Pelvic Ultrasonography Workup
- Author: Shoreh Kooshesh, MD; Chief Editor: Gowthaman Gunabushanam, MD, FRCR more...
Transabdominal imaging uses a low frequency and is performed to view large fibroids and ovaries that are high in the pelvis; to determine the shape and size of the bladder, uterus, vagina, and cervix; and to illustrate intrauterine or ectopic pregnancy.
A full bladder provides a sonographic window for evaluation of the uterus and adnexa. A full bladder has a teardrop-shaped appearance on the longitudinal view and is rectangular on the transverse view.
The uterus (longitudinal orientation) is oval and more echogenic than the bladder and located posterior to the bladder, appearing to wrap under it, ending in the cervix and vaginal canal. The endometrial stripe is an echogenic (bright) line in the central uterus.
The vagina is a hypoechoic tubular structure posterior to the bladder and caudal to the uterus. A vaginal stripe can be identified.
The cervix is seen between the uterus and vaginal canal.
The cul-de-sac is important, especially in the evaluation of patients at risk for ectopic pregnancy. It is also evaluated during the trauma assessment. A small amount of fluid can be seen in the middle of the menstrual cycle. Otherwise, the cul-de-sac is considered a potential space.
Ovaries may not be clearly identified on transabdominal images. Ovaries have a characteristic follicular appearance and may be in various positions. Endovaginal scanning uses a high-frequency transducer and provides high-quality images of the endometrium, myometrium, cul-de-sac, and ovaries.
The uterus usually is identified easily posterior to the bladder. In the longitudinal/sagittal view, the fundus is located on the left side of the imaging screen, with the cervix on the right. The entire uterus may not be seen at one time or on one particular endovaginal view. The uterus is pear-shaped on the longitudinal view and round on the transverse view.
The endometrial stripe is located within the central uterus; its thickness varies with the patient's menstrual cycle. The stripe is thin and less echogenic after menses but becomes thick and echogenic from ovulation to the secretory phase.
The ovaries usually are located posterior and lateral to the uterus and anterior to the internal iliac artery and vein. They usually are medial to the external iliac vessels. The iliac vessels provide an anatomic landmark for localization of the ovaries.
The typical follicular appearance of the ovaries aids in their identification; however, the follicles can be confused with vessels. Using the nonscanning hand, the ultrasonographer can place gentle pressure over the lower abdomen; this may help in moving the ovary into the ultrasound image.
Some ultrasound machines have endovaginal transducers that are capable of color flow imaging. This feature usually is seen on more expensive machines. This capability is helpful in localizing vessels within the pelvis and in determining blood flow to the ovaries, as is required to diagnose or exclude ovarian torsion.[15, 32]
Use of color flow imaging in ectopic pregnancy has been documented.
Transvaginal 3D imaging is as reliable as 2D imaging in evaluating the uterus.
The videos below depict abnormal transvaginal ultrasonographic findings.
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