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Ultrasound - US of the Non-Pregnant Uterus
- 1. ULTRASOUND OF THE NON-PREGNANT UTERUS RT. NATNAEL S. 1
- 2. Outline Introduction Indication Preparation for the examination Scanning techniques Sonographic features of normal uterus Congenital uterine malformations Leiomyomas(fibroids) Adenomyosis Endometrial abnormalities 2
- 3. Introduction US is the optimal imaging modality for the evaluation of uterus 2 approaches based on the type of uterine pathology being evaluated ◦ Transabdominal ◦ Transvaginal Transvaginal approach is preferred ◦ Higher resolution ◦ Closer proximity to pelvic organs ◦ Allows for direct contact Transabdominal for large uterine masses ◦ Extend uterus outside of the pelvis 3
- 4. Indication Pelvic pain Dysmenorrhea( painfull menses) Amenorrhea(absence of menses) Menorrhagia (excessive menstrual bleeding) Metrorhagia (irregular uterine bleeding) Menometrorrhagia Follow up of previously detected abnormality Evaluation,monitoring,and/or treatment of infertility patient Delayed menses or vaginal bleeding in a prepubertal child Postmenopausal bleeding Signs or symptoms of pelvic infection Evaluation of congenital uterine anomalies Localization of an intrauterine contraceptvie device Urinary incontinence or pelvic organ prolapse 4
- 5. Preparation for examination Transvaginal ◦ Empty bladder ◦ Dorsal lithotomy position ◦ Legs flexed ◦ Perineum at the edge of the table Transabdominal ◦ Full bladder ◦ Supine ◦ Don’t over-distend bladder 5
- 6. Scanning techniques Transabdominal ◦ use 2 planes Longtiudinal Transverse ◦ Check for the orientation of uterus ◦ Assess the uterine size and shape ◦ Assess the myometrium ◦ Assess the endometrial status and measure the thickness ◦ Assess the cervix ◦ Look for free fluid in the pouch of douglass ◦ Check the ovaries and adnexae ◦ Assess bladder 6
- 7. Con… 7
- 8. Con… 8
- 9. Con… Transvaginal approach ◦ Start with longitudinal scan Reference notch on the transducer at the 12 o’clock position Uterine fundus , uterine isthmus and cervix is seen Uterine length is meaured from the fundus to the external os Depth (height ) and endometial thickness is also measured perpendicular to the length Assess the endometrium 9
- 10. Con… ◦ Transverse view Rotate the transducer 90 degrees counterclockwise from longitudinal position Fan the probe in the superior –inferior direction until the widest transverse view of the uteus is displayed Then measure the maximum width of the uterus 10
- 11. Con… ◦ Advantages High frequency transducers with better resolution Exam of pts who are unable to fill their bladder Exam of obese pts Exam of retroverted uterus Better distinction b/n adnexal masses and bowel loops Better detail of a pelvic lesion Better detail of the endometrium 11
- 12. Con… ◦ Contraindications Virgin pts Pts who are not willing to the exam Pts with narrow introitus or vagina, who experience discomfort at attempted insertions of the transducer 12
- 14. Con… 14
- 15. Sonographic features of normal uterus Uterus is primarily a muscular organ located in the true pelvis Is smoothly contoured and pear shaped has the urinary bladder anteriorly and the rectosigmoid colon posteriorly Space b/n uterus and rectosigmoid colon is the cul-de-sac ◦ Most dependant area in the peritoneal cavity 15
- 17. Con… 17
- 18. Con… Has 4 anatomical parts ◦ Fundus Dome-shaped upper most aspect Laterally extends into the interstitial part of each fallopian tube ◦ Corpus Extends from fundus to cervix ◦ Isthmus Junction b/n corpus and cervix ◦ cervix 18
- 19. Con… Uterine size vary with age In neonatal- cervix is much longer than the body/fundus Prepubertal- body half the size of cervix Adult (nulliparous)-cervix equals body Adult (multiparous)-body/fundus is 2x the cervix Postmenopausal-overall organ atrophy 19
- 20. Con… 20
- 21. Con… 21
- 22. Con… 22
- 23. Con… Length of a normal ◦ Nulliparous uterus is 6-8.5 cm and in ◦ Multiparous uterus is 8-10.5 cm Depth (height) ◦ Nulliparous 2-4 cm ◦ Multiparous 4-6 cm Widest transverse plane ◦ Nulliparous 3-5 cm ◦ Multiparous 4-6 cm 23
- 24. Con… Its important to describe orientation of the uterus 2 terms used are flexion and version Flexion is the bending of the uterus on its self ◦ When there is an angle b/n the cervix/lower uterine segment and the fundal portion ◦ Anteroflexed when the angle is an acute or obtuse angle (<180 degrees) and with the fundal portion close to bladder ◦ Retroflexed uterus is one with a reflex angle(>180 degrees) and with fundal portion close to rectosigmoid colon. 24
- 25. Con… Version describes displacement of the entire uterus forwards or backwards ◦ Anteverted fundal portion is close to bladder ◦ Retroverted when the fundal region is close to the rectosigmoid 25
- 26. Con… 26
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- 31. Con… Uterus has three wall layers ◦ Endometrium-inner most layer ◦ Myometrium-middle layer , thickest layer ◦ Perimetrium-outer most layer , serosa , composed of fibrous connective tissues 31
- 32. Con… Myometrium ◦ Less echogenic than the endometrium ◦ Cab be divided into 3 layers Inner or junctional layer Middle layer Outer layer ◦ The inner and outer layers are thin and hypoechoic ◦ The middle layer is thick and homogeneous ◦ The arcuate vessels separate the middle from the outer layer 32
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- 34. Con… Endometrium ◦ Undergoes significant changes during menstrual cycle ◦ 5-14 mm uniform thickness in reproductive age is normal ◦ Divided into inner functional layer and the outer basal layer ◦ In the immediate postmenstrual phase , it appears as a thin echogenic line and measures b/n 3-8mm ◦ During proliferative phase-anterior and posterior hypoechoic layer separated in the midline by an echogenic central line Trilaminar layer 34
- 35. Con… ◦ During late proliferative period endometrial lining is 8-12 mm in thickness ◦ After ovulation- uniformly hyperechoic endometrium ◦ Postmenopause endometrial thickness of 4mm or less (if not on HRT) is considered normal 35
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- 39. Con… 39
- 40. Congenital uterine malformations Its when mullarian duct is not developed correctly ◦ Agenesis ◦ Defective vertical or lateral fusion ◦ Resorption failure Leads to ◦ Uterine agenesis ◦ Arcuate uterus ◦ Unicornuate uterus ◦ Uterine duplicational anomalies Uterus didelphys Bicornuate uterus Septate uterus 40
- 41. Uterine fibriods Most common gynecological tumor Vast majority are situated in the uterine body Smooth muscle with varying amount of Connective tissue Estrogen dependent growth Have pseudocapsules , which are formed of compressed surrounding myometrium Nature of clinical presentation depends on size and position of the tumor 41
- 42. Con… Usually are multiple and asymptomatic 3 main types ◦ Intramural-with in the myometrium with minimal or no bulging into serosa or endometrium ◦ Submucosal-A significant portion of the leiomyoma is bulging into the endometrial cavity ◦ Subserosal-A significant portion of the leiomyoma is bulging into the serosal surface 42
- 43. Con… 43
- 44. Con… Sonographic features of leiomyomas ◦ Solid echogenic mass arising from the myometrium ◦ Well defined contour(pseudocapsule) ◦ Whorled appearance due to smooth muslcle and connective tissue arranged in concentric pattern ◦ Significant attenuation of ultrasound beam ◦ Distorted outer contour of uterus or endometrial cavity ◦ Minimal to moderate vascularity on color doppler ◦ Color doppler can on occassions identifay a stalk and connect it to the uterus in pedunclated leiomyomas 44
- 45. Con… 45
- 46. Con… 46
- 47. Con… 47
- 51. Adenomyosis Is also a common condition that affects women in the late reproductive years Is the presence of ectopic endometrial glands and stroma with in the myometrium Symptoms related to adenomyosis include dysmenorrhea,dyspareunia,chronic pelvic pain and menometrorrhagia. Usually presents as a diffuse disease involving the entire myometrium but can also present in a focal area ◦ adenomyoma 51
- 52. Con… Ultrasound findings in adenomyosis ◦ Globular enlargment of the uterus ◦ Anechoic spaces in the myometrium ◦ Asymmetric anterior and posterior uterine wall thickening ◦ Subendometrial echogenic linear striations ◦ Heterogeneous echo texture ◦ Obscure endometrial-myometrial border ◦ Thickening of the transition zone 52
- 53. Con… 53
- 54. Con… 54
- 55. Con… 55
- 56. Endometrial abnormalities Endometrial polyps ◦ Common finding in women of 35 to 50 years with abnormal vaginal bleeding ◦ Arises from the basal layer of the endometrium ◦ Usually vascularised by a single vessel that passes through its stalk ◦ Unresponsive to steriod hormones therefore their appearance remians similar throughout the menstural cycle 56
- 57. Con… ◦ On ultrasound , appear as distinct hyperechoic areas with in the endometrium ◦ Optimally visualized in the proliferative phase ◦ The incidence of endometrial carcinoma arising with in a polyp is less than 1% ◦ Sonohysterography has been shown to be a superior imaging modality in the evaluation of intracavitery endometrial lesions ◦ Top Ddx for endometrial polyps is 57
- 58. Con… ◦ Differentiating sonographic features Polyps are contained with in the endometrial cavity whereas leiomyomas extend into the myometrium Polyps are more echogenic than the myometrium whereas echogenicity of leiomyomas is similar to myometrium Polyps tend to have a visible vascular pedicle on color doppler and are homogeneous in echotexture Leiomyomas lift the endometrial lining Leiomyomas tend to shadow the ultrasound beam Polyps have narrow base of attachment to the underlaying myometrium Leiomyomas are broad-based 58
- 59. Con… 59
- 60. Con… 60
- 61. Con… 61
- 62. Con… Endometrial hyperplasia ◦ Results from the prolonged action of estrogens that are unopposed by ptogesterone ◦ More common in women who have high circulating levels of estrogen E.g poly-cystic ovaries,obesity and women on HRT ◦ Considered as Precursor of endometrial carcinoma ◦ 3 types Cystic , adenomatous and atypical 62
- 63. Con… ◦ On US , the endometrium is thickened (>10 mm)demonstrates increased echogenicity ◦ Can be focal or diffuse ◦ Final diagnosis is made histologically 63
- 64. Con… 64
- 65. Con… Endometrial cancer ◦ The most common gynacological malignancy ◦ Post menopausal bleeding ◦ Transvaginal ultrasound is the initial imaging investigation of choice Appears as thickening of endometrium Myometrial invasion ◦ If the endometrium thickness is greater than 4mm , further evaluation is needed with endometrial sampling sonohysterography or hysteroscopy 65
- 66. Con… 66
- 67. Con… 67
- 68. Con… Endometrial adhesions and RPC ◦ Intrauterine adhesions are clearly visible on sonohysterography as thick or thin echogenic bands that attach to the endometrial walls ◦ RPC appear as an echogenic mass within endometrial cavity 68
- 69. Con.. 69
- 70. Con… 70