This document provides guidance on performing and interpreting a normal pelvic ultrasound exam. It reviews female pelvic anatomy including the uterus, endometrium, myometrium, ovaries, fallopian tubes, and pouch of Douglas. Exam preparation and approaches using transabdominal and transvaginal ultrasound are outlined. Key steps include reviewing the patient's history and symptoms, obtaining consent, and examining the uterus, ovaries, and other pelvic structures in both sagittal and coronal views to evaluate size, shape, echogenicity, and presence of any abnormalities. Fluid may normally be present in the pouch of Douglas but is abnormal elsewhere in the pelvis.

1. Normal Pelvic Ultrasound
Nazari L,
Assistant professor OB/GYN
Shahid Beheshti University of Medical Sciences
Spring 2016

2. Introduction
Chief complaint
Symptoms
Check duration of symptoms
Any ultrasound done previously. Check
the records carefully
 LMP
 Any tests done and their reports
 Referring doctors requisition slip

3. Female Anatomy Review

4. Uterus: Size, shape, mobility and probe
tenderness
Endometrium: Thickness and morphology.
Any focal abnormality
 Myometrium : Echo pattern and presence of
fibroids and their location

5. Ovaries: Size and echo pattern. Any
abnormality to be mentioned in terms of size,
echo pattern, walls and focal abnormalities
within it
 Extra-ovarian adnexal
areas: Report whether
any mass is delineated
or not
 Free fluid or fluid in the
pouch of Douglas or adnexa

6. Transabdominal approach :
•Lower frequency
•Lower resolution image
•Better visualized with full bladder

7. Transvaginal approach:
•Higher frequency
•higher resolution image
•Better visualized with empty bladder

10. Indications of TVS
Gynecologic sonography
Early first trimester obstetric
Later OB: Cervix, placenta previa and
evaluation of fetus before 14 weeks’
Suspected EP
Suspected lower abdominal disease in whom
a diagnosis has not been made with TAS
Follicle monitoring
Monitoring for ART

11. Preparation for TVS
Empty bladder
Explain to the patient
Consent ( Verbal / written)
Be sure about virginity!
Chaperone
Privacy ; Cover the Patient with a sheet
Supine position , bending knees
Anterior limitation : Flex her hips and bring
her knees up toward her chest

12. Sagittal

13. Coronal

14. Uterus
Is a reliable landmark because of its
central location, relatively large size
and the well-known pear-shape
The cervix is less mobile than the
uterine body due to uterosacral
ligaments that position the cervix in
the midline of the pelvis

15. Uterus
Size: varies with age:
 Neonate: Relatively Large, Body> cervix
 Childhood: Tubular, Body< cervix
 Menarche: Large, Body> Cervix
 Post menarche: Body = 2x Cervix
 Reproductive age: 80x40x40 mm
 Multiparous : +10 mm in each dimension

16. Version : Angle of the cervix to the vaginal

17. Flexion: Angle of body of the uterus at the
isthmus

18. Cysts within the cervix, termed nabothian
cysts, occur frequently
Result from the retention of mucus within
obstructed endocervical glands

19. Myometrium
•Myometrium is moderately hypoechoic,
especially in relation to the more echogenic
endometrium
•Normal myometrium is homogeneous in
echotexture

20. Endometrium
Endometrium is the innermost layer of the
uterus that lines the uterine cavity
There is often blood and shed tissue in the
uterine cavity during mensturation

21. During the late proliferative phase, the
endometrium (calipers) has a multilayered
appearance: echogenic around its periphery
and in the midline, and hypoechoic in between

22. During the secretory phase, the endometrium
is thick and echogenic

23. Measurement of the endometrial thickness is
useful in a number of clinical settings
This measurement is best obtained from a
sagittal transvaginal sonographic image,
after sweeping through the uterus to find the
site of maximal thickness
Excluding any fluid that may be present in
the endometrial cavity

24. Fallopian tubes
Interstitial portion :
seen as a hyperechoic line
extending from the
lateral uterine angle to
the origin of the broad ligament
Isthmus and ampulla : rarely seen without
the use of contrast media
Infundibulum can be seen if it is floating in
peritoneal fluid

25. Interestitial portion of tube

26. Fimbria of the tube surrounded by fluid

27. Ovaries
Iliac vessels are a reliable landmark for
their visualization
Due to mobility of the ovaries and
transducer pressure, position of the ovaries
is often varying for example:
• Cul-de-sac
• In front of the uterus
• Above the uterus
• In the abdominal cavity

28. Ovaries
Ovaries are imaged as homogeneous,
hypoechogenic ovoid structures with
slightly echogenic central part
Antral follicles 5-12 per ovary

29. The pouch of douglas
In women of fertile age, fluid is almost
always seen in the pouch of douglas, at least
in the late follicular phase and in the
secretory phase of the menstrual cycle
In the early luteal phase , the pouch of
douglas normally contains 15-25ml fluid

30. Fluid outside the pouch of douglas in the
space between the uterus and the bladder is
abnormal
An ultrasound finding of even a small
amount of fluid in the pouch of douglas in a
postmenopausal woman is unusual, a follow
up scan is advisable to exclude that the fluid
is a first sign of ascites