• Yes
Intracavity fluid
• No
• Yes
• … mm
•
Echogenicity
• Anechoic, low level
echogenicity
• Ground glass
• “Mixed“ echogenicity
Colour Doppler assessment:
•
•
13
Score within the endometrium
I.
No flow
II.
Minimal flow
III.
Moderate flow
IV.
Abundant flow
Vascular pattern
• No vessels seen
• Single “dominant“ vessel
•
•
•
•
Single “dominant“ vessel
without branching
• Single “dominant“ vessel
with branching
Multiple “dominant“ vessels
• Focal origin
• Multifocal origin
Scattered vessels
Circular flow
2.2.2
Uterus and Myometrium
The procedure used to measure the size of the uterus (Fig. 7) should take into
account the various proportions between the corpus with fundus on the one hand and
the cervix on the other hand at different ages in life. The length of the uterus should
always be given with the cervix. The pre-puberty uterus is, on average, 41 mm long
and 9 mm deep. In women of child-bearing age, the length of the uterus, measured
transabdominally, is 76 +/- 7 mm with a depth of 29 +/- 4 mm in the case of
nulliparous females15. The uterus of a multiparous woman is 12 mm more in all
dimensions, i.e. 89 +/- 9 mm in length with a depth of 38 +/- 6 mm15.
Transvaginally, Merz16 recorded significantly smaller values (Tab. 1). During the
menstrual cycle, the uterus seems small in size but can nevertheless vary with the
largest measurements being recorded on the 27th day of the cycle17. In
postmenopausal women, the uterus slowly decreases in size but this can vary
considerably (Fig. 8). The late postmenopausal uterus can shrink to a length of 45
mm and a width of 15 mm (Fig. 9).
Fig. 7 Standard uterine measurement in the median sagittal section
a) Length halved (measurement 1,2), depth (3) and
endometrial thickness (4) in the sagittal section
b) Maximal cervical width (measurement 1) and fundal
width (2), on cross-section
Fig. 8 Uterus 10 years after the menopause with
hormone therapy
Fig. 9 Uterus 20 years after the menopause
The thickness of the myometrium compared to the endometrium should not be
affected by an oestrogen-based hormone replacement therapy during the
14
postmenopausal stage18. From the vagina, the cervix is clearly displayed and
delineated, which is often feasible only with restrictions on TAS.
Uterine weight can be estimated from sonographic masses for length, width and
depth, based on Becker’s formula: Estimated uterine weight (g) = length (mm) x
depth (mm) x width (mm) x 0.00038 + 2419.
Tab. 1 Biometry of the uterus (guidelines)
15
16
TAS
TVS
Max. length (mm)
Nulliparous
female
90
Multiparous
female
100
Nulliparous
female
73
Multiparous
female
92
Max. depth (mm)
50
60
32
43
Max. width (mm)
60
70
40
51
Max. weight (g)
120
150
2.2.3
Endometrium
A normal female cycle averaging 28 days is assumed.
Measuring the thickness of the endometrium: In the median (organ-related) sagittal
section, the thickest point of the endometrium from the echogenic boundary
outwards as far as the opposite echogenic boundary should be measured
perpendicular to the endometrial tail. This includes both layers of the endometrium –
the “bilayer”. The hypoechoic innermost layer of the myometrium is not included.
(Fig. 7a). If intrauterine fluid or a definable polyp is present, these should be
removed and described separately (Fig. 10). Maximum permissible endometrial
thickness (Tab. 2).
Tab. 2 Endometrial thickness, measured as the overall thickness = bilayer (guidelines) 20,21
Max. overall thickness (mm)
Regardless of premenopausal cycle
Premenopausal 4th – 6th day of the cycle
12
5
Postmenopausal (with hormone replacement
therapy)
Postmenopausal
(without
hormone
replacement therapy)
8
5
Physiologically, the endometrium appears as a homogeneous, echodense, delineated,
continuous caudate, the apex of which begins in the cervix and ending in a concave
shape in the fundus. The thin, echodense line that separates the two layers runs
through the centre. Deviations from this shape and inner or outer limits, especially
changes in calibre, are clear indications of disease (myoma, polyps, adenomyosis,
deformities, etc.).
15
Fig. 10 Endometrial measurement in the presence of intrauterine fluid (water) Both layers are measured
individually (measurement 1,2) without fluid and added up.
a) Premenopausal, transversal
b) Postmenopausal, sagittal
2.2.4
Cycle diagnostics and the effect of hormones on the
endometrium
At the end of menstruation from the 4th – 6th day of the cycle (CD), function is
diminished and the endometrium can shrink to a thickness of up to 1 mm (Fig. 11a).
It can then appear as a thinner, echogenic line on TVS.
During the proliferation phase, the thickness of the endometrium constantly
increases. From the 10th day of the cycle, the superficial cells loosen due to oedema.
Typical layering is then apparent with an echodense margin, hypoechoic volume and
echodense streaking in the central endometrial echo. Prior to ovulation, around the
14th day of the cycle (Fig. 11b), the thickness is between 10 and 12 mm.
During the median secretion phase, the endometrium reaches its maximum thickness
as a result of secretory transformation on the 20th to 25th day of the cycle, with an
overall bilayer thickness of 10 – 15 mm (Fig. 11 c), increasingly transforming itself
into echodense streaks. During the late secretion phase (26th to 28th day of the cycle,
the thickness of the endometrium perceptibly decreases once more. Shortly before
the start of menstruation, hypoechoic areas projected onto the endometrium indicate
the onset of desquamation (Fig. 11d). The layering of the endometrium quickly
disappears as a result.
Fig. 11 Cyclic changes in the endometrium
a) 5th day of the cycle. Low endometrium
b) 14th day of the cycle Elevated endometrium. Mucous
clearly present in the region of the cervical canal (arrow)
16
c) 21st day of the cycle. Maximum build-up of
endometrium, increasingly echodense
d) 28th day of the cycle. Non-homogeneous
endometrium, decreasing thickness, hypoechoic zones
Optimum evaluation of the contour of the uterine cavity can be obtained via 2D
sonography from the 20th to the 25th day of the cycle, with a well built-up image of
the endometrium. This is particularly useful for diagnosing uterine anomalies
(Uterus bicornis, subseptus, arcuatus, etc.) (Figs. 19, 20, 21).
At the pre-menopausal stage, endometrial thickness of over 12 mm can be indicative
of disease (endometrial polyp, submucous myoma, etc.) or of pregnancy. If disease
is assumed, a post-menstrual check-up should be performed (around the 6th day of
the cycle). From a physiological aspect, a streaky endometrium would be expected.
Following administration of atrophying gestagens, the endometrium should present
with a uniform atrophic appearance, i.e. with a bilayer thickness of less than 5 mm
(Fig. 12).
Fig.12 Streaky endometrium (measurement 1) during long-term gestagen administration
Postmenopausal without hormone replacement therapy indicates that vaginal
bleeding must be clarified histologically. One exception to the rule is an endometrial
thickness of < 5 mm measurable on sonography, which, given the extremely
negative predictive significance of this value, must be initially viewed as
anticipated/expectative, assuming atrophy-induced bleeding21,22
Postmenopausal during hormone-replacement therapy – regular or minor bleeding
and an endometrial thickness of > 8 mm initially suggests hormone-related
17
withdrawal bleeding. A histological examination must be carried out if the
endometrium does not decrease considerably thereafter.
As a general rule, unclear situations regarding the endometrium can be initially
clarified by HyCoSy or hydrosonography thus contributing to a minimally invasive
procedure regardless of whether or not the patient is bleeding22.
2.2.5
Ovaries
Detection of the ovaries does not generally pose any problems in premenopausal
patients given the specific morphology of these organs with follicles and their usual
position in the ovarian fossa in the vicinity of the external iliac vessels (Fig.16).
Follicles can be distinguished from major vessels (e.g. in the case of Pelvic
Congestion Syndrome) by manoeuvring the probe through 900, i.e. if the section
displayed forms a tube after turning through 900, it is most likely to be a vessel as
opposed to a follicle. The explanation can also be given via a positive or negative
blood flow on the Doppler colour scan.
In the postmenopausal patient, ”postmenopausal sonographic ovary“ refers to a
homogeneous, hypoechogenic, ovular structure of myometrium echogenicity, < 20
mm long, with an echogenic margin and no peristalsis23,24. This image is mostly
small and atrophied on direct macroscopic examination. Pathological significance is
only seldom attributed to this phenomenon on microscopic investigation23,25.
The simplified form of the ellipsoidal formula should be used to measure the
ovaries26,27. Ovarian volume (ml) = diameter1(mm) x diameter2 (mm) x diameter3
(mm) x 0.000523. Three axes should be displayed that are all perpendicular to each
other. The image shown on the monitor is divided up into sections for this purpose
and the magnification is selected so as to highlight the left and right ovaries in full
(Fig. 13).
Markedly divergent data have been published regarding the presentability of the
ovaries, ranging from 99 %24 to 85 % for at least one ovary and 60 % for both
ovaries in the same patient23. In practice, the ovaries can nearly always be detected
in pre- and perimenopausal women and in over 50 % of postmenopausal women
based on the criteria outlined above.
Fig.13 Calculation of ovarian volume based on length, breadth and depth
a) Premenopausal, 12th day of the cycle
b) Postmenopausal
18
A clear-cut correlation between uterine and ovarian measurements recorded on
sonography and anatomical/pathological examination has been confirmed by various
authors in studies with large patient cohorts23,28.
Structures with an average diameter not exceeding 30 mm in pre- and perimenopausal
women are referred to as ovarian follicles. The pathological term "ovarian cysts" is
justified for values over 30 mm. In postmenopausal patients, every round, echo-free
structure projecting on to the ovary is classed as a cyst. The maximum ovarian
volumes according to age are general a good marker for ruling out a disease (Tab. 3).
Another rule used in practice is that one ovary should not be more than twice the size
of the other one.
Tab. 3 Ovarian volumes, upper limits (guidelines)28
max. Volume (ml)
Premenopausal
Postmenopausal
2.2.6
18
8
Cyclic diagnostics in the ovary
As with the endometrium, an ovarian cycle averaging 28 days is assumed.
During the first 5 days of the cycle (corresponding to menstruation), only “antral”
follicles can be detected in the ovary under normal conditions (Fig. 14a). These appear
as echo-empty, small, < 8 mm round zones in the ovary. Their number correlates with
the ovarian reserve in that 15 have an excellent reserve and less than 7 indicate
severely limited fertility.
From these follicles, one follicle crystallises as the dominant follicle per cycle and
grows linearly, averaging 1.5 - 2 mm per day. The other antral follicles become
atretic.
Prior to ovulation, the dominant follicle grows to approximately 22 mm (Fig. 14b). As
the follicle is occasionally clearly oval instead of largely spherical, the average
diameter of three internal diameters, perpendicular to each other, is used for
folliculometry. The largest possible magnification should be chosen. This mass is
particularly significant for assisted reproduction medicine. With mature follicles, the
Cumulus oophorus is often (in 40 - 80 % of cases) portrayed as a parietal more
echodense structure (Fig. 14c).
Immediately after ovulation, the ruptured follicle is generally no longer visible and is
replaced by a small, collapsed, cystic structure filled with some fluid. Above all, the
persistence of a structure resembling a follicle does not prevent ovulation. Free fluid
in the pouch of Douglas and an obviously dilated cervical canal with echo-empty
content are indirect, rather uncertain signs that ovulation has taken place.
19
Fig. 14 Cyclic changes in the ovary
a) 5th day of the cycle Some antral follicles (under 8 mm)
b) 14th day of the cycle Clearly oval predominant follicle
c) 14th day of the cycle Predominant follicle with
Cumulus oophorus prior to ovulation.
d) 16th day of the cycle Typical Corpus rubrum postovulation with marked perifocal blood flow
e) 21st day of the cycle Corpus luteum, on 2 perpendicular
planes
f) Corpus albicans (white arrow)
The Corpus rubrum (haemorrhagicum), characterised by fine internal echoes (Fig.
14d) is formed as a result of bleeding in the hatched follicle. The Corpus luteum is
then formed by producing vessels (Fig. 14e). Sonographic image quality can vary
considerably with this structure. The Corpus luteum either has a predominantly
hypoechoic content and an echodense margin or a mainly homogeneous echodense
content. The dimensions can also vary.
20
Corpus albicans presents as an echodense, lobed, rounded structure, generally
devoid of any direct contact with the cortex (Fig. 14f).
Antral follicles are mostly detected under ovulation inhibitors (Fig. 15). Otherwise,
reliable contraception is doubtful.
Fig. 15 Resting ovaries under ovulation inhibitors
2.2.7
Tubes
Normal, unchanged tubes cannot be seen and cannot be separated in the adnexal
region. Only a tube filled or surrounded by fluid can be seen.
2.2.8
Major vessels
The right and left external iliac A and V are regularly visible lengthwise. If shown
transversally, avoidable cystic or double cystic findings can be displayed lengthwise
per se or transmitted as pulsating vessels by manoeuvring through 90°.
Fig. 16 Image of the external iliac A and V, lengthwise, and the ovarian fossa No distinction can be
made between the vessels on the left and right side of the body in this image.
right
a) Ovarian fossa, right
left
b) Ovarian fossa, left
The division into the common iliac A and the internal and external iliac A is
generally visible. This division represents a landmark in ovarian scans because they
often lie in the ovarian fossa, which is formed by the vessels (Fig. 16). It should be
21
noted that, when the images are shown as outlined above, the external iliac vessels
always run from left and right in the image from the top left to the bottom right as
opposed to the vessels on the right side of the body which then run from top right to
bottom left. This is consistent with the fact that TVS shows distances without stating
whether the section is positioned to the right or left of the median sagittal plane.
Many US devices give the option of portraying the image left-right according to the
position of the section. However, this is not considered a practical option and is not
recommended. The sagittal sections in TVS always appear from the right in the
patient.
2.2.9
Muscles
The two muscles that are regularly portrayed in the dorsal direction on TVS are the
M. obturatorius internus and the M. piriformis. On scanning at depth, they are
identified as small, delineating pelvic structures in the dorsal lateral and caudal
lateral regions. They are structured like all fasciated muscles, i.e. generally
hypoechoic with fine, echodense stripes in one direction (Fig. 17). No further
pressure should be applied on contact with this structure.
Fig. 17 M. piriformis. Note muscle pinnates (white arrow)
2.2.10
Pouch of Douglas
Particular clinical relevance is attached to the pouch of Douglas. In the standing
female, it represents the lowest point of the abdominal cavity. All of the fluids that
penetrate the unobstructed abdominal cavity and are not encapsulated are expected
to reach the pouch of Douglas where they can be aspirated if need be.
Physiologically, some free, echo-empty to hypoechoic fluid can very often be seen
in the Pouch of Douglas (Fig.18a). This mainly occurs mid-cycle, after ovulation.
Finally, when the depth of the free fluid exceeds the depth of the cervix, the free
fluid is referred to as abundant.
Physiologically, one or both ovaries can be found in "solid" space-occupying lesions
in the Pouch of Douglas. Enlarged adnexa are often found in the Pouch of Douglas
due to gravity.
The most common findings in the Pouch of Douglas are large and small intestinal
loops, the walls, calibre and peristalsis of which can be clearly seen an evaluated.
22
Fig. 18 Free fluid in the Pouch of Douglas
a) A smaller physiological quantity
2.2.11
b) An abundant quantity, echo-empty
Urinary bladder
The urinary bladder should be considered during every sonographic procedure. The
bladder should, if possible, be empty for TVS scans and full for TAS scans. In this
way, every cystic finding in the small pelvis is to be considered suspicious on TVS.
It should, however, be noted that the bladder can fill up very quickly, especially in
stressful situations. Urine in the bladder is always seen to be devoid of echoes
(exceptions: marked haematuria, pyuria). The settings on the device can be adjusted
(“calibrated”) for a bladder examination so that the urine appears devoid of echoes.
This reference value is often of major importance when assessing the intensity of the
internal echoes in the small pelvis. Particular attention should be paid to concrement
and bladder tumours. The jet phenomenon with the ejaculation of urine from both
ureteral ostia in the urinary bladder can also be detected without any problem.
2.3
2.3.1
Diseases of the internal genitalia
Congenital Deformities
Uterine deformities affect approximately 0.4 % of all women, 4 % of sterility and
infertility patients and up to 40 % of patients with ≥ 2 miscarriages.
The development of Müllerian Duct Anomalies (MDA) can be attributed to a narrow
period of time in embryonal or foetal development. Uterine hypoplasias or –aplasias,
complete (Mayer-Rokitansky-Küster syndrome, etc.) or incomplete, or only onesided (Uterus unicornis, etc.), develop during the 8th – 11th week of pregnancy due
to partial or complete underdevelopment of one or more ducts. Partial or complete
double systems (Uterus didelphys, bicornis bicollis, bicornis unicollis, etc.) develop
in the 12th – 14th week of pregnancy due to incorrect fusion of the ducts (Fig. 19a).
Deformities that primarily affect the uterus (Fig. 19b) (Uterus arcuatus, septus,
subseptus) originate during the 15th – 19th week of pregnancy due to incomplete
resorption of the embryonal section of the wall that connects the ducts. The currently
23
most widely used MDA classification was that developed by the AFS (American
Fertility Society) in 198829.
Fig. 19a Transverse Uterus bicornis Corpus /
fundus very wide and interrupted (MDA!),
amniotic sac in early pregnancy in the right horn
(Fig. 19b Transverse uterus arcuatus: Fundus is
very wide, the endometrium in a narrow, concave
manner to the angles of the tubes (sagittal: Fundus
is flat on the outside to minimally convex, arched)
Fig. 19c Uterus subseptus (3D image see Fig. 20) transversal: the suspect isolated endometrial islets to
the angles of the tubes suggest MDA (sagittal: the unchanged elevated position of the thick white dot
(fundus) from right to left rules out Uterus bicornis, in the centre, the marked movement of the small
white dot (inner fundus) in the caudal direction is indicative of uterus subseptus as arcuatus
Transversal: fundus
Sagittal: fundus right
Fundus in the centre
Fundus left
Sonographic indications of uterine anomalies are mostly apparent in the fundus with
a highly built-up image in the endometrium in the 2nd half of the cycle (Fig. 19c).
Firstly the presence of rejuvenated “endometrial islets” in the direction of the fundus
as far as the angles of the tubes should firstly be clarified in the transverse sections
from the fundus to the cervix and back again. If these are present, they are indicative
of MDA. The uterus should be examined from left to right and vice versa in sagittal
sections and any infiltrations in the fundus investigated (Fig. 19c, large white dot).
Significant infiltration suggests Uterus bicornis. If no infiltration can be detected, the
upper inner section of the fundus should be examined to establish whether it clearly
deviates in the caudal direction. A slight deviation is indicative of Uterus arcuatus
whilst a marked deviation suggests Uterus suptus.
24
Further indicators shown on the image include:
• A suspiciously wide neck of uterus
• The presence of septa
• Missing kidney (suspected Uterus unicornis?).
If sonography does not give a conclusive diagnosis, hydrosonography30, HyCoSy or
MRI scan can be carried out.
3D sonography (Fig. 20)31 provides an excellent image of the uterine contours under
investigation. It provides ultrasound practitioners with considerable potential for the
diagnosis of uterine deformities, especially when combined with a gynaecological
examination.
Fig. 20 a,b) Uterus subseptus in 3D images (Uterus from Fig. 19c), c,d) normally configured Uteri
(white dots: Small fundus on the inside, large fundus on the outside)
a) Virtual 2D section plane
b) 3D surface rendering
c) Normal uterus, 1-para
d) Normal uterus, 0-para
2.3.2
Diseases originating in the uterus
2.3.2.1
Myoma
Myomas are the most common gynaecological tumour. Every third woman of childbearing age is a myoma carrier32. Myomas can also develop postmenopause. Isolated
myomas are less common than multiple myomas and more than half are located in
the region of the fundus. In addition to localised myomas, there is also diffuse
25
myomatosis (Fig. 21) with a very non-homogeneous myometrium. Submucous
myomatosis (Fig. 22) can be indicative of a major fertility problem. Occasionally
giant myomas are sufficiently visible as far as the upper abdomen. Myomas with a
diameter of more than 10 cm should be examined using TAS.
Sonographically, myomas typically have a swirling internal structure with
echodense and hypoechoic areas. They are spherical in shape and are generally
clearly delineated against the myometrium (Fig. 23). Myomas with a good blood
flow have a hypoechoic internal pattern (Fig. 24). Echogenicity also decreases as the
degenerative changes increase (Fig. 25). However, calcification leads to extremely
echodense, non-homogeneous areas. The acoustic shadows that constantly appear
with varying density behind the myomas are interesting to note. Blood flow is
regularly detected on Doppler colour scans with the largest vessels appearing on the
outer boundary.
Fig. 21 Diffuse myomatosis
Fig. 22 Submucous myomatosis with at least 7
small myomas directly below the endometrium
Fig. 23 TVS on two planes perpendicular to each other, subserous myoma, non-homogeneous, maximum
measurement of 53 mm
26
Fig. 24 Subserous, with a broad-based stem,
diameter of just 12 mm, small hypoechoic anterior
wall myoma, clinically silent
Fig. 25 Subserous myoma with severe
degenerative changes, liquefied centre, originating
from the fundus to the left (DD: malignant
adnexal finding)
Fig. 26 17 mm submucous myoma, unenhanced
2D on 2 perpendicular planes
Fig.27 Intraligamentary myoma, 38 mm, broad
base attached to uterus, maximum diameter
Rounded foci detected in the myometrium should be described as follows: 1.
Position [submucous (Fig. 26), intramural (Fig. 21), subserous (Fig. 23),
pedunculated subserous (Fig. 24), intraligamentary (Fig. 27)], 2. Average of the
three main diameters, 3. Echogenicity, 4. Homogeneity. The position of the myoma
in relation to the uterus / endometrium is highly relevant for clarifying the clinical
symptoms and planning surgical treatment.
The growth of myomas is clearly oestrogen-dependent and should therefore be
monitored at appropriate, i.e. three-monthly intervals in premenopausal women until
a stable size is detected. Growth following the menopause is suspicious although
malignant degeneration at < 0.3 % is extremely rare and uterine sarcoma appears to
be largely independent of myoma formation33.
It should be pointed out that measuring the size of the myoma varies considerably
from one examination to the next and from one practitioner to the next. This must be
taken into account when assessing an overall growth trend.
27
2.3.2.2
Polyps
Small polyps in the corpus mucosa are often difficult to diagnose. The first signs
include an increased middle echo, an enlarged “undulating” endometrium in one or
more areas, a smooth area and a local increase in tail-shaped delineation. The
sonographic image with spherical to cone-shaped, non-homogeneous and possibly
small cystic space occupying lesions on the macroscopic image are only
occasionally reminiscent of polyps (Fig. 28). If fluid is present at the same time, the
evaluation of an already unenhanced 2D image is relatively simple (Fig. 29).
Artificially produced fluid as part of contrast agent sonography (Fig. 5 HyCoSy, Fig.
6 Hydrosonograpy) can be extremely useful when distinguishing between an
accentuated endometrium and a polyp via scans.
Corpus polyps can be very long, even extending as far as the cervix. In terms of
width, they seldom exceed 10 mm. Polyps of unknown origin, which are clinically
displayed in the cervical canal, are known as “cervical canal polyps” until confirmed
sonographically. In principle, a cervical polyp can be directly removed whereas the
cavum should be clarified by hysteroscopy and curettage in the case of a corpus
polyp.
Principally, all polyps developing in the postmenopausal phase require histological
clarification particularly since polyps are frequently associated with endometrial
carcinoma without actually being the cause of the carcinoma.
Fig. 28 Echodense corpus polyp, isodense to the endometrium clearly portraying the middle echo and
highlighting the endometrium
Fig. 29 Polypoidal endometrium with 2 additional polyps (arrows) on 2 planes perpendicular to each
other
28
2.3.2.3
Fluid accumulation in the uterine cavity
This can be seen regularly during menstruation. “Spontaneous” fluid accumulation
regularly occurs in the presence of a stenosed cervix, especially during the
postmenopausal phase (Fig. 10). Fluid accumulation in the uterine cavity per se is
not indicative of malignancy35. On the contrary, it highlights the mucosal contours
against a contrast-enriched background and facilitates a better evaluation. Intracavity
fluid should be aspirated on measuring endometrial thickness (bilayer ap).
2.3.2.4
Adenomyosis
The endometrium can be detected in the myometrium with uterine adenomyosis.
This can only affect the innermost, basal layer (Fig. 30a). The endometrium is only
unclearly delineated against the myometrium in the presence of numerous fine,
echodense areas. However, the deeper myometrium as far as the serosa can also be
affected (Fig. 30b). This is expressed in the form of a non-homogeneous
asymmetric to sphere-shaped thickening of the uterus (Fig. 30c), occasionally
accompanied by more extensive cyst formation with echodense margins.
Fig. 30 Adenomyosis uteri
a) Affecting the basal layer
b) Broadly positioned in the innermost layer of the
myometrium
29
c) Surrounding and infiltrating the myometrium
2.3.2.5
Echodense spots in the region of the uterine cavity
Echodense spots projected on to the uterine cavity often appear. They mostly appear
after pregnancy and can be evidence of curettage or the expression of small
degenerative changes (Fig. 31)36. They are rarely associated with a serious disease.
Very rarely, spots highlighted sonographically can mask ossification of the
endometrium, which would be evident on histological examination36.
Fig. 31 Echodense spots (arrows) projected onto the cavum/endometrium
a) 6 weeks post-partum, insignificant (clearer section
stigma with triangular expansion in the region of the
section scar)
b) Multiple, focal spots 1 year after spontaneous delivery
2.3.2.6
Ovula Nabothii
Spherical, echo-empty, isolated (e.g. punched-out), often multiple structures are
frequently found in the neck of the uterus in premenopausal women. These
structures vary in length from a few to several centimetres (Fig. 32) with clear echo
amplification behind the finding. They are located only a few millimetres from the
head of the probe but do not cause any discomfort. These sonographic findings are
pathognomonic for Ovula Nabothii. They can often be confirmed by colposcopy37.
Fig. 32 Multiple Ovula Nabothii
a) Stroma in cervix, retroflexed uterus
b) Internal cervical tissue, anteflexed uterus
30
2.3.2.7
Endometrial carcinoma
No histological diagnosis should be made sonographically but the suspicions
surrounding an excessively built up endometrium, non-homogeneity and unclear
delineation against the myometrium with corresponding clinical findings (especially
postmenopausal bleeding) should be expressed.
Fig. 33 Endometrial carcinoma, exophytic and
infiltrating, myometrium infiltrated by >50%
(dots)
Fig. 34 Endometrial carcinoma extending to the
cervix (internal cervical tissue marked with white
dots)
If corpus carcinoma is detected histologically, an experienced practitioner will be
able to confirm “sonostaging” in terms of depth of invasion38 (Fig. 33) and
infiltration in the cervix (Fig. 34). Statements regarding infiltration in the parametria
or surrounding organs (tubes, ovaries, bladder, rectum) cannot be assessed as
reliably via sonography.
The endometrium must be dealt with separately under Tamoxifen (Fig. 35). Since
evidence points to the fact that conditions such as proliferating endometrium,
hyperplasias, polyps, invasive carcinoma and sarcoma occur in large numbers but
only very occasionally in postmenopausal women receiving tamoxifen39, TVS as a
fixed element of the routine follow-up procedure is discussed controversially in
those patients affected. It is unanimously agreed that a histological explanation must
be given for a patient who bleeds whilst taking tamoxifen. This approach should also
be adopted for an asymptomatic patient with an overall endometrial thickness of > 8
mm. Tamoxifen-induced changes not only of the endometrium but also of the
innermost layers of the myometrium contribute to the sonographically highlighted
endometrium in the conventional form with enlarged cystic lesions (“Swiss cheese
lesion”)
2.3.2.8
Uterine sarcoma
Uterine sarcoma can only be suspected sonographically: spherical space-occupying
lesion with non-homogeneous, hyperechoic and hypoechoic areas40 and, above all,
rapid growth. The diagnosis is always based on histological examination. Uterine
sarcoma seems to develop almost exclusively as de novo cases as well as through
degeneration of the existing myoma (estimated proportion < 0.3 %)41.
31
Fig.35 Endometrium under tamoxifen
a) “Swiss Cheese Lesion”, sonographic image of
endometrium, 22 mm, atrophy evident on hysteroscopy
b) Low, non-homogeneous endometrium, amenorrhoea,
retroflexed uterus
c) Endometrium, 8 mm thick, with cysts, no bleeding, retroflexed uterus
2.3.2.9
Cervical carcinoma
Basically, routine sonography is not yet suitable for diagnosing or helping to stage
cervical carcinoma42. Even parametrial involvement cannot be assessed primarily
via sonography. In the case of status post cervical amputation, the remaining cervix
can be assessed lengthwise using sonography (Fig. 36).
Fig. 36
Short residual cervix (measurement 2) – status post cervical amputation due to cervical
carcinoma stage 1A1
32
2.3.2.10 Abnormal uterine bleeding (AUB)
The FIGO classification system for the potential causes of premenopausal abnormal
uterine bleeding43 comprises 9 categories, which are referred to under the acronym
“PALM-COEIN”. “PALM” stands for causes that can be highlighted via
sonography: Polyps, Adenomyosis, Leiomyoma and Malignancy, which should be
thoroughly investigated. Finally, an overall bilayer thickness of over 12 mm is
suspicious20.
A conservative approach should be considered at the postmenopausal stage with
uterine bleeding and a maximum endometrial thickness of < 5 mm confirmed on
sonography21,22. Following the random detection of an endometrial thickness of 5
mm and over, a test for hormone-induced withdrawal bleeding should be carried out
followed by a check-up at least in the early postmenopausal stage44.
2.3.3
Diseases originating in the adnexal region
Clinical practitioners should note that the discovery rate of an adnexal finding
during a purely clinical examination without sonography is very low, depending on
the extent of the finding, i.e. just a 33% chance with a lesion of 4 – 6 cm and 75 %
with lesions of 6 – 8 cm45. Thus a combination of clinical investigation and
sonography is vital for a correct diagnosis in the adnexal region.
Initial imaging for adnexal investigations should be carried out with the TVS
method. This can then be effectively supplemented by TAS especially in the case of
small pelvic tumours or when investigating other tumour masses in the central and
upper abdomen, ascites, lymph node and liver metastases and evaluating the urinary
ducts. Overall sonographical diagnosis with an empty bladder is an exception to the
rule since, in principle, every cystic finding warrants clarification. Objective imaging
should generally be strived for.
Clarification of organ identification is extremely useful. For instance, a solid
adnexal tumour can clearly be attributed to a subserous pedunculated myoma (Fig.
37). Hence as a common benign uterus finding, it is to be assessed and treated very
differently from a genuine adnexal finding thought to be malignant.
Fig. 37 Solid adnexal finding corresponding to subserous myoma, ovary (arrow) evident with skilled
probe guidance
33
Any attempt to pre-empt histopathological diagnosis via sonography warrants
reservation on the part of the practitioner. Even experts make the correct diagnosis
in only 42 % of cases46. A so-called n:m problem arises in that virtually every
sonomorphological criterion can be allocated to every histopathological diagnosis
and vice-versa.
The following criteria of dignity have proved useful in assessing the dignity of an
adnexal finding. Tumour size, wall structure, cyst structure, wall thickness, septal
thickness, inner surface of the cyst, internal echoes in cystic and solid sections,
surface properties and ascites47. The classification of adnexal findings in the
following groups can also prove useful for the subsequent procedure48: simple cysts,
cystic tumours with internal echoes, cystic-solid tumours and solid tumours. It is
anticipated and largely supported in the literature with single-chamber, echo-empty,
smooth walled cysts, that malignant neoplasms cannot be detected at the pre- or
postmenopausal stage.
Bernaschek49 should be consulted in practice since a simpler classification system
focusing on three sonographic groups has been devised: Simple cysts, apparently
benign findings and seemingly malignant findings, with different treatment
recommendations for each group.
The SGGG50 recommendation to estimate and deal with adnexal findings is based on
a clinical examination followed by TVS with or without an estimate using the
Sassone or Mainzer score (Tab. 4) and with or without determination of CA125 (see
also51,52).
More recent concepts with possibly simpler rules and regulations such as the
estimation of adnexal tumours based on IOTA (International Ovarian Tumour
Analysis Group) criteria initially advocate testing for benign and malignant lesions
using few characteristics.
The estimate should directly lead into the procedure both in the pre- and
postmenopausal stage: benign findings should be checked sonographically, probably
benign findings should be removed laparoscopically, probably malignant findings
should initially be clarified by laparoscopy and any evidence of malignancy should
be investigated via median laparotomy.
2.3.3.1
Simple adnexal cysts
The sonomorphological image of simple adnexal cysts comprises a spherical to
ellipsoidal smooth-walled space-occupying lesion (Fig. 38). The finding must be
isolated with no evidence of septa or deposits, and, above all, regular, fine internal
echoes should be detectable. Simple adnexal cysts include in particular the large
group of virtually always self-limiting, functional ovarian cysts (follicular cysts,
Corpus luteum cysts (Fig. 39), cysts with superstimulation and PCOS (Fig. 40),
etc.).
These also include retention cysts [parovarial cysts (originating from embryonal
structures of the rete ovarii), pseudoperitoneal cysts, etc.], benign tumours [serous
cyst adenoma (Fig. 41), purely cystic mature teratoma, etc.].
34
Fig. 38 Simple ovarian cyst measuring 73 mm.
Note the enormous echo amplification behind the
cyst
Fig. 39 Corpus luteum measuring 33 mm, with
cystic changes
Fig. 40 Typically configured, PCOS-like ovaries. These appear to be enlarged with follicles measuring
8 mm and are arranged like strings of pearls under the Tunica albuginea, without displaying a dominant
follicle in the cycle.
A whole series of studies could not detect any malignancy with simple cystic
adnexal findings either at the pre- or postmenopausal stage, e.g. in the on-going
Kentucky Ovarian Cancer Screening Project, 256 simple cysts were detected in
7705 postmenopausal women (3.3 %), 125 (49 %) of which resolved spontaneously
within 60 days and 131 (51 %) persisted53. Of the latter, 45 underwent surgery and
86 were followed up. No cancer has been detected in either group to date.
On discovering a simple adnexal cyst, the practitioner is responsible for avoiding
unnecessary surgery by authorising sonographic check-ups at appropriate intervals.
The patient should be informed about the possible complications, namely bleeding,
torsion or rupture. All of these events are associated with acute pain. In such a
situation, the patient should seek medical treatment immediately and should not
travel in remote regions.
The OEGGG Guidelines of 199854 offer a suitable algorithim for dealing with a
simple adnexal cyst – an approach that is still used today. According to the
guidelines, a diameter of 5 cm is the boundary for a surgical procedure. At least
once ultrasound check-up must still be performed at the premenopausal stage whilst
postmenopausal cases are subject to immediate surgical exploration. This is based
above all on clinical experience.
35
Fig. 41 Serous cyst adenoma >10 cm
a) Simple cyst with no echoes
b) Simple, weak, echogenic cyst (compared to echoempty cyst, minimally filled bladder (arrow)
Contradictory statements have been published regarding dignity criteria for septated
cystic adnexal findings (e.g.48,55). Since septated cystic adnexal lesions must be
closely monitored, practitioners should initially decide against surgery.
2.3.3.2
Benign adnexal findings
This group includes all cystic adnexal findings with (a clear) internal structure,
which in the densest case, is difficult to distinguish from purely solid tumours. The
findings should be investigated on the basis of all dignity criteria and described from
a purely sonomorphological perspective (see chapter on „objective image
descriptions“)
The histology of this sonographical group ranges from blood-filled ovarian cysts
(Fig. 42), via endometrial cysts (Fig. 43), retention cysts, serous and mucinous
cystic adenoma (Fig. 44), deep teratoma (Fig. 45), fibroma, myoma (Fig. 21-27) and
inflammatory processes such as sactosalpinx (Fig. 46), through to critical/malignant
ovarian findings.
A series of extragenital cystic space occupying lesions in the small pelvis as well as
pitfalls can clearly compound differential diagnosis.
This group also includes highly typical sonomorphological features of certain
histopathological findings.
Fig. 42 Typical images of blood-filled ovarian cysts, resorption haematoma
36
Fig. 43 a) Diagram of the sectional planes:
Fig. 44 Mucinous cystic adenoma Note the universally evenly distributed, pleomorphic echogenic
internal echoes
A blood-filled ovarian cyst (Fig. 42) is virtually always accompanied by a
hypoechoic, homogeneous internal echo reminiscent of a spider’s web and with a
honeycomb structure. Some areas appear devoid of echoes depending on the
condition of the images.
Similar images can be recorded with endometrial cysts (Fig.43). They tend to
display a clumpy or honeycomb internal echogenic pattern, often accompanied by
additional fluid levels.
Benign dermoid cyst, also referred to as mature teratoma is another common
adnexal disease. It is often an entirely echogenic tumour (Fig. 42), even if a purely
cystic dermoid is present (Fig. 45). A round, echodense nucleus is often seen
comprising either solid parts or a mass of sebum. Very often a streaked echodense
pattern is visible, which is probably caused by hair. Typically, the dermoids tend to
“float on the surface”, thus moving from the small pelvis in the ventral direction,
often submerging into the acoustic shadows of the intestinal loops on TVS.
It is interesting to note that the typical findings are also evident in inflammatory
adnexal processes, such as the sactosalpinx (Fig. 46). With appropriate probe
guidance, the septated cysts are mostly portrayed as a tightly wound hose. This
image is also referred to as “meandering” like the tortuous path of an uncorrected
river. Depending on the inflammatory stage, vascularisation is mainly seen in the
septa to varying degree together with a very low flow index.
37
Fig. 45 Dermoids (mature teratoma)
a) Typical echocomplex dermoid with echogenic,
spherical nucleus (arrow). The internal echoes are
irregular, evenly distributed, loose to dense, weak to
strong, fine to coarse
b) predominantly cystic dermoid with small echodense
nucleus (arrow)
In routine daily practice, these four benign adnexal findings together with simple
adnexal cysts account for over 60 % of all adnexal lesions, thus providing competent
sonographers with an impressive list of criteria on which to accurately assess their
findings and decide on a suitable procedure47. It must be assumed that the large
group of cystic adenomas can also be correctly recognised and classified in practice,
thus increasing the quota of cases routinely encountered.
Fig. 46 Sactosalpinx
Retroperitoneal tumours originating from the vertebral column, for instance, also
belong to the rare extragenital cystic space occupying lesions in the adnexal area.
Tarlov cysts (extradural nerve root cysts) develop in around 5% of humans (Abb.
47). Pitfalls such as the clinically unrecognised overflow incontinence seldom occur.
2.3.3.3
Malignant adnexal findings
The typical sonomorphological image of this group ranges from purely solid to
complex [solid-cystic (Fig. 48), and cystic-solid (Fig. 49), depending on which
component predominates]. Once again the findings should be investigated on the
38
basis of all dignity criteria and described from a purely sonomorphological
perspective.
Prömpeler47 discovered over 60% of malignant neoplasms in purely solid tumours
during the pre and postmenopausal stages compared to 20% of malignant cases with
complex premenopausal tumours and 60% at postmenopausal level. Timmermann56
was able to show that an estimation of the dignity of an adnexal finding by an
experienced ultrasound practitioner clearly exceeded all other methods.
Morphological scores (e.g.57,58), Doppler colour scans, logistic regression models
and artificial neuronal networks proved less effective on the whole. Experienced
practitioners managed to distinguish between benign and malignant adnexal findings
with a 95% hit quota. In Timmermann’s study and a whole series of other studies,
papillary deposits, irregularly limited solid areas, septa and increased
vascularisation in Doppler colour scans are viewed as clear indicators of
malignancy (malignancy criteria).
More recent concepts with possibly simpler rules and regulations such as the
estimation of adnexal tumours based on IOTA (International Ovarian Tumour
Analysis Group) criteria initially allow testing for benign and malignant tumours
using 5 criteria59. If only malignancy criteria are discovered, the finding is obviously
malignant. If only benign criteria are discovered, the finding is obviously benign.
The 10 rules outlined below could be applied in 75% of cases with a sensitivity of
92 % and specificity of 96 %60. If a finding displays both benign and malignant
criteria, it cannot be classified even if no criteria are satisfied61. The final estimation
by an expert scored the highest number of hits. The procedure according to IOTA
yields similarly correct statements like the complex pattern identification.
Tab. 4
Mainzer’s score for the sonomorphological evaluation of adnexal tumours (see also
documentation sheet appended).
Mainzer-Score: Sonomorphological evaluation of adnexal tumours using TVS
(according to Merz)
Criteria
1. Overall structure of the
0 Points
-
1
simple
2
complex
2. Tumour delineation
smooth
slightly irregular
markedly irregular
3. Wall thickness
< 3 mm
≥3 mm, ≤ 5 mm
4. Internal echoes of the cystic
none
homogeneous
non-
5. Septa
6. Shape of the complex or purely
solid section
7. Echogenicity of the complex
or purely solid section
8. Acoustic shadows
none
no solid section
≤ 3 mm
smooth
> 3mm
bumpy
no solid section
homoge
non-
echo amplification
partly acoustic shadows
9. Ascites
none
a few
10.
Liver
carcinosis
metastases/
Premenopausal:
Postmenopausal:
39
peritoneal could not be detected
cannot
moderate
be
evaluated
presentable
max. 20 points
Up to 8 points: benign, ≥ 9 points: malignant, 96 sens, 8% spec 81%, 47% ppV, 99.6% npV (Merz
Up to 9 points: benign, ≥ 10 points: malignant, 97% sens, 91% spec, 91% ppV, 97% npV (Weber et
al. 1999)
Tab. 5 IOTA criteria to estimate adnexal tumours60
IOTA Criteria
Benign
Malignant
B1 unilocular
M1 Irregular solid tumour
B2 solid components <7 mm present
M2 Ascites present
B3 Acoustic shadows present
M3 At least 4 papillary structures
B4 smooth-walled multilocular tumour <100 mm
M4 irregular, multilocular, solid tumour > 100 mm
B5 No blood flow present (Colour score 1)
B5 Extremely heavy blood flow present (Colour score 4)
Fig. 48 Solid cystic ovarian cancer
Fig. 49 Cystic solid ovarian cancer
In an impressively comprehensive meta-analysis of 445 publications62, the grey
level-coded TVS with a sensitivity of 82 – 91 % and specificity of 68 – 81 % was
described as superior to all other current methods. Doppler colour sonography, the
tumour marker CA125, CT scanning, magnetic resonance imaging and PositronEmission-Tomography are all less beneficial.
2.4
2.4.1
Early pregnancy
Intact early pregnancy
An intact, timely developed intrauterine embryo63 characterised by:
• Evidence of the amniotic sac measuring from 1.6 mm, no later than 4 + 4 weeks
of amenorrhoea
• Evidence of the yolk sac no later than 5 + 0 weeks of amenorrhoea
• Positive heart action no later than 5 + 5 weeks of amenorrhoea.
Thus it should be [possible to diagnose an intrauterine pregnancy up to 5 + 5 weeks
of amenorrhoea during TVS with almost 100% accuracy64, at a time when there is
still no pain and only occasional minor bleeding (Tab. 6).
40
Tab. 6 Correlation of sonographic signs (thick dots represent the latest appearance of a sign in 95 % of
pregnancies, GS amniotic sac, YS yolk sac, HA heart action, CRL- crown-rump length, clinical signs on
EUP (pain and bleeding), hCG serum values, cwog completed weeks of gestation)
2.4.2
Diseases with a positive pregnancy test
2.4.2.1
Early miscarriages
In principle, any doubt regarding the correct development of a precocious pregnancy
should be clarified with at least a second examination at an appropriate time interval.
Abortus imminens and incipiens are essentially clinically dictated circumstances
during which, in addition to the anticipated on-going pregnancy, hypoechoic
haematoma or recent bleeding sites can also be detected behind the foetal
membranes. Evidence of heart action is the most important argument for pregnancysupporting measures.
Abortus incompletus can lead to differential diagnostic problems if no monitoring
has been carried out and only non-homogeneous tissue can be seen in utero without
any specific pregnancy-related elements. If in doubt, “extrauterine pregnancy”
should also be suspected. This also applies for an assumed complete miscarriage.
Depending on the clinical situation, treatment can be dispensed with if the overall
thickness of the cavity is below 10 mm.
2.4.2.2
Extrauterine pregnancy
In principle, extrauterine pregnancy (EUP) must always be assumed in the event of a
positive pregnancy test (urine-hCG, SST) with no proof of pregnancy in the uterine
cavity (IUP) as this condition is potentially life-threatening.
The sonomorphology of EUP (definition: a pregnancy outside the uterine cavity),
mostly in the tubes (96 %), and, more rarely, an interstitial, cervical, ovarian or
peritoneal pregnancy, marked by several sonomorphological findings that are not
only inconsistent but which vary in terms of intensity. On EUP diagnosis, the TVS
displays sensitivity of 73 – 93% depending on the actual gestational age and the
experience of the practitioner65.
41
Above all, in precocious pregnancy, with a positive SST, only indirect EUP signs
often prevail. These are...
• A built-up endometrium without an amniotic sac (“empty uterine cavity”)
• Evidence of variable quantities of echogenic, free fluid (blood) in the pouch of
Douglas and/or on vesicouterine excavation.
Fig. 50 Tubal pregnancies
a) Oviduct pregnancy with amniotic sac and
embryonal pole (double ring sign, right arrow),
with directly adjacent echo-empty Corpus luteum,
hGG i.S. 1848 IU/L
b) Vital oviduct pregnancy, heart action (arrow),
rounded, double ring sign surrounded by haematoma,
hCG i.S. 1460 IU/L
Direct signs of EUP: In a vast number of suspected cases, a non-homogeneous space
occupying lesion can be found near an ovary. This is hypoechoic in the centre,
slightly compressible and mostly painful on pressure. The positive predictive value
(ppV) for an EUP is 80 - 90%66 with these non-simple cystic adnexal findings66 . If,
in addition, an amniotic sac with an echodense margin (ring signs) is apparent,
occasionally surrounded by a hypoechoic margin (double ring sign), the ppV
increases to 93 %67and to 96% with the additional proof of foetal pole (Fig. 50a). In
approximately 7 % of suspect cases with positive heart action in the centre of the
image (vital EUP, Fig. 50b), the ppV increases to almost 100 %.
In addition to medical history and sonography, the human choriogonadotropin
(hCG) assay makes a substantial contribution to the diagnosis of precocious
pregnancy. The significance of an individual hCG serum value lies in checking
whether the “threshold value” of (1500 to) 3000 IU/L was exceeded, whereby in
almost 100 % of cases, an EUP must be detected sonographically (Tab. 6). If this is
not the case, an EUP or miscarriage is likely. Repeated hCG assays can shed
important light on the status of a precocious pregnancy since 50 % of all EUPs
record an hCG increase of less than 53% in 48 hours and 50 % an hCG decrease of
up to 35 %. Clinical courses with a higher increase in hCG values indicate an intact
IUP whereas those with a substantial hcG decrease suggest spontaneous
miscarriaget67.
Echogenic free fluid in the small pelvis with suspected EUP should always be
interpreted as a sign of intra-abdominal bleeding. If large quantities of fluid are
found in the pouch of Douglas and on vesicouterine excavation, a significant intraabdominal blood volume of over 500 ml can be assumed. Even with appropriate
42
clinical care, this generally constitutes an emergency situation that must be
surgically corrected.
The following must be anticipated in the case of a check-up without any surgical
procedure...
• In 70 % of cases, the EUP will resolve itself completely
• The hCG falls considerably faster as the sonographic findings regress
• A perceptible reduction in EUP volume on TVS within 7 days makes
spontaneous resolution probable with 84 % sensitivity and 100 % specificity.
2.5
2.5.1
Anticonception
Effect of ovulation inhibitors
Ovulation inhibitors (OI) suppress follicle growth by almost 100% on account of
which every ovary with follicle formation must be viewed as suspicious and in need
of clarification DD: dosing errors, medication-induced reduction in OI effect,
functional findings, neoplasms and extraovarian cysts).
2.5.2
Intrauterine Devices (IUD), “Spirals”
Copper-containing IUDs can be detected directly via the highly echogenic, metalbased shaft, with full dorsal acoustic damping (Figure 51). Non-metal IUDs can be
detected indirectly via their dorsal acoustic damping (Figs, 53 and 54). Furthermore,
Mirena for example, has an echogenic caudal and cranial shaft end whereby the
actual cranial end with the wings moves a further 5 mm in the cranial direction.
TVS is currently the method of choice for checking the position of intrauterine
pessaries (IUD). Various methods for checking the position of IUDs have been
recommended in the past69,70,71,72. We suggest using the “distance rule” to check the
position of the IUD (e.g. 73). The distance (x) from the tip of the IUD to the end of
the cavity should be determined in a sagittal section (Fig. 52). It should be noted that
the ends of the IUD mostly comprise a hypoechoic section, which must be
calculated for the IUD. The endometrium also has a certain fundal thickness, which
must not be included in the measurement. A distance “x” of < 5 mm is described as
normal, 5 mm as the limit value, 6 – 10 mm as the grey zone and > 10 mm as the
IUD depth. A check-up should be carried out in 3 months’ time with a 5 mm
distance. Individual procedures are required for a distance of 6 – 10 mm. If inserted
at depth, the IUD must be removed after a detailed explanation (N.B. pregnancy is
already confirmed).
Furthermore, IUDs should be scanned via TAS with a full bladder (Fig. 55),
whereby the patient holds the ultrasound probe on her abdomen and creates the
ultrasound image. Finally, the direct position of the IUD is checked via TVS. In
favourable situations, this procedure results in pain-free, completely atraumatic
insertion
43
Fig.51 Highly echogenic IUD, containing
copper, correct position
Fig.52 Checking the position of the IUD, x
Distance between the upper pole of the IUD and
the end of the cavity
x
Abb.53 Mirena, correct position
a) Note the extremely hypoechoic IUD with marked
acoustic shadows and the two echogenic poles
b) Transverse section with wings extended in the fundus
(left). Drop shadows behind the corporal shaft (right)
Fig. 54 TAS, both poles of the Mirena are
portrayed as echogenic spots; the shaft precisely
triggers a trapezoidal acoustic shadow
Fig. 55 TAS via patient-steered Mirena device.
Mirena® is successfully positioned in utero. The
inserter is withdrawn, evidence of speculum
shadows to the right
44
2.5.3
Subcutaneous implants
Problems mainly arise with implants to be removed but which are no longer
palpable. An important pre-requisite for recognising an implant under the skin is
precise knowledge of the implant geometry and the exact insertion site, which is
often highlighted by a small scar on the skin. High-frequency linear probes (e.g.
mammary probes) should be used to examine from the dermis as far as the muscles,
extending centripedally if required. Particular attention should be paid to the end of
the object, which can easily be recognised by the way in which the dorsal acoustic
pattern falls (Fig. 56, 57). The objects themselves are often echogenic and only a
few millimetres thin. This is mostly portrayed as a fine echogenic line or echogenic
point, with the acoustic shadows close to the probe. Longitudinal imaging often
leads to reverberation artefacts on account of which the position of the implant in
relation to its depth is best portrayed in the transverse section. It should also be
noted that some linear probes cannot grasp the entire width of one implant in one
attempt, and the object must be portrayed in at least two parts.
In terms of differential diagnosis, an implant must not be separated from long
connective tissue septa, its own reverberation artefacts and occasionally also from
nerves and vessels. Major diagnostic problems can also trigger perifocal scarred
structures under the skin.
Fig. 56 Non-palpable, rod-shaped implant inserted under the skin (white arrow). The ends are marked
(black arrow)
a) Longitudinal section: proximal end
b) Longitudinal section: distal end
c) Transverse section
Fig. 57 Non-palpable, rod-shaped implant that has penetrated the muscles (white arrow). The ends are
marked (black arrow)
a) Longitudinal section: proximal end
45
b) Longitudinal section: distal end
c) Transverse section
2.6
Extragenital diseases
Knowledge of these tumours is relevant from a differential diagnosis perspective for
unclear space occupying lesions that can be attributed to the adnexal regions.
Essentially extragenital cystic space occupying lesions in the small pelvis are:
• Cystic kidneys
• Ileus
• Peritoneal cysts
• Retroperitoneal tumours, e.g. Tarlov
cysts
• Dilated ureters
•
Mucoceles of the appendix
• Fluid-filled intestinal loops
• Crohn’s disease
Essentially extragenital solid space occupying lesions in the small pelvis:
• Filled intestinal loops as pseudo
• Cancer of the bladder
tumour, faecolit
• Small pelvis metastases
• Pelvic kidneys
• Retroperitoneal tumours (neurinoma,
• Transplanted kidneys
schwannoma, lymphoma)
• Bladder / intestinal endometriotic
• Spleen with splenomegaly
foci
(haematological diseases,
infections).
• Perityphlitic abscess
• Rectal cancer
2.7
The most common differential diagnoses...
The differential diagnoses listed below are based on symptoms or findings. They
also include diagnoses that cannot always be confirmed on ultrasound, if at all. The
sonomorphology of the diagnoses in question are not listed here in any detail. They
have been discussed at length in the individual chapters.
2.7.1
... of premenopausal genital bleeding
• Physiological menstruation
• Pathological processes (trauma, inflammations, tumours, atrophy) originating
from the vagina, cervix, endometrium, uterus, ovary, bladder and intestine)
• Coagulation disorders
• Drug-related effects especially on the endometrium (hormone-active
preparations, tamoxifen, anticoagulants, etc.)
• Pregnancy-related.
Sonography is particularly useful for evaluating pathological changes in the cervix,
endometrium, myometrium, urinary bladder and pregnancy-induced bleeding.
2.7.2
... of postmenopausal genital bleeding
Apart from induced withdrawal bleeding associated with hormone replacement
therapy, postmenopausal bleeding is always pathological It can be triggered by:
46
• Pathological processes (trauma, inflammation, tumours, atrophy) originating in
the vagina, cervix, endometrium, uterus, ovary, bladder and intestine
• Coagulation disorders
• Drug-related effects, especially on the endometrium (hormone-active
preparations, tamoxifen, anticoagulants, etc.
Malignancies of the endometrium and cervix should be considered in particular
when carrying out exploratory ultrasound scans. Ovarian processes trigger genital
bleeding only very occasionally at the postmenopausal stage. In such cases,
hormone-active, solid adnexal tumours should be considered.
2.7.3
•
•
•
•
•
•
•
•
•
•
•
... on acute lower abdominal pain
Adnexitis
Parametritis
Ovarian tube abscess
Abscess of the pouch of Douglas
Pedunculated ovarian tumour
Blood-filled ovarian cysts
Endometriosis
Ruptured ovarian cells
Myoma
Haematometra
IUD expulsion
2.7.4
• Iatrogenic-related changes such as
calcification after curettage
• Tamoxifen-induced changes
• Haematometra
• Cervix-induced changes.
... of the simple cystic adnexal findings without internal echoes
• Follicle cysts
• Corpus luteum cysts
• Retention cysts
47
• Uterine sarcoma
• Cervical cancer.
... of the highly built-up endometrium
• Polyps of the corpus mucosa
• Highly built-up endometrium with
hormone replacement
• Endometrial hyperplasia
• Submucous myoma
• Corpus carcinoma
2.7.6
EUP
Abortus incipiens
Appendicitis
Diverticulitis
Gastroenteritis
Urolithiasis
Cystitis
Crohn’s disease
Ileus
Acute porphyria
Pelvic venous thrombosis
... of uterine space occupying lesions
• Myoma (submucous, intamural,
subserous, intraligamentary)
• Polyps
• Foreign bodies (IUD), pregnancy
residues, etc.
2.7.5
•
•
•
•
•
•
•
•
•
•
•
• Hydrosalpinges
• Peritoneal cysts
• Parovarial cysts
• Serous cystic adenoma
• Overflow incontinence
2.7.7
... of the cystic adnexal findings with internal echoes, cystic
solid or solid cystic adnexal findings
•
•
•
•
•
•
•
•
•
Corpus luteum cysts
Endometriotic cysts
Ovarian tube abscesses
Pedunculated ovary with bleeding
Dermoid
Pyosalpinges
Serous cyst adenoma
Mucinous cystic adenoma
Ovarian cancer
2.7.8
Myoma due to degenerative changes
EUP
Filled intestinal loops
Ileus
Procedure-related changes such as
post-operative haematoma
... of the solid adnexal finding
• Ovarian cancer (especially serous)
• Gonadal stromal tumours (suspected
granulosa cell tumours, theca cell
tumours, androblastoma)
• Germ cell tumours (especially
mature cystic teratoma= dermoid)
• Rarer ovarian tumours
• Pedunculated sub-serous myoma
• Intraligamentary myoma
• Endometriotic cysts
• Filled intestinal loops
2.8
•
•
•
•
•
• Pelvic kidneys
• Ovarian metastases (especially with
breast cancer)
• Hyperplastic lymph nodes
• Fallopian tube carcinoma
• Intestinal tumours
• Bladder cancer
• Retroperitoneal tumours
• Tumour recurrence
General recommendations and consequences
Appropriate caution must be exercised when deriving recommendations and
consequences from sonography findings. In principle, ultrasound scans should only
be used in conjunction with clinical findings, medical history, cycle or menopause
status, laboratory findings or other imaging techniques, e.g. after a dignity estimate
of an adnexal finding or depending on the risk to the patient, e.g. due to an assumed
EUP.
Sonographic check-ups in addition to other observation parameters, sonographically
guided procedures and surgical intervention, either endoscopically or via an openaccess are available.
2.9
1
2
References
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3 Urogynaecological sonography
Gabriel Schär
3.1
The objectives of urogynaecological sonography
Fine structural imaging of the urethrovesical and perirectal anatomy
Dynamic evaluation of the urethrovesical anatomy
Post-operative evaluation following sling and net surgery
Quality control and analysis of recurrences or complications
Valuable morphological information for study purposes
Documentation
3.2
Advantages
Urogynaecological sonography supplements the clinical examination by providing
fine structural information about the urethra, bladder and anal sphincter. A dynamic
anatomical evaluation of images improves the understanding of pathophysiological
processes and any underlying disruption in the pelvic floor region. Prior to
incontinence or descensus surgery, anatomical and dynamic information can
influence treatment decisions. Post-operatively, sonography helps to assess the
position of inserted nets and correlates with the surgical outcome.
Urogynaecological sonography is thus an indispensable tool for monitoring quality
control and, above all, for analysing persistent symptoms or recurrence following
incontinence surgery. Standardised urogynaecological sonography can be used as a
valuable scientific instrument. Angle and distance measurements, Doppler scans,
3D- and intraluminal sonography are essentially of prime importance in terms of
scientific use. Urogynaecological sonography is also beneficial for documenting
images of the medical findings. As is generally the case in overall urogynaecological
diagnostics, neither a diagnosis nor a therapeutic conclusion can be obtained from
sonographic findings alone. Urogynaecological sonography is mostly beneficial
when it is used as part of the overall urogynaecological diagnostic procedure.
3.3
The quality of urogynaecological sonography
The quality of urogynaecological sonography depends on the following factors:
the practitioner, anatomy, ultrasound device, bladder filling and patient co-operation.
1.
Experience of the practitioner
Urogynaecological sonography warrants a certain acclimatisation period in order to learn how to operate
the ultrasound probe during dynamic functional diagnostics. The Interpretation of the findings improves
in terms of quality with experience in urogynaecological diagnostics. If the practitioner applies excessive
pressure to the ultrasound probe when scanning the perineum, artefacts can appear in the urethra and on
the bladder floor1.
52
2.
Anatomy
The urethra, bladder, symphysis and perianal muscular structures are nearly always visible. In some cases
the structures are difficult to detect because of large cystoceles2.
3.
Bladder filling
Bladder filling mainly affects image quality. If the bladder is not full enough, the evaluation of the
bladder floor is not sufficiently reliable whereas the evaluation of the urethra is almost unaffected. If the
bladder is over-filled, the extent of the descensus cannot be reliably assessed since the over-full bladder
can reduce the descensus1.
4.
Patient co-operation
As urogynaecological sonography is essentially a functional sonographic method, patient co-operation is
required with coughing, on straining and on pelvic floor contractions.
5.
Ultrasound device
The ultrasound devices used in the specialist fields of gynaecology and obstetrics can also be used for
urogynaecological sonography. Sound frequencies of 5 – 7.5 mHz (vaginal probe) and 3.5 – 5 mHz are
set for scanning the vaginal orifice and perineal region, respectively. Curved linear probes are an
advantage in perineal sonography since they allow better contact with the vaginal orifice than straight
probes. For rapid movements such as coughing or straining, autocorrelation is beneficial in order to avoid
streaking phenomena. We recommend the Cineloop function to examine the urethrovesical anatomy on
coughing. An increasing number of devices offer 3D sonography for pelvic floor examinations. This is
particularly beneficial for scientific investigations.
3.4
Examination procedure
Urogynaecological sonography is based on the recommendations of the Deutsche
Arbeitsgemeinschaft für Urogynäkologie AUG2 (German Association for
Urogynaecology) (Tab. 7).
Tab. 7
Recommendations from the Deutsche Arbeitsgemeinschaft für Urogynäkologie (German
Association for Urogynaecology) for standardised sonographical examination
•
•
•
•
•
Measuring technique: The symphysis forms the reference point. The meatus internus is
measured either using a co-ordinate system with x and y axes or by distance and an angle
Bladder filling: 300 ml
Examination position: Supine position or standing
Artefacts: Apply light pressure to the probe
Dynamic tests: Valsalva, coughing, contraction.
Urogynaecological sonography should be included in overall gynaecological
diagnostics. It is either carried out as part of a basic diagnosis with a clinical
examination and evaluation of medical history or in conjunction with urodynamic
examination. The patient is scanned in the supine position on the gynaecological
examination couch.
The ultrasound probe is applied to the vaginal orifice using ultrasound gel to
generate a sagittal cross-section through the midline of the small pelvis. The
cartilage of the symphysis (discus interpubicus) provides an ultrasound window that
shows retrosymphseal structures and forms reference planes for the midline (Fig.
58).
53
An overview is initially given in order to subsequently record the resting image and
functional images on straining, coughing and pelvic floor contraction. In conjunction
with the ventral compartment evaluation, the ultrasound probe is tilted in the dorsal
direction to highlight the perirectal structures before being rotated through 90° to
assess the anal sphincter structures. Patients generally understand the ultrasound
images. Along the lines of a biofeedback instruction, the function of the pelvic floor
is highlighted in order to promote understanding of pelvic floor contractions and to
ensure that the exercises are performed more reliably.
Fig. 58 a) Diagram of the sectional planes: In the sectional plane of the discus interpubicus (1), the
ultrasound scan can penetrate cartilage, whereas the section through the paramedian osseous symphyseal
structure (2) is associated with shadow formation. b) Ultrasound image through the window of cartilage
(1): The entire cartilage section of the discus interpubicus is visible, providing an ideal reference plane.
c) Paramedian sectional plane (2) with cranial shadow formation due to osseous symphysis.
a)
b)
c)
LA = Arcuate ligament, DI = Discus interpubicus, BB = Bladder floor, B = Bladder, R = Rectum,
S = Symphysis, U = Urethra, UT = Uterus, V = Vagina
3.5
Documentation
The following organs and their structures can be highlighted by sonography:
• Bladder: Bladder lumen and bladder wall (comprising the mucosa and detrusor
muscles)
• Urethra: Urethral wall (comprising mucosa, adventitia, smooth and fasciated
muscles)
• Symphysis: Cartilage of the discus interpubicus
• Vagina: Comprising mucosa, adventitia, smooth muscles
• Rectum: Comprising mucosa, adventitia, anal sphincter (smooth and fasciated
muscles)
Method-related differences are, however, apparent. In contrast to perineal
sonography, an overall view of the symphysis is mostly impossible on
ultrasonography of the vaginal orifice.
Based on the recommendations of the AUG, imaging is directed as follows: Cranial
structures are shown in the upper section of the image and caudal structures in the
54
lower section. The ventral region is shown on the right and the dorsal on the left
(Fig. 59).
Fig. 59 Direction of the urogynaecological ultrasound image. The caudal pelvic structures are displayed
in the lower section and the cranial structures in the upper section. Dorsal pelvic structures are shown on
the left and ventral structures on the right (cranial cranial, kaudal caudal, Rektum rectum).
3.6
Evaluation
Evaluation of the urogynaecological ultrasound images is based on quantitative and
qualitative parameters. These are important for pre- and post-therapeutic
comparisons and are thus factors in quality control evaluations and scientific
investigations. Only the qualitative parameters are relevant for purely clinical image
evaluation. This involves assessing the movements of the bladder floor and the
urethra during straining, coughing and pelvic floor contraction and evaluating
funnelling and kinking of the urethra during an increase in intra-abdominal pressure.
As far back as 1975, Green described typical qualitative changes in the
urethrovesical unit on lateral urethrocystography3. They still apply to this day.
According to Green, the urethrovesical unit can descend in a rotatory or vertical
manner or in the form of a cystocele on increased intra-abdominal pressure. (Fig.
60). Funnelling by the proximal urethra mainly occurs with rotary and vertical
descensus whilst kinking of the urethra is mostly observed with cystoceles as well as
rotatory descensus. Since this is a purely descriptive evaluation of the images, there
are no clear limit values with reference to rotatory descensus or cystoceles.
Sonographic findings are therefore significant only when assessed in conjunction
with clinical symptoms.
55
Fig. 60 Typical forms of bladder descensus according to Green
Normal finding
rotatory
vertical
cystocele
Fig. 61 Measuring system to determine the position of the urethral meatus internus and retrovesical ß
angle (Blase Bladder, Blasenhals Bladder neck, y Achse y axis , x Achse x axis, Zentrale
Symphysenlinie Central line of symphysis, Symphyse symphysis, obere Symphysenkante Upper edge of
symphysis, Symphysenunterkannte mit Lig. Arcuatum lower edge of symphysis with arcuate ligament
.
Retrovesical angle β and the position of the urethral und meatus internus are
determined for the quantitative evaluation of the ultrasound images2,4 (Fig. 61). The
urethral meatus internus is located in a co-ordinate system. The co-ordinate system
is based on a central line of symphysis drawn through the symphysis (X axis) and a
vertical line (Y axis) to the X axis on the lower edge of symphysis. DX is the
horizontal distance of the cranioventral urethral exit from the bladder and DY the
vertical distance of the cranioventral urethral exit from the bladder to the Y axis.
Retrovesical angle β is measured such that one leg angle is drawn along the bladder
floor and the other along the dorsal border of the urethra.
Urogynaecological sonography findings can be recorded on a special report form
(see Appendix).
56
3.7
3.7.1
Examples with interpretation
Continence, normal finding
The images shown in Fig. 62 were recorded in a continent female with normal
mobility of the urethra and meatus internus. The physiological mobility of the
urethra is highlighted by light dorsocaudal movements on straining as well as
cranioventral elevation on pelvic floor contraction. Despite considerable straining,
the urethra moves only a few millimetres in the dorsal direction. This reflects the
intact suspension structures where excessive dorsal caudal movement is prevented.
This normal image highlights 3 facts:
The urethrovesical unit is firmly anchored in the small pelvis as the endopelvic
fascia and the attachment of the sacrouterine and cardinal ligaments are intact.
A certain amount of urethral mobility is a physiological phenomenon and helps to
promote flawless micturition. Urethral mobility is mainly shown to advantage on
straining since pelvic floor relaxation is associated with straining.
The Levator ani muscle also stabilises the bladder and urethra through intact muscle
contraction and actively prevents the movement of the urethra in the dorsal-caudal
direction.
Fig. 62 urogynaecological sonography in a healthy, i.e. continent female: Normal anatomy at rest (a).
Slight physiological urethral mobility on straining b), cranioventral movement of the urethra on pelvic
floor contraction (c)
a)
3.7.2
b)
c)
Stress incontinence and paravaginal defect
Fig. 63 was recorded in a patient with stress incontinence and paravaginal defect. At
rest, the urethra and bladder lie in an almost vertical position but display intensified
dorsocaudal movement on straining (hypermobile urethra). The urethral meatus
internus is located on the same level as the lower edge of the symphysis and the
bladder floor descends to the same extent as the urethra in the caudal region. On
pelvic floor contraction, the urethra, bladder floor and vagina are forcibly lifted in
the cranioventral direction.
The image highlighting straining with the hypermobile urethra and bladder floor
descensus shows a paravaginal defect whereby the endopelvic fascia is no longer
firmly attached to the pelvic wall and the passive attachment mechanism is distorted
thus increasing the mobility of the urethra and bladder floor. In such situations,
57
pelvic floor contraction generally no longer guarantees stabilisation of the
urethrovesical unit whereby the bladder and urethra deviate in the caudal and dorsal
directions, also on coughing. Disrupted pressure transmission can occur in the
absence of a passive (endopelvic fascia, ligaments) and active (Levator ani)
counteracting force on increased abdominal pressure whereby intravesical pressure
exceeds urethral pressure and urine is discharged.
Fig. 63 Perineal sonography in a stress incontinent female with paravaginal defect. At rest (a) normal
sonographic anatomy with vertical urethra and elevated urethral meatus internus (MI). On straining (b)
evidence of a hypermobile, horizontal urethra and urethral meatus interna descending under the lower
edge of the symphysis. The urine flowing into the urethra is indicative of incontinence and is visible as a
funnelling phenomenon (arrow). On pelvic floor contraction (c) powerful cranioventral elevation of the
urethra and visible compression of the rectum, vagina and urethra by the dorsal levator muscle (L)
a)
3.7.3
b)
c)
Stress incontinence and vertical descensus
The images shown in Fig. 64 were recorded in a female presenting with vertical
descensus and stress incontinence. Whereas the image taken at rest shows no sign of
disease compared to a healthy female, straining causes a funnel-like extension of the
bladder neck with descensus.
Fig. 64 Patient with vertical descensus of the urethrovesicular unit. At rest (a) elevated position of the
urethral meatus internus, as in a healthy female. On straining (b) funnel-like expansion of the bladder
neck (arrow) and opening of the ß angle. Via pelvic floor contraction (c) prompt elevation of the urethral
meatus internus and bladder floor
a)
b)
c)
58
Retrovesical angle β opens in contrast to the resting image. The vertical descensus
of the urethra is based on two anatomical aspects; on the one hand, the bladder floor
and proximal urethra are inadequately supported by the levator muscle, leading to
slight descensus with opening of the β angle, and on the other hand, the urethral
muscle cannot prevent the funnel-shaped opening of the bladder neck.
3.7.4
Cystocele
Fig. 65 shows the situation in a female presenting with a pure cystocele. The image
taken at rest shows the bladder at a normal height whilst the urethra is in an almost
vertical position. On straining, the bladder descends further in the caudal direction
and forms a large cystocele (hour glass shape of the bladder) whilst the urethral
meatus internus also descends thus causing the centre of the urethra to bend. Such
forms of cystocele are generally indicative of a central defect in the endopelvic
fascia whilst the urethra per se is either adequately fixed or is held in position by the
cystocele.
Fig. 65 Perineal sonography in a female with a large cystocele and a central defect: At rest (a) vertical
urethra and bladder floor in a normal position. On straining (b) the bladder floor descends markedly in the
caudal direction. The meatus internus descends slightly (arrow) and the urethra bends in the centre (<U).
65b also shows that substantial cystocele formation can hamper evaluation of the urethrovesical anatomy
a)
3.7.5
b)
Rectocele and enterocele
Rectoceles and enteroceles are highlighted in Fig. 66 and Fig. 67. The probe is tilted
in the dorsal direction in order to scan the rectum and rectosigmoidal junction. The
perirectal smooth muscle is recognisable as a hypoechogenic structure. Rectoceles
can be seen more clearly on straining by eversion of the anterior rectal wall. The
width and depth of the rectoceles can be measured.
59
Fig. 66 Rectocele (RC) with stool and air (nonhomogeneous,
essentially
hyperechogenic
content) and the hypoechogenic circular smooth
muscles (ventral and dorsal M) on straining. Base
(distance marker 1) and depth (distance marker 2)
can be measured (Rektum rectum)
3.7.6
Fig. 67 Enterocele (image recorded on straining)
Dorsally, evidence of the rectum, ventrally,
arching of a large enterocele with the contents of
the small intestine in this female with apical
descensus (Enterozele enterocele)
Perianal structures
Exoanal sonography is highlighted in Fig. 68. The probe is tilted in the dorsal
direction and rotated through 90° in order to highlight the anal structures. Internally,
the mucosa is visible. The hypoechogenic structure corresponds to the M. sphincter
ani internus (internal anal sphincter), the circular structure with greater echodensity
corresponds to the M. sphincter ani externus (external anal sphincter muscle) and the
U-shaped echodense structure is the section of the M. levator ani (anal levator
muscle), which is also known as the M. pubovisceralis (pubovisceral muscle). The
integrity of the anal structures can be assessed by means of exoanal sonography.
Fig. 68 exoanal sonography highlighting perianal structures
La
M
Se
Si
3.7.7
=
=
=
=
M. levator ani
Mucosa
M. Sphincter ani externus
M. Sphincter ani internus
Imaging of slings and pelvic floor nets
Fig. 69 to Fig. 71 display post-operative ultrasound images following incontinence
and descensus surgery with net material. Polypropylene, a thread material used in
the production of incontinence tapes or pelvic floor nets, is portrayed as a
60
hyperechogenic structure on an ultrasound scan5,6. Post-operative imaging of nets
and tapes is probably the most beneficial aspect of urogynaecological sonography
since it helps to identify whether the incontinence tape is correctly positioned under
the distal or middle section of the urethra, or if it has slipped under the bladder floor
in the event of recurring incontinence. Similarly, sonography can be carried out to
establish the position of the pelvic floor net post-surgery and whether it provides
adequate support for the urinary bladder. Sonography of the nets and tapes is
extremely useful in analysing surgical successes and failures (quality control).
Fig. 69 Image of a tape correctly positioned beneath the central section of the urethra (arrow). Left at
rest (a), centre on straining (b) right on coughing (c) When the abdominal pressure is raised, the tape acts
as a buffer on which the urethra is compressed and no urine can escape.
a)
b)
c)
Fig. 70 incorrectly positioned incontinence tapes: Left (a) intraurethral tape in a patient with recurring
stress incontinence and dysuria (tape with arrow and marked as 1, caudal urethra muscle*, cranial urethral
muscle**), Centre (b) tape in the urethral muscle (arrow No. 2) in a female with a micturition disorder
and dysuria but also with an unattached section of tape in the intravaginal region (arrow No. 3) in the
right vaginal wall (probe rotated through 90° - coronal view). Right (c) an intravesical tape in a female
with recurring urinary tract infections (arrow No. 4)
a)
61
b)
c)
Fig. 71 Image of nets after prolapse surgery Left (a) correctly positioned net following laparoscopic
sacrocolpopexy. The ventral net is placed with the section nearest the caudal region (arrow No. 1) at
greater depth than the urethral Meatus internus (MI), thus supporting the entire bladder floor. This can
prevent recurrent cystocele. Right (b) incorrectly positioned net to correct a cystocele (anterior Prolift).
The net (arrow No. 3) was not stretched enough. The arm of the net was not placed sufficiently close to
the Spinae ischiadicae, hence the folded net supports the bladder only over a distance of 10 mm. On the
one hand, a cystocele (CC) recurred and, on the other hand, the patient experienced pain and dyspareunia
a)
b)
The filling material injected under the urethral mucosa is highlighted on an
ultrasound scan. Fig.72 highlights the situation following intraurethral injection of a
bulking agent (Bulkamid®). These bulking agents are injected urethroscopically in
order to improve urethral occlusion. Possible indications include: Stress
incontinence with urodynamically confirmed hypotonic urethra or recurring
incontinence with an immobile urethra.
Fig. 72 Ultrasound image following intraurethral injection to eradicate stress incontinence. In this case
Bulkamid® was used, which is visible in the bladder neck region as hypoechogenic structures (*). Left
(a) at rest – the urethral lumen in the region of the bladder neck is completely surrounded by Bulkamid®.
Right (b) on straining, evidence that the urethra is not adequately closed because of the influx of urine
(arrow). Clinically, incontinence regressed but the patient did not experience full remission.
a)
3.8
b)
Further options and future developments
3D and 4D sonography in particular is developing in addition to routine sagittal
urogynaecological sonography. 3D imaging and navigating in a tissue block of
62
pelvic floor structures makes 3D sonography particularly interesting for scientific
applications such as analysis of post-partum muscle defects in the levator muscle
and for highlighting pelvic floor nets7,8. These indications have not yet been
incorporated as part and parcel of routine clinical diagnostics and are therefore not
discussed in any further detail in this report.
3.9
References
1
Schaer GN, Koechli OR, Haller U. Perineal ultrasound - determination of reliable examination procedures.
Ultrasound Obst Gynecol 1996;7:347-52.
2
Tunn R, Schaer G, Peschers U, Bader W, Gauruder A, Hanzal E, et al. Updated recommendations on
ultrasonography in urogynecology. Int Urogynecol J 2005;16:236-41.
3
Green TH. Urinary stress incontinence:differential diagnosis, pathophysiology and management. Am J Obstet
Gynec 1975;122:368-400.
4
Schaer GN, Koechli OR, Schuessler B, Haller U. Perineal ultrasound for evaluating the bladder neck in urinary
stress incontinence. Obstet Gynecol 1995;85:220-4
5
Sarlos D, Kuronen M, Schaer GN. How does tension-free vaginal tape correct stress incontinence? Investigation by
perineal ultrasound. Int Urogynecol J 2003;14:395-8.
6
Kociszewski J, Rautenberg O, Perucchini D, Eberhard J, Geissbuhler V, Hilgers R, Viereck V. Tape functionality:
Sonographic tape characteristics and outcome after TVT incontinence surgery. Neurourol Urodyn 2008;27:485-90.
7
Dietz HP. Pelvic floor ultrasound in incontinence: what's in it for the surgeon? Int Urogynecol J 2011;22:1085-97.
8
Tubaro A, Koelbl H, Laterza R, Khullar V, de Nunzio C. Ultrasound imaging of the pelvic floor: where are we
going? Neurourology and urodynamics 2011;30:729-34.
63
4 Mammasonography
Gilles Berclaz
4.1
Indications for mammasonography
Mammasonography has developed to such an extent over the last 15 years that it is
nowadays used to investigate any form of breast pain, assumed or palpable breast
nodes or unclear findings on mammography and MRI breast scans1.
Moreover, in most diseases, sonography can confirm the diagnosis by guiding a
punch biopsy.
Recognised indications for sonography include:
•
•
•
•
•
•
•
•
•
•
•
Unclear findings on palpation or mammography
Mammograms that are difficult to evaluate (dense gland bodies)
Evaluation of the chest wall and skin
Mastitis and abscesses, breast secretion
Checking of implants
Carcinoma (size, to preclude multicentricity, axilla)
Cancer follow-up
Screening of risk patients
Women under 35 years of age, pregnancy and lactation
To guide biopsies for diagnosis
To guide the puncture of cysts or abscesses
4.2
Examination technique and documentation
The patient should be lying in the supine position or across a cushion, with her arms
elevated. A sufficient quantity of gel should be applied to the skin.
The 7.5-15 MHz linear ultrasonic probe should be placed perpendicularly on the
skin. An optimal focal range and suitable image size should be selected. We
recommend antiradial ultrasonic probe guidance (from the periphery to the nipple).
Slight pressure should be constantly applied to the tissue.
If there are no suspicious findings, the examination can be documented with an
image of the outer/upper quadrants.
If a medical finding is recorded, this must be displayed on all axes in order to
preclude artefacts. Findings should be documented in writing, quoting a clock
position and the distance to the nipple, e.g.: Right breast with a 15-mm, unclearly
delineated, hypoechoic finding at 9 o’clock, 4.5 cm from the nipple.
There must be a definite correlation between the ultrasound findings and the
outcome of the clinical examination and mammogram.
64
4.3
Normal anatomy of the breast glands and axilla
A distinction must be made between the following structures: derma, subcutaneous
fatty tissue, Cooper’s ligaments, echodense gland bodies and hypoechoic fatty
segments, nipples, mammary ducts, retromammary fatty tissue, major and minor
pectoral muscles with fascia, ribs with intercostal muscles, axillary vessels and level
I to III lymph nodes.
Particular attention should be paid to the gland parenchyma, which presents in
various ways: individual patient variation depending on location in the breast, age or
hormone status (cycle, pregnancy, menopause and hormone replacement).
4.4
Disease
In principle, all findings are examined on several planes and documented. The
following criteria should be taken into account (Tab. 8).
Tab. 8 Criteria of dignity in mammosonography
•
•
•
•
•
•
•
•
•
•
Shape
Axis
Contour
Marginal echo
Echo pattern
Compressibility
Moveability
Exit echo (acoustic shadow or amplification)
Lateral marginal shadow
Structural deformity
Benign lesions are generally characterised by a round or horizontal-oval shape, a
horizontal axis, a smooth contour, a clearly delineated marginal echo, a uniform
echo pattern, mobility, an amplified exit echo, lateral marginal shadows and no
structural deformity.
4.4.1
Cysts
Typical sonomorphology: Horizontal-oval or round, smooth contour, narrow
margin, echo-free content, good compressibility, homogeneous dorsal acoustic
amplification, unchanged surrounding structure (Fig. 73, 74).
Differential diagnosis: Debris-containing cysts with an echodense content or
carcinomas with virtually echo-free content. A colour Doppler scan can prove useful
in these situations. If vessels are present, the structure is solid and must be clarified.
65
Fig. 73 Cysts, echo-free, with smooth walls
4.4.2
Fig. 74 Double cysts
Fibroadenoma
Typical sonomorphology: horizontal-oval or round, narrow, regular contours,
hypoechoic, uniform content, less readily compressible and moveable, uniform
slight acoustic amplification in approximately 25% of the region, lateral marginal
shadows, surrounding area unaffected (Fig. 75, 76).
Differential diagnosis: Carcinoma can look like fibroadenoma, especially in young
patients.
Fig.75 Fibroadenoma, homogeneous
4.4.3
Fig.76 Fibroadenoma, non-homogeneous
Carcinoma
Carcinoma is generally characterised by an irregular and extremely oval shape,
unclear contours, echodense marginal echoes (hyperechoic cap), non-homogeneous,
hypoechoic echo pattern, no compressibility, poor moveability, dampened exit echo,
no lateral marginal shadows and structural deformity (Fig. 77).
Differential diagnosis: Round, smooth, homogeneous carcinoma (Fig. 78);
circumscribed advancing medullary and mucinous carcinoma; sclerosing adenosis
that is difficult to distinguish from carcinoma.
66
Fig. 77 Breast cancer, typical finding with “local
cancer spread”
Fig. 78 Breast cancer with only slightly irregular
delineation, rather homogeneous, hypoechoic,
with slight dorsal acoustic amplification,
differential diagnosis: Atypical fibroadenoma!
Fig. 79
Breast cancer, punch biopsy with
punctured finding
Investigations focus on evidence of multifocal sites or multicentricity in cancer.
Infiltration of the muscle or skin can have a crucial impact on subsequent diagnosis
or therapy. The axillary lymph nodes must be examined carefully and a histological
evaluation carried out if required (Fig. 79).
4.5
BI-RADS (Breast Imaging Reporting and Data System)
As for mammography, the American College of Radiology has developed a system
to assess sonography images and confirm procedures: This is known as the BIRADS System2 (Tab. 9).
Tab. 9 BI-RADS System
BI-RADS Category 0:
BI-RADS Category 1:
BI-RADS Category 2:
BI-RADS Category 3:
BI-RADS Category 4:
BI-RADS Category 5:
BI-RADS Category 6:
67
Incomplete. Other images should be evaluated
Negative. Routine check-ups
Benign finding: Routine check-ups
Probably a benign finding: Short-term follow-up recommended
Suspicious finding: Biopsy recommended
Cancer diagnosed in > 95% of cases: Biopsy recommended
Cancer confirmed Surgery or neoadjuvant therapy recommended
4.6
Recommendations and consequences
Sonography complements mammography or MRI in breast diagnostics. Sonography
is initially recommended for patients under 30 years of age, pregnant women or
nursing mothers. If evaluation of the mammogram is limited (e.g. because of dense
gland bodies), the absence of any suspicious findings on sonography can largely rule
out diseases and thus avoid unnecessary biopsies. Suspicious findings on
mammography must, however, be clarified further even in the absence of
sonographic malignancy criteria.
Cysts are diagnosed on sonography with virtually 100 % accuracy and do not
generally require any histological clarification. They can be dispersed if painful.
As a general rule, all solid masses must be clarified. Punch biopsy is currently the
method of choice.
4.7
References
1
Khouri NF: Breast Ultrasound. In Diseases of the Breast, Fourth Edition. Chapter 13, pp 131-151. Lippincott
Williams & Wilkins, a Wolters Kluwer business, 530 Walnut Street, Philadelphia, PA 19106 USA.
2
American College of Radiology (ACR). ACR BIRADS: ultrasound. In: Breast imaging reporting and data system:
breast imaging atlas. 4th ed. Reston VA: American College of Radiology, 2003, pp 1-86.
68
5 Report sheets (PDF @ www.sgumgg.ch)
The following report forms are available to download in PDF format from
www.sgumggg.ch:
• Gynaecological sonography
• Urogynaecological sonography
• Mammasonography
69

Swiss Gynaecologic Ultrasound Guideline

Transcription

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