Urinary Bladder

Practice Guidelines for the
Performance of Pelvic Ultrasound
• Collaborative Guidelines –
– American College of Radiology
(ACR)
– American Institute of Ultrasound in
Medicine (AIUM)
– American College of Obstetricians
and Gynecologists (ACOG)
– Society of Radiologists in
Ultrasound (SRU)
Gynecologic Ultrasound
By Alfred Kurtz, M.D.
• Most recent update - 2009
Indications for a Pelvic
Ultrasound Examination
Practice Guidelines
• I. Introduction
• 19 Indications
– 7 - Bleeding – with or without pain –
• Prepubertal
• Menstrual
• Postmenopausal
– 2 - Follow up to physical examination or
other imaging study
– 2 - Infection – 1° or following surgery
– Pain
– Infertility
– Localizing IUD
– Screening for malignancy
– Guidance for procedure
= 10
• II. Indications
• III. Qualifications of Personnel
• IV. Written Request for the
Examination
• V. Specification of the Examination
• VI. Documentation
• VII. Equipment Specifications
• VIII. Quality Control &
Improvement, Safety, Infection
Control, Patient Education
V. Specification
A. General
Transabdominal
Transvaginal
B. Uterus
C. Adnexa
Ovaries
FallopianTubes
Cul-de-Sac
Helpful Hint 1: Urinary Bladder
Helpful Hints
Bladder shape –
• Identify Urinary Bladder
long axis
• Bladder
– esp. on TA images
• Any abnormality?
• Mass – site of origin
– Solid – almost always uterine - fibroid
– Cystic – almost always ovarian
– Tubular – almost always adnexa
Sag
Sag
Sag
Cystitis
Ovarian Cyst
Cancer
• Bowel/Mesentery/Peritoneal –
– if identify abnormality
• with normal appearing uterus and ovary
Sag
Axial
Axial
1
Helpful Hint 3:
Bowel/Mesentery/Peritoneal
Helpful Hint 2: Solid, Cystic, Tubular
Solid - Uterine
Cystic - Ovarian
RLQ
Pelvis
Cul-de-Sac
Tubular – Adnexa
F
Follicle
Sag
Sag
Acute Appendicitis
Hydrosalpinx
Normal Small
Bowel & Ascites
Axial
Rt. Adnexa - Fibroid (F)
Endometrioma
Widespread Ovarian
Cancer
Axial
V. Specification of the Examination
A. General
V. Specification of the Examination
TA
– Transabdominal
• Distended but not
overly distended
bladder
– Transvaginal
• Ideally empty bladder
• Consider a chaperone
B. Uterus
– Uterine size, shape & orientation
– Endometrium
– Myometrium
– Cervix & Lower Uterine Segment
TA
TV
Uterus - Size and Shape
Uterus - Size
• Overall uterine length
– Length
– Depth (A-P diameter)
– Width
– ?? Volume ??
Menstruating Perimenopausal
Prepubertal
Menopausal
TA
Size = 7 cm (L) x 3 cm
(A-P) x 5 cm (W)
TA
Measurements by TA and TV
examinations equally precise
TV
TV
2
B. Uterus - Orientation
• Version (in relation
to cervix):
– Anteverted (b)
– Retroverted (d)
• Flexion (in relation
to uterine body)
Uterine Positions – determined from from long axis
image of uterus (ideally determined during TV imaging)
Retroverted
Anteverted
Anterior margin
Neutral position is
obtained from the
TV sagittal image
Anterior margin
Anteflexed
Retroflexed
Anterior margin
– Anteflexed (c)
– Retroflexed (a)
Anterior margin
Vertical Uterus
?
Fundus
Endometrium and Myometrium
Normal appearance (from
interior to exterior)
– Endometrium
(hyperechoic)
– Junctional Zone
(hypoechoic)
– Myometrium
(hyperechoic)
– Subserosal
(anechoic)
Fibroids
Myometrial Pathology
• Leiomyomas
(Fibroids)
• Adenomyosis
• Most common female tumors
• Benign tumors
–
–
–
–
Intramural – within myometrium
Subserosal - outer margin
Submucosal – near endometrium
Pedunculated – thin stalk
• Intracavitary
• Outer margin
• Histology: smooth muscle, connective
tissue, blood vessels, occasionally fat
• Can undergo necrosis, hemorrhagic,
calcification, rarely malignant
transformation
3
Intramural Fibroids
Exophytic Fibroids
Subserosal
Peduculated
U
Stalk
Broad-based
Central fibroid
Complicated Fibroids
? submucosal component
Necrotic
Calcifications
Both
F
F
F
Hysteroscopy
Axial
Fluid in Endometrial Canal
TV - Axial
Sag
Sag
F
F
Sonohysterogram*
F
*Practice Guideline For The
TA - Sag
Performance of
Sonohysterography (SHG)
Sag
Normal
Lipoleiomyoma
Sag
NORMAL
Adenomyosis
Myometrial cysts
Unusual appearing fibroids
Rare, benign, usually in postmenopausal woman. Histology variable amounts of smooth muscle, fat cells, and fibrous tissue
Distortion/loss of
endometrial complex –
loss of junctional zone
4
Adenomyosis
Fibroids vs. Adenomyosis
Can overlap in appearance
Uterine Appearance
• Enlarged
• Masses
• Heterogeneous
• Distortion/loss of
endometrial complex
• “Picket fence”
shadowing from
myometrium
• Myometrial cysts
“Picket fence” shadowing
from myometrium
Giant Fibroid (Leiomyomatous) Uterus
Pathology
Fibroids
Fibroids
Fibroids
Likely
Adenomyosis
• Likely
Adenomyosis
•
•
•
•
• Definitively
Adenomyosis
Cervix
F
Sag midline
Sag Rt.
Endocervical fluid
Fibroids (F)
C
Any solid mass
abdominal/pelvic in a woman,
without a site of origin –
consider fibroid uterus
Axial
Endometrium
Composed of:
• Endometrium
– Endometrial Lining
– Subendometrial Layer
• Junctional Zone
US Appearance:
Hyperechoic
– usually
inseparable
Hypoechoic
Nabothian cyst (C)
Endocervical polyp
Endometrium
• Echogencity
• Thickness
– Uniform Thickness
• Menstruating/Perimenopausal
– Related to menstrual cycle –
» from 1 to 15 mm
– PLEASE - Never forget –
Pregnancy related issues –
» Intrauterine
» extrauterine
• Postmenopausal
– Normal up to 5 mm
– Focal Thickening - ? mass
• Presence of fluid
• IUD evaluation
5
Identifying Endometrium when
there are Fibroids
Identifying Endometrium when
there are Fibroids
F
F
F
TV Sag
TA Sag
Can sometimes identify
entire complex
Thickened Endometrium
Often Endometrium incomplete
identified – avoid areas where only
see borders of fibroids
Endometrium – Fibroids Focally
thickening/heterogeneity
Menstrual & Postmenopausal
Submucosal
Distort/Thicken
• Uniformly thick
– Hypertrophy
• Focally thickening/heterogeneous
– Fibroid
• Distorted
• Submucosal
• Intracavitary
– Polyp
– Cancer
• Fluid or Obstruction of the Endometrial
Canal
• Distort
and/or
thicken
• Submucosal
• Intracavitary
F
– If more than a small amount and/or if
associated with soft tissue, cancer to be
considered
F
F
TV - Sag
Focal Thickening - Polyps
TV – Sag
TV - Sag
Axial
PELVIC DOPPLER MASS EVALUATION
Three Step Approach
Color/Power, Pulsed
– 1. Color or Power Doppler –
More sensitive that Pulsed
Doppler
• Determine if a mass has
flow
– 2. If flow, Pulsed Doppler to
determine if flow is
• Arterial
• Venous
– 3. If arterial, Pulsed Doppler to
determine if high or low
resistance
• Make certain Doppler flow within
the mass
• Flow adjacent to a mass has no
clinical significance.
High resistance (little or no
diastolic flow), most likely
benign
Low resistance (high diastolic
flow), DDx includes
neovascular or inflammatory
vasculature
– Carcinoma
– Some benign
tumors, e.g
dermoids
– Infection
Often Vascular Pedicle
6
Endometrial Cancer
Focal Thickening
Obstructed Uterus
Subendothelial cysts – Tamoxifen (orally active
selective estrogen receptor modulator, SERM, induced)
TA - Sag
TV - Sag
TV - Sag
TV - Sag
TV - Sag
Endothelial lining normal cannot prove without SHG
IUD
Intrauterine Contraceptive Devices (IUD)
Correct position
• Many different types – some difficult to identify
(esp. Mirena)
• Ultrasound performed for
– String no longer seen on pelvic
examination
• ? IUD expelled
• ? String retracted – IUD still in good position
• ? Perforated
Partially Perforated
Multiplanar/3-D Ultrasound
– If pregnancy – is IUD still in uterus
– Unexplained pain
• Sonohysterogram/3-D sonography
Mirena
IUD Complications
First Trimester Pregnancy
- IUD in endocervical canal
Broken IUD
Adnexa & Cul-De-Sac
• Adnexa – including Ovaries &
Fallopian Tubes
– Attempt to identify the ovaries
• Measure in 3 dimensions
– Fallopian Tubes not normally
identified
• Cul-De-Sac
IUD - 2008
– Evaluate for free fluid and mass
– DDX normal bowel from mass
• If mass detected:
– Relationship to ovaries and uterus
– Evaluate its size, shape,
sonographic characteristics
• Doppler – may be useful –
color/power, spectral
Now - broken
7
Ovaries
Transabdominal
• Can be identified TA
and/or TV, better
sonographic
evaluation TV
• Easier to identify if
follicles or cysts
present
• Measure three
orthogenal planes
(usually length and
AP from long axis)
Sag
Axial
Reproductive Ovaries
(Menstrual/Perimenopausal)
– Nulliparous – 3 cm x 3 cm x 2 cm
– Parous
– 5 cm x 5 cm x 2 cm
– Maximum volume (if indicated) –
• Prolated ellipse formula, L x W X H/2 > 15 cm3
Transvaginal
– Consider in polycystic ovaries (PCO)
– Cyclical hormonal changes
• Follicles change
– within each ovary
– with each cycle
Sag
Axial/Coronal
Ovaries
Postmenopausal Ovaries
Decrease in size – by years
•
•
•
•
From 1-2 yrs postmenopausal – 9.0 cm3
To 15+ yrs postmenopausal – 3.6 cm3
Echogenicity most important
? both ovaries should be approx. equal in
size
– prolated ellipse formula, L x W X H/2
No follicles. However Simple benign cyclical cysts can occur in up to
10 % of women: 23 % resolve; 60 % stable,
10+% have new cysts
Simple Ovarian Cysts*
Left ovary
*Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at
US: Society of Radiologists in Ultrasound Consensus Conference Statement,
Levine et al, Radiology 2010
28 y o woman
• Reproductive Age (Menstrual/Perimenopausal)
– Cysts < 3 cm: Normal, ? Describe, No F/U
– Cysts > 3 to < 5 cm: Almost certainly benign, Describe,
No F/U
– Cysts > 5 to < 7 cm: Almost certainly benign, Describe,
Yearly F/U
– Cysts > 7 cm: Difficult to assess, ? MRI, ?Surgery
7 cm – cyst or follicle?
• Postmenopausal
– Cysts < 1 cm: Inconsequential, ? Describe, No F/U
– Cysts > 1 to < 7 cm: Almost certainly benign, Describe,
Initial yearly F/U
– Cysts > 7 cm: Difficult to assess, ? MRI, ?Surgery
2 months later – resolved follicle
8
Ovarian Cysts*
Reproductive Age
• Simple Cyst
– < 3 cm – normal
– 3 to 5 cm – no f/u
– 5 to 7 cm – f/u yearly
– > 7 cm – work up
• Complex (Hemorrhagic)
Cyst
– < 3 cm – normal
– 3 to 5 cm – no f/u
– > 5 cm – 6 to 12 week f/u
Hemorrhagic follicles
Postmenopausal
• Simple Cyst
– < 1 cm – normal
– 1 to 7 cm – initial
yearly f/u
– > 7 cm – work up
• Complex (Hemorrhagic)
Cyst
– Early postmenopausal –
6 to 12 week f/u
– Later - work up
Typical appearance
*Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in
Ultrasound Consensus Conference Statement, Levine et al, Radiology 2010
Hemorrhagic Ovarian Cysts*
*Management of Asymptomatic Ovarian and Other Adnexal Cysts
Imaged at US: Society of Radiologists in Ultrasound Consensus
Conference Statement, Levine et al, Radiology 2010
No Color Doppler flow
Hemorrhagic Follicle
Sag - Rt. Ovary
• Reproductive Age
– Cysts < 3 cm: ? Describe, No F/U
– Cysts >3 to < 5 cm: Describe, No F/U
– Cysts > 5 cm: Describe, Short interval follow
up - 6 to 12 wks
• Postmenopausal
– Early: may still ovulate - Describe, Short
interval follow up - 6 to 12 wks
– Later: Consider neoplastic, surgery
Resolved 3
months later
No Color Doppler flow
Ovarian Cysts*
Reproductive Age
• Simple Cyst
– < 3 cm – normal
– 3 to 5 cm – no f/u
– 5 to 7 cm – f/u yearly
– > 7 cm – work up
• Complex (Hemorrhagic)
Cyst
– < 3 cm – normal
– 3 to 5 cm – no f/u
– > 5 cm – 6 to 12 week
f/u
Ovarian Cysts - as per Kurtz
Postmenopausal
• Simple Cyst
– < 1 cm – normal
– 1 to 7 cm – initial yearly
f/u
– > 7 cm – work up
• Complex (Hemorrhagic)
Cyst
– Early postmenopausal
– 6 to 12 week f/u
– Later - work up
Reproductive Age
Terminology: Cyst/Follicle
• Simple Cyst/Follicle
– < 3 cm – normal
– 3 to 7 cm – 3-4 cycle/month f/u
– If resolve, no further workup –
otherwise 1 yr f/u
– > 7 cm – work up
• Complex (Hemorrhagic)
Cyst/Follicle
– < 3 cm – normal
– > 3 cm – 3-4 cycle/month f/u
– If resolve, no further workup –
otherwise 1 yr f/u
Postmenopausal
• Simple Cyst
– < 1 cm – normal
– 1 to 7 cm – 3-4 month f/u
– If resolve, no further workup
– otherwise 1 yr f/u
– > 7 cm – work up
• Complex (Hemorrhagic)
Cyst
– Early postmenopausal – 6 to
12 week f/u
– Later - work up
*Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in
Ultrasound Consensus Conference Statement, Levine et al, Radiology 2010
9
Ovarian Malignancies
Cysts with Characteristics
Worrisome for Malignancy*
*Management of Asymptomatic Ovarian and Other Adnexal Cysts
Imaged at US: Society of Radiologists in Ultrasound Consensus
Conference Statement, Levine et al, Radiology 2010
•
•
•
•
Thick Septations - > 3 mm
Solid Elements with Doppler flow
Focal areas of wall thickening > 3 mm
Additional findings
Rt. Ovary - Axial
Lt. Ovary - Sag
– Moderate ascites
– Peritoneal and/or omental masses
Doppler
in Normal
Ovaries
Rt. Ovary
Flow not
always
detected –
often unequal
Tortion
Lt. Ovary
3 % of GYN emergencies
• Ovarian and/or tubal tortion
• Ages
– Usu in reproductive age, mid 20’s
• 20% in pregnant
– Postmenopausal
• Rt. > Lt., occasionally bilateral
• 50 to 60% have tumors, many 8 –
12 cm in size
• Tortion in normal ovaries – rare
Symptoms
• Acute, severe,
unilateral pain
• 67% with
nausea/vomiting
• Intermittent episodes
may precede acute
episode by
days/weeks
– Only in children
• Rarely in malignant tumors
• 10% subsequently have opposite
side tortion
Tortion - Lt. Ovarian/Fallopian Tube
Right Ovary
Left Ovary
Sag
Axial
Polycystic Ovaries (PCO)
• Associated with polycystic ovarian
syndrome (PSOS). Findings include:
– Infertility
– Hirsuitism
– Obesity
– Hypertension
– Diabetes Mellitus
• PCO can be seen in women without the
syndrome
• Normal ovaries can be seen in PSOS
• Description
– Bilateral
– Oval to Round
– Subcentimeter cysts on periphery –
“string of pearls”
– > 15 cc in size
10
Dermoid Cyst
(Mature Cystic Teratoma)
• Benign
• Developmentally mature
(ectodermal) elements: skin,
hair, sebum, nail, sweat glands,
eyes, cartilage, thyroid tissue
• Multiple boundary interfaces
Endometriomas
Can mimic
hemorrhagic
follicles
Fallopian Tube and Cul-de-Sac
Extra-ovarian and extra-uterine findings
Dermoids –
“Tip of the
Iceberg” Sign
Hemorrhagic Follicle
Inflammation/Infection
TuboOvarian
Abscesses
Para-Ovarian Cysts
Separate
from ovary
On TV
scanning,
moves
away from
ovary
11
Hydrosalpinx/Pyosalpinx
Often Tubular Appearance
Hydrosalpinx
Pyosalpinx
Varix
Hydronephrosis – UVJ stone
Cul-de-Sac
Fluid – often anechoic
Ruptured Ectopic Pregnancy
12