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Pelvic Ultrasonography Workup

  • Author: Shoreh Kooshesh, MD; Chief Editor: Gowthaman Gunabushanam, MD, FRCR  more...
 
Updated: Mar 20, 2016
 

Imaging Studies

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.

Transabdominal longitudinal view of the female pel Transabdominal longitudinal view of the female pelvis.
Transabdominal transverse view of the female pelvi Transabdominal transverse view of the female pelvis: The bladder is rectangular. The ovaries are seen bilaterally in the adnexa.

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.[4] 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.

Endovaginal longitudinal view of the uterus: The e Endovaginal longitudinal view of the uterus: The endometrial stripe (st) is thickened. The arcuate vessels (arc) can be seen within the uterus and should not be confused with free fluid in the cul-de-sac.

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.

Endovaginal view of the ovary: Note its location a Endovaginal view of the ovary: Note its location adjacent to an iliac vessel.

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.[4]

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]

Video depicts 2 findings: first, it shows an enlarged hypovascular left ovary; second, it shows flow in the healthy right ovary. A small amount of intraperitoneal fluid surrounds the left ovary.

Use of color flow imaging in ectopic pregnancy has been documented.

Transvaginal 3D imaging is as reliable as 2D imaging in evaluating the uterus.[33]

The videos below depict abnormal transvaginal ultrasonographic findings.

Cine loop depicting transvaginal ultrasonography with free fluid in the uterus and right ovary. Video courtesy of Meghan Kelly Herbst, MD. Also courtesy of Yale School of Medicine, Emergency Medicine.
Cine loop of transvaginal ultrasonography showing free fluid in the uterus. Video courtesy of Meghan Kelly Herbst, MD. Also courtesy of Yale School of Medicine, Emergency Medicine.
 
 
Contributor Information and Disclosures
Author

Shoreh Kooshesh, MD Resident Physician, Division of Emergency Medicine, Stanford University School of Medicine

Shoreh Kooshesh, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Student Association/Foundation, American Medical Womens Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Laleh Gharahbaghian, MD Director, Emergency Ultrasound Program and Fellowship, Clinical Associate Professor, Department of Surgery, Division of Emergency Medicine, Stanford University Medical Center

Laleh Gharahbaghian, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Gowthaman Gunabushanam, MD, FRCR Assistant Professor, Department of Diagnostic Radiology, Yale University School of Medicine

Gowthaman Gunabushanam, MD, FRCR is a member of the following medical societies: American Roentgen Ray Society, Connecticut State Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

James Quan-Yu Hwang, MD RDMS, RDCS, FACEP, Staff Physician, Emergency Department, Kaiser Permanente

James Quan-Yu Hwang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Institute of Ultrasound in Medicine, Society for Academic Emergency Medicine

Disclosure: Received salary from 3rd Rock Ultrasound, LLC for speaking and teaching; Received consulting fee from Schlesinger Associates for consulting; Received consulting fee from Philips Ultrasound for consulting.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Verena T Valley, MD, and Christopher A Fly, MD, to the development and writing of this article.

Medscape Reference thanks Meghan Kelly Herbst, MD, Emergency Ultrasound Director, Department of Emergency Medicine, Hartford Hospital, for assistance with the video contribution to this article. Medscape Reference also thanks Yale School of Medicine, Emergency Medicine for assistance with the video contribution to this article.

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Transabdominal longitudinal view of the female pelvis.
Transabdominal transverse view of the female pelvis: The bladder is rectangular. The ovaries are seen bilaterally in the adnexa.
Endovaginal longitudinal view of the uterus: The endometrial stripe (st) is thickened. The arcuate vessels (arc) can be seen within the uterus and should not be confused with free fluid in the cul-de-sac.
Endovaginal view of the ovary: Note its location adjacent to an iliac vessel.
Endovaginal ultrasound scan. Endometritis with air in the endometrial cavity and bilateral tubo-ovarian abscesses are shown.
Video depicts 2 findings: first, it shows an enlarged hypovascular left ovary; second, it shows flow in the healthy right ovary. A small amount of intraperitoneal fluid surrounds the left ovary.
Demonstration of a transvaginal ultrasonographic pelvic evaluation. Video courtesy of Meghan Kelly Herbst, MD. Also courtesy of Yale School of Medicine, Emergency Medicine.
Cine loop depicting transvaginal ultrasonography with free fluid in the uterus and right ovary. Video courtesy of Meghan Kelly Herbst, MD. Also courtesy of Yale School of Medicine, Emergency Medicine.
Cine loop of transvaginal ultrasonography showing free fluid in the uterus. Video courtesy of Meghan Kelly Herbst, MD. Also courtesy of Yale School of Medicine, Emergency Medicine.
 
 
 
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