- Gartners duct cyst
- Bartholin duct cyst
- Vaginal carcinoma
- Hydro/haematocolpos (secondary to imperforate hymen or vaginal stenosis)
- Foreign body
Ultrasound image- Gartner Duct Cyst.
A pelvic cyst can be correctly diagnosed on the basis of its location.
A Gartner duct cyst arises from the wall of the vagina in a classically anterolateral location above the level of the symphysis pubis, in the upper vagina.
Ultrasound image- Bartholin Gland Cyst.
Located at the posterolateral vaginal introitus at or below the level of the symphysis pubis. They are generally well marginated.
- Nabothian (retention) cysts
- Cervical fibroids
- Cervical carcinoma
- Cervical stenosis
Visualisation of the cervix may be difficult with transvaginal scanning if the probe is placed too close to the cervix. Try varying the position of the probe and the angle of insonation to see all walls suitably. It can be difficult to detect a cervical carcinoma vs a polyp.
Ultrasound image- Normal cervix transvaginal.
Ultrasound image- Caesarean Scar: A linear scar can often be seen in the anterior lower uterine segment.
There is fluid and debris within the endometrial canal as a result of a stenosis. May be found in elderly postmenopausal women.
This is a trans perineal view of a cervical mass. It is hypoechoic and vascular (as seen below). They can be extremely difficult to detect in the early stage and may be mistaken for a polyp or fibroid.
Ultrasound image- Cervical mass.
The mass shows low resistance arterial and venous flow consistent with agenesis and a malignant tumour, usually squamous call carcinoma. It could easily be misdiagnosed as a polyp.
Haematometra as a result of a Cervical Stenosis
There is fluid and debris within the endometrial canal as a result of a stenosis. May be found in elderly postmenopausal women.
Uterine Fibroids (Leiomyoma)
Ultrasound image- The differential diagnosis for a polyp is an intracavitary fibroid. These will generally be hypoechoic and heterogeneous. If there is any invasion of the endometrium, this will be suspicious for endometrial cancer.
Ultrasound image- Intramural Fibroid: Intramural fibroids are within the wall of the uterus (muros=wall).
Ultrasound image- Subserosal fibroid: Subserosal fibroids are on the outer surface of the uterus.
Ultrasound image- A large fundal subserosal fibroid.
Ultrasound image- Transverse view of an intramural fibroid abutting the endometrial cavity with a Mirena IUCD in situ. When available a reconstructed coronal view of the uterus from a 3D volume set would be useful.
Other myometrial abnormalities include:
Lipoleiomyoma is an exceedingly rare benign uterine tumour made up of a mixture of fat, smooth muscle and fibrous tissue . The tumour is generally found in postmenopausal women, in any region of the uterus and may be asymptomatic or may cause pelvic pain or abnormal bleeding. It may be difficult to differentiate between a haemorrhagic leiomyoma and a lipoma. CT may be done to confirm. Commonest location is uterine fundus. If it is subserosal or pedunculated it may mimic a dermoid tumour.
Calcified Fibroid – positioned posteriorly.
They develop when the fibroid outgrows its own blood supply resulting in a process of degeneration. As this degeneration occurs, the process initiates calcium deposition, leading to calcification. This commonly occurs in menopause with the decrease of oestrogen. There is a gestational sac anteriorly.
Adenomyosis is the condition of ectopic endometrial tissue within the muscular myometrium. Generally diffuse and presenting on ultrasound as bulky echogenic change within the myometium. If focal is may be seen as a complex myometrial cyst called an adenomyoma.
It is a form of, and may be associated with, endometriosis. Increase risk in patients who have had uterine surgery including Caesarian sections, curettes or ablation.
The following figure demonstrates the variations in adenomyosis presentations.
Reference: Van den Bosch, T., et al. (2015). “Terms and definitions for describing myometrial pathology using ultrasonography.” Ultrasound in Obstetrics and Gynecology.
Adenomyosis: Endometriosis within the myometrium. ie ectopic endometrial cells in the muscular wall of the uterus. Characterised by increased echogenicity and attenuation by the myometrium.
Ultrasound image of adenomyosis, with multiple macroscopic cysts surrounding the endometrium. Also called endometrial lacunae.
Ultrasound image of adenomyosis with marked thickening of the posterior myometrial wall.
Ultrasoundpaedia would like to thank and acknowledge Ms. Alison Deslandes for sharing her endometriosis images and information.
The vesicouterine space and pouch of douglas are highlighted above.
Endometriosis is a common chronic gynaecological condition affecting approximately 1 in 10 female-born people. It manifests in three ways;
- Superficial (peritoneal) endometriosis
- Ovarian endometriosis (endometriomas)
- Deep Endometriosis (DE)
Superficial endometriosis will not be routinely detected via ultrasound but the presence of “soft markers” can indicate its existence.
DE occurs when deposits of endometriosis penetrate >5mm below the surface of the peritoneum and is the most severe form of the disease.
known or suspected endometriosis
chronic pelvic pain
Normal ultrasound anatomy
- uterus and ovaries (as for a routine pelvic ultrasound)
- Anterior compartment
Appears uniformly thin-walled
The potential space located between the anterior uterus and the posterior urinary bladder. In real-time these two structures should be seen to move apart with the sliding sign
Hypoechoic tubular structures which are seen to vermiculate (i.e. contract to move urine from the kidneys to the bladder) in real-time 2
- Posterior compartment
-the colon walls appear sonographically as an alternating hyper/hypoechoic layered structure 1
-the colon walls appear sonographically as an alternating hyper/hypoechoic layered structure 1
Pouch of Douglas (POD_
The use of the sliding sign 1 should reveal the POD to be open.
A small-to-moderate amount of free fluid in the POD is normal.
The normal uterosacral ligaments are seen as a very thin hyperechoic line or may not be seen at all. The midline joining point of the left and right uterosacral ligaments is the torus uterinus 2,3
Posterior vaginal wall / posterior vaginal fornix
It is a thin, hypoechoic line directly posterior to the face of the transducer
It is a thin, hyperechoic line between the hypoechoic posterior vaginal wall and the rectum 1,4
Pelvic ultrasound of endometriosis is an extension of a traditional transvaginal pelvic ultrasound. Transabdominal imaging of little use in the assessment of deep endometriosis. The highest possible frequency transducer should be used. If required, a moderate amount of ultrasound gel (approx. 20 mL) can be instilled into the vagina or placed within the probe cover to use as a stand-off for assess the superficial structures of the posterior compartment but is not essential.
Bowel preparation can be used to help visualise the bowel but is not essential.
The scan should be performed in four steps as proposed by the IDEA consensus statement 1:
- assessment of the uterus and ovaries
- assessment for ‘soft markers’ (ovarian mobility and site-specific tenderness)
- assessment of the sliding sign
- assessment of the anterior and posterior compartments
Uterus and Ovaries
This is done as per a traditional pelvic ultrasound. Specific attention should be paid to the presence of adenomyosis or ovarian endometrioma. An anteverted/ retroflexed uterus has a strong association with adhesions in the posterior compartment 1.
Assessment for ‘soft markers’ (ovarian mobility and site specific tenderness)
By applying gentle pressure with the transducer and the sonographers freehand on the abdomen, the ovaries can be seen to move in real-time. If mobility is reduced or not present, this can suggest adhesions.
The sonographer should take note of any sites which are tender when gentle pressure is applied.
Assessment of the sliding sign
The sliding sign is assessed by using pressure with the transvaginal probe and the sonographers free hand to palpate the uterus over the abdomen to see the uterus/ cervix move away for the bowel.
The sliding sign is considered negative if the structures do not move freely and indicated that the Pouch od Douglas is obliterated.
Assessment of the anterior and posterior compartments
The bladder walls are difficult to assess without urine in the bladder
A full bladder, however, will hinder the view of other structures transvaginally 4 with the transducer in the anterior fornix, the probe is moved side to side, and cranial-caudal to assess the walls for nodularity.
If needed, the bladder can be assessed fully distended with a transabdominal scan.
With the transducer in the anterior fornix and the sonographers free hand placed over the suprapubic region, the posterior bladder should slide freely over the anterior uterine wall with pressure from both the transducer and the hand. 1
With the transducer in the anterior fornix, move laterally to visualise the vesicoureteric junction (VUJ) at the bladder base and rotate slightly until the distal ureter can be seen running parallel to the bladder. The ureter can then be followed high into the pelvis.
In real-time, the ureters should be seen to vermiculate. 2
With the transducer at the opening of the vagina, trace the lower rectum until the transducer is in the posterior vaginal fornix; continue to follow the longitudinal plane of the rectosigmoid colon until it can no longer be visualised (usually past the level of the uterine fundus and left ovary); repeat in the transverse plane.
Due to the normal twisting of the bowel, constant fanning and rotating of the transducer is essential to keep the bowel walls in view. 4
The view of the bowel may be hindered by the presence of mass lesions such as endometriomas or fibroids.
Pouch of Douglas (POD)
Assess using the sliding sign – the posterior uterus and the anterior rectum should move apart freely with transducer pressure. 1
Also, assess the POD for the presence of any nodules
With the transducer in the posterior fornix, move the transducer laterally and rotate slightly (30-45 degrees); the uterosacral ligaments will be seen in long axis as a thin white line immediately deep to the vaginal wall. 3,4
If the white line does not appear crisp (but heterogeneous in nature), the transducer is too lateral and imaging the parametrium. 3
In the transverse plane, within the transducer in the anterior vaginal fornix, the uterosacral ligaments can be seen immediately lateral to the cervix as the level of the internal os as they travel inferomedial to join at the torus uterinus.
When endometriosis is present, the uterosacral ligaments may appear thicker due to a thickening of the surrounding fat; a hypoechoic nodule may be present. 4
Posterior vaginal wall / Posterior vaginal fornix
The walls of the lower vagina are best assessed with the rectovaginal septum .
Endometriosis of the rectovaginal septum is rare, it is best assessed whilst removing the transducer from the vagina at the conclusion of the scan, gently fanning side to side to assess for nodules. 1
Tips and Tricks to assessing for DE
- If the ureters are dilated or extensive pelvic endometriosis is present, the scan should be extended to include a transabdominal assessment of the kidneys. 2
- when endometriosis is present, dynamic assessment and pressure in the posterior compartment can be painful, as such, a throughout explanation of the procedure and frequent checking on the patient’s comfort are a must. Over the counter pain relief (such as ibuprofen) can be beneficial to some people post scan.
- mobility of the organs can be affected by the position of the ovaries, body habitus and pain tolerance; care should be taken when labelling an ovary immobile to insure this is pathological rather than technical
- Adhesions within the pelvis can be due to prior (or current) pelvic infection, surgery or endometriosis. 1
- If using a three-dimensional mechanical transvaginal transducer, the steering or tilt function can be employed to assess places otherwise difficult to access comfortably (e.g. distal rectum)
- extensive deep endometriosis can cause significant distortion of the normal pelvic anatomy; if the exact location of a nodule cannot be definitively determined, describing as being located in the “anterior compartment” or the “posterior compartment” is most clinically helpful .1
- one-third of women with a previous Caesarean section will have adhesions in the VU space1
- Free fluid in the POD this can be used as an acoustic window to visualise small (even superficial) lesions within the posterior compartment
- S. Guerriero, G. Condous, T. van den Bosch, L. Valentin, F. P. G. Leone, D. Van Schoubroeck, C. Exacoustos, A. J. F. Installé, W. P. Martins, M. S. Abrao, G. Hudelist, M. Bazot, J. L. Alcazar, M. O. Gonçalves, M. A. Pascual, S. Ajossa, L. Savelli, R. Dunham, S. Reid, U. Menakaya, T. Bourne, S. Ferrero, M. Leon, T. Bignardi, T. Holland, D. Jurkovic, B. Benacerraf, Y. Osuga, E. Somigliana, D. Timmerman. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. (2016) Ultrasound in Obstetrics & Gynecology. 48 (3): 318. doi:10.1002/uog.15955– Pubmed
- Mathew Leonardi, George Condous. How to perform an ultrasound to diagnose endometriosis. (2018) Australasian Journal of Ultrasound in Medicine. 21 (2): 61. doi:10.1002/ajum.12093
- Mathew Leonardi, George Condous. A pictorial guide to the ultrasound identification and assessment of uterosacral ligaments in women with potential endometriosis. (2019) Australasian Journal of Ultrasound in Medicine. 22 (3): 157. doi:10.1002/ajum.12178
- Jing Fang, Sofie Piessens. A step‐by‐step guide to sonographic evaluation of deep infiltrating endometriosis. (2018) Sonography. 5 (2): 67. doi:10.1002/sono.12149
Non mobile uterus with fundus fixed and endometriosis pulling the uterus posteriorly.
Rectal endometriotic nodule
- Endometrial Polyps
- Endometrial Carcinoma
- Endometrial hyperplasia
- Cystic hyperplasia secondary to
- Adhesions- Ashermans Syndrome
- Submucosal fibroids
- Arterio-venous malformation (AVM)
- Blood/fluid/infection or retained products of conception (RPOC)
Patients with breast cancer on prolonged tamoxifen therapy have increased risk of developing endometrial polyps, hyperplasia, and cancer. Some of these patients may actually have mixed histopathologic abnormalities.
Ultrasound image- An endometrial polyp is usually a rounded echogenic lesion seen as a focal thickening of the endometrium. If clinically suspected, it is best to examine for polyps immediately following menstruation before Day 10 .
Ultrasound image- Endometrial Polyp is best seen when the endometrium is thinnest. Saline infusion sonohysterography is a useful technique to delineate polyps.
Endometrial Hyperplasia: The endometrium is indicated by the red arrows. Note the microcystic changes (blue arrow).
The most common endometrial abnormality seen on ultrasound associated with tamoxifen, is a thickened endometrium showing multiple cystic foci. Other findings include homogeneous hyperechoic endometrial thickening and heterogeneous endometrial thickening.
Transvaginal ultrasound is the superior imaging modality of choice for screening for endometrial cancer.
Postmenopausal bleeding is the most common presenting symptom .
The earliest finding is a diffusely thickened endometrium that is usually heterogeneous and poorly defined or has irregular contours. Measuring the double wall thickness of 5mm or greater is sensitive to detecting endometrial cancer. Usually the endometrium is either diffusely or partially more echogenic than the myometrium. These findings are nonspecific, as there is considerable overlap in the US appearances and thickness of the endometrium in patients with carcinoma, hyperplasia, or polyp. Laifer-Narin et.al., found a lack of distendability of the uterine cavity during SIS as the most consistent finding in women with endometrial cancer. Histopathologic evaluation is necessary to determine the diagnosis.
Transvaginal power doppler blood flow mapping can be useful to differentiate benign from malignant endometrial pathology in women presenting with postmenopausal bleeding and thickened endometrium .
Adenocarcinoma is often detected at an early stage because it frequently produces vaginal bleeding this slow-growing cancer is likely to be confined to the uterus.
Papillary serous carcinoma and clear cell carcinoma are two other types of endometrial cancer. These types usually develop in postmenopausal women and are more likely to metastasize (spread) and recur.
Papillary serous Carcinoma ultrasound image.
Lobulated heterogenous endometrium with areas of an indistinct myometrial boundary. Fluid is present in the endometrial cavity.
Transverse ultrasound view.
The same endometrial carcinoma with overlying large fibroids.
Arteriovenous Malformation (AVM)
- Uterine AVMs are rare in nonpregnant women.
- Bleeding is the major presenting symptom in AVMs.
- It can be due to arrested vascular embryologic development.
- They may be the result of previous uterine trauma (eg, prior pelvic surgery, curettage), use of intrauterine contraceptive devices, pathologic pregnancy-related events, and previous treatment for gestational trophoblastic disease.
This patient had continual bleeding following a dilatation and curettage for a termination of pregnancy.
This transvaginal ultrasound image shows multiple anechoic spaces.
This Colour Doppler Ultrasound image shows a mosaic pattern of color signals within the cystic spaces.
Ultrasound image- Spectral analysis of the arterial
vessels within the lesion shows high blood flow velocity with a low resistive index.
IUD ( intrauterine contraceptive device)
- Ultrasound is the best method to assess the position of an intrauterine contraceptive device.
- The ultrasound should show the IUD centrally located within the endometrial canal in the fundal portion of the cavity.
Complications of IUDs may be low position, infection , myometrial migration , uterine perforation , intrauterine or extrauterine pregnancy , fragmentation of the IUD.
Ultrasound image- The IUD has perforated through the posterior myometrial wall. It is not centrally located in the endometrial cavity.
The arms of the mirena are seen within the cervical canal only 1cm from the ext. os.
This 3D image of the uterus helps emphasise the displaced mirena which should be sitting up in the fundus at the end of the endometrium.
The Mirena has slipped down to the body of the uterus.
Acknowledge:Mrs Alison Deslandes AMS
Ultrasound image- Ascites Long.
Ultrasound image- Ascites outlines the uterus and broad ligament.
Uterine Anatomical Variations
Uterine and endometrial variations.
Longitudinal ultrasound view of the left endometrial cavity in a septus uterus.
Ultrasound image- Dual uterine bodies.
This could be bicornuate or didelphis. That cannot be decided without assessing the cervix and vagina.
Ultrasound image- Transvaginal scan showing the dual uterine bodies.
Ultrasound image- 2 Cervix’ seen with Didelphic Variation.
Ultrasound image showing 2 vaginas.
Transverse ultrasound view of a septate uterus with a pregnancy in the right endometrium. Note the single uterine body.
Longitudinal ultrasound view of the right endometrial cavity in a septus uterus.
Pouch of Douglas (POD) and Adnexae (see ovarian pathology)
- Pelvic inflammatory disease-PID (may be indicated by above conditions)
- Cysts (Mesenteric)
- Ectopic pregnancy
- Pelvic venous congestion
- Bowel pathology may be seen (but cannot be excluded)
Ultrasound image- Fluid in Pouch of Douglas.
Ultrasound image- Mesenteric Cysts.
They can occur anywhere in the mesentery of the gastrointestinal tract from the duodenum to the rectum, and they may extend from the base of the mesentery into the retroperitoneum. Mesenteric and omental cysts can be simple or multiple, unilocular or multilocular, and they may contain haemorrhagic, serous, chylous, or infected fluid. They can range in size from a few millimeters to 40 cm in diameter.
Ultrasound image- There is no Vascularity in a mesenteric cyst . This one is seen inferior to the left kidney.
The 3 main pelvic floor pathologies easily identifiable are:
- Cystocele (bladder prolapse)
- Rectocele (rectal prolapse)
- Enterocele (small bowel prolapse)
The pelvic floor at rest.
The same patient, post straining.
The large cystocele bulges against (and out) the anterior vaginal vault.
Translabial ultrasound scan of the pelvic floor.
The red arrow shows the bowing of the pelvic floor, even at rest
Ultrasound image- During downward straining fat and bowel bulges posteriorly between the vagina and rectum.
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