Transvaginal Sonography 아주대학교 의과대학 영상의학과 이 은 주
Transvaginal Sonography 아주대학교 의과대학 영상의학과 이 은 주 Introduction TVS-related Scan US imaging techniques Normal findings Common variations and potential pitfalls Diagnosis TVS-related imaging Conventional Color TVS / Power Doppler sonography Sonohysterography 3-dimensional sonography Contrast-enhanced Endoluminal sonography sonography Transrectal, transabdominal sonography TVS-guided procedures Color & Power Doppler Sonography Routine Applications of TV-CDI uterine, ovarian, and tubal tumors infertility vascular lesions torsion, HOC, and TOA pregnancy-related lesions Contrast-enhanced US Sonohysterography Fluid is friend of US Instillation of saline or contrast with catheters with/without balloon Applications of SH clinical indications abnormal endometrium at TVS Sensitive and improved specificity 3-D sonography (4-D) multiplane images surface rendering” hysteroscopic view” SH-guided biopsy TVS - Scan Techniques High frequency 5-8 MHz endovaginal transducer 3 basic maneuvers of transducer rotating along its axis angling by pointing the tip from side-to-side or anterior-to-posterior advancement or withdrawal along the axis of vagina 2 image planes : long-axis (sagittal), short-axis (semi-axial or coronal) TVS - Scan Techniques Systemic approach to the pelvic organs Uterus & cervix Ovary Cul-de-sac, tube, ligament, vessel, side-wall, lymph node, bowel, bladder TVS – Helpful Scan Techniques Manual compression of lower abdomen & transabdominal scan pelvic adhesion in C-sec patients highly or laterally located ovary large, protruding mass with extrapelvic extension TVS – Helpful Scan Techniques Probe pressure sliding sign and compressibility at pushing with probe tip free “moving” sign at striking pressure sonographic tenderness at gentle pressure Uterus Normal uterus ante- or retro-version, deviation to the one side of the pelvis anteriorly located due to previous surgery or adhesion Infantile shape IUD : type, location, and complication Endometrium Normal cyclic change Measurement of endometrial thickness bi-layer, thickest AP diameter in midsagittal plane fluid within endometrial cavity : one layer x 2 Endometrial echomorphology undulating or polypoid surface, inhomogeneous echotexture menstrual phase proliferative phase secretory phase Normal Variations & Pitfalls Endometrial cavity fluid collection Common, < 2 ml, in all menstrual phase: postmenstrual, periovulatory Intraluminal contents: mucous, blood, blood clot, pus, air Endometrium – Normal Variations & Pitfalls Secretory change & focal secretory change Disordered proliferative endometrium Estrogen / progesterone breakthrough Normal Variations & Pitfalls Endometrial calcifications Psammoma body formation or dystrophic calcifications Ass. with previous D&C, trauma, scar Osseous metaplasia Endometrium – Normal Variations & Pitfalls Synechia Endometrial cysts ass. with cystic atrophy, polyp, and hyperplasia Myometrium 3 layers : inner (subendometrial halo), middle, outer Arcuate plexus of arteries & veins Symmetric myometrial thickness Myometrial contractions inner-myometrial, all-layer myometrial contraction, antegrade vs retrograde focal myometrial contraction Myometrium – Normal Variations & Pitfalls Small echogenic foci within inner myometrium 3-6 mm, linear, non-shadowing, single or multiple, adjacent to endometrium calcification or fibrosis at mechanical injury or hemorrhage at adenomyosis foci Myometrial focal calcifications Myometrium – Normal Variations & Pitfalls Myometrial cysts adenomyosis, leiomyoma, endosalpingiosis, Tamoxifen Tx Uterus in Postmenopausal Women Atrophy Endometrial atrophy a thin echogenic line, endometrial thickness ≤ 4 mm poorly visualized endometrium (7-10%), indistinct subendometrial halo Calcifications of arcuate artery in myometrium Increased resistance of uterine blood flow With HRT Uterus in Postmenopausal Women Endometrial cavity fluid collection Small amount fluid in asymptomatic woman 10-16%, 3.5 times ↑ in HRT normal or ass. with cervical stenosis Large amount fluid *appearance of surrounding endometrium frequently benign cause, clue of endometrial / cervical cancer Visualization of polyp due to cavity fluid Cervix 2.5 –4 cm long, endocervix and fibromuscular stroma Endocervical cavity fluid Inclusion cysts (Nabothian cyst) Cervical stenosis, polyp, myoma, cyst Cervix C-section scar defect visualized with fluid within a defect - “diverticuli” or “niche”, endometrial and myometrial disruption or scarring Cervical stump & vaginal cuff in women with hysterectomy Ovary Normal size & volume, shape, extraovary Location in ovarian fossa postero-medial aspect of EIV, anterior to ureter and IIA mobile in cul-de-sac, adjacent to uterus, upper pelvis, pelvic inlet, iliac fossa but may fix in abnormal location due to previous surgery or adhesion Ovary – Normal Cyclic Changes Predominant follicle Graffian follicle and ovulation Corpus luteum thick irregular wall, internal echos, pseudo-septa and -solid “hypervascular ring” Normal Variations & Pitfalls Ovary – Physiologic Cysts Functional vs non-functional Follicular cyst Corpus luteum cyst Theca-lutein cyst, luteinized cyst Persistency Normal Variations & Pitfalls Ovary – Polycystic Ovaries Common 14.2- 27% in TVS Multi-follicular ovary Polycystic ovarian disease Macropolycystic ovary Normal Variations & Pitfalls Ovary – Echogenic Foci Common 49%, in parenchyme or surface Small 1-3 mm, punctate, multiple peripherally distributed echogenic foci without shadowing Ass. with calcification, focal hemosiderin deposit, clusters of tiny cysts, dense cortical nodules Surface-epithelial inclusion cysts or endosalpingiosis DDX: large echogenic foci, focal calcification, intratumoral calcifications Ovary in Postmenopausal Women Atrophy Difficult localization and nonvisualization of ovary in TVS : 25-40% Ovarian volume not influenced by HRT Premature ovarian failure: 1-2%, premature menopause < 40 yrs old Adnexal Cysts in Postmenopausal Women 10-18% (14.8%), no correlation with HRT, yrs since menopause, age Cyst ≤ 2.5 cm: surface-epithelial inclusion cyst, degenerated corpora albicans, simple cyst, parovarian or paratubal cyst Unilocular anechic cystic lesion ≤ 5 cm can be exclude malignancy Serial TVS examination every 3 to 6 months if > 3-5 cm TVS Visualization of Normal Tube In superior part of broad ligament 4 segments: interstitial, isthmic, ampullary, infundibular (fimbria) Mucosal(endosalpingeal folds), muscular, serosal layers Normal tube: diameter < 5 mm(ampulla <10 mm), wall thickness ≤ 3 mm, no luminal fluid Normal Variations & Pitfalls Tube Tubal thickening diameter ≥ 5 mm, wall thickness ≥ 4 mm luminal fluid or blood, thick edematous endosalpingeal folds Hydrosalpinx and hematosalpinx Normal Variations & Pitfalls Tube Tubal ligation Pseudotube bowel loops, vessels, ligament Normal Variations & Pitfalls Tube – Paratubal Cysts Hydatid cyst of Morgagni in fimbrial end Parovarian cyst 1. mesonephric cyst (wolffian duct cyst) 2. tubal cyst (paramesonephric or mullerian) = paratubal mesosalpingeal cyst 3. mesothelial cyst Normal Variations & Pitfalls Pelvic Cavity Fluid in cul-de-sac and pelvic cavity small amount free fluid in all menstrual phases in cul-de-sac and adnexal region TVS visualization 42.5%, 5 – 45 cc (mean 11.2-16.5 cc) Echogenic fluid Normal Variations & Pitfalls Pelvic Cavity Peritoneal adhesions adhesion bands, fixed ovary & tube loculated fluid collection (pseudocyst) ass. with previous PID, endometriosis, hemorrhage, surgery Normal Variations & Pitfalls Pelvic Cavity Peritoneal calcifications sclerosing peritonitis, Tbc, PID, postsurgical heterotopic ossification psammoma bodies (IUD, endometriosis, endosalpingiosis) DDX: peritoneal metastasis from ovarian cancer (serous papillary cystadenoca) Peritoneal loose body (mice) small 0.5-2.5 cm, calcified free bodies in the peritoneal cavity Pelvic Ligaments Round, broad, uterosacral ligament Infundibulopelvic, utero-ovarian ligament from cornus, mesovarium from broad ligament Pelvic Vessels Parauterine or paracervical vascular plexus, vessels in pelvic side-wall Uterine & ovarian vessels in pelvic ligaments: vascular pedicle of ovary & tube adnexal and ovarian branch of uterine vessels, ovarian vessels Pelvic congestion Twisting vessel sign Pelvic Cavity Pelvic side-wall muscles Lymph nodes Pelvic fat echogenic pelvic fat sign Pelvic Cavity Pseudotumors bowel loops, muscle, vessels, tube, ligament, bladder distension TVS - Diagnosis TVS diagnosis is essential in planning managements TVS-assisted pelvic examination in acute pelvic pain (A palpatory TVS) TVS-based triage of abnormal uterine bleeding TVS-based management for pelvic mass (Oncology)
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