Ultrasound of uterus, part 1

Describes ultrasound appearance of uterus through different ages, basic transvaginal ultrasound and ultrasound of the cervix. It talks of how to do transvaginal ultrasound.

1. The Uterus and Cervix (Part 1) Durr-e-Sabih

2. Its not only the size that is different in the infant and child

3. Uterine Ratios Change With Age

4. Uterine Ratios Change With Age Int os 2/3 1/3 1/2 1/2 1/3 2/3

5. Neonatal Uterus Neonatal uterus is prominent and measures 3.5 cm in length Cervix is dominant and fundus:cervix length ratio is 1:2 (<1). In women of childbearing age, the FCR should be >1.0 Has a bright endometrial lining

6. Neonatal Uterus Neonatal uterus is prominent and measures 3.5 cm in length Cervix is dominant and fundus:cervix length ratio is 1:2 Has a bright endometrial lining

7. Infant Uterus By 3 months uterus regresses, becomes tubular Length is 2.5 – 3cm, fundus:cervix ratio 1:1 Endometrial echoes not visible

8. Prepubertal Uterus

9. Pubertal Uterus Length increases to 5-7cm Adult shape, fundus to cervix ratio is 3:1

10. Adult Uterus 8 (L) x 5 (W) x 4 (D) cm, multiparity increases all measurements by 1 cm

11. Adult Uterus 8 (L) x 5 (W) x 4 (D) cm, multiparity increases all measurements by 1 cm © Gunjan Puri, Surat

12. Menopausal Uterus Atrophy, the corpus atrophies more than the cervix 3.5 – 6.5 cm (L) x 1.2 – 1.8cm (D) Endometrium becomes thin (< 8mm)

13. Uterus Neonatal 3.5 cm Infant 2.5 – 3.0 cm 2 – 7 years 3.3 – 4.0 cm 10 years 4.0 – 5.2 cm 13 years 5.4 – 7.6 cm Nullparous adult 8.0 – 9.0 cm Multiparous adult 11.0 - 12.0 cm Post menopausal 5.0 – 12.0 cm

14. Adult Uterus 8 (L) x 5 (W) x 4 (D) cm, multiparity increases all measurements by 1 cm © Gunjan Puri, Surat

15. Examining the Uterus Trans-abdominally Trans-vaginally Trans-perinially Trans-rectally

16. Transabdominal scans

17. Transabdominal scans Empty bladder artifact

18. Change probe

19. Common Uterine Position Anteverted and anteflexed

20. Common Uterine Position Anteverted and anteflexed Version is the angle between the cervix and the vagina. Flexion is the angle between the cervix and the body of the uterus. Seen trans-abdominally with an empty bladder.

21. Flexion Version Anteverted, Anteflexed Uterus

22. Anteverted, Retroflexed

23. Anteverted retroflexed

24. Uterine Positions

25. Uterine Shapes Straight uterus Cochleate

26. Cochliate

27. Cochliate

28. Myometrium Homogenous medium density Smooth contours Anterior wall as thick as posterior wall

29. Myometrium Three layers recognizable on US Inner hypoechoic zone, subendometrial halo Intermediate myometrial layer Subserosal layer (variable echogenicity) Arcuate vessels run between intermediate and subserosal layers

30. Layers

31. Uterine Vessels Uterine arteries, from the internal iliac Run along the sides of the uterus, joins branches from the ovarian artery Branches dip into the uterine substance and form the “arcuate” arcade These give off radial and spiral arteries that move inwards to the endometrium

32. Uterine Arteries Uterine Arcuate Radial

33. Arcuate vessels

34. Calcification of arcuate arteries

35. TVS

36. TVS Unless the patient has never been sexually active, the few indications for doing a gynecological ultrasound transabdominally (with a full bladder) include lesions that are above the level of the fundus or too much to the side

37. There can be no serious pelvic ultrasound without TVS

38. TAUS vs. TVS Transabdominal Transvaginal Field size Large Limited Flexibility Can examine any part of the abdomen with the same setup Must use dedicated transducer, setup only good for looking at pelvis Acceptability, invasiveness Non-invasive Some might consider this as invasive and uncomfortable, even painful Not indicated for paediatric patients or those who are sexually inactive Privacy concerns Communication with patient essential Preparation Full bladder Empty bladder Resolution Standard High resolution Essential for early diagnosis of progressive conditions like early pregnancy and ectopic

39. Doing TVS Sterilize the probe according to manufacturers recommendations Cover the probe with a sterile cover (condom?) Gel inside and outside the probe cover/condom Insert the probe into vagina, pointer vertical, aim for the posterior fornix Rotate the probe 90 o for coronal sections Move and rotate the probe laterally for adnexa Withdraw the probe for cervix Add 3D for endometrial lesions

40. TVS

41. TVS (probe at the top) Rotates 90 o counter clockwise

42. TVS Rotates 90 o counter clockwise

43. TVS Rotates 90 o counter clockwise

44. TVS Rotates 90 o counter clockwise

45. TVS Rotates 90 o counter clockwise

46. Retroflexed © Allan J Worral

47. Things to See Size, shape and position Myometrium Cervix Endometrium Vascular structures

48. The cervix The cervical lips The fornices The cervical canal The cervical length cannot be accurately assessed in the nonpregnant uterus because the internal os is not visible

49. Cervix

50. Cervical cancer Comparable to MRI for diagnosing and staging cervical cancer (Sensitivity 80%, specificity 50% and diagnostic accuracy of 50%) For parametrial invasion, ultrasound is more sensitive than MR (86%, 40%) Moloney F, Ryan D, Twomey M, et al. Comparison of MRI and high-resolution transvaginal sonography for the local staging of cervical cancer. Journal of Clinical Ultrasound . [online ahead of print]. 2015. DOI: 10.1002/jcu.22288.

51. To look at the cervix Withdraw the probe

52. Cervical Masses

53. Post hysterectomy cervical stump

54. Cervical tear

55. Prolapsing masses

56. Nabotian cysts Associated with chronic cervicitis and represent mucinous cysts due to obstruction from overgrowth of squamous epithelium.  Few millimetres to up to 4 cm. Tunnel cluster: a special type of Nabothian cyst, is characterised by complex multicystic dilatation of the endocervical glands 

57. Nabothian Cysts

58. Nabothian Cysts

59. End of part 1