Fudan University



|NORMAL ANATOMY |

|The primary indications for pelvic sonography are the evaluation of pelvic masses, pelvic pain, and abnormal bleeding. Views of the pelvis are obtained |

|transabdominally through a full urinary bladder and transvaginally with an empty bladder. These two methods complement each other and allow for complete |

|evaluation of the pelvic organs (Table 28-1) . Longitudinal and transverse views of the uterus, cervix, cul-de-sac, and adnexa are obtained. Measurements of the |

|uterus, ovaries, and any pathologic findings should be documented in three dimensions. The anteroposterior diameter of the endometrium should be measured on |

|a longitudinal view of the uterus. This measurement includes both layers of the endometrium (Fig. 28-1)  . Views of the kidneys are obtained to exclude |

|hydronephrosis. Color Doppler is helpful in the evaluation of pelvic masses, especially in distinguishing between cysts and vessels, in documenting the solid nature |

|of a lesion, and in the evaluation of ovarian torsion. [28.1 ] [28.2 ] [28.3 ] |

|Figure - 28-1. |

|Normal postmenarchal uterus. The uterine body (u) is larger than the cervix (c) The endometrium (arrows) is the region of relatively bright central linear echoes. v, |

|vagina. |

|[pic] |

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Uterus

Normal Uterus

Normal uterine size varies with age. Because of maternal hormone stimulation, the neonatal uterus is relatively large, with the body being larger than the cervix. The size rapidly decreases so that in early childhood the uterus has a tubular shape with the uterine body being smaller than the cervix (1)  (Fig. 28-2A and Fig. 28-2B) . As the child approaches menarche, the uterine body again increases in size. In the postmenarchal period, the body is typically twice the size of the cervix. The dimensions of the normal uterus in women of childbearing age is 8 x 4 x 4 cm. The multiparous uterus is larger than the nulliparous uterus by up to 1 cm in each dimension.

|Figure - 28-2a. |[pic] |

|Transabdominal view of the uterus in a 4-year-old girl. The cervix is larger than the body of the | |

|uterus. | |

|Figure - 28-2b. |[pic] |

|Transvaginal view of the uterus in a postmenopausal woman. The endometrium is a thin linear hyperechoic| |

|band (calipers). The patient also has prominent arcuate vessels (curved arrows). | |

The myometrium should be homogeneous with smooth margins. The arcuate vessels are in the periphery of the uterus and can be seen as a segmented hypoechoic band in the outer third of the myometrium (see Fig. 28-2A and Fig. 28-2B) .

The body of the uterus is separated from the cervix by the isthmus at the level of the internal os. The uterus assumes a variety of different positions described in relation to the angle of the cervix to the vaginal (version) and the angle of body of the uterus at the isthmus (flexion). The most common position is anteverted. When the uterus is retroverted or retroflexed, it is difficult to evaluate transabdominally and should be scanned with the vaginal probe (Fig. 28-3A and Fig. 28-3B ) . [28.4 ]

|Figure - 28-3a. |[pic] |

|Retroflexed uterus in a woman with intermenstrual bleeding. Transabdominal examination shows a | |

|retroflexed uterus, but is difficult to evaluate the fundus and the endometrium. | |

|Figure - 28-3b. |[pic] |

|Transvaginal examination shows a thickened endometrium that measures 18 mm (calipers) with a focal area| |

|of increased echogenicity (arrows) which was a polyp. Transvaginal examination is necessary to | |

|completely evaluate the uterus in patients with retroverted or retroflexed uterus and to evaluate the | |

|endometrium in women with abnormal bleeding. | |

The cervix is homogeneous in echotexture with a hypoechoic central canal. Nabothian cysts are commonly seen in the cervix of older women. These cysts measure less than 2 cm and are usually anechoic, but occasionally contain debris. They are probably caused by prior inflammation.

Duplication Anomalies

Duplication anomalies of the uterus occur in 0.5% of women because of incomplete fusion of the müllerian ducts (Table 28-2 ) . In these cases, transabdominal scanning is valuable in identifying the degree of separation of the uterine horns and defining the external uterine contour. Endovaginal scanning during the secretory phase (when the endometrium is most prominent) is helpful in defining two separate endometrial stripes. In subtle cases, magnetic resonance imaging often is helpful in delineating the type of duplication anomaly.

Duplication anomalies usually are asymptomatic. Conditions associated with these anomalies include the following: an increased incidence of spontaneous abortion and pregnancy complications (2)   ; an obstructed duplicated horn that presents as a pelvic mass; and renal anomalies, especially unilateral renal agenesis (3)  (Fig. 28-4A and Fig. 28-4B) .

|Figure - 28-4a. |[pic] |

|Bicornuate uterus. Transabdominal transverse view of the uterus demonstrates two horns that are widely | |

|separated. Only one cervix was seen on vaginal scanning. | |

|Figure - 28-4b. |[pic] |

|(B) View of the right renal fossa demonstrates an absent right kidney. | |

Endometrium

The endometrium is visualized as a hyperechoic band in the center of the uterus. The total thickness of the endometrium represents the anterior and posterior opposed layers. Endovaginal scanning is required to optimally visualize the endometrium. [28.5 ] When endometrial fluid is present, this should not be included in the endometrial thickness measurement. The hypoechoic layer around the endometrium represents an inner compact layer of myometrium and should not be included in endometrial thickness measurements. (4)

Normal endometrial thickness and appearance varies with the phase of the menstrual cycle (5)  ( Fig. 28-5A , Fig. 28-5B  , and Table 28-3 ). During the menstrual phase, hypoechoic material can be seen centrally, which represents blood and tissue. In the proliferative phase, the endometrium has the appearance of three lines with an echogenic central line surrounded by a more hypoechoic layer, with a peripheral hyperechoic layer. In the late secretory phase, the endometrium is at its greatest thickness, with homogeneously increased echogenicity and increased through transmission. (6)

|Figure - 28-5a. |[pic] |

|Normal endometrium. "Triple line" endometrium in midcycle. | |

|Figure - 28-5b |[pic] |

|Secretory phase endometrium that is thick and echogenic with posterior acoustic enhancement. | |

Fallopian Tube

The normal fallopian tube is difficult to distinguish from surrounding vessels and ligaments. It usually is not visualized unless abnormal or surrounded by fluid.

Ovaries

Ovarian Size

Ovaries in girls younger than 2 years of age are typically less than 1 mL in volume, although in neonates they can be slightly larger. Recent literature also documents in these young girls the presence of cysts, which usually are less than 5 mm (with the exception of neonates, where they may be larger than 1 cm). (7-9)

The ovaries increase in size in prepubertal girls with follicles up to 1 cm in size. After menarche, the ovaries are ovoid in shape and generally measure 3 x 2 x 1 to 2 cm (Fig. 28-6 ). Follicles typically are present. A study of ovarian size in women of menstrual age reveals a mean ovarian volume of 10 ml. (10)  (Table 28-4 ) lists the size and appearance of ovaries with respect to patient age. [28.2 ]

|Figure - 28-6. |[pic] |

|Normal ovary with multiple small follicles. | |

Ovarian Cysts

In the proliferative phase of the menstrual cycle, multiple small follicles are visualized, usually 1 cm in diameter or less. A dominant follicle develops in the midcycle, which measures up to 2 cm in diameter. After ovulation, the corpus luteum cyst develops. [28.6 ] This frequently contains hemorrhage and has a complex appearance. (Table 28-5 ) describes the appearance of ovary follicles with respect to phase of the menstrual cycle. (Table 28-6 ) lists the various appearances of hemorrhagic cysts.

Ovarian cysts are common in all age groups, but especially in women of menstrual age. Anechoic benign cysts are completely anechoic with enhanced through transmission. They have a thin wall, no septations, and no solid elements. Because dominant follicles and luteal cysts frequently are up to 3 cm in size, benign-appearing lesions in this size range require no follow-up. Hemorrhagic cysts have a more complex appearance (see Table 28-6 ) with internal septations and retractile clot (Fig. 28-7 ) . [28.7 ] However, if a cyst is small (less than 3 cm) and has the classic appearance of a hemorrhagic cyst, it can be treated as a benign cyst and therefore does not require follow-up.

|Figure - 28-7. |[pic] |

|Hemorrhagic cyst. Transvaginal view of the right ovary demonstrates a cyst with multiple internal | |

|echoes and strands of internal echoes. This is the classic appearance of a hemorrhagic cyst. | |

If a lesion has a questionable appearance or is larger than 3 cm, serial scans are helpful since hemorrhagic cysts undergo rapid change of internal characteristics. A follow-up sonogram in 6 weeks (when the patient is at a different phase of the menstrual cycle) typically demonstrates resolution of the cyst. For large lesions, hormonal therapy frequently is used to suppress follicular activity and the development of new cysts (Table 28-7 ) .

Free Fluid

A small amount of fluid is present in the cul-de-sac of asymptomatic women throughout the menstrual cycle. The largest quantity of normal free fluid occurs after the mature follicle ruptures in the midcycle, (11)  but fluid also is seen during menstruation and can be visualized throughout the cycle from serosal transudate from the ovary or other peritoneal organs. (12)

Complex fluid (with debris or septations) is abnormal and results from hemorrhage, infection, or neoplasm

SONOGRAPHIC PITFALLS

Extrauterine Solid Pelvic Masses

A variety of nonovarian tumors and other abnormalities can masquerade as solid ovarian masses (Table 28-8 ) . The most common of these is the pedunculated fibroid (Fig. 28-8A and Fig. 28-8B ) . This diagnosis is made sonographically when the ovaries are seen separate from the otherwise suspicious-appearing mass. A stalk can be present connecting the pedunculated fibroid to the uterus. Magnetic resonance imaging is helpful in difficult cases. Nongynecologic conditions that may mimic solid ovarian masses include pelvic kidney (Fig. 28-9A ), diverticulitis (see Fig. 28-9B ) , rectosigmoid carcinoma, vascular masses, pelvic lymph nodes, an inflamed appendix, and pelvic hematomas.

|Figure - 28-8a. |[pic] |

|Pedunculated fibroid. Transabdominal view of the pelvis demonstrates a mass (M) adjacent to the uterus | |

|(U). | |

|Figure - 28-8b. |[pic] |

|Transvaginal examination demonstrates a tissue plane between the uterus and the mass. | |

|Figure - 28-9a. |[pic] |

|Mimics of solid adnexal masses. Pelvic kidney. Transvaginal view of the uterus (U) with a mass (K) seen| |

|behind the uterus with a tissue plane between the two. Echogenic fat (arrows) can be seen in the center| |

|of this pelvic kidney. | |

|Figure - 28-9b. |[pic] |

|Diverticulitis. Transvaginal view in the left pelvis shows a hypoechoic mass arising from sigmoid colon| |

|in this patient with diverticulitis. | |

Extrauterine Cystic Pelvic Masses

|Figure - 28-10. |[pic] |

|A 6-cm parovarian cyst (C) is seen medial to the right ovary (calipers). | |

Multiple lesions within the pelvis can masquerade as an ovarian cyst (Table 28-9 ).The etiology of extraovarian cysts is suggested by visualization of a separate ipsilateral ovary (Fig. 28-10  ) and in some cases by connection with the organ of origin, such as in the case of a bladder diverticulum (13)  or a Tarlov cyst. (14)

Bowel loops frequently mimic ovarian cysts. Therefore, watch for peristalsis when a questionable lesion is visualized

Nonvisualization of a Palpable Pelvic Mass

Dermoid cysts have a variety of appearances because of their complex nature. Frequently, the dermoid cyst mimics bowel gas and is seen only as an echogenic area with shadowing. In a patient with a palpable pelvic mass in whom no abnormality is visualized, consider an echogenic dermoid (Fig. 28-11A and Fig. 28-11B ) and carefully scan in the region of the palpable mass.

|Figure - 28-11a. |[pic] |

|Dermoid. Transabdominal view of the uterus (UT) demonstrates a questionable right adnexal mass (RT). | |

|Figure - 28-11b. |[pic] |

|Endovaginal scan demonstrates extremely echogenic nature of this mass, which was not recognized on two | |

|prior sonograms. | |

Don't Stop After One Lesion Is Found

Many benign ovarian tumors occur bilaterally (dermoids, serous cystadenomas, and metastases). In addition, women with one gynecologic malignancy are at increased risk for a second malignancy (Fig. 28-12A and Fig. 28-12B ) . Some ovarian tumors, such as endometrioid tumors and estrogen-producing thecoma and granulosa cell tumors, are associated with endometrial hyperplasia and endometrial cancer (Fig. 28-13A and Fig. 28-13B ) . There also are rare syndromes in which gynecologic malignancies are grouped such as the Lynch cancer family syndrome, in which there is an association between ovarian cancer, colon cancer, and endometrial cancers. (15)

|Figure - 28-12a. |[pic] |

|Concurrent lesions: a 90-year-old woman with endometrial cancer and ovarian cancer. transabdominal view| |

|of the uterus demonstrates ill-definition of the endometrium with invasion of the endometrium into the | |

|myometrium. | |

|Figure - 28-12b. |[pic] |

|A 6-cm left adnexal cyst with multiple septations and solid nodules from ovarian cancer. | |

|Figure - 28-13a. |[pic] |

|Concurrent lesions: granulosa cell tumor with endometrial hyperplasia. Thickened endometrium (15 mm) | |

|with a small cyst. | |

|Figure - 28-13b. |[pic] |

|The histologic type was endometrial hyperplasia, probably secondary to the estrogenic effect of the | |

|granulosa cell tumor. (Levine D. Sonography of the postmenopausal pelvis. In: Anderson J, ed. | |

|Gynaecological imaging. London, Churchill Livingstone [in press]) | |

SONOGRAPHIC ABNORMALITIES OF THE PELVIS

Abnormal Uterus

Uterine Enlargement

Causes of uterine enlargement are listed in (Table 28-10 ). These include fibroids, pregnancy and pregnancy-related conditions, uterine sarcoma, endometrial carcinoma, and obstruction with a fluid-filled uterus.

Fibroids

Fibroids occur in approximately 25% of women of reproductive age ( Fig. 28-14A , Fig. 28-14B , and Fig. 28-14C ). They consist of nodules of myometrium and typically cause an enlarged uterus with multiple masses that are echo-attenuating. They are sensitive to estrogen stimulation and therefore increase in size during pregnancy. (16)  Cystic areas are secondary to degeneration. Clumps of calcification cause echogenic foci with shading. Fibroids are described by their location: they can be submucosal, intramural, subserosal, or pedunculated (see Fig. 28-8A and Fig. 28-8B ). Cervical and broad ligament fibroids are rare. Findings in patients with fibroids are summarized in (Table 28-11 ).

|Figure - 28-14a. |[pic] |

|Fibroids. Transabdominal view of a fibroid uterus. The uterus is enlarged with a heterogeneous | |

|echotexture and a lumpy contour caused by fibroids. | |

|Figure - 28-14b. |[pic] |

|Submucosal fibroids surrounded by fluid during a sonohysterogram. | |

|Figure - 28-14c. |[pic] |

|Subserosal fibroid with broad attachment to the myometrium and a exophytic component. | |

|Figure - 28-8a. |[pic] |

|Subserosal fibroid with broad attachment to the myometrium and a exophytic component. | |

|Figure - 28-8b. |[pic] |

|Transvaginal examination demonstrates a tissue plane between the uterus and the mass | |

Small fibroids can be difficult to detect sonographically. They cause a heterogeneous echotexture of the myometrium without sonographically visible focal lesions. At times, only a contour distortion along the interface between the uterus and bladder is seen.

Uterine Sarcoma

Sarcomas comprise less than 5% of uterine malignancies. They resemble fibroids or endometrial carcinoma. (17)  When a rapid change in the size of fibroids is noticed, a uterine sarcoma should be considered as the etiology (Fig. 28-15A and Fig. 28-15B ) .

|Figure - 28-15a. |[pic] |

|Uterine sarcoma. Transabdominal view of the uterus in a woman with a recent myomectomy demonstrates an | |

|enlarged uterus with a bizarre appearance to the myometrium with multiple cystic spaces. | |

|Figure - 28-15b. |[pic] |

|CT has a similar appearance. | |

Adenomyosis

Adenomyosis is a cause of heavy painful menses. The condition is produced when nests of endometrial tissue are located within the myometrium. The sonographic diagnosis is difficult to make. In general, the uterus is enlarged without focal mass (18,19)  (Fig. 28-16 ) . At times, small blood-containing spaces in the uterus can be seen caused by dilated glands filled with menstrual products.

|Figure - 28-16. |[pic] |

|Enlarged uterus in a 53-year-old woman with abnormal bleeding. The uterus is enlarged slightly and | |

|heterogeneous in echotexture but has no focal masses. Histologic examination revealed adenomyosis. | |

Focal adenomyomas also occur. These are difficult to distinguish from fibroids. Fibroids tend to be well circumscribed. In contrast, focal adenomyomas are ill defined and may have lacunae.

The preoperative distinction between fibroids and adenomyosis is important in women who are being treated for infertility or abnormal bleeding since myomas can be removed; however, adenomyosis typically requires a hysterectomy. Magnetic resonance is helpful in this distinction. (20)

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|Obstruction |

|Patients with hydrocolpos (fluid in the vagina) and hydrometrocolpos (fluid in the vagina and uterus) usually are studied soon after birth or at puberty when secretions |

|cause obstruction because of an intact hymen or vaginal atresia. Hematometra is seen in patients with cervical cancer or cervical stenosis (Fig. 28-17 ) . |

|Figure - 28-17. |

|Hematometra. Sagittal view of the uterus in a 63-year-old asymptomatic woman placed on cyclic hormonal replacement therapy demonstrates a large endometrial fluid |

|collection with a thin surrounding endometrium. She subsequently underwent surgical dilation for cervical stenosis. (Levine D. The postmenopausal pelvis. In: Nyberg DA, |

|ed. Transvaginal ultrasound. St. Louis, MO, Mosby Year Book, 1992:228) |

|[pic] |

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|Endometrial Cancer |

|Enlargement of the uterus is a late finding in endometrial cancer. This disease is discussed in more detail in Chapter 29. |

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|Bright Reflectors In The Uterus |

|Causes of bright echoes in the uterus and endometrium are listed in (Table 28-12 ) . |

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|Uterine calcifications |

|The most common cause of dense echoes in the uterus are calcifications resulting from fibroids. These appear as clumps of calcification (Fig. 28-18A ) or as rim |

|calcification around a mass. |

|Figure - 28-18a. |

|Uterine calcifications. Transvaginal transverse view of the uterus in a postmenopausal woman with abnormal bleeding demonstrates a well-defined echogenic focus with |

|shadowing secondary to a calcified fibroid. Adjacent to this area is a fluid collection in a region of thickened endometrium (arrows). This was endometrial hyperplasia. |

|[pic] |

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|A less common cause of calcification within the uterus is that of the arcuate artery. Arcuate artery calcifications are seen around the periphery of the uterus, usually in|

|older women with severe medical problems such as diabetes, chronic renal failure, or hypertension. (21) |

|Punctate calcifications occasionally are seen at the endometrial myometrial interface (see Fig. 28-18B ). These are probably secondary to a prior infection or procedure. |

|(22) |

|Figure - 28-18b. |

|Punctuate calcifications at the endometrial myometrial interface in a patient with two prior dilatation and curettage procedures. |

|[pic] |

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Intrauterine Contraception Devices

Another cause of bright reflectors within the uterus are intrauterine contraception devices (IUDs) (Fig. 28-19A and Fig. 28-19B ) . Ultrasound is helpful in locating an IUD when the string cannot be felt. The IUD should be located centrally within the endometrium. A straight shaft IUD gives a bright linear reflector with entrance-exit reflections and ring-down artifacts. (23)  The Lippes loop IUD also has a characteristic appearance with segmental reflectors with shadowing (see Fig. 28-19B ).

|Figure - 28-19a. |[pic] |

|Intrauterine contraception devices (IUDs). Straight shaft IUD. | |

|Figure - 28-19b. |[pic] |

|Lippes loop IUD. | |

If the IUD is not visualized sonographically, radiographs should be obtained to exclude an extrauterine location of an IUD.

Abnormal Endometrium

Thick Endometrium

Causes of a thickened endometrium include the normal secretory phase endometrium, endometrial hyperplasia, endometrial polyps, fibroids, endometritis, early pregnancy, and complications of pregnancy. These are listed in (Table 28-13 ) .

Secretory Endometrium

In women of menstrual age, the upper limit of normal endometrial thickness is 14 to 16 mm. However, the endometrium can be thicker than this in the secretory phase and still be normal. An asymptomatic woman who is in the secretory phase by menstrual history, with a homogeneously echogenic thickened endometrium with posterior acoustic enhancement, probably needs no follow-up (see Fig. 28-5B ). If any atypical features are seen, a follow-up examination after menstruation is helpful.

|Figure - 28-5b. |[pic] |

|Secretory phase endometrium that is thick and echogenic with posterior acoustic enhancement | |

Fibroids

Submucosal fibroids also give the appearance of a thick endometrium caused by the distortion of the endometrial-myometrial interface.

Endometritis

Endometritis occurs in association with pelvic inflammatory disease (PID) and in postpartum patients. The endometrium appears prominent or irregular with a small amount of endometrial fluid. (24,25)  Gas bubbles can be present; however, these are also a normal postpartum finding. (26)

Synechiae

Synechiae rarely are visualized in the nongravid uterus. They are found in women with a history of spontaneous abortion or uterine curettage. Vaginal sonography may demonstrate bright echoes within the endometrial cavity in this condition. (27)

Endometrial Hyperplasia, Polyps, and Cancer

As women approach menopause, the incidence of endometrial hyperplasia, polyps, and cancer increase as causes of endometrial thickening ( Fig. 28-20A  , Fig. 28-20B , and Fig. 28-20C ). Endometrial hyperplasia is caused by unopposed estrogen; the endometrium is thickened either diffusely or focally (see Fig. 28-13A and Fig. 28-18A ). Endometrial polyps usually are asymptomatic but may cause uterine bleeding. They also cause diffuse or focal endometrial thickening (24)  (see Fig. 28-3B and Fig. 28-20B ). In both of these conditions (endometrial hyperplasia and polyps), the interface between the endometrium and the myometrium is preserved.

|Figure - 28-20a. |[pic] |

|Utility of endometrial fluid in outlining endometrial abnormalities is demonstrated. Sonohysterography | |

|catheter (arrows) is seen entering the endometrial cavity. Fluid outlines a well-defined intracavitary | |

|mass. | |

|Figure - 28-20b. |[pic] |

|Fluid outlines an echogenic mass on a stalk (curved arrows) with an endometrial polyp. | |

|Figure - 28-20c. |[pic] |

|Small amount of fluid in the endometrium outlines an ill-defined mass (calipers) with distortion of the| |

|endometrial myometrial interface in this patient with endometrial cancer. | |

|Figure - 28-13a. |[pic] |

|Concurrent lesions: granulose cell tumor with endometrial hyperplasia. Thickened endometrium (15 mm) | |

|with a small cyst. | |

|Figure - 28-18a. |[pic] |

|Uterine calcifications. (A) Transvaginal transverse view of the uterus in a postmenopausal woman with | |

|abnormal bleeding demonstrates a well-defined echogenic focus with shadowing secondary to a calcified | |

|fibroid. Adjacent to this area is a fluid collection in a region of thickened endometrium (arrows). | |

|This was endometrial hyperplasia. (B) Punctuate calcifications at the endometrial myometrial interface | |

|in a patient with two prior dilatation and curettage procedures. | |

|Figure - 28-3b. |[pic] |

|Transvaginal examination shows a thickened endometrium that measures 18 mm (calipers) with a focal area| |

|of increased echogenicity (arrows). Which was a polyp. Transvaginal examination is necessary to | |

|completely evaluate the uterus in patients with retroverted or retroflexed uterus and to evaluate the | |

|endometrium in women with abnormal bleeding. | |

Endometrial cancer also is a cause endometrial thickening. The diagnosis is suggested when there is loss of the endometrial-myometrial interface (see Fig. 28-12A and Fig. 28-20C  ). These conditions are discussed in detail in Chapter 29.

|Figure - 28-12. |[pic] |

|Concurrent lesions: a 90-year-old woman with endometrial cancer and ovarian cancer. transabdominal view| |

|of the uterus demonstrates ill-definition of the endometrium with invasion of the endometrium into the | |

|myometrium. | |

Sonohysterography

When endometrial thickening is present sonographically and the etiology is unclear (or if the result of an endometrial biopsy is negative despite an abnormal sonogram), sonohysterography often is helpful in identifying the cause of the endometrial thickening. (28,29)   For this procedure, a catheter is placed into the endometrial cavity under sterile conditions, and 10 mL of saline is injected into the endometrial cavity to identify the cause of the thickening. [28.8 ] In this manner, polyps and fibroids are outlined and better characterized ( Table 28-14 ; see Fig. 28-20A, Fig. 28-20B and Fig. 28-20C ).

|Figure - 28-20a. |[pic] |

|Utility of endometrial fluid in outlining endometrial abnormalities is demonstrated. Sonohysterography | |

|catheter (arrows) is seen entering the endometrial cavity. Fluid outlines a well-defined intracavitary | |

|mass. | |

|Figure - 28-20b. |[pic] |

|Fluid outlines an echogenic mass on a stalk (curved arrows) with an endometrial polyp. | |

|Figure - 28-20c. |[pic] |

|Small amount of fluid in the endometrium outlines an ill-defined mass (calipers) with distortion of the| |

|endometrial myometrial interface in this patient with endometrial cancer. | |

Color Doppler with calculation of the pulsatility or the resistive index is not helpful in the distinction between benign and malignant causes in endometrial thickening. (30-32)

Endometrial Fluid

Fluid within the endometrial cavity is seen in both normal and pathologic conditions (24,25,33)  (Table 28-15 ) . In women in the menstrual phase of their cycle, a tiny amount of fluid is a normal finding. Fluid within the endometrium also is seen in normal early pregnancy and abnormal pregnancy (missed abortion, ectopic pregnancy, and molar pregnancy). Other causes of endometrial fluid include infection, degenerating fibroids, and obstruction. (25)  In older patients, fluid can be secondary to malignancy (uterine, cervical, tubal, or ovarian); however, cervical stenosis of a benign etiology (especially in women who previously had children or instrumentation) is more common (34)  (see Fig. 28-17  ). The presence of fever in a woman with a fluid collection suggests pyometra.

|Figure - 28-17. |[pic] |

|Hematometra. Sagittal view of the uterus in a 63-year-old asymptomatic woman placed on cyclic hormonal | |

|replacement therapy demonstrates a large endometrial fluid collection with a thin surrounding | |

|endometrium. She subsequently underwent surgical dilation for cervical stenosis. (Levine D. The | |

|postmenopausal pelvis. In: Nyberg DA, ed. Transvaginal ultrasound. St. Louis, MO, Mosby Year Book, | |

|1992:228) | |

Abnormal Cervix

The most common mass within the cervix is the Nabothian cyst. Solid masses include fibroids (Fig. 28-21A ) and malignancies (see Fig. 28-21B  ). Cervical fibroids are hypoechoic and typically well defined, whereas cervical cancer is more likely to have ill-defined margins. Less common cervical masses include ectopic pregnancy and polyps (Table 28-16 ) .

|Figure - 28-21a. |[pic] |

|Cervical masses Sagittal view of the cervix demonstrates a large cervical fibroid which deviates the | |

|lower uterine segment anteriorly | |

|Figure - 28-21b. |[pic] |

|Transvaginal view of the cervix demonstrates an ill-defined relatively isoechoic mass (M) in this | |

|patient with cervical cancer. | |

Abnormal Vagina

Vaginal masses are rare. The most common visualized with sonography are Gartner cysts. These cysts usually are located within or near the vaginal wall and typically are palpable on physical examination. Vaginal adenocarcinoma and rhabdomyosarcoma appear as solid masses, occasionally with areas of necrosis. (1)

Abnormal Fallopian Tube

The major cause of fallopian tube abnormalities are infection and ectopic pregnancy (Table 28-17 ) . Less frequent causes of fallopian tube masses are chronic tuboovarian abscess (TOA) and a fallopian tube cancer, both of which appear as a solid mass within the tube or adjacent to the ovary ( Fig. 28-22A  , Fig. 28-22B , Fig. 28-22C  , Fig. 28-22D , and Fig. 28-22E  ).

|Figure - 28-22a. |[pic] |

|Abnormal fallopian tube. Transvaginal view of the right adnexal reveals an elongated tubular structure | |

|with a thin wall and no internal debris. This is the typical appearance of a hydrosalpinx. | |

|Figure - 28-22b. |[pic] |

|Thick walled tubular structure (arrows) in a patient with pelvic inflammatory disease. | |

|Figure - 28-22c. |[pic] |

|Transabdominal view of the uterus (U) and adnexa (RT, LT) reveals bilateral enlarged adnexa. | |

|Figure - 28-22d. |[pic] |

|Endovaginal examination reveals a heterogeneous adnexal mass mixed cystic and solid in a patient with | |

|bilateral tuboovarian abscess. | |

|Figure - 28-22e. |[pic] |

|Well-circumscribed echogenic 2.5 cm mass (M) adjacent to the right ovary (O) in a patient with a | |

|chronic tuboovarian abscess. | |

Hydrosalpinx

An obstructed tube usually is caused by PID. Other causes are endometriosis and postoperative adhesions.

Pelvic Inflammatory Disease

Old infection presents as an uncomplicated hydrosalpinx (a fluid-filled tubular structure with a thin wall; (see Fig. 28-22A  ). When an acute infection is present, the tube wall is thickened, nodular, and hyperemic (see Fig. 28-22B  ). Internal debris (pyosalpinx) can be present. In addition to hydrosalpinx or pyosalpinx, sonographic findings of PID include fluid in the cul-de-sac, mild uterine enlargement, and endometrial fluid or thickening. (35)

When the ovary is involved, this is a TOA. This creates a heterogeneous pelvic mass that typically is bilateral (see Fig. 28-22C ). The sonographic appearance of TOA frequently is nonspecific with a complex pattern. Although PID usually is bilateral, it can present unilaterally, especially in a patient with an IUD in place.

Ectopic Pregnancy

Ectopic pregnancy presents as a complex adnexal mass in patients with a positive result on a pregnancy test and pain or bleeding (Fig. 28-23A and Fig. 28-23B ) . When an extrauterine mass is present, it most frequently is within the fallopian tube. Either an echogenic mass or an echogenic ring can be present. A fetal pole is seen in up to 20% of cases. (36,37)  Ectopic pregnancy should be suspected in a woman with a positive pregnancy test result and empty endometrial cavity, even in the absence of a sonographic adnexal mass. Fluid in the peritoneal cavity also is a worrisome finding, being reported in approximately 75% of cases of ectopic pregnancy. (36)

|Figure - 28-23a. |[pic] |

|Ectopic pregnancy. A complex left adnexal mass (ADNEX) is seen between the uterus (UT) and left ovary | |

|(OV). | |

|Figure - 28-23b. |[pic] |

|A different patient with ectopic pregnancy demonstrates free fluid in the cul-de-sac with multiple | |

|internal echoes caused by hemoperitoneum. | |

Chronic ectopic pregnancy appears as echogenic masses adjacent to the uterus in a patient with fever and a retrouterine mass.

Fallopian Tube Carcinoma

Fallopian tube carcinoma is rare. It is suggested when a solid or complex adnexal mass is visualized separate from the ovary in a woman without ectopic pregnancy. (38)  The tube may become distended with secretions, causing pain.

Abnormal Ovary

The differential diagnosis of an ovarian abnormality depends on a variety of factors, including patient age (Table 28-18 ) , time since last menstrual period, hormonal status, symptoms (pain), positive pregnancy test result, prior surgery, and findings on physical examination. Functional cysts and benign neoplasms comprise most of the adnexal lesions in women of reproductive age. Malignant lesions are more common in older women.

The differential diagnosis also is influenced by the sonographic characteristics of the lesion as well as any associated findings (Table 28-19 ) .

The classic sonographic description of adnexal masses is based on the cystic nature of most adnexal lesions. They are categorized as completely cystic, complex (mixed cystic and solid), or solid. Findings that increase the likelihood of malignancy are listed in (Table 28-20 ) .

Doppler Analysis Of Adnexal Masses

Color Doppler is helpful in determining if a questionable lesion is a cyst or a vessel. [28.9 ] It is also helpful in establishing the solid nature of a hypoechoic solid mass. When pulsed Doppler analysis of tumor vascularity is to be performed, color Doppler aids in the placement of the Doppler gate.

A large amount of literature has been dedicated to use of Doppler sonography for distinguishing between benign and malignant adnexal masses.

Because tumor vessels lack a muscular layer, they frequently have low resistance flow. This resistance can be quantified either with the resistive index (peak systole - end diastole/peak systole) or the pulsatility index (peak systole - end diastole/mean). A resistive index of 0.4 or less or a pulsatility index of 1.0 or less is associated with malignant disease. (39,40)  However, many other physiologic and benign neoplastic lesions can have a low resistive index (Table 28-21 ) .

The corpus luteum typically has low resistance flow; therefore, if possible, patients should be scanned in the first 10 days of the cycle to avoid confusion with luteal flow. However, even when physiologic masses are excluded from analysis, the sensitivity and specificity of Doppler resistive index are not sufficient to replace the morphologic impression of a lesion being benign or malignant. (30,32,41)  Gray scale morphologic features are more sensitive in this discrimination. (30,32)

Other Doppler findings associated with malignancy include lack of a diastolic notch (40)  and presence of blood flow within solid portions of the tumor.

Anechoic Cysts

Anechoic cysts have a thin wall, are completely anechoic, and are enhanced through transmission. Regardless of their size, they are unlikely to be malignant (42-46)  (Fig. 28-24 ) . In women of menstrual age, the most common anechoic cyst is the functional cyst. These usually are small and measure less than 2 cm in diameter; however, they may enlarge up to 10 cm. They typically regress spontaneously. At times, birth control pills are necessary to suppress their growth. When an anechoic cyst is seen that is larger than 6 cm, the likelihood of neoplasm is high. If there are no wall irregularities or septations, the cyst is most likely secondary to a benign neoplasm such as a cystadenoma.

|Figure - 28-24. |[pic] |

|A 10-cm anechoic cyst in a 59-year-old woman. There is a thin wall and internal debris or septations. | |

|This was a benign cystadenoma. | |

Other causes of simple adnexal cysts include paraovarian (Fig. 28-10 ) and paratubal cysts, peritoneal inclusion cysts (Fig. 28-25 ) , and luteal cysts (Fig. 28-26  and Table 28-22 ) . When an adnexal cyst is visualized, look for the ovary as separate or adjacent to the mass. In the case of paraovarian and paratubal cysts, the ovary is seen separately, as in cases of cysts of nongynecologic etiology. (47)

|Figure - 28-25. |[pic] |

|Peritoneal inclusion cyst: a 6-cm right adnexal mass in a patient with multiple prior pelvic surgeries.| |

|There were areas of septation with blood flow. This was a peritoneal inclusion. | |

|Figure - 28-26. |[pic] |

|Hyperstimulated ovary in a woman being treated for infertility. | |

Paraovarian cysts

Paraovarian cysts account for 10% of adnexal masses (see Fig. 28-10  ). They arise from the broad ligament. (48)  Their size does not change during the menstrual cycle.

|Figure - 28-10. |[pic] |

|A 6-cm parovarian cyst (C) is seen medial to the right ovary (calipers). | |

Theca Lutein cysts

Theca lutein cysts are large bilateral ovarian cysts that can appear as multiloculated masses (see Fig. 28-26  ). They are associated with high levels of human chorionic gonadotropin, usually secondary to infertility drugs, gestational trophoblastic disease, or multiple gestations.

Complex Cysts

Complex cysts are those that do not meet the criteria for anechoic cyst. In women of menstrual age, the hemorrhagic cyst is the most common etiology of a complex ovarian cyst. [28.10 ] The internal architecture of the cyst is important in establishing an appropriate differential diagnosis. In many cases, it allows for a specific diagnosis (Table 28-23 ) . This is usually true for hemorrhagic cysts, endometriomata, and dermoid cysts. If the classic benign appearance of a hemorrhagic cyst-an endometrioma, or a dermoid cyst-is not visualized, a neoplasm (either benign or malignant) must be considered (see Fig. 28-23A and Fig. 28-23B  ).

|Figure - 28-23a. |[pic] |

|Ectopic pregnancy. A complex left adnexal mass (ADNEX) is seen between the uterus (UT) and left ovary | |

|(OV). | |

|Figure - 28-23b. |[pic] |

|A different patient with ectopic pregnancy demonstrates free fluid in the cul-de-sac with multiple | |

|internal echoes caused by hemoperitoneum. | |

Endometriosis

Endometriosis is a common condition in which endometrial tissue is present outside of the uterus. In most cases, sonography cannot demonstrate the tiny implants. In the diffuse form of the disease, there is an appearance similar to PID or chronic ectopic pregnancy with endometrial implants scattered over the peritoneum, especially in the dependent portions of the pelvis. (49)

The localized form of the disease creates an endometrioma. This is seen as a cyst on transabdominal scanning. With endovaginal scanning, diffuse low-level echoes are seen: the "chocolate" cyst ( Fig. 28-27A and Fig. 28-27B ).

|Figure - 28-27a. |[pic] |

|Endometrioma. Transvaginal view of the right ovary demonstrates 4-cm cyst with diffuse low-level | |

|internal echoes. Wall thickening is seen in a few areas. This is the classic appearance for an | |

|endometrioma. | |

|Figure - 28-27b. |[pic] |

|At times, a thin septation can be seen within an endometrioma. Low-resistance flow can be seen. | |

Dermoids

Dermoids are the most common ovarian neoplasm. They have a spectrum of sonographic appearances, including a completely cystic mass, a cystic mass with an echogenic mural nodule, a fat-fluid level, echogenic foci with shadowing (teeth or bone), or a complex mass with internal septations and bright linear echoes (50-52)  ( Fig. 28-28 ; see Fig. 28-11A and Fig. 28-11B  ). Rare forms of dermoids include the specialized tumors of struma ovarii (with thyroid tissue) and carcinoid tumors. Malignant degeneration (into squamous cell carcinoma) of dermoids is rare. This typically occurs in older women.

|Figure - 28-28. |[pic] |

|Dermoid: a 2.7 cm left adnexal mass in a 30-year-old woman demonstrates a cyst with a 7-mm echogenic | |

|mural nodule. (Levine D. The postmenopausal pelvis. In: Nyberg DA, ed. Transvaginal ultrasound. St. | |

|Louis, Mo, Mosby Year Book, 1992:237) | |

|Figure - 28-11a. |[pic] |

|Dermoid. Transabdominal view of the uterus (UT) demonstrates a questionable right adnexal mass (RT). | |

|Figure - 28-11b. |[pic] |

|Endovaginal scan demonstrates extremely echogenic nature of this mass, which was not recognized on two | |

|prior sonograms. | |

Immature teratomas occur in young women 10 to 20 years of age. Alpha-fetoprotein is elevated in 50% of cases. They can revert to mature teratoma after treatment.

Epithelial tumors

The cystadenoma and cystadenocarcinoma are the most common types of epithelial tumors. Serous tumors tend to be anechoic with septations. Mucinous tumors tend to have internal debris. The number and thickness of septations as well as the presence of mural nodularity increase the likelihood of malignancy ( Fig. 28-29A , Fig. 28-29B  , and Fig. 28-29C  ). Less common varieties of epithelial tumors are endometrioid, clear cell, Brenner, and undifferentiated carcinoma.

|Figure - 28-29a. |[pic] |

|Serous and mucinous tumors. Transvaginal view of the right adnexa demonstrates a 10.8 cm mass with a | |

|few septations (arrows). This was a serous cystadenoma. | |

|Figure - 28-29b. |[pic] |

|A 4 cm adnexal mass that is predominantly cystic but with multiple mural nodules. Histologic diagnosis | |

|was serous cystadenocarcinoma. | |

|Figure - 28-29c. |[pic] |

|A 10 cm right adnexal mass with diffuse internal echoes and irregular solid elements. Histologic | |

|diagnosis was mucinous cystadenocarcinoma. | |

Peritoneal Inclusion Cysts

Peritoneal inclusion cysts also can have the appearance of malignancy. The cysts occur in women who have had previous pelvic surgery. They can have thick walls and septations with blood flow suggestive of malignancy (see Fig. 28-24  ).

|Figure - 28-24. |[pic] |

|A 10-cm anechoic cyst in a 59-year-old woman. There is a thin wall and internal debris or septations. | |

|This was a benign cystadenoma. | |

Enlarged Ovaries Without Focal Mass

Enlarged ovaries without a focal mass can be a normal finding when bilateral. Other causes of bilateral enlarged ovaries include polycystic ovary disease, (53)  PID, and neoplasms (either primary or metastatic), especially lymphoma (Table 28-24 ) . Unilateral causes of an enlarged ovary without a focal mass include malignancy, ovarian torsion, an isoechoic hemorrhagic cyst, and PID.

Polycystic Ovaries

Polycystic ovary disease, which includes Stein-Leventhal syndrome (infertility, hirsutism, and oligomenorrhea), is one of the most common endocrine disorders. (54)  The diagnosis is made on the basis of clinical, sonographic, and biochemical criteria. Luteinizing hormone is elevated and follicle-stimulating hormone levels are low. Sonographically, the ovaries are normal or enlarged with multiple small peripheral cysts, less than 8 mm in diameter (55,56)  (Fig. 28-30 ) .

|Figure - 28-30. |[pic] |

|Polycystic ovary. A 24-year-old woman presented with right adnexal pain. Vaginal examination | |

|demonstrated bilateral enlarged ovaries with multiple small peripheral cysts. Doppler demonstrated | |

|symmetric and equal flow in both ovaries. The patient had the stigmata of polycystic ovary syndrome | |

|with obesity, hirsutism, and oligomenorrhea. | |

Torsion

The diagnosis of torsion is made when a patient presents with localizing pain. The ovary is enlarged and edematous with multiple small peripheral follicles. (57,58)  Free fluid often is present.

In the classic case of torsion, blood flow is absent on the affected side. It is helpful if blood flow can be visualized on the unaffected side, to ensure that Doppler controls are set appropriately. If an enlarged ovary demonstrates blood flow in a patient with acute pain, this may be secondary to torsion that has not yet caused necrosis. In this case, laparoscopic untwisting of the adnexa can be successful in saving the ovary. (59)  Torsion commonly is associated with an underlying lesion such as an ovarian cyst or neoplasm.

Isoechoic Hemorrhagic Cyst

When a hemorrhagic cyst is isoechoic compared with the remainder of the ovary, it is difficult to distinguish from a large ovary without a focal mass. Follow-up demonstrates resolution of the cyst with decreased size of the affected ovary.

Solid Ovarian Masses

The most worrisome cause of unilateral enlarged ovary is a solid ovarian neoplasm (Fig. 28-31 ). Whereas the serous and mucinous tumors tend to present as cystic and sold masses, there are less common ovarian neoplasms that present as solid ovarian masses. These are listed in (Table 28-25 ) .

|Figure - 28-31. |[pic] |

|A 4 cm solid hypoechoic mass in a 52-year-old woman. This was a fibrothecoma. | |

TABLE 28-1. Transvaginal and Transabdominal Scanning

| TRANSABDOMINAL ADVANTAGES |

|View of entire pelvis |

|Evaluate large masses |

|Evaluate masses out of range of transvaginal probe |

|Can be used in patients with intact hymen |

|TRANSABDOMINAL DISADVANTAGES |

|Full bladder requires time for patient to fill and may cause pain during examination |

|Some patients cannot adequately fill bladder |

|Difficult to evaluate retroverted uterus |

|TRANSVAGINAL ADVANTAGES |

|Proximity to pelvic organs with higher frequency transducer allows for better tissue characterization |

|Empty bladder scanning typically is less painful with a distended bladder |

|Good for obese patients and patients with abdominal wall scars, which limit ability to scan |

|transabdominally |

|TRANSVAGINAL DISADVANTAGES |

|Limited field of view; masses out of the range of the transducer are missed |

|Cannot be used in patients with intact hymen |

|Some patients will not be comfortable with examination |

TABLE 28-2. UterineAbnormalities

|   |Horns |Ultrasound Diagnosis |

|Unicornuate |1 horn |Difficult to diagnose sonographically |

|  |  |Small uterus |

| | |Lateral position |

| Bicornuate |2 horns |Visualization of separate horns |

| | |> 105 degrees apart |

|    One cervix | | |

|��� (Bicornis unicollis) | | |

|    Two cervices | | |

|��� (Bicornis bicollis) | | |

|    Didelphys |2 horns |Has duplication of cervix and upper vagina |

|Arcuate | |Smooth indentation of fundal endometrium |

| | |Mild form of bicornuate |

|Septate | |Smooth external contour |

| | |< 75 degrees between horns |

| | |Fibrous septum can be removed surgically |

|DES exposure | |T-shaped uterus |

| | |Short cervix |

 DES, diethystilbestrol.

TABLE 28-3.� Normal Endometrium

 

 

|Day of cycle | |Thickness | |

| |Phase |(mm) |Appearance |

|1-4 |Menstrual phase |1-4 |Small amounts of fluid may be seen endovaginally |

| | | |Thin interrupted central cavity |

|5-14 |Proliferative phase |4-8 |Mildly echogenic surrounded by thin hypoechoic band |

| |Periovulatory | |Multilayered with echogenic line of opposing endodremetria and |

| | | |echogenic outer rim |

|15-28 |Secretory phase |8-16 |Thick |

| | | |Echogenic with through transmission |

TABLE 28-4.� Ovary Appearance With Respect to Age

| Age |Size |Appearance |

|Neonate |May be larger than 1 cm |Follicles ................
................

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