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