Benacerraf B.R. Gynecologic Ultrasound (2014)

GYNECOLOGIC ULTRASOUND
A Problem-Based Approach
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GYNECOLOGIC
ULTRASOUND
A Problem-Based Approach
Beryl R. Benacerraf, MD
Clinical Professor of Radiology and Obstetrics and Gynecology and
Reproductive Biology
Harvard Medical School
Radiologist
Brigham and Women’s Hospital
Consultant in OB-GYN
Brigham and Women’s Hospital and Massachusetts General Hospital
Boston, Massachusetts
Steven R. Goldstein, MD
Professor of Obstetrics and Gynecology
New York University School of Medicine
Director, Gynecologic Ultrasound
Co-Director, Bone Densitometry
New York University Langone Medical Center
New York, New York
Yvette S. Groszmann, MD, MPH

Clinical Instructor in Obstetrics, Gynecology, and Reproductive Biology
Harvard Medical School, Brigham and Women’s Hospital
Boston, Massachusetts
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
GYNECOLOGIC ULTRASOUND: A PROBLEM-BASED APPROACH ISBN: 978-1-4377-3794-3

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Library of Congress Cataloging-in-Publication Data
Benacerraf, Beryl R., author.

Gynecologic ultrasound: a problem-based approach / Beryl R. Benacerraf, Steven R. Goldstein, Yvette S.
Groszmann.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4377-3794-3 (hardcover : alk. paper)
I. Goldstein, Steven R., author. II. Groszmann, Yvette S., author. III. Title.
[DNLM: 1. Genital Diseases, Female--ultrasonography. 2. Ultrasonography--methods. WP 141]
RG107.5.U4
618.1’07543--dc23 2013046132
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This book is dedicated to my husband, Peter Libby,
who gave me love, encouragement, inspiration, and support
throughout my life; and to my children, Oliver and Brigitte Libby,
who make me proud and complete my life.
Beryl Benacerraf
This book is dedicated to the late Robert F. Porges, MD,

who believed in me when some others didn’t and gave me the
opportunity to prove I “could,” and it is dedicated as well to
the very-much-alive Wendy J. Sarasohn, who has connected
to the part of me now able to see the “rainbows.”
Steven Goldstein
I would like to dedicate this to my parents, Dr. Roberto Groszmann

and Aida Groszmann, for giving me a wonderful life. Additionally,
I would like to thank David Sella, my lifelong friend and talented
photographer. Lastly, I need to thank Dr. Beryl Benacerraf. She is a
brilliant physician and a wonderful colleague, and I am lucky to call
her my mentor.
Yvette Groszmann

About the Authors
Beryl R. Benacerraf Steven R. Goldstein Yvette S. Groszmann
Receiving her MD in 1976 from Harvard Medical board member of the International Society of Ultra-
School, Beryl R. Benacerraf went on to complete her sound in Obstetrics and Gynecology. Dr. Benacerraf
internship at Peter Bent Brigham Hospital, her resi- is also the medical director and president of Diagnos-
dency at Massachusetts General Hospital, and her fel- tic Ultrasound Associates, PC, a medical practice that
lowship in ultrasound and computed tomography at she founded in 1982. She served as Editor in Chief of
Brigham and Women’s Hospital. During her 34-year the Journal of Ultrasound in Medicine from 2000 to
academic affiliation with Harvard Medical School, 2010. Her contributions to the field of diagnostic
she has risen to the rank of clinical professor in ultrasound have been recognized by the Ian Donald
obstetrics, gynecology, and reproductive biology and Gold Medal of the International Society of Ultra-
radiology. From 1991 through 1993, Dr. Benacerraf sound in Obstetrics and Gynecology, the Frye Award,
was co-director of high-risk obstetric ultrasound at and the Holmes award (both from the American
Brigham and Women’s Hospital, and from 1993 Institute of Ultrasound). She was selected to deliver
through 1999 she was director of the obstetric ultra- the Silver Lecture at Barnard College in 2007, and she
sound unit at Massachusetts General Hospital. received the 2008 Marie Curie Award from the Asso-
Active in the ultrasound community, Dr. Benacer- ciation of Women Radiologists. In 2010, she was the
raf has directed and organized a host of postgraduate recipient of the Larry Mack award for lifetime achieve-
ultrasound courses. Among her many roles in the ment in ultrasound research from the Society of Radi-
ultrasound community, she is an elected fellow of the ologists in Ultrasound.
American College of Radiology and the Society of Having authored more than 260 peer-reviewed arti-
Radiologists in Ultrasound, was treasurer of the World cles, she has focused her research on the detection
Federation for Ultrasound in Medicine and Biology and significance of fetal anomalies. Dr. Benacerraf
for 7 years, is the current president-elect of the Ameri- did the original research that linked nuchal thicken-
can Institute of Ultrasound in Medicine, and is a ing directly to an increased risk for fetal Down
vii
About the Authors
syndrome and developed the genetic sonogram, both His pioneering work in menopausal and perimeno-
of which have changed the way all pregnant women pausal ultrasound led him into design of uterine
are currently screened for fetal Down syndrome. She safety studies for several Selective Estrogen Receptor
has also made important contributions to the imple- Modulators. In addition he is the Co-Director of the
mentation of 3-D ultrasound in both obstetrics and Bone Densitometry Unit at NYU Langone Medical
gynecology. She has contributed chapters to many Center. Clinically, his practice has evolved into issues
textbooks in the field and is the sole author of Ultra- of menopausal and perimenopausal medicine with
sound of Fetal Syndromes, recently published in its sec- particular interest in ultrasound applications for both
ond edition. More recently, she has taken a special adnexal masses and abnormal bleeding.
interest in ultrasound of gynecologic patients, in par- He has authored textbooks titled Endovaginal Ultra-
ticular those with chronic pelvic pain. sound and Ultrasound in Gynecology. More recently, he
authored Imaging in the Infertile Couple and Textbook of
Steven R. Goldstein, MD, is a Magna Cum Laude Perimenopausal Gynecology. He is one of the most
graduate of Colgate University with a Baccalaureate highly recognized and regarded individuals in the
degree in Biology. He graduated from the New York field of vaginal probe ultrasound worldwide. He has
University School of Medicine and did an internship authored more than 60 chapters in textbooks and
in Obstetrics and Gynecology at Parkland Memorial more than 80 original research articles. He has been a
Hospital in Dallas, Texas. He did a residency in guest faculty member, invited speaker, visiting profes-
Obstetrics and Gynecology at New York University sor, or course director more than 400 times through-
Affiliated Hospitals/ Bellevue Hospital Center. There- out the United States and the world.
after he joined the faculty of the Department of Dr. Goldstein has a long history as an adviser and
Obstetrics and Gynecology at New York University consultant to the pharmaceutical industry. He has
School of Medicine, rising to his current rank of Pro- been on gynecologic advisory boards and/or con-
fessor of Obstetrics and Gynecology, a tenured full- sulted for Amgen, Bayer, Boehringer Ingelheim, Eli
time academic position. However, in this capacity, he Lilly, Merck, GlaxoSmithKline, Novo Nordisk,
maintains a half-time private practice as a generalist Wyeth, Procter & Gamble, Warner Chilcott, Shion-
in Obstetrics and Gynecology in the Faculty Practice ogi, QuatRx, Depomed, and Pfizer. He has repre-
suites at New York University. sented Eli Lilly, Pfizer, and Mirabilis Medica in their
His longstanding interests in OB-GYN ultrasound appearances before FDA Advisory Boards. He has
have led him to his current position as Director of designed studies of uterine safety for Eli Lilly,
Gynecologic Ultrasound at New York University Wyeth, Pfizer, and GlaxoSmithKline. He holds two
Medical Center. He is a Fellow of the American patents in the medical device arena. He was director
Institute of Ultrasound in Medicine and is currently of a publicly traded ultrasound company, SonoSite,
President of this national organization. He is a past Inc., from its inception until its sale to Fuji Medical
President of the North American Menopause Soci- in 2012.
ety. He served on the Board of Directors of the He resides in New York City.
American Registry of Diagnostic Medical Sonogra-
phers, having prepared the test and administered Yvette S. Groszmann attended Tufts University
policy for the certification of over 40,000 sonogra- and graduated with a BS in Biopsychology. She
phers nationwide. He is a past Chairman of the obtained her medical degree in 2000 from the Uni-
American College of Obstetrics and Gynecology, versity of Connecticut, as well as a Master’s in Public
New York section. He was author of their Technical Health. She then completed a residency in Obstetrics
Bulletin Ultrasound in Gynecology as well as the and Gynecology at Pennsylvania Hospital in Phila-
author of their practice guidelines on SERMs (selec- delphia. Her residency training emphasized the
tive estrogen receptor modulators). He serves as the importance of ultrasound as part of the routine prac-
liaison physician from the American College of tice of obstetrics and gynecology. As a result, she
Obstetrics and Gynecology to the Women’s Health received considerable training and practice in ultra-
Imaging Panel of the American College of Radiol- sound during her time at Pennsylvania Hospital.
ogy. He has been an examiner for the American After completing her formal training, she joined a
Board of Obstetrics and Gynecology. multispecialty medical group in Boston as a full-time
viii
About the Authors
obstetrician-gynecologist with hospital appointments received a teaching award during residency. She is
at Brigham and Women’s Hospital and Faulkner Hos- currently a clinical instructor at Harvard Medical
pital. In 2009, Dr. Groszmann left her practice as a School and teaches gynecologic ultrasound to the
generalist to do a fellowship in diagnostic ultrasound OB-GYN residents.
under the guidance of Dr. Beryl Benacerraf. She joined Dr. Groszmann is a fellow of the American College
Diagnostic Ultrasound Associates in 2010 and contin- of Obstetrics and Gynecology and a member of the
ues her affiliation with Brigham and Women’s American Institute of Ultrasound in Medicine. She is
Hospital.Dr. Groszmann enjoys teaching, and she board certified in Obstetrics and Gynecology.
ix

Preface
This book is designed for the clinician as a practi- Differential Diagnosis, Clinical Aspects and
cal approach to problem-solving for gynecologic Recommendations, and Suggested Reading.
patients. The book provides a stepwise and con- There is also a chapter on the normal ultra-
venient guide to the diagnosis of gynecologic sound examination of the female pelvis, fol-
abnormalities for practitioners providing gyne- lowed by a series of 26 test cases of abnormalities
cologic care. for readers to see what they have learned.
The book is organized by a listing of symptoms This book is not a standard textbook on gyne-
or findings that a practitioner might encounter cologic ultrasound, of which there are many
when evaluating a patient sonographically (in the excellent offerings. Most of these textbooks are
Contents section called List of Differential Diag- constructed with separate chapters for each organ
noses). These categories include a variety of topics, (such as the uterus, ovary, and fallopian tubes).
including pelvic pain, pelvic masses, and post- Rather, this book is intended as a reference
menopausal bleeding. Under each category, there focused on problem solving. A clinician can con-
is a list of differential diagnostic possibilities. For sult the book to look up a specific symptom or
example, within pelvic pain, the differential diag- finding and help narrow down the differential
noses include appendicitis, ectopic pregnancy, diagnoses to one correct entity.
hemorrhagic cyst, degenerating fibroid, and so This book is intended for radiologists,
on. The reader can select or refer to the specific obstetricians/gynecologists, infertility specialists,
disease or entity to go into a “mini-chapter” (there emergency physicians, sonographers, and resi-
are 54 of these) and read more about that particu- dents in OB-GYN and radiology who perform
lar entity and its sonographic appearance, as well pelvic ultrasound. The book may also be useful
as review images illustrating it. to primary care physicians, nurse practitioners,
The 54 mini-chapters focus on each entity or physician’s assistants, and other personnel who
diagnosis (such as hemorrhagic cyst, fibroid, or see patients with pelvic symptoms and order the
polyps) and contain abundant images (more imaging. The diagnoses are presented by symp-
than 600) from several patients to give compre- tom, differential diagnosis, and alphabetically
hensive examples of the sonographic and for easy searching.
Doppler findings for each of these findings or It is hoped that this book will give practitio-
disease states. Each mini-chapter is arranged in ners who take care of women with pelvic com-
a standard format that includes Synonyms/ plaints a practical reference that will be useful in
Description, Etiology, Ultrasound Findings, solving their diagnostic dilemmas.
xi

Contents
Section 1 ENTITIES M
A Metastatic Tumor to the Ovary 118
Mucinous Cystadenoma 122
Adenomyosis3
Müllerian Duct Anomalies 125
Adhesions (Peritoneal Inclusion Cyst) 8
Appendiceal Mucocele 11 O
Atrophic Endometrium 14
Ovarian Calcifications 136
B Ovarian Cancer (Epithelial) 137
Ovarian/Tubal Torsion 147
Bladder Masses 15
Ovarian Vein Thrombosis 153
Borderline Ovarian Tumor 21
Bowel Diseases 26 P
Brenner Tumor 32
Paratubal or Paraovarian Cysts 155
C Pelvic Congestion Syndrome 157
Pelvic Kidney 159
Cervical Masses 34
Polycystic Ovaries 161
Cesarean Scar Defect 39
Polyps, Endometrial 163
Corpus Luteum and Hemorrhagic Cyst 43
Premature Ovarian Failure 170
Cyst, Clear 48
Cystadenofibroma51 R
D Retained Products of Conception 172
Dermoid Cyst 53 S
Dysgerminoma56
Scarred Uterus and Asherman’s Syndrome 177
E Schwannoma182
Serous Cystadenoma 184
Ectopic Pregnancy 58
Struma Ovarii 186
Endometrial Carcinoma 65
Endometrial Hyperplasia and the Differential T
Diagnosis for Thick Endometrium 71
T-Shaped Uterus 189
Endometriosis76
Tarlov Cysts 192
Epidermoid Cyst 83
Theca Lutein Cyst 194
F Tube Carcinoma, Primary Fallopian 196
Tubo-Ovarian Abcess and Pelvic Inflammatory
Fibroids85
Disease199
Fibroma (Ovarian), Thecoma, and Fibrothecoma 93
U
G
Ureteral Stone 203
Granulosa Cell Tumor 96
Uterine Sarcoma 205
H V
Hematometra and Hematocolpos 98
Vaginal Masses 209
Hydrosalpinx104
I Section 2 NORMAL PELVIC ULTRASOUND

Intrauterine Device Location, Abnormal 109 AND COMMON NORMAL VARIANTS
Intravenous Leiomyomatosis 114
Normal Pelvic Ultrasound and Common
L Normal Variants221
Lymph Nodes, Enlarged 116 Section 3 CASE STUDIES FOR REVIEW

List of Differential Diagnoses
Pelvic Pain
Acute
Appendicitis or mucocele 11
Degenerating fibroid 85
Ectopic pregnancy 58
Hemorrhagic cyst 43
Ovarian/adnexal torsion 147
Ovarian torsion 147
Ovarian vein thrombosis 153
Tubo-ovarian abscess/PID 199
Ureteral stone 203
Chronic
Adenomyosis 3
Adhesions—peritoneal inclusion cyst—loculated fluid 8
Cystitis 15
Deep penetrating endometriosis 76
Endometriosis/endometrioma 76
Fibroids 85
Hydrosalpinx 104
Inflammatory bowel disease 26
IUD (abnormal location) 111
Pelvic congestion 157
Pseudomyxoma peritonei 11
Salpingitis 199
Pelvic Mass
Uterine
Adenomyosis 3
Degenerating fibroid 85
Fibroid 85
Hematometra/hematocolpos 98
Nabothian cyst 38
Sarcoma 205
xv
Vaginal mass
Fibroid 85 and 209
Gartner’s duct cyst 209
Lymphoma 116 and 209
Sarcoma 209
Cervical mass
Cervical cancer 38
Cervical fibroid 38 and 85
Cervical lymphoma 38 and 116
Cervical polyp 38 and 163
Complex cystic mass
Appendiceal mucocele 11
Corpus luteum 43
Cystadenofibroma 51
Decidualized endometrioma in pregnancy 76
Endometrioma 76
Epidermoid cyst 83
Hemorrhagic cyst 43
Hydrosalpinx 104
Mucinous cystadenoma 122
Ovarian malignancy (borderline or invasive) 137
Serous cystadenoma 184
Theca luteum cyst 194
Tubal malignancy 196
Tubo-ovarian abscess 199
Solid mass
Bowel-related masses 26
Brenner tumor 32
Dermoid 53
Dysgerminoma 56
Endometriosis implants 76
Enlarged lymph node (lymphoma) 116
Epidermoid cyst 83
Fibroma 93
Granulosa cell tumor 96
Hemorrhagic cyst (acute) 43
Intravascular leiomyomatosis 109
Massive ovarian edema 147
Metastatic carcinoma 118
Ovarian calcifications 136
Ovarian malignancy (borderline or invasive) 137
xvi
Pelvic kidney 159
Schwannoma 182
Tarlov cysts (bilateral) 192
Theca cell tumor 194
Clear cyst
Cystadenoma 122 and 184
Follicle/unilocular physiologic cyst 48
Paraovarian cyst 155
Adnexal mass with normal ovary documented
Appendix- or bowel-related mass 11 and 26
Broad ligament fibroid 85
Hydrosalpinx 104
Intravascular leiomyomatosis 109
Paratubal cyst 155
Pelvic kidney 159
Peritoneal inclusion cyst 8
Tubo-ovarian abscess 199
Abnormal Bleeding
Premenopausal
Adenomyosis 3
C-section scar defect (with collected blood) 34
Endometrial carcinoma 65
Endometrial hyperplasia 71
Functional ovarian cyst 48
Hematuria—bladder masses 15
IUD (abnormal location) 111
Polyps 163
Retained products of conception 172
Postmenopausal bleeding
Atrophic endometrium 14
Endometrial carcinoma 65
Endometrial hyperplasia 71
Hematuria—bladder masses 15
“One more cycle” 221
Polyps 163
Amenorrhea
Asherman’s syndrome 177
Excessive exercise/anorexia No page reference
xvii
PCOS 161
Perimenopause No page reference
Pregnancy No page reference
Infertility
Hydrosalpinx or salpingitis 104 and 199
Lack of follicular development 170
Lack of normal maturation of the endometrium during the cycle No page reference
Müllerian duct abnormalities 125
PCOS 161
Pelvic inflammatory disease 199
Premature ovarian failure 170
Submucous fibroid 85
T-shaped uterus 189
Tubal occlusion No page reference
Uterine synechiae 177
Recurrent Pregnancy Loss—Possible Ultrasound Findings

Müllerian duct abnormalities—septate or subseptate, unicornuate, bicornuate
T-shaped uterus 125 and 189
xviii
Video Contents
Appendiceal Mucocele Video 1 Endometriosis/Endometrioma Video 3

Bowel-Related Masses Video 1 Ovarian Cancer (Epithelial) Video 1
Endometrial Carcinoma Video 1 Ovarian/Tubal Torsion, Edema (Massive) Video 1
Endometriosis/Endometrioma Video 1 Retained Products of Conception Video 1
Endometriosis/Endometrioma Video 2 Retained Products of Conception Video 2
xix

Section 1
Entities

Section 1
Adenomyosis A
Synonyms/Description outline of the endometrial cavity on 3-D coronal
Endometriosis of the uterus or myometrium view of the uterus.
Although magnetic resonance imaging (MRI)
Etiology has been useful for diagnosing adenomyosis, it is
Adenomyosis is defined pathologically when unnecessary because ultrasound has similar
endometrial glands and stroma are found in the accuracy. A comparison between ultrasound and
myometrium, distant from the endometrial cav- MRI was reported using 23 articles (involving
ity itself. This ectopic endometrial tissue has the 2312 women). Transvaginal ultrasound had a
ability to induce hypertrophy of the surrounding sensitivity and specificity of 72% and 81%,
myometrium. This process can be focal or diffuse respectively, whereas MRI had a sensitivity and
and thus accounts for the variability in the ultra- specificity of 77% and 89%, respectively.
sound appearances noted. The endometrium- Doppler evaluation of adenomyosis usually
myometrium junctional zone is jagged and fuzzy does not add to the diagnosis because the
because the endometrial mucosa essentially amount of vascularity is variable and
invades the underlying myometrium, thus blur- nonspecific.
ring the interface between these two, typically
distinct zones. (This may be focal or global.) Differential Diagnosis
If the area of adenomyosis is focal, it may be con-
Ultrasound Findings fused with a fibroid or a polyp if it projects into
Generalized Adenomyosis the endometrial cavity. Because of the lucencies
The uterus is typically enlarged and globular and heterogeneities in the myometrium, uterine
with heterogeneous myometrium, which is typi- malignancy (though very rare) is sometimes con-
cally wider on one side than the other. The het- sidered. The clue to the correct diagnosis is the
erogeneous myometrium often contains asymmetry of the width of the myometrium
myometrial cysts, which likely represent areas of comparing the posterior to the anterior aspect
glandular dilatation or hemorrhage caused by on longitudinal view as well as the shaggy
repeated bleeding. These cysts are also frequently appearance of the endometrial echo in a patient
seen in a subendometrial location. with chronic pain and abnormal bleeding.
Adenomyoma Clinical Aspects and Recommendations

An adenomyoma appears as a focal, somewhat Historically, heavy menstrual bleeding (menor-
circumscribed island of heterogeneity in the rhagia) and painful menstruation (dysmenor-
myometrium, suggesting a fibroid, but typically rhea) are the major symptoms of adenomyosis
without clear borders. When the borders are and are said to occur in approximately 60% and
sharp, one cannot distinguish an adenomyoma 25% of women, respectively. It has also been
from a fibroid. The adenomyoma may project implicated in some cases of chronic pelvic pain.
into the cavity in the form of a broad-based In the past, symptoms typically developed in
polyp (polypoid adenomyoma). women in the fourth and fifth decade of life
Three-dimensional (3-D) ultrasound is helpful (perimenopausally); however, this probably
to demonstrate the multitude of linear hyper- reflects the fact that in the past the diagnosis of
echoic bands emanating from the endometrium adenomyosis historically was made at the time
into the myometrium, producing the shaggy of hysterectomy and not with sophisticated
3
Section 1 Adenomyosis
imaging techniques as are currently available. In endometrial tissue confined within the
A fact the obvious presence of endometrial glands
and stroma contained within the myometrium
myometrium.
Definitive treatment for adenomyosis is hys-
in a large number of asymptomatic women terectomy. Because disease is confined to the
should cause clinicians to rethink whether ade- uterus, ovarian conservation can be considered
nomyosis is truly a “disease” or whether in some unless there are other reasons for their removal.
cases it may be co-existing and not causal of the As there is no true plane separating the adeno-
patient’s symptoms. The exact percentage of myotic tissue from normal myometrium, surgical
patients who will have classic findings of adeno- excision as in myomectomy is not appropriate.
myosis on sophisticated ultrasound studies and Various medical (nonsurgical) approaches have
yet be totally asymptomatic is unknown. been employed, including oral contraceptive
When present, the menorrhagia is probably pills for treatment of the dysmenorrhea and
related to the increased endometrial surface area menorrhagia, progestin only therapy, and more
of the enlarged uterus. Dysmenorrhea may be recently levonorgestrel-releasing intrauterine
caused by the cyclic bleeding and swelling of the devices (IUDs).
Figure A1-1 Two different patients. Typical appearance of the myometrium, which is asymmetric because of
adenomyosis. Note that the endometrial echo is closer to the anterior than the posterior wall of the uterus.
4
Adenomyosis Section 1
Figure A1-2 Heterogeneous myometrium containing small echolucencies, typical of adenomyosis (two different
patients).
A B
Figure A1-3 Adenomyoma projecting into the endometrial cavity from a broad base within the myometrium.
A shows the mass as ill-defined within the cavity, worrisome for a malignancy, especially in a postmenopausal patient.
B from the same patient shows the sonohysterogram with saline outlining the adenomyoma diagnosed by pathology.
5
Section 1 Adenomyosis
A B
C
Figure A1-4 Three-dimensional ultrasound of two different patients with extensive adenomyosis. A shows the
reconstructed coronal view of the uterus with a fuzzy, ill-defined junction and linear echogenicities emanating out
from the edges of the endometrium. B shows a different patient with adenomyosis and a right-sided fibroid
demonstrating similar echolucencies. C (same patient as B) shows the inverse mode of the 3-D image that accentu-
ates the lack of a clear border at the junction of the endometrium and myometrium.
6
Adenomyosis Section 1
Suggested Reading Maheshwari A, Gurunath S, Fatima F, Bhattacharya S.

Bocca SM, Oehninger S, Stadtmauer L, Agard J,
Duran EH, Sarhan A, Horton S, Abuhamad AZ.
Adenomyosis and subfertility: a systematic review
of prevalence, diagnosis, treatment and fertility
A
A study of the cost, accuracy, and benefits of outcomes. Hum Reprod Update. 2012;18:374-392.
3-dimensional sonography compared with hys- Valentini AL, Speca S, Gui B, Soglia G, Miccò M,
terosalpingography in women with uterine abnor- Bonomo L. Adenomyosis: from the sign to the
malities. J Ultrasound Med. 2012;31:81-85. diagnosis. Imaging, diagnostic pitfalls and differ-
Champaneria R, Abedin P, Daniels J, Balogun M, ential diagnosis: a pictorial review. Radiol Med.
Khan KS. Ultrasound scan and magnetic resonance 2011;116:1267-1287.
imaging for the diagnosis of adenomyosis: system- Wéry O, Thille A, Gaspard U, van den Brule F. Adeno-
atic review comparing test accuracy. Acta Obstet myosis: update on a frequent but difficult diagnosis.
Gynecol Scand. 2010;89:1374-1384. J Gynecol Obstet Biol Reprod. 2005;34:633-648.
Exacoustos C, Brienza L, Di Giovanni A, Szabolcs B,
Romanini ME, Zupi E, Arduini D. Adenomyosis
three-dimensional sonographic findings of the
junctional zone and correlation with histology.
Ultrasound Obstet Gynecol. 2011;37:471-479.
7
Section 1
A Adhesions (Peritoneal Inclusion Cyst)

Synonyms/Description masses. These include hydrosalpinx, paraovarian
Benign adhesions trapping fluid cyst, or ovarian neoplasm such as a cystadenoma.
In the setting of prior pelvic surgery, the correct
Etiology diagnosis of peritoneal inclusion cysts can be
Peritoneal inclusion cysts develop from peritoneal made, especially if a normal-appearing ovary is
adhesions trapping fluid, often generated from an seen trapped in the edge of the cyst and the cyst
active ovary. The normal peritoneum absorbs fluid conforms to the shape of the adjacent peritoneal
regularly. When the peritoneum is injured, as can cavity.
occur with surgery, infection, or endometriosis,
normal fluid absorption is hampered. This results Clinical Aspects and Recommendations
in fluid accumulation within adhesions or perito- Because peritoneal inclusion cysts are virtually
neal inclusion cysts. Reportedly at least 70% of all always a form of adhesive disease, many of these
patients with peritoneal inclusion cysts in one patients complain of pain, especially with activ-
study had a known prior peritoneal insult. ity such as intercourse, exercise, or bowel move-
ments. This is especially true in those patients
Ultrasound Findings whose adhesions are secondary to pelvic inflam-
Peritoneal inclusion cysts are multilocular, cystic matory disease, endometriosis, or possibly,
masses that conform to the shape of the perito- although less likely, previous pelvic surgery.
neum and surrounding organs. They appear as Many peritoneal inclusion cysts, however, are
multicystic, septate adnexal or cul-de-sac masses asymptomatic and discovered incidentally dur-
that can be small or attain large sizes. The septa- ing imaging. Because of the variable nature of
tions can be thick or thin and can be multiple as their sonographic appearance, such “masses”
the “mass” insinuates itself in the crevices of the may occasionally appear concerning, and surgi-
pelvic side wall. Often a normal-appearing ovary cal exploration may be undertaken. If such
can be identified embedded along the edges of masses are clearly recognized as peritoneal inclu-
the mass as the ovary is usually trapped in the sion cysts and are asymptomatic or mildly symp-
web of adhesions but not actually part of the tomatic, conservative therapy is appropriate. In
peritoneal inclusion cyst itself. most patients with significant pain, surgical cor-
rection with lysis of adhesions may be appropri-
Differential Diagnosis ate, although the risk of recurrence is
Peritoneal inclusion cysts are easily confused approximately 30% to 50% after surgical
with other complex cystic and septate adnexal treatment.
8
Adhesions (Peritoneal Inclusion Cyst) Section 1
A
1
A 2 B
LT ovary
D
C
Figure A2-1 A and B show two views of a left peritoneal inclusion cyst. The top of the ovary is noted along the
lateral aspect of the cyst. C (arrows) and D show the ovary in the lateral aspect of the cyst, but showing normal
ovarian architecture.
9
Section 1 Adhesions (Peritoneal Inclusion Cyst)
A RT
Right
A
A 1
RT
Right
1
B
B
Figure A2-3 Atypical appearance. A shows a multi-
Figure A2-2 Two views of a right peritoneal inclu-
septate cystic mass with color flow in the septations,
sion cyst. A shows the cyst with its typical fine
originally thought to be a cystadenoma. B, This
septations. B shows the right ovary trapped along the
peritoneal inclusion cyst that was diagnosed at
lateral aspect of the cyst.
surgery and pathology.
Suggested Reading Vallerie AM, Lerner JP, Wright JD, Baxi LV. Peritoneal
Guerriero S, Ajossa S, Mais V, Angiolucci M, Paoletti inclusion cysts: a review. Obstet Gynecol Surv. 2009;
AM, Melis GB. Role of transvaginal sonography in 64:321-334.
the diagnosis of peritoneal inclusion cysts. J Ultra- Veldhuis WB, Akin O, Goldman D, Mironov S,
sound Med. 2004;23:1193-1200. Mironov O, Soslow RA, Barakat RR, Hricak H. Perito-
Jain KA. Imaging of peritoneal inclusion cysts. Am J neal inclusion cysts: clinical characteristics and imag-
Roentgenol. 2000;174:1559-1563. ing features. Eur Radiol. 2013;23:1167-1174.
10
Section 1
Appendiceal Mucocele A
Synonyms/Description appearance of an appendiceal mucocele is more
A mucocele is an appendiceal mass characterized easily confused with a tubal lesion such as a
by hypersecretion of mucus contained within the hydrosalpinx, tubo-ovarian abscess, or endome-
appendix causing dilatation of the lumen. triosis. It is essential to identify the uterus and
ovaries separately from the mass to identify a
Etiology bowel etiology. Once the origin of the mass is sus-
Mucoceles of the appendix are caused by exces- pected to be appendix, the differential diagnosis
sive mucous production secondary to retention includes acute inflammation of the appendix
cyst (simple) (18%), mucosal hyperplasia (20%), (appendicitis), malignancy (adenocarcinoma),
mucinous cystadenoma (52% to 84%), or muci- mucocele, carcinoid, and appendiceal endome-
nous cystadenocarcinoma (10% to 20%). They triosis. Other diagnostic possibilities include a
occur in males twice as frequently as females and colonic mass or mesenteric cyst. The sonographic
most often in the fifth or sixth decade. The inci- appearance of the mucocele is very characteristic,
dence of mucocele of the appendix is 0.2% and even pathognomonic, with the onion-skin texture
0.3% of all appendectomies. and nonvascular center of a tubular mass. Other
etiologies for an appendiceal mass are almost
Ultrasound Findings impossible to distinguish from one another with-
Mucocele of the appendix is an elongated tubular out a history such as acute pain and fever, or
mass with a very specific onion-skin texture of the endometriosis.
internal structure, giving the appearance of echo- See Bowel Diseases.
genic layers. There is no internal blood flow, and
Doppler signal is confined to the outer walls of Clinical Aspects and Recommendations
the mass. Although the mass is usually seen using Appendiceal mucoceles are symptomatic in
transvaginal ultrasound, it is also usually visible about half of cases. The most common symp-
using a transabdominal approach in the right toms are a palpable mass and abdominal pain.
lower quadrant. The dreaded complication of The treatment is appendectomy to prevent rup-
mucocele rupture or leak is pseudomyxoma peri- ture and to diagnose any malignant component.
tonei, which appears as diffuse gelatinous ascites. If the mucocele is the result of a cystadenocarci-
noma and the tumor has spread, more extensive
Differential Diagnosis surgery is needed.
Most cases are incidental findings and often mis- The feared complication of this entity is pseu-
diagnosed. In women, it is commonly diagnosed domyxoma peritonei, which results from the dis-
as an ovarian or tubal mass. The correct preop- semination of the mucinous cells because of
erative diagnosis based on imaging studies is rupture of the mucocele. This complication is
made in only 15% to 29% of cases. very serious and extremely hard to treat; it can
The appendix is typically located in the right lead to intestinal obstruction and death. Treat-
lower quadrant just cephalad to the right adnexa; ment typically involves a combination of surgery
therefore it is important to consider an appendi- for debulking and intraperitoneal chemotherapy.
ceal etiology for a right lower quadrant tubular Although the prognosis for appendiceal muco-
mass with or without pelvic pain. Diagnostic pos- cele without complication is excellent, the 3-year
sibilities for a complex, right lower quadrant mass survival of patients with pseudomyxoma perito-
include an ovarian etiology, although the tubular nei is reportedly 81%.
11
Section 1 Appendiceal Mucocele
A E8
Figure A3-2 Low-grade mucinous cystadenoma.

Right
Note the characteristic pattern of linear echoes
within the mass.
1
Figure A3-1 Two different patients both suspected

of having a tubal lesion but diagnosed by ultrasound
to have a mucocele of the appendix. Note the
characteristic onion-skin pattern of the linear echoes
within both masses revealing the correct diagnosis.
RT
Figure A3-4 Pseudomyxoma peritonei. Note the

diffuse involvement of the surfaces of the peritoneal
cavity with solid nodular masses.
Figure A3-3 Nonspecific appendiceal mass proved

to be endometriosis of the appendix.
12
Appendiceal Mucocele Section 1
Videos Pickhardt PJ, Levy AD, Rohrmann CA, Kende AI. Pri-
Videos 1, 2, and 3 on appendiceal mucocele are
available online.
mary neoplasms of the appendix: radiologic spec-
trum of disease with pathologic correlation.
A
RadioGraphics. 2003;23:645-662.
Witkamp AJ, de Bree E, Kaag MM, van Slooten GW,
Suggested Reading
van Coevorden F, Zoetmulder FA. Extensive surgi-
Caracappa D, Gullà N, Gentile D, Listorti C,
cal cytoreduction and intraoperative hyperthermic
Boselli C, Cirocchi R, Bellezza G, Noya G. Appen-
intraperitoneal chemotherapy in patients with
diceal mucocele. A case report and literature review.
pseudomyxoma peritonei. Br J Surg. 2001;88:
Ann Ital Chir. 2011 May-Jun;82(3):239-245.
458-463.
Dragoumis K, Mikos T, Zafrakas M, Assimakopoulos E,
Yabunaka K, Katsuda T, Sanada S, Fukutomi T. Sono-
Venizelos I, Demertzidis H, Bontis J. Mucocele of
graphic appearance of the normal appendix in
the vermiform appendix with sonographic appear-
adults. J Ultrasound Med. 2007;26:37-43.
ance of an adnexal mass. Gynecol Obstet Invest.
2005;59:162-164.
Papoutsis D, Protopappas A, Belitsos P, Sotiropoulou
M, Antonakou A, Loutradis D, Antsaklis A. Muco-
cele of the vermiform appendix misdiagnosed as
an adnexal mass on transvaginal sonography. J Clin
Ultrasound. 2012;40:522-525.
13
Section 1
A Atrophic Endometrium
Synonyms/Description
Endometrial atrophy
Etiology
Endometrial atrophy is most often the result of
postmenopausal status, although it may also
occur in premenopausal women with lack of
estrogen from other etiologies.
Ultrasound Findings
A very thin endometrial echo is characteristic of
atrophic endometrium. This occurs primarily in
postmenopausal or anovulatory women. Often Figure A4-1 Retroverted uterus of a postmeno-
the endometrium is so thin it is reflective of pausal patient with atrophic endometrium. Note the
sound waves, such that it looks like a continuous very thin linear endometrial echo.
line. An atrophic endometrium measures less
than 4 mm, but is more commonly 1 to 2 mm in
width. In postmenopausal women there can
occasionally be a small amount of fluid in the
cavity outlining a paper-thin endometrial lining.
This is usually transudate associated with cervi-
cal stenosis and not associated with pathology.
1
2
Differential Diagnosis
If the endometrial lining is very thin in a patient
who is hypoestrogenic, the diagnosis is likely to
be atrophic endometrium.
Figure A4-2 There is a small amount of fluid in the
Clinical Aspects and Recommendations endometrial cavity, outlining a very thin endome-
Postmenopausal bleeding is often caused by trium. This finding is normal.
atrophy of the endometrium.
In the absence of estrogen, the functional layer
atrophies, leaving only the basalis layer. In Suggested Reading
patients with postmenopausal bleeding, a Davidson KG, Dubinsky TJ. Ultrasonographic evalua-
workup is necessary to rule out uterine cancer, tion of the endometrium in postmenopausal vagi-
hyperplasia, and polyps before the cause can be nal bleeding. Radiol Clin North Am. 2003;41:
attributed to atrophic endometrium, especially 769-780.
because endometrial cancer can coexist with Goldstein SR. Sonography in postmenopausal bleed-
atrophic endometrium. ing. J Ultrasound Med. 2012;31:333-336.
Tsai MC, Goldstein SR. Office diagnosis and manage-
ment of abnormal uterine bleeding. Clin Obstet
Gynecol. 2012;55(3):635-650.
14
Section 1
Bladder Masses
Synonyms/Description Urethral Diverticula
B
Bladder tumor Urethral diverticula occur just under the bladder
Focal bladder lesion along the urethra. They can be quite painful,
especially when the patient voids.
Etiology
Transitional Cell Cancer Other Bladder Masses
In the United States, bladder cancer is reportedly There are many benign tumors such as paragan-
the fourth most common malignancy. The vast glioma, plasmacytoma, hemangioma, neurofi-
majority of bladder neoplasms arise from the broma, and lipoma that can occasionally (rarely)
epithelium, with urothelial (transitional cell) occur in the bladder. Malignant neoplasms
carcinoma accounting for 90% of cases. Squa- reported in the bladder include rhabdomyosar-
mous cell carcinoma is rare and accounts for 2% coma, leiomyosarcoma, lymphoma, osteosar-
to 15% of bladder cancers. The least common is coma, and metastatic tumors such as melanoma.
adenocarcinoma, which may be primary or met-
astatic to the bladder. Ultrasound Findings
Bladder masses are typically located in the blad-
Fibroma der wall. Because these arise from the submuco-
Fibroma (leiomyoma) is the most common sal portion of the bladder wall, they typically
benign tumor of the bladder, although it repre- appear as smooth intramural lesions. Transi-
sents only 0.4% of all bladder neoplasms. It is tional cell carcinoma is a focal mucosal lesion,
most prevalent among women in the third to which is fungating and extends into the lumen of
fifth decades of life. the bladder with an irregular surface. Color Dop-
pler usually reveals abundant blood flow, as with
Endometriosis other pelvic malignancies. Bladder wall lesions
Endometriosis occurs as a fusiform mass in the are typically fusiform with an intact mucosal sur-
bladder wall and is covered in the section on face and focally widen the wall of the bladder.
endometriosis. Endometriosis of the bladder wall (likely the
most common diagnosis in gynecologic patients)
Diffuse Bladder Wall Thickening has spotty blood flow by Doppler and a smooth
Diffuse bladder wall thickening is seen in cases inner and outer wall. Lesions involving the ure-
of severe chronic cystitis or in chronic bladder teral orifice can be cystic, such as ureteroceles
outlet obstruction where the bladder becomes (which are usually asymptomatic); in the case of
trabeculated (more common in males with large reimplantations, there will be a surgical history.
prostates). Urethral diverticula are complex masses along
the urethra, just under the bladder (see Vaginal
Findings Specifically Related to the Ureteral Masses). These may indent the floor of the blad-
Orifice der and be quite painful during the ultrasound.
They are best seen by placing the transducer on
• Ureterocele
the perineum and looking cephalad toward the
• Ureteral reimplantation site
bladder. They are usually cystic with varying
• Stone at the ureteropelvic junction (UPJ)
amounts of solid area and calcification, depend-
with edema of ureteral orifice
ing on chronicity of the lesion.
15
Section 1 Bladder Masses
Differential Diagnosis Clinical Aspects and Recommendations

Mucosal lesions with an irregular surface and Bladder lesions can cause dysuria, frequency,
protruding into the bladder are usually transi- and hematuria, but often may be asymptomatic.
B
tional cell carcinomas. Lesions that are solid and Bladder malignancies typically present with
completely contained within the bladder wall hematuria because of their location in the muco-
may be endometriosis (fusiform with little sal layer of the bladder. Pedunculated intralumi-
detectable blood flow) or fibroma (rounded and nal masses may lead to obstruction of urine flow
ball-like) versus other rare solid rounded tumors. or inability to completely empty the bladder. If a
If the bladder wall is diffusely abnormal and bladder mass arises in proximity to one of the
thickened, etiologies may include long-standing ureters, it can obstruct the ureter, thus present-
bladder dysfunction or obstruction or chronic ing with flank pain and hydronephrosis. Lesions
cystitis. It is normal for the bladder wall to appear that develop outside the wall of the bladder not
thickened and trabeculated if the bladder is impinging on the lumen may remain asymp-
underfilled. tomatic for a long time. There are no general
If the lesion is along the urethra, it is likely to management recommendations because this
be a urethral diverticulum. depends on the type of lesion diagnosed.
RT
Figure B1-1 Transitional carcinoma of the bladder.

A, A 2-D view with color Doppler showing abundant
vascularity. B and C, The same tumor using 3-D surface
ultrasound. Note the fungating mucosal surface lesion
C
typical of bladder carcinoma.
16
Bladder Masses Section 1
B
1
B
B
Figure B1-2 A, Fusiform bladder wall mass (calipers)
Figure B1-3 Ureterocele. A, A longitudinal view of
in a patient with endometriosis. B, The 3-D volume
the ureterocele implant into the bladder. B, The
view of the bladder wall mass, showing a smooth
patient has bilateral ureteroceles.
mucosal surface.
17
Figure B1-4 Patient with surgically reimplanted ureters. Note the homogeneous rounded structures at the site of
reimplantation, 2-D and 3-D.
18
Bladder Masses Section 1
B
Figure B1-5 Urethral diverticulum (arrows). A, Note the complex mass, partly calcified, indenting the floor of the
bladder. B, The long axis view of the mass alongside the urethra.
19
A B
C
Figure B1-6 A and B, Two small stones stuck in the distal end of the ureter. C, The associated hydronephrosis.
Suggested Reading Wong-You-Cheong JJ, Woodward PJ, Manning MA,

Fasih N, Prasad Shanbhogue AK, Macdonald DB, Davis CJ. From the archives of the AFIP: inflamma-
Fraser-Hill MA, Papadatos D, Kielar AZ, Doherty tory and nonneoplastic bladder masses: radio-
GP, Walsh C, McInnes M, Atri M. Leiomyomas logic-pathologic correlation. Radiographics. 2006;
beyond the uterus: unusual locations, rare mani- 26:1847-1868. Review.
festations. Radiographics. 2008;28:1931-1948. Wong-You-Cheong JJ, Woodward PJ, Manning MA,
Review. Sesterhenn IA. From the archives of the AFIP: neo-
Kocakoc E, Kiris A, Orhan I, Poyraz AK, Artas H, Fir- plasms of the urinary bladder: radiologic-
dolas F. Detection of bladder tumors with pathologic correlation. Radiographics. 2006;26:
3-
dimensional sonography and virtual sono- 553-580. Review.
graphic cystoscopy. J Ultrasound Med. 2008;27:
45-53.
20
Section 1
Borderline Ovarian Tumor

Synonyms/Description also tended to have a higher number of papillary
B
Tumor of low malignant potential (LMP tumor) excrescences and a lower percentage of multiloc-
ular lesions when compared with the intestinal
Etiology type. Solid tumors were found only among the
Ten to fifteen percent of epithelial ovarian tumors serous tumors.
are considered borderline malignancies. They
tend to occur in women in their forties and fif- Differential Diagnosis
ties, younger than those with frankly invasive The sonographic appearance of borderline
tumors, and they are not thought to be related to tumors is often similar to that of invasive cancers.
hereditary breast/ovarian cancer syndromes. Other diagnostic possibilities include a decidual-
These tumors are stage I at diagnosis in more ized endometrioma in a pregnant woman (see
than 90% of patients, have infrequent recur- Endometriosis) or a cystadenofibroma. Typically
rence, and an excellent prognosis. The survival the cystadenofibromas and benign cystadenomas
rates for stage I and stage III are close to 100% have smaller areas of nodularity with little if any
and 80% to 90%, respectively. The survival is blood flow within the nodule or septae.
good even in patients who have developed peri-
toneal spread. Just more than half are serous, Clinical Aspects and Recommendations
with the rest being mucinous and occasional The vast majority of mucinous borderline tumors
mixed intestinal cell or endometrioid types. The are stage I, with typically benign behavior. On the
mucinous tumors tend to be unilateral and are other hand, the less common endocervical type
most often of the intestinal type, with a minority of mucinous tumor has a worse prognosis, pre-
being of the endocervical type. Serous tumors senting with invasive implants more frequently
have a higher incidence of bilaterality. and recurring more often than the intestinal type.
Serous borderline tumors are stage I at presenta-
Ultrasound Findings tion in 65% to 70% of cases with a 5-year survival
The typical ultrasound appearance of a border- of 95% when there are noninvasive implants and
line ovarian cancer is a complex cystic mass with 66% in patients with invasive implants.
septations, nodularity/papillations, and irregular The prognosis of patients with borderline
walls. Flow is typically identified in the solid ovarian tumors is largely based on the presence
areas, although not so much flow nor so many of invasive peritoneal implants or residual dis-
irregular vessels as are usually seen in invasive ease after surgery.
cancers. This difference is neither sufficient nor Treatment is surgical removal as well as stag-
reliable enough to differentiate invasive from ing. In patients who have not completed child
borderline tumors accurately sonographically. bearing, the uterus and contralateral ovary may
In a study of 113 borderline ovarian tumors, be preserved.
the mucinous tumors of the intestinal type Increasingly in stage I disease, ovarian cystec-
tended to be the largest compared with those of tomy only and close observation are being advo-
the cervical type or serous lesions. The serous cated for those who have not completed child
and the mucinous endocervical type of tumors bearing.
21
Section 1 Borderline Ovarian Tumor
Figure B2-1 A papillary serous cystadenoma with

irregular nodularity. A, The lateral side of the mass.
B, The medial side with thicker nodularity. Note the
modest blood flow in the solid areas, less than would be
expected in a more aggressive tumor. C, A 3-D image of
B
the surface texture of the inner aspect of the tumor.
Figure B2-2 A mucinous borderline tumor. Note the abundant solid portions and unilocular and large lesion.
22
Borderline Ovarian Tumor Section 1
C
Figure B2-3 A and B, Borderline serous papillary tumor. Note the papillations and color Doppler, indicating flow
in the solid areas. C, The papillations using 3-D surface imaging.
23
Section 1 Borderline Ovarian Tumor
B 1
LT
D
Figure B2-4 Bilateral serous borderline tumors. A and B, The left ovarian mass with the small lesion containing a
single vascular nodule. C, The right ovarian mass is larger, with low-level echoes and a large vascular nodule. D, A
3-D volume illustrating the surface of the nodularity.
24
Borderline Ovarian Tumor Section 1
Suggested Reading
Behtash N, Modares M, Abolhasani M, Ghaem-
maghami F, Mousavi M, Yarandi F, Hanjani P. Bor-
derline ovarian tumours: clinical analysis of 38
cases. J Obstet Gynaecol. 2004;24:157-160.
Fruscella E, Testa AC, Ferrandina G, De Smet F, Van
B
Holsbeke C, Scambia G, Zannoni FG, Ludovisi M.
Ultrasound features of different histopathological
subtypes of borderline ovarian tumors. Ultrasound
Obstet Gynecol. 2005;26:644-650.
Morice P, Uzan C, Fauvet R, Gouy S, Duvillard P,
Darai E. Borderline ovarian tumour: pathological
diagnostic dilemma and risk factors for invasive or
Figure B2-5 Color flow is seen using Doppler in the lethal recurrence. Lancet Oncol. 2012;13:103-115.
septation of this borderline tumor. Tropé CG, Kaern J, Davidson B. Borderline ovarian
tumours. Best Pract Res Clin Obstet Gynaecol.
2012;26:325-336.
Figure B2-6 The unusually solid appearance of a

borderline tumor, mimicking an invasive cancer.
25
Section 1
Bowel Diseases
B Synonyms/Description from the mass to correctly diagnose it as a bowel
Pelvic masses related to bowel such as appendici- problem.
tis, endometriosis, colon cancer, Crohn’s disease,
ulcerative colitis, diverticulitis, lymphoma, sar- Endometriosis
coma, or other bowel-specific diseases identified Endometriosis of the rectosigmoid colon is cov-
on a pelvic ultrasound ered in the section on endometriosis.
Etiology Appendicitis
There are multiple etiologies in this grouping of The typical ultrasound findings include a dis-
bowel diseases. The etiologies range from inflam- tended, noncompressible tubular mass, greater
matory/infectious such as appendicitis, inflamma- than 7 mm in diameter and with relatively cystic
tory bowel diseases, and diverticulitis to neoplasms center suggesting bowel. In the transverse view, the
such as lymphomas, carcinomas, and sarcomas. abnormal appendix often appears as a double ring
In the small bowel, neuroendocrine tumors, indicating the swollen wall. Gentle compression
adenocarcinomas, sarcomas, lymphomas, and will displace normal loops of bowel to better dem-
miscellaneous tumors comprise 36.5%, 30.9%, onstrate the inflamed appendix, although the com-
10.0%, 18.7%, and 3.9% of malignancies, respec- pression is usually uncomfortable for the patient.
tively. In the appendix, neuroendocrine tumors, There can also be inflammation of the adjacent
adenocarcinomas, sarcomas, lymphomas, and omental fat with a very echogenic characteristic
miscellaneous tumors comprise 31.7%, 65.4%, appearance, sometimes with shadowing from an
greater than 1%, 1.7%, and 1.1% of malignan- appendicolith. The sensitivity for ultrasound com-
cies, respectively. Colon tumors include mostly pared with computed tomography to diagnose
adenocarcinomas (93.0%), whereas sarcomas appendicitis is 75% versus 90%, and the specificity
and lymphomas are relatively rare. is 86% versus 100%. Ultrasound is often the only
These entities are briefly discussed in terms of imaging needed to make the diagnosis.
ultrasound findings because they may be encoun-
tered during a sonographic gynecologic exam. Inflammatory Bowel Diseases
For more detailed information about any of these These include Crohn’s disease and ulcerative
lesions, please refer to the suggested reading. colitis, which typically produce a diffuse thicken-
ing of a segment of bowel wall, with reduced
Ultrasound Findings peristalsis and a “stiff-looking,” relatively straight
Diseases of the bowel are detectable and can be segment of bowel. There is usually a loss of the
accurately diagnosed using ultrasound. Typically normal striated gut appearance because of the
the sonographic evaluation of bowel abnormali- disease involving multiple layers of the bowel
ties includes the appearance of the bowel wall, wall. Ulcerative colitis is found mostly in the rec-
amount and quality of peristalsis, reaction to tum and rectosigmoid, whereas Crohn’s is typi-
manual compression using the transducer, and cally seen in the distal ileum.
relative “stiffness” of the bowel loop. Also there
may be a nonspecific mass, which is difficult to Diverticulitis
distinguish from adnexal or uterine masses. It is When a diverticulum becomes inflamed, it
crucial to identify the uterus and ovaries separate appears sonographically as a segmental area of
26
Bowel Diseases Section 1
thickened bowel wall with an inflamed out- homogeneous soft-tissue solid masses that may
pouching (diverticulum) and inflamed sur- be small or grow into a large necrotic, heteroge-
rounding pericolic fat. Diverticulitis can also neous mass. They are usually malignant tumors
B
result in an abscess that can be seen sonographi- that can metastasize to the liver.
cally. The bowel wall thickening is usually asym-
metric but retains its normal three layers, thus Differential Diagnosis
differentiating it from the appearance of inflam- The main differential diagnosis for a tender mass
matory bowel disease. in the right lower quadrant includes appendicitis
as well as many gynecologic etiologies such as
Duplication Cyst hydrosalpinx, hemorrhagic cyst, or degenerating
Bowel duplication cysts are rare congenital fibroid. It is important to view the mass transab-
anomalies that may be asymptomatic for much dominally as well as transvaginally to get a better
of a person’s life. However, when these undergo sense of its location. As previously discussed, iden-
hemorrhage, infection, or torsion, the symptoms tifying the uterus and ovaries separately from the
are similar to appendicitis or ovarian torsion. mass is essential to making the correct diagnosis.
Sonographically, when these cysts are symptom- A thickened loop of bowel suggests a more dif-
atic, they will show internal hemorrhage and fuse diagnosis such as lymphoma or chronic
appear similar to an endometrioma. inflammatory disease. A focal area of bowel wall
nodularity or thickening may indicate an endo-
Lymphoma metriotic implant or diverticulitis. (A careful his-
Lymphomas of the bowel wall are typically B-cell tory may help differentiate these diagnoses.) A
tumors and usually involve the small intestine in solitary mass separate from the uterus or ovaries
the region of the distal ileum. The ultrasound may represent a bowel tumor such as a leiomy-
appearance is that of a bulky circumferential oma, sarcoma, or adenocarcinoma. A cyst sepa-
irregular wall thickening with occasional dila- rate from the ovary or tube may represent a bowel
tion of the bowel and lymph node enlargement. duplication cyst, although these can be confused
with endometriomas.
Colon Cancer
Adenocarcinoma is the most common malig- Clinical Aspects and Recommendations
nant tumor of the colon. The ultrasound appear- Ultrasound should be the first test done in
ance is that of a hypoechoic mass with many tiny patients suspected of having appendicitis and is
echogenic septations, some areas of calcification, often sufficient to make an accurate diagnosis. In
and a bubbly or airy texture. In many cases, the many cases of bowel malignancy or chronic
original loop of colon affected is difficult to see inflammatory disease, other imaging modalities
sonographically and often the mass is not ini- and procedures are necessary to arrive at the cor-
tially attributed to the bowel. rect diagnosis, and the treatment and prognosis
depend on the final diagnosis. However, ultra-
Gastrointestinal Stromal Tumor sound may be the entry point at which patients
These are a group of mesenchymal sarcomas that with various bowel problems enter the medical
arise typically from the muscularis mucosa of care system, and it is important to keep these
the bowel wall and are therefore submucosal. diagnoses in mind when performing pelvic
Gastrointestinal stromal tumors (GISTs) are ultrasound.
27
B
A
B
Figure B3-1 A and B, Transvaginal view of acute appendicitis (longitudinal and transverse views). The calipers
show the distended thick-walled appendix with echogenic surrounding edema. This was misdiagnosed as a tubal
abscess.
A B
C
Figure B3-2 A, B, and C, Same case as Figure B3-1 after a course of antibiotic and after the correct diagnosis of
28appendicitis had been made.
RT
Figure B3-3 Appendiceal abscess, seen transvagi-

nally, with characteristic linear echogenicities with
shadowing consistent with air pockets.
B
Figure B3-5 A and B, Two different patients, both
with Crohn’s disease. Note the diffuse bowel wall
2 1
thickening in a relatively straight loop of bowel, with
loss of architecture of the wall layers.
B
Figure B3-6 Multiple diverticula in a loop of colon.
Figure B3-4 A and B, Enlarged appendix later Note the smooth posterior wall compared with the
diagnosed as adenocarcinoma of the appendix. multiple outpouchings (arrows) of the anterior wall.
29
Section 1 Bowel Diseases
Figure B3-7 Lymphoma. Note the marked thicken-

ing of the bowel wall with complete loss of normal
architecture. The appearance is that of a diffuse and
global process involving a long segment of bowel.
Figure B3-9 Colon cancer. Note the complex mass

with multiple bright areas and irregular septations.
This is a characteristic bubbly or airy texture often
LT
seen with this tumor.
Figure B3-10 Rectal duplication cyst, originally

mistaken for an endometrioma in a patient present-
ing with pelvic pain.
B
Figure B3-8 A and B, Gastrointestinal stromal
sarcoma (GIST tumor). Note the large 20-cm tumor,
mostly solid but with a few cystic spaces. B shows
relatively little internal blood flow because of
necrotic spaces.
30
Videos Lee NK, Kim S, Kim GH, Jeon TY, Kim DH, Jang HJ,
Video 1 on bowel-related masses is available Park DY. Hypervascular subepithelial gastrointesti-
online. nal masses: CT-pathologic correlation. RadioGraph-
ics. 2010;30:1915-1934.
Suggested Reading
Ackerman SJ, Irshad A, Anis M. Ultrasound for pelvic
Linam LE, Munden M. Sonography as the first line of
evaluation in children with suspected acute appen-
B
dicitis. J Ultrasound Med. 2012;31:1153-1157.
pain. II: Nongynecologic causes. Obstet Gynecol
Maturen KE, Wasnik AP, Kamaya A, Dillman JR, Kaza
Clin North Am. 2011;38:69-83.
RK, Pandya A, Maheshwary RK. Ultrasound imag-
Gustafsson BI, Siddique L, Chan A, Dong M, Drozdov
ing of bowel pathology: technique and keys to
I, Kidd M, Modlin IM. Uncommon cancers of the
diagnosis in the acute abdomen. AJR.
small intestine, appendix and colon: an analysis of
2011;197:1067-1075.
SEER 1973-2004, and current diagnosis and ther-
O’Malley ME, Wilson SR. Ultrasound of gastrointesti-
apy. Int J Oncol. 2008;33:1121-1131.
nal tract abnormalities with CT correlation. Radio-
Hughes JA, Cook JV, Said A, Chong SK, Towu E, Reidy
Graphics. 2003;23:59-72.
J. Gastrointestinal stromal tumour of the duode-
num in a 7-year-old boy. Pediatr Radiol. 2004;34:
1024-1027.
31
Section 1
Brenner Tumor
B Synonyms/Description co-existent cystic epithelial neoplasm, such as a
Transitional cell tumor of the ovary serous or mucinous cystadenoma. These cystic
Typically asymptomatic, rare, benign ovarian components can have solid papillations, and
tumor they may be malignant (about 15% of cases).
Etiology Differential Diagnosis

These tumors account for approximately 3.2% of Most Brenner tumors appear similar sonographi-
ovarian epithelial neoplasms and typically occur cally to other solid ovarian masses such as
in the fourth to sixth decades of life. They belong fibromas-thecomas, and can be mistaken for

to the combined surface epithelial-stromal group pedunculated fibroids. Those with complex cys-
of tumors, although they have been described as tic components are indistinguishable from
having similar histologic appearance to transi- serous and mucinous cystadenoma/cystadeno-
tional cell tumors of the urothelium. carcinoma, or endometrioid carcinoma.
Ultrasound Findings Clinical Aspects and Recommendations

These masses are typically solid, hypoechoic, fre- These are rare ovarian masses that are typically
quently contain some calcifications, and have asymptomatic. Management depends on the
minimal detectable color Doppler flow. Approxi- type of mass, which can be benign, proliferative,
mately 25% of the time, there is a cystic compo- or (rarely) malignant. If intervention is indi-
nent indicating the possible presence of a cated, surgical management is undertaken.
Figure B4-2 Longitudinal view of a Brenner tumor

with extensive calcification and shadowing.
Figure B4-1 A 1- to 10-cm Brenner tumor masquer-
ading as a pedunculated fibroid. Note the heteroge-
neous texture of the tumor with linear shadows
similar to fibromas.
32
Brenner Tumor Section 1
Suggested Reading Hermanns B, Faridi A, Rath W, Füzesi L, Schröder W.

Athey PA, Siegel MF. Sonographic features of Brenner Differential diagnosis, prognostic factors, and clin-
tumor of the ovary. J Ultrasound Med. 1987;6: ical treatment of proliferative Brenner tumor of the
367-372.
Dierickx I, Valentin L, Van Holsbeke C, Jacomen G,
Lissoni AA, Licameli A, Testa A, Bourne T, Timmer-
ovary. Ultrastruct Pathol. 2000;24:191-196.
Hiroi H, Osuga Y, Tarumoto Y, Shimokama T,
Yano T, Yokota H, Taketani Y. A case of estrogen-
B
man D. Imaging in gynecological disease (7): clini- producing Brenner tumor with a stromal compo-
cal and ultrasound features of Brenner tumors of nent as a potential source for estrogen. Oncology.
the ovary. Ultrasound Obstet Gynecol. 2012;40: 2002;63:201-204.
706-713.
Green GE, Mortele KJ, Glickman JN, Benson CB.
Brenner tumors of the ovary: sonographic and
computed tomographic imaging features. J Ultra-
sound Med. 2006;25:1245-1251.
33
Section 1
Cervical Masses
Synonyms/Description Ultrasound Findings
C None Cervical masses can obstruct the cervical canal
and result in a hematometra, which may be the
Etiology first sonographic sign of a cervical malignancy.
Cervical cancer accounts for the majority of cer- Cervical carcinomas, especially squamous, are
vical malignancies and is second to breast cancer often subtle or undetectable sonographically as
in incidence worldwide. Approximately 85% to they can be quite small. As they grow, they appear
95% of cervical cancers are squamous cell carci- as solid lobulated masses with abundant vascu-
nomas and develop at the squamous-columnar larity. Sarcomas and lymphomas are typically
junction. large solid vascular tumors when discovered. The
Adenocarcinomas represent only 5% of cervi- appearance of these malignant tumors is non-
cal cancers and arise from glandular cells found specific, although the excessive and disorganized
in the endocervical canal. Squamous cell lesions blood flow within the tumor suggests a malig-
of the cervix are typically detected early using nancy. Epstein and colleagues compared the
conventional cytologic screening methods (Pap sonographic characteristics of squamous cell and
test) because they are easy to sample. The major- adenocarcinoma of the cervix. The ultrasound
ity of endocervical glands are deep within the appearances of the tumors were all solid masses;
cervical canal, so detection usually occurs at however, 73% of the squamous cell carcinomas
more advanced stages of disease; hence they have were hypoechoic, whereas 68% of the adenocar-
a poorer prognosis than squamous cell cancers. cinomas were isoechoic (p = 0.03). Mixed echo-
The survival for stages I, II, and III cervical ade- genicity was a nonspecific finding, and Doppler
nocarcinoma is 60%, 47%, and 8% compared color flow was abundant in almost all the tumors
with 90%, 62%, and 36% for squamous cell of both types.
carcinoma. Benign masses of the cervix also tend to be
Non-Hodgkin’s lymphoma of the cervix is solid sonographically, although the blood flow
rare, accounting for 1% of all extranodal lym- pattern seen with color Doppler tends to be dif-
phomas. Clinically it may present as a large ferent from that of the cancers. Polyps typically
lobular vascular solid mass of the cervix. have a single feeding vessel, and are usually
Metastatic disease, such as melanoma and
echogenic, sometimes containing a cystic center.
breast, lung, and ovarian cancers, may also Fibroids are solid masses with a similar appear-
involve the cervix. ance to those in the uterine corpus. They are well
Malignant mixed Müllerian tumors and leio- circumscribed, with acoustic shadowing, often
myosarcomas occur more frequently in the uter- with a pattern of stripes or swirls caused by these
ine corpus, but may arise in the cervix in rare shadows. The blood flow in fibroids is variable
cases. Embryonal rhabdomyosarcomas typically although less abundant than in malignant
occur in the pediatric age group. lesions and more peripheral.
Benign masses of the cervix include fibroids Nabothian cysts appear as very smooth and
and polyps, which are similar in origin and round, cystic, hypoechoic masses without any
appearance to their counterparts in the uterine areas of Doppler color flow, and are extremely
corpus. Nabothian cysts are also commonly common, especially in women with previous
seen. pregnancies.
34
Cervical Masses Section 1
Differential Diagnosis arising or metastasizing deep in the cervix. A bulky

The differential diagnosis for a cervical mass cervical non-Hodgkin’s lymphoma may present
includes the common entities such as a polyp or as an irregular, palpable, bulky mass, but a punch
fibroid. If the mass is lobulated and highly vascu- biopsy will often reveal normal squamous tissue.
lar, a cervical malignancy such as a carcinoma, A cone or excisional biopsy is required in cases in
lymphoma, sarcoma, or metastatic tumor must be which the initial biopsy does not correlate with
considered. A biopsy is necessary to arrive at a
definitive diagnosis because these cervical malig-
the sonographic findings. Management then
depends on the diagnosis. Malignancies are C
nancies have a similar sonographic appearance. treated with multiple modalities, including, but
Transvaginal ultrasound can also be helpful for not limited to, surgery, radiation, chemotherapy,
staging of cervical cancers although MRI, CT, and and immunotherapy. Asymptomatic fibroids do
PET/CT are typically used for these work-ups. not typically require treatment, except in cases in
which they may affect reproductive outcomes.
Clinical Aspects and Recommendations When indicated, treatment is generally surgical.
The management of a sonographically detectable Cervical polyps often present with spotting and
cervical mass depends on the etiology. Masses usually can be excised, although dilation and
that are hypervascular or that appear atypical curettage may be required to get the entire stalk
should be biopsied. However, simple punch removed. Nabothian cysts are not pathologic, and
biopsy may be inadequate, especially for tumors thus no treatment is indicated.
Figure C1-1 Small squamous cell carcinoma of the surface of the cervix, identified by the cluster of blood vessels
(arrow) on the external os region.
35
Section 1 Cervical Masses
Figure C1-2 Transvaginal view of a large cervical tumor (arrows) with abundant blood flow, arising from the
endocervical canal and protruding through the cervix. This proved to be an adenocarcinoma of the cervix.
Figure C1-3 Cervical polyp originating from the lower uterine segment and protruding through the cervix. Note
the feeding vessel.
36
Cervical Masses Section 1
1 C
Figure C1-4 Small endocervical polyp with single feeder vessel.
Figure C1-6 Cervical lymphoma. Note the large

Figure C1-5 Cervical fibroid. Note the round, mass (arrows) with modest vascularity surrounding
well-demarcated mass on the side of the cervix. the entire outer aspect of the cervix.
37
Section 1 Cervical Masses
Figure C1-7 Large vascular mass protruding through the cervix. The appearance was worrisome because of the
heterogeneity of the mass and the abundant blood flow. This mass proved to be a benign fibroid at surgery.
Suggested Reading Sahdev A. Cervical tumors. Semin Ultrasound CT MR.

Chan JK, Loizzi V, Magistris A, Hunter MI, Rutgers J, 2010;31(5):399-413.
DiSaia PJ, Berman ML. Clinicopathologic features Semczuk A, Skomra D, Korobowicz E, Balon B, Rech-
of six cases of primary cervical lymphoma. Am J berger T. Primary non-Hodgkin’s lymphoma of the
Obstet Gynecol. 2005;193:866-872. uterine cervix mimicking leiomyoma: case report
Epstein E, Di Legge A, Måsbäck A, Lindqvist PG, Kan- and review of the literature. Pathol Res Pract.
nisto P, Testa AC. Sonographic characteristics of 2006;202:61-64.
squamous cell cancer and adenocarcinoma of the
uterine cervix. Ultrasound Obstet Gynecol. 2010;36(4):
512-516.
Gaurilcikas A, Vaitkiene D, Cizauskas A, Inciura A,
Svedas E, Maciuleviciene R, Di Legge A, Ferrandina
G, Testa AC, Valentin L. Early-stage cervical cancer:
agreement between ultrasound and histopatholog-
ical findings with regard to tumor size and extent of
local disease. Ultrasound Obstet Gynecol. 2011;38(6):
707-715.
38
Section 1
Cesarean Scar Defect

Uterine dehiscence The C-section scar defect is a wedge-shaped cystic
Etiology
or hypoechoic area in the anterior lower uterine
segment myometrium, directly above the level of
C
Cesarean sections (C-sections) are performed in the cervix.
the United States at the rate of 20% to 50% of Saline distention of the cavity during a sono-
deliveries depending on clinical environment hysterogram can further delineate the scar defect,
and demographics. The C-section scar is readily if clinically indicated. This more clearly shows the
visible sonographically in the nonpregnant uterus diverticulum-like outpouching of the endometrial
as a focal narrowing of the anterior lower uterine cavity into the thinned, scarred myometrium.
segment, which becomes more pronounced with Occasionally if the patient has had a classical
increasing number of prior sections. There is C-section, a vertical scar can be seen on the front
often a small myometrial discontinuity within of the uterus, puckering the length of the body of
the scar, seen as a triangular fluid collection or the uterus (see Figure C2-3).
“niche,” likely representing menstrual blood that Rarely the C-section scar can dehisce, resulting
pools within the defect. Many patients who have in a myometrial defect, bulging anteriorly under
had C-sections complain of intermittent inter- the bladder. This cystic mass typically has low-
menstrual or prolonged menstrual bleeding. level echoes consistent with unclotted blood that
Uppal and colleagues reported that among 71 has accumulated during menses (see Figure C2-2).
patients with a history of C-section, 29 (40%)
had a sonographically visible fluid-filled defect in Differential Diagnosis
the hysterotomy incision, and the presence of The appearance of a C-section scar defect is
such a defect was significantly associated with characteristic and unmistakable. If the scar has
prolonged periods or intermenstrual spotting. ballooned anteriorly and caused a cystic mass in
The incidence of abnormal bleeding was more the lower uterine segment, the lesion could be
frequent in patients with larger defects, and the confused with a degenerating fibroid or even a
size of the defect or niche was directly related to lesion involving the floor of the bladder such as
the number of prior C-sections. Wang and col- an endometrioma. Most cases of C-section scar
leagues studied 207 patients with C-section scars defects do not present a diagnostic dilemma.
and also found that those who had multiple
C-sections had larger myometrial defects (width Clinical Aspects and Recommendations
and depth) compared with those with only one The presence of a fluid collection in the scar defect
prior C-section. Patients with retroflexed uteri is an important finding that may explain abnormal
also had wider defects than those whose uterus uterine bleeding in some patients. It has also been
was anteflexed. associated with dysmenorrhea as well as infertility.
The myometrial thickness at the C-section scar At this point, most of the research is still focused
becomes thinner as the number of C-sections on the prevalence and conditions associated with
increases; however, there is no established norm C-section scar defects. There are some reports of
for this measurement. The presence of a C-section surgical repair of the defects resulting in improved
scar defect and the size of this myometrial niche fertility and resolution of prolonged or intermen-
seem to be better predictors of abnormal bleeding strual bleeding. Given that this is a relatively new,
and even risk of uterine dehiscence in subsequent although rapidly increasing diagnostic entity, there
pregnancies. are as of yet no standard recommendations.
39
Section 1 Cesarean Scar Defect
C
1
Figure C2-1 Longitudinal view of the normal uterus of a patient with a C-section scar defect. A small amount of
fluid outlines the C-section scar defect (arrow) in the anterior lower uterine segment where the C-section scar is
located. The niche is formed by the puckering of the anterior wall of the uterus, just above the cervix.
B
Figure C2-2 Large rounded area of dehiscence of a C-section scar ballooning anteriorly and indenting the bladder.
A and B, Two-dimensional views of the lower uterine segment taken obliquely, showing the mass-like defect between
the cervix and bladder. The defect (calipers) is filled with low-level echoes indicating unclotted blood. Note the
proximity of the defect to the bladder. C, A 3-D longitudinal view of the anterior aspect of the uterus, showing the
defect (arrows) originating from the lower uterine segment and bulging anteriorly at the level of the C-section scar.
40
Cesarean Scar Defect Section 1
COR UT
Figure C2-4 Dehiscence of the C-section scar in a

pregnant patient with one prior section. The mem-
branes are seen herniating through the defect in the
lower uterine segment (arrows).
B
Figure C2-3 Classical C-section scar in a pregnant
patient. A, Note the puckering of the anterior surface
of the entire uterus (arrows). B, A 3-D multiplanar Naji O, Abdallah Y, Bij De Vaate AJ, Smith A,
reconstruction of the uterus showing the linear Pexsters A, Stalder C, Mcindoe A, Ghaem-
vertical scar in three orientations (arrows). Maghami S. Standardized approach for imaging
and measuring Cesarean section scars using
ultrasonography. Ultrasound Obstet Gynecol.
Suggested Reading 2012;39:252-259.
Bujold E, Jastrow N, Simoneau J, Brunet S, Gauthier Uppal T, Lanzarone V, Mongelli M. Sonographically
RJ. Prediction of complete uterine rupture by sono- detected caesarean section scar defects and menstrual
graphic evaluation of the lower uterine segment. irregularity. J Obstet Gynaecol. 2011;31:413-416.
Am J Obstet Gynecol. 2009;201:320. Vikhareva Osser O, Jokubkiene L, Valentin L. High
Jastrow N, Chaillet N, Roberge S, Morency AM, Lacasse prevalence of defects in Cesarean section scars at
Y, Bujold E. Sonographic lower uterine segment transvaginal ultrasound examination. Ultrasound
thickness and risk of uterine scar defect: a systematic Obstet Gynecol. 2009;34:90-97.
review. J Obstet Gynaecol Can. 2010;32:321-327. Vikhareva Osser O, Jokubkiene L, Valentin L. Cesar-
Monteagudo A, Carreno C, Timor-Tritsch IE. Saline ean section scar defects: agreement between trans-
infusion sonohysterography in nonpregnant vaginal sonographic findings with and without
women with previous cesarean delivery: the “niche” saline contrast enhancement. Ultrasound Obstet
in the scar. J Ultrasound Med. 2001;20:1105-1115. Gynecol. 2010;35:75-83.
41
Section 1 Cesarean Scar Defect
Vikhareva Osser O, Valentin L. Clinical importance of Wang CB, Chiu WWC, Lee CY, Sun YL, Lin YH,
appearance of cesarean hysterotomy scar at trans- Tseng CJ. Cesarean scar defect: correlation
vaginal ultrasonography in nonpregnant women. between Cesarean section number, defect size,
Obstet Gynecol. 2011;117:525-532. clinical symptoms and uterine position. Ultrasound
42
Section 1
Corpus Luteum and Hemorrhagic Cyst
Functional cyst (corpus luteum)
of the CL is the “ring of fire” pattern of color
Doppler, showing intense and abundant circum- C
No synonym for hemorrhagic cyst ferential blood flow. The hemorrhagic CL often
has a fine reticular or fishnet-like internal pattern
Etiology and/or a solid area consistent with a retracting
The corpus luteum (CL) is a transient structure clot. Color Doppler reveals circumferential flow
formed as a result of ovulation, due to the mid- but no internal blood flow. The specific diagno-
cycle luteinizing hormone surge from the pitu- sis is often possible sonographically, but because
itary gland. The CL is responsible for the the CL is a mimicker of adnexal pathologies, a
production of progesterone, hence the term follow-up scan may be helpful when uncertain
“functional cyst.” It is necessary for regulating of the diagnosis, as discussed in clinical recom-
menses and for maintaining a pregnancy until it mendations. A hemorrhagic cyst will have the
develops the ability to make its own progester- same appearance as a hemorrhagic corpus
one. If a pregnancy does not occur, the CL breaks luteum but without color flow. If internal hem-
down. It can, on occasion, undergo internal orrhage occurs with cyst rupture or partial rup-
hemorrhage and develop into a hemorrhagic ture, then complex fluid may be seen in the
cyst. When such a cyst continues producing pro- cul-de-sac or higher, or surrounding the ovary.
gesterone, it is a hemorrhagic corpus luteum. If
progesterone synthesis ceases, but the cyst Differential Diagnosis
persists, then it is considered a hemorrhagic cyst. The correct diagnosis is often challenging because
Hemorrhagic cysts can enlarge up to 5 cm or of variations in size, irregularity of the cyst wall,
more, causing pain, and may occasionally rup- and internal solid areas (clot), all of which are
ture, resulting in a hemoperitoneum. The pain nonspecific sonographic findings mimicking
typically resolves within a few days, whereas the pathology. Knowing the menstrual cycle day is
cyst may take 1 to 3 months to regress. Patients very helpful, although not always possible, in
with symptomatic hemorrhagic cysts typically patients with irregular bleeding or menses.
present with acute unilateral pelvic pain and In the setting of a patient presenting with pel-
have a complex-appearing lesion on ultrasound vic pain and a tender, cystic adnexal mass, the
evaluation. Often they are asymptomatic and differential diagnosis is vast and includes most
can be an incidental finding. The nonspecific commonly ectopic pregnancy, pelvic inflamma-
and confusing sonographic appearance of the tory disease (PID), adnexal torsion, and neo-
hemorrhagic corpus luteum and hemorrhagic plasm in addition to a functional or hemorrhagic
cyst often results in misdiagnosis and unneces- cyst. In a patient with a positive pregnancy test,
sary surgery. the adnexal ring of an ectopic pregnancy can
have a similar appearance to a CL, including the
Ultrasound Findings “ring of fire” Doppler pattern. Useful sono-
The CL is an ovarian cystic structure, typically 2 graphic discriminators between these two enti-
to 3 cm in size. Gray scale ultrasound character- ties are the location of the cyst and the
istics include an irregular thick wall, unilocular appearance. An ectopic pregnancy typically has a
cyst, often with internal debris or echogenic more echogenic rim than a corpus luteum,
material. The most constant and specific feature and most (although not all) ectopics are
43
Section 1 Corpus Luteum and Hemorrhagic Cyst
extraovarian, whereas functional cysts are always Clinical Aspects and Recommendations
in the ovary. The circumferential Doppler pat- It is important to understand that the CL is a nor-
tern of a corpus luteum (ring of fire) is easily mal, short-lived, functional cyst found in pre-
distinguishable from a torsed ovary, which menopausal and pregnant women. Its function
would typically have a paucity of flow. Doppler is essential, and if the corpus luteum is surgically
pattern is also a key factor in distinguishing a CL removed in early pregnancy an abortion will
C from a neoplasm. Sometimes, the retracting

blood clot of a CL may have a nodular shape
ensue. Occasionally, the development of a cor-
pus luteum may cause acute pain, even without
resembling a mural nodule. An ovarian malig- internal hemorrhage, known as Mittelschmerz.
nant tumor will typically have blood flow visible Hemorrhage may develop within a functional
in the internal solid area, whereas the CL only cyst, resulting in acute pain, although not all
has circumferential flow with no internal Dop- hemorrhagic cysts are symptomatic. Hemor-
pler signal. If the CL has undergone acute hem- rhagic cysts will resolve over 1 to 3 months,
orrhage, the internal clot will be transiently depending on their size, as the clot is broken
echogenic and may be confused with a dermoid down and reabsorbed. If the pain and cystic mass
cyst. A follow-up ultrasound will be helpful do not resolve, the diagnosis may not be a hem-
because a hemorrhagic cyst will resolve, whereas orrhagic cyst (see Differential Diagnosis, earlier).
the dermoid will not. Patients with PID are often It is essential to know the menstrual history, if
clinically ill (e.g., fever, elevated white blood cell the patient is pregnant, or if there is associated
count), and the mass is typically more tubular fever indicating an infection. Follow-up scans are
than an ovarian cyst, often involving the fallo- particularly useful to track progress toward spon-
pian tube. taneous resolution of the lesion.
Figure C3-1 Typical corpus luteum with crenated edges, thick wall, and internal debris. The color Doppler image
shows the signature intense circumferential flow of the corpus luteum.
44
Corpus Luteum and Hemorrhagic Cyst Section 1
Right
Figure C3-2 Two different patients showing the characteristic “ring of fire” flow in the corpus luteum, as seen
with color Doppler.
Figure C3-3 Two views of the same hemorrhagic cyst. Note the solid areas within the cyst representing retracting
clot.
45
Section 1 Corpus Luteum and Hemorrhagic Cyst
Figure C3-5 Fluid debris level in an acutely hemor-

rhagic cyst.
B
Figure C3-4 Two different cases of hemorrhagic
cysts with retracting clot. A, The typical reticular or
fishnet internal structure consistent with a retracting
clot. B, A more solid internal structure of the cyst.
Note that the solid areas are retracting toward the Figure C3-6 Ectopic pregnancy adjacent to a normal
periphery of the cyst rather than growing into the ovary. Note that the tubal ring is highly echogenic
center, as would a neoplasm. No flow was seen within (arrows), distinguishing it from the appearance of a
the clot. corpus luteum.
46
Corpus Luteum and Hemorrhagic Cyst Section 1
Figure C3-7 Large hemorrhagic corpus luteum with internal solid areas consistent with clot. The rounded solid
areas could be confused with an ovarian neoplasm; however, the signature color Doppler “ring of fire” makes the
correct diagnosis simple.
Suggested Reading Stein MW, Ricci ZJ, Novak L, Roberts JH, Koenigsberg
Guerriero S, Ajossa S, Melis GB. Luteal dynamics dur- M. Sonographic comparison of the tubal ring of
ing the human menstrual cycle: new insight from ectopic pregnancy with the corpus luteum. J Ultra-
imaging. Ultrasound Obstet Gynecol. 2005;25: sound Med. 2004;23:57-62.
425-427. Swire MN, Castro-Aragon I, Levine D. Various sono-
Jain KA. Sonographic spectrum of hemorrhagic ovar- graphic appearances of the hemorrhagic corpus
ian cysts. J Ultrasound Med. 2002;21:879-886. luteum cyst. Ultrasound Q. 2004;20:45-58.
Parsons AK. Imaging the human corpus luteum.
J Ultrasound Med. 2001;20:811-819.
47
Section 1
Cyst, Clear
Synonyms/Description Any cyst that has a thick wall or any solid com-
C Simple cyst
Clear ovarian cyst
ponent is in a different category and discussed in
other sections (refer to the differential diagnosis
list for a complex cyst).
Etiology It is very important to scrutinize the sono-
A simple ovarian cyst is a clear, thin-walled, uni- graphic appearance of cysts for any solid compo-
locular cyst. nents or areas of wall thickening. A study by
Valentin reports that 11 (0.96%) out of 1148
Premenopausal masses classified as unilocular cysts on ultra-
Simple cysts up to 3 cm in maximal diameter are sound were malignant. However, postoperatively,
considered normal physiologic follicles in 7 of the 11 malignancies thought to be unilocular
cycling women, and thus should not be reported cysts on ultrasound had gross papillary projec-
as a cyst, particularly when the patient is midcy- tions on the surgical specimen. Therefore accu-
cle. If a clear simple cyst does not resolve, it may rate classification of a cyst as clear and unilocular
be extraovarian, specifically paraovarian or para- is crucial on ultrasound examinations. Color
tubal. A persistent thin-walled and unilocular Doppler may be useful to interrogate the walls of
cyst may also represent a serous cystadenoma. a cyst to better demonstrate any wall irregularity.
Postmenopausal Differential Diagnosis

Small simple cysts up to 1 cm may be seen in up In a premenopausal patient, a simple cyst is most
to 21% of postmenopausal women, and these likely follicular and thus functional. If the patient
are not considered clinically significant, even is postmenopausal or the cyst does not regress in
though the patient is no longer cycling. These 3 months, the differential diagnosis includes cyst-
less than 1 cm cysts typically should not be adenoma, paratubal or paraovarian cyst, hydro-
reported on an ultrasound examination and do salpinx, or peritoneal inclusion cyst. Occasionally,
not require follow-up. serous cystadenomas can be unilocular and thin
In a study by Greenlee and colleagues, 2217 walled, although some may have a worrisome
(14.1%) out of 15,735 women screened sono- component such as a focally thick wall or septa-
graphically had one or more simple cysts on tions. Paratubal or paraovarian cysts may mimic a
ultrasound examination. Among women with- follicle but can be distinguished sonographically
out a cyst on the first screen, 8.3% had a new by their location off the edge, or distant, from the
simple cyst 1 year later. There was no statistical ovary. Hydrosalpinges are rarely clear and thin
difference in rate of subsequent ovarian cancer walled, and are usually tubular with incomplete
when those with simple cysts were compared septations. Peritoneal inclusion cysts develop as a
with those without a cyst. result of fluid being trapped within peritoneal
adhesions. They typically have thin walls, an odd
Ultrasound Findings shape and may have multiple thin septations—
A simple and clear ovarian cyst is a thin, smooth- all clues to the correct diagnosis.
walled structure containing fluid with no inter-
nal echoes or solid areas. The cyst is usually Clinical Aspects and Recommendations
round but can be oval, especially as it regresses In general, simple clear cysts do not convey an
and changes shape. increased risk of ovarian cancer, even in
48
Cyst, Clear Section 1
postmenopausal patients. With benign epithelial benign sonographically and yearly follow-up is
ovarian lesions there is no indication that malig- recommended.
nant transformation occurs; for example, cystad- Cysts larger than 7 cm may be difficult to assess
enomas do not become cystadenocarcinomas. fully with ultrasound; thus surgical evaluation or
Current recommendations for management of alternative imaging should be considered.
simple cysts are the result of a collaborative con-
sensus panel hosted by the Society of Radiologists
in Ultrasound. The following recommendations C
pertain only to thin smooth-walled, completely
clear, unilocular cysts.
In Premenopausal Women
Cysts less than 3 cm are considered normal and
need not be followed. Cysts measuring 3 to 5 cm
1
should be reported with a statement that they are
almost certainly benign and may not need fol-
low-up. Cysts between 5 and 7 cm are almost
certainly benign but should be followed yearly
with ultrasound. Cysts larger than 7 cm may be
difficult to evaluate completely sonographically
and might warrant further imaging.
Figure C4-2 Five-centimeter unilocular simple cyst
In Postmenopausal Women showing the characteristic thin smooth walls and
Cysts less than 1 cm are clinically inconsequen- anechoic internal structure.
tial and may not be reported.
Cysts between 1 and 7 cm should be reported
with a statement that they are almost certainly
1
3
1 D 2.15 cm
2 D 1.53 cm
3 D 1.94 cm
Figure C4-1 Two views of a thin-walled unilocular Figure C4-3 Differential diagnosis—paraovarian
cyst. This is a dominant follicle and is entirely cyst (see Paratubal or Paraovarian Cysts). Note that
normal. Such a cyst should not be mentioned in the the unilocular cyst is located adjacent to the ovary
ultrasound report because it is a normal finding. (arrows).
49
Section 1 Cyst, Clear
Suggested Reading
Greenlee RT, Kessel B, Williams CR, Riley TL, Ragard
RT
LR, Hartge P, Buys SS, Partridge EE, Reding DJ.
Prevalence, incidence, and natural history of sim-
ple ovarian cysts among women >55 years old in a
large cancer screening trial. Am J Obstet Gynecol.
2010;202:373.e1-9.
C 2
Levine D, Brown DL, Andreotti RF, Benacerraf B, Ben-
son CB, Brewster WR, Coleman B, DePriest P,
1
Doubilet PM, Goldstein SR, Hamper UM, Hecht
JL, Horrow M, Hur HC, Marnach M, Patel MD,
Platt LD, Puscheck E, Smith-Bindman R. Society of
Radiologists in Ultrasound. Management of
Figure C4-4 Differential diagnosis of large perito- asymptomatic ovarian and other adnexal cysts
neal inclusion cyst (see the section on complex cysts). imaged at US Society of Radiologists in Ultrasound
This cyst is neither totally anechoic nor unilocular. It consensus conference statement. Ultrasound Q.
seems to take on the shape of the peritoneal space, a 2010;26:121-131.
characteristic that is typical of a peritoneal inclusion Valentin L, Ameye L, Franchi D, Guerriero S, Jurkovic
cyst secondary to adhesions after pelvic surgery. D, Savelli L, Fischerova D, Lissoni A, Van Holsbeke
C, Fruscio R, Van Huffel S, Testa A, Timmerman D.
Risk of malignancy in unilocular cysts: a study of
1148 adnexal masses classified as unilocular cysts
at transvaginal ultrasound and review of the litera-
ture. Ultrasound Obstet Gynecol. 2013;41:80-89.
50
Section 1
Cystadenofibroma
Synonyms/Description incidentally during pelvic imaging. Less com-
Benign ovarian tumor that arises from surface
epithelium and underlying cortical connective
monly they can be associated with pelvic pain,
which may be a result of enlargement of the mass. C
tissue of the ovary. Unlike fibroadenomas, which are primarily solid
tumors, the epithelial portion of cystadenofibro-
Etiology mas always has a cystic component. The presence
These are rare benign ovarian tumors represent- of papillary projections (solid mural nodules)
ing less than 2% of benign ovarian neoplasms. emanating from the cyst wall may raise concerns
Originally thought to be fibrous variants of cyst- about potential malignancy. However, emerging
adenomas (the most common benign epithelial clinical evidence suggests that when cystadenofi-
ovarian neoplasms), these tumors actually origi- bromas present as a unilocular cystic structure with
nate from the surface epithelium as well as the a small avascular mural nodule, conservative man-
underlying cortical connective tissue of the ovary. agement may be a more appropriate approach.
Ultrasound Findings
Cystadenofibromas are often complex in their
sonographic appearance. They are at least partly
if not predominantly cystic and may contain
septations, solid areas, and nodularity. The most
common appearance (69% in a series of 58
cases) is a unilocular cyst with papillations that 1
project into the lumen but do not demonstrate
blood flow using color Doppler. The appear-
ance, however, can be quite variable, and can
mimic the appearance of a malignancy, with A
thick septations and blood flow in the solid
areas. Occasionally, ovarian cystadenofibromas
may be borderline tumors (5 in a series of 47
tumors).
In some patients, the tumor has an appearance
indistinguishable from a malignancy, with solid
areas and septations containing color flow on
Doppler evaluation; these are usually removed.
The majority of cystadenofibromas are unilocular
with solid areas devoid of blood flow. The main
differential diagnosis includes an endometrioma
B
or a cystadenoma (mucinous or serous).
Figure C5-1 A, Typical appearance of a cystadenofi-
Clinical Aspects and Recommendations broma: a unilocular cyst with a solid nodule. B, The
Like most adnexal masses, such tumors are usually nodule contains a paucity of blood flow by color
Doppler.
discovered at the time of bimanual examination or
51
Section 1 Cystadenofibroma
LT
Figure C5-2 Atypical appearance of a cystadenofibroma appearing as a multiseptate cystic mass with solid
components. A paucity of blood flow is demonstrated in the solid areas, although scant blood flow is present in
the septae.
Suggested Reading Washish A, Elsayes K. Ovarian cystadenofibroma: a

Tang YZ, Liyanage S, Narayanan P, Sahdev A, Sohaib masquerader of malignancy. Indian J Radiol Imag.
A, Singh N, Rockall A. The MRI features of histo- 2010;20:297-299.
logically proven ovarian cystadenofibromas-an
assessment of the morphological and enhance-
ment patterns. Eur Radiol. 2013;23:48-56.
52
Section 1
Dermoid Cyst
Synonyms/Description Differential Diagnosis
Mature cystic teratoma The diagnosis of a dermoid is very specific when
the appearance is characteristic. When the
Etiology appearance is not typical, dermoids can be mis-
This is a benign germ cell tumor containing ecto-
derm, mesoderm, and endoderm, thought to
taken for endometriomas, fibromas, and struma
ovarii. The absence of color flow on Doppler D
arise from a single germ cell. Components may examination is a very important and helpful fea-
include hair, teeth, fat, and bone. These tumors ture of dermoids. If a dermoid is suspected but
represent 25% of all ovarian neoplasms and 60% color flow is observed in the solid areas, other
of all benign ovarian tumors. They are bilateral etiologies must be considered. The sonographic
and or recurrent in 10% of cases. These lesions appearance of the rarer malignant teratoma is
are benign and typically occur in teenagers and similar to the mature lesions except for the Dop-
young adults, although approximately 1% may pler pattern of blood flow. This is rarely seen in
be immature teratomas with malignant compo- the benign lesions but common in malignancies.
nents mixed with mature elements. The short growth interval of the lesion may also
suggest a malignancy.
Ultrasound Findings
The classic sonographic appearance of a dermoid Clinical Aspects and Recommendations
is an echogenic mass with intense acoustic shad- Most dermoid cysts are asymptomatic. If symp-
owing obscuring the back wall. A finding coined toms are present, it often depends on the size
“tip of the iceberg” refers to this characteristic, of the mass. Such ovarian pathology is not usu-
which can make obtaining accurate measure- ally associated with adhesion formation, and
ments of the mass difficult. The intensely echo- adnexal torsion can occur, especially if the cyst
genic components of dermoid cysts represent is large. They rarely rupture, but when they do,
varying combinations of fat, sebaceous material, spillage of sebaceous material into the abdomi-
hair, teeth, and bone. There are often a multitude nal cavity may cause chemical peritonitis and
of thin echogenic lines emanating from the echo- development of dense intra-abdominal adhe-
genic center representing strands of hair within sions. This rare complication can present with
the mass. The so-called “Rokitansky nodule” is a acute symptoms, but the most common cause
very echogenic, discrete, rounded protuberance of acute pelvic pain in the presence of a der-
characteristic of a dermoid. There is typically no moid is torsion.
demonstrable blood flow within these lesions. Malignant transformation, although extremely
Less commonly, dermoids can be predomi- rare (quoted to be 0.2% to 2% in such benign
nantly cystic with only a small echogenic nodule teratomas), can occur. This is unlike epithelial
that is easy to miss and that indicates the correct ovarian neoplasms, in which benign growths do
diagnosis. There can be septations and low-level not transform into malignant ones.
echoes, which may be confused as findings con- Ovarian cystectomy is the treatment of choice
sistent with an endometrioma. Occasionally, in reproductive-age women when intervention
dermoids can be made up of a multitude of small is indicated. This allows for a definitive diagno-
round balls within a mass, like a cluster of bil- sis, preservation of ovarian tissue, and decreased
liard balls. This is rare but when visualized is a risk of torsion or rupture. For those women
characteristic appearance of a dermoid cyst. who have completed their child bearing,
53
Section 1 Dermoid Cyst
salpingo-oophorectomy is an acceptable treat-

ment option. There is a 10% to 20% incidence
of bilaterality, and a thorough ultrasound
examination of the nonaffected ovary preopera-
tively should be carried out rather than the his-
torical approach of bivalving that ovary.
D RT
Figure D1-3 Predominantly cystic dermoid mimick-

ing an endometrioma. The small echogenic nodule
along the right side of the mass is a clue to the
correct diagnosis.
Figure D1-1 Dermoid. Large mass with typical

round echogenic foci and thin linear strands emanat-
ing from the center. Note the lack of color flow in the
solid portions.
Figure D1-4 Unusual but characteristic appearance

of a dermoid, containing a cluster of small solid
spheres representing small balls of fat.
Figure D1-2 Dermoid. Typical heterogeneous

echogenic mass with shadowing obscuring posterior
wall.
54
Dermoid Cyst Section 1
Suggested Reading
Outwater EK, Siegelman ES, Hunt JL. Ovarian terato-
mas: tumor types and imaging characteristics.
Radiographics. 2001;21:475-490.
Sokalska A, Timmerman D, Testa AC, Van Holsbeke
C, Lissoni AA, Leone FP, Jurkovic D, Valentin L.
Diagnostic accuracy of transvaginal ultrasound
examination for assigning a specific diagnosis to
adnexal masses. Ultrasound Obstet Gynecol. 2009;34:
D
462-470.
Ushakov FB, Meirow D, Prus D, Libson E, BenS-
hushan A, Rojansky N. Parasitic ovarian dermoid
tumor of the omentum. A review of the literature
and report of two new cases. Eur J Obstet Gynecol
Reprod Biol. 1998;81:77-82. Review.
Figure D1-5 Cystic mass with typical echogenic

rounded component with intense shadowing. This
typical dermoid was located in the cul-de-sac unre-
lated to either ovary. At surgery it proved to be a
parasitic dermoid of the rectovaginal septum.
55
Section 1
Dysgerminoma
Synonyms/Description can have a similar appearance although less vas
Malignant germ cell tumor diagnosed predomi cular. Other solid ovarian malignancies should
nantly in young adults ages 20 to 30. The most be considered, including metastatic disease to
common benign germ cell tumor is the mature the ovary, lymphoma, and predominantly solid
D teratoma, commonly called a dermoid cyst (see
Dermoid Cyst).
cystadenocarcinomas (although the common cys
tic portions of these cystadenocarcinomas are
not usually seen in dysgerminomas). The exten
Etiology sive blood flow makes the fibroma and mature
Primitive germ cell tumors include the dys dermoid unlikely.
germinoma, immature teratoma, endodermal
sinus/yolk sac tumor, embryonal carcinoma, Clinical Aspects and Recommendations
and nongestational choriocarcinoma. Dysgerminomas may present either as palpable
Ovarian dysgerminomas arise from primor adnexal masses or as incidental findings on an
dial germ cells and represent 1% to 2% of ovar imaging study. Occasionally, these tumors dis
ian malignancies and 30% of all malignant germ play unusually rapid growth, and patients may
cell tumors. Dysgerminoma is a rare tumor simi present with abdominal enlargement and pain
lar in histology to the male testicular seminoma caused by rupture with hemoperitoneum or tor
and can arise bilaterally in 15% of affected sion. If the tumor is hormonally active, men
patients. Serum human chorionic gonadotropin strual abnormalities may occur. These tumors
(hCG) is occasionally elevated. can produce placental alkaline phosphatase and
LDH. Thus, in patients with a solid-appearing
Ultrasound Findings adnexal mass, assessment of such tumor markers
Findings involve a solid, mostly isoechoic, but het may be helpful. An occasional patient may pro
erogeneous mass with apparent lobulations. The duce hCG but virtually never produces alpha
lobulations are caused by inhomogeneous internal fetoprotein (AFP). Studies indicate that approxi
echogenicity giving the sonographic appearance of mately 75% of women with dysgerminomas
different compartments in this solid tumor. Blood present with stage I disease. There is bilateral
flow is moderate to abundant in most lesions, involvement in approximately 10% to 15% of
indicating a high risk of malignancy. cases. Because the ultrasound findings are non
specific, treatment is surgical exploration and
Differential Diagnosis resection in virtually all cases. These patients are
The solid appearance of this tumor makes the often young and have not completed their child
differential diagnosis extensive. Struma ovarii bearing; therefore, unilateral salpingo-oophorec
(ectopic thyroid tissue, monodermal teratoma) tomy is appropriate and is curative in most cases.
56
Dysgerminoma Section 1
1
1
A
2
D
C
Figure D2-1 Dysgerminoma (two patients). A and B, Solid rounded lobular ovarian mass with no visible cystic
component. C, Color flow Doppler of the mass shows blood flow pattern in a different patient with dysgerminoma.
Suggested Reading Kim SH, Kang SB. Ovarian dysgerminoma: color

Gordon A, Lipton D, Woodruff JD. Dysgerminoma: a Doppler ultrasonographic findings and compari
review of 158 cases from the Emil Novak Ovarian son with CT and MR imaging findings. J Ultrasound
Tumor Registry. Obstet Gynecol. 1981;58:497-504. Med. 1995;14:843-848.
Guerriero S, Testa AC, Timmerman D, Van Holsbeke Vicus D, Beiner ME, Klachook S, Le LW, Laframboise
C, Ajossa S, Fischerova D, Franchi D, Leone FP, S, Mackay H. Pure dysgerminoma of the ovary
Domali E, Alcazar JL, Parodo G, Mascilini F, Vir 35 years on: a single institutional experience. Gyne-
gilio B, Demidov VN, Lipatenkova J, Valentin L. col Oncol. 2010;117:23-26.
Imaging of gynecological disease (6): clinical and
ultrasound characteristics of ovarian dysgermi
noma. Ultrasound Obstet Gynecol. 2011;37:596-602.
57
Section 1
Ectopic Pregnancy
Synonyms/Description difficult. Approximately 7% to 20% of women
Tubal, cornual, cervical, ovarian, or abdominal presenting with a PUL are ultimately diagnosed
pregnancy/ectopic with ectopic pregnancy.
When there is no visible intrauterine preg-
Etiology nancy, it is important to determine the level of
An ectopic pregnancy is a pregnancy that occurs human chorionic gonadotropin (hCG). Serial
as a result of implantation of a fertilized ovum hCG levels are necessary when evaluating preg-
E outside the endometrial cavity. Ectopic preg-
nancy occurs in approximately 1.5% to 2.0% of
nancies of unknown location to observe the
trend. In a normal early pregnancy, hCG levels
gestations and can be life threatening, account- will rise by at least 53%, but typically greater
ing for 6% of all maternal deaths because of late than or equal to 100% (99% confidence interval)
presentation or unrecognized symptoms. Ecto- every 48 hours. Most ectopic pregnancies are
pic pregnancy is most common in the fallopian associated with a low and abnormally slow ris-
tube, especially when damaged by prior tubal ing hCG level. The reported “discriminatory hCG
surgery, pelvic inflammatory disease, endome- value” at which an intrauterine pregnancy must
triosis, or previous ectopic pregnancies. be identified sonographically has varied in the
Less than 10% of ectopic pregnancies occur in literature between 1000 and 3000 mIU/mm. It is
the cervix, the cornua, the ovary, or the abdo- probable that a patient with an empty uterus and
men. These are more difficult to diagnose and an hCG level of greater than 3000 mIU/mm has
treat, thus resulting in higher morbidity than an ectopic pregnancy unless she has had a recent
tubal pregnancies. More recently, implantation complete spontaneous abortion between the
in Cesarean section scars has been described time of the hCG and the sonogram.
with increasing frequency. In the absence of an intrauterine pregnancy,
the most common sonographic signs of a tubal
Ultrasound Findings pregnancy include an adnexal mass (heteroge-
Transvaginal ultrasonography has 73% to 93% neous cystic and/or solid), a tubal ring (small
sensitivity for diagnosing ectopic pregnancy, round cyst with echogenic rim), a tubular mass
depending on sonographer expertise and gesta- consistent with a hematosalpinx, and echogenic
tional age. On rare occasions, there is a gestational free fluid in the cul-de-sac consistent with blood.
sac with a live embryo in the adnexa and the sono- Color Doppler often shows circumferential flow
graphic diagnosis of an ectopic pregnancy can be around a tubal ring, similar to a corpus luteum,
definitive. In 8% to 31% of women suspected of but there is typically no flow inside a hematosal-
having an ectopic pregnancy, the initial ultrasound pinx. It is helpful to distinguish the ovary as sep-
does not show the whereabouts of the pregnancy arate from the ectopic pregnancy mass so as not
(pregnancy of unknown location [PUL]). to misdiagnose the mass as ovarian in origin.
An empty-appearing uterus may indicate an Pushing the mass gently past the ovary can dem-
intrauterine pregnancy too early to see (less than onstrate that they are separate.
5 weeks), a failed pregnancy too small or already Cornual ectopic pregnancies account for 1%
passed, or an ectopic pregnancy. Technical fac- to 6% of ectopic pregnancies and can be diag-
tors such as fibroids, adenomyosis, morbid obe- nosed if the gestational sac is located clearly out-
sity, or an axial uterus may make imaging more side of the endometrial cavity but surrounded by
58
Ectopic Pregnancy Section 1
a thin rim of myometrium. If there is myome- An ectopic pregnancy can masquerade as a

trium between the gestational sac and the endo- hydrosalpinx, pelvic inflammatory disease,
metrial cavity, then the pregnancy is cornual. endometriosis, appendicitis, ovarian tumor,
Cervical ectopic pregnancies account for less degenerating pedunculated fibroid, and so on.
than 1% of ectopics and are diagnosed when the In the setting of a positive pregnancy test and no
gestational sac is clearly seen within the cervix. A visible intrauterine pregnancy, an adnexal lesion
sac can slide through the cervix during a sponta- should raise suspicion for an ectopic pregnancy.
neous pregnancy loss; therefore if this is sus- A cervical pregnancy may be confused with an
pected, a follow-up scan in 24 hours may be ongoing spontaneous abortion. Doppler is use-
necessary to confirm a cervical pregnancy. Blood ful to determine whether the sac is attached in
flow is typically present around the sac of a preg- the cervix or just passing through. A cornual
nancy implanted in the cervix as opposed to an pregnancy may mimic a degenerating fibroid, but
ongoing pregnancy loss in which circumferential
blood flow is absent.
the clinical history and pregnancy test should
contribute to the correct diagnosis.
E
Cesarean section scar pregnancies account for
up to 6% of ectopic gestations in women with Clinical Aspects and Recommendations
prior Cesarean sections. The gestational sac is Many tubal ectopic pregnancies can be treated
typically located low and anterior, just cephalad with methotrexate. Before injecting such an agent
to the internal os, obliterating the site of the to terminate the pregnancy in a patient with
C-section scar. The sac deforms the anterior lower PUL, there must be no possibility that the preg-
uterine segment, causing an anterior bulge, with nancy could still be intrauterine. Even if the
very little myometrium, if any, stretched around uterus is empty on the initial ultrasound, serial
the outer surface of the sac, bringing it adjacent hCGs and follow-up ultrasounds are often
to the bladder. needed in a stable patient to be certain that an
Although the presence of an intrauterine preg- early intrauterine pregnancy is not overlooked.
nancy is good evidence against the presence of an Methotrexate will irrevocably destroy tropho-
ectopic pregnancy, the presence of a heterotopic blastic tissue and potentially damage a desired
pregnancy (co-existing intrauterine and extrauter- intrauterine pregnancy. Cervical and cornual
ine pregnancies) is possible, and is more com- pregnancies are typically injected with metho-
mon with the use of assisted reproduction. The trexate or potassium chloride directly into the
sonographic signs of ectopic pregnancy should sac or embryo to provide local and direct treat-
be sought even if an intrauterine pregnancy is ment. Sometimes follow-up methotrexate injec-
present. tions are necessary. Ultimately, patients may need
laparoscopy if medical treatment fails. Laparos-
Differential Diagnosis copy is usually necessary with large tubal preg-
The diagnosis of ectopic pregnancy depends nancies or those in which cardiac activity is
entirely on the presence of a positive pregnancy present. The treatment for C-section scar ectopics
test, which is an essential finding before a differ- depends on multiple factors and includes medical
ential diagnosis is attempted. and surgical approaches.
59
Section 1 Ectopic Pregnancy
E Figure E1-1 Intrauterine pregnancy. Longitudinal and transverse views of the uterus showing a small 5-week-size
gestational sac. The rounded sac with echogenic rim within the decidua is the earliest visible indication of an
intrauterine pregnancy.
Figure E1-2 Tubal ectopic pregnancy. View of the right adnexa showing a hemorrhagic cyst within the ovary,
adjacent to which is a small ectopic pregnancy (arrow). Note the intense echogenic rim of the ectopic sac, com-
pared with the echolucent border of the hemorrhagic corpus luteum.
60
A
E
C D
Figure E1-3 Live ectopic pregnancy. A, Transverse view of the uterus, showing that there is no intrauterine
pregnancy. B and C, A live ectopic pregnancy with a gestational sac and an embryo in the adnexa. The embryo has
a heartbeat seen with Doppler and m-mode. D, A moderate amount of echogenic free fluid in the cul-de-sac of the
same patient, indicating leakage of blood from the ectopic pregnancy.
61
Uterus
E
Figure E1-4 Longitudinal view of an empty uterus in a patient with a ruptured ectopic pregnancy. Note multiple
blood clots (arrows), both in front of and behind the uterus.
Figure E1-5 Cervical pregnancy. Longitudinal view and 3-D rendering of a 5-week cervical pregnancy. Note the
presence of the gestational sac within the cervix (arrows on 3-D view).
62
Cervix
Fundus
A
A
E
Endometrial cavity
C-section ectopic
B
Figure E1-6 Cornual pregnancy. A, The gestational
sac with its echogenic rim, located adjacent to the
fundus of the uterus. B, A 3-D rendered image Cervix
showing the proximity of the cornual ectopic sac to

the endometrial cavity. The arrow demonstrates a
B
thin tongue of myometrium separating the sac and
the edge of the cavity. Figure E1-7 C-section scar ectopic pregnancy.
A, A longitudinal view of a uterus with a C-section
scar ectopic pregnancy located in the anterior lower
uterine segment. Note the anterior bulge made by
the invading trophoblast (arrows). There is no visible
myometrium seen around the outside of the sac.
B, The coronal view of the uterus using 3-D render-
ing. Note the location of the pregnancy in the lower
uterine segment.
63
E A B
RT
C
Figure E1-8 Heterotopic pregnancy at 12 weeks. A, The normal intrauterine pregnancy at 12 weeks. B and C, A
tubular solid mass in the right adnexa of the same patient. Note that there is only peripheral vascularity and no
blood flow in the center of the mass. This was an ectopic pregnancy with a hematosalpinx in the setting of a
co-existing intrauterine pregnancy.
Suggested Reading Lin EP, Bhatt S, Dogra VS. Diagnostic clues to ectopic
Barnhart KT. Ectopic pregnancy. N Engl J Med. 2009; pregnancy. RadioGraphics. 2008;28:1661-1671.
361:379-387. Osborn DA, Williams TR, Craig BM. Cesarean scar
Kamaya A, Shin L, Chen B, Desser TS. Emergency pregnancy: sonographic and magnetic resonance
gynecologic imaging. Semin Ultrasound CT MRI. imaging findings, complications, and treatment.
2008;29:353-368. J Ultrasound Med. 2012;31:1449-1456.
Kirk E, Bourne T. Diagnosis of ectopic pregnancy with
ultrasound. Best Pract Res Clin Obstet Gynaecol.
2009;23:501-508.
64
Section 1
Endometrial Carcinoma
Synonyms/Description or ill defined, a sonohysterogram can be per-
Uterine cancer formed to outline the endometrium and deter-
mine whether there is a focal or diffuse process.
Etiology More advanced tumors often have a texture of
Endometrial cancer is the most common cancer mixed echogenicity and abundant vascularity evi-
of the female genital tract. The overall 5-year sur- dent on color Doppler. The tumor vessels are typi-
vival rate is 85%, 75%, 45%, and 25% for stages cally multiple, disorganized, and entering from
I through IV, respectively.
Risk factors for endometrial cancer include
multiple foci. As the tumor continues to grow, the
borders become increasingly irregular and ill-
E
obesity, diabetes, nulliparity, estrogen-producing defined, invading the myometrium, with loss of
ovarian tumors, polycystic ovarian syndrome, definition of the endometrial-myometrial junction.
advanced age, unopposed estrogen therapy, There can be cystic spaces within the characteristi-
tamoxifen, and a family history of nonpolypoid cally solid tumor and, sometimes, fluid in the endo-
colorectal cancer. metrial cavity outlining the mass. As the endometrial
The prognosis depends on the tumor type and tumor invades further into the myometrium, the
stage. Type 1 endometrial cancer or endometri- uterus enlarges and becomes blotchy in texture.
oid carcinoma accounts for 80% of uterine carci- With extensive myometrial invasion, the residual
nomas and is associated with increased and mantle of myometrium may be very thin. Some
unopposed estrogen exposure. It typically arises tumors seem to be entirely in the myometrium
from a background of endometrial hyperplasia rather than the endometrium (see Figure E2-3).
and is frequently low-grade and slow-growing. Endometrial cancer can arise not only in the
Type 2 tumors are not estrogen driven and are uterine fundus (most common), but also in the
generally far more aggressive than type 1. They lower uterine segment, at the cervical junction,
often occur in the setting of atrophic endome- distorting the shape of the lower segment (see
trium and include serous, clear cell, and other Figure E2-5).
cell types. These tumors tend to invade the myo-
metrium earlier and spread rapidly. Differential Diagnosis
When the endometrial abnormality is confined to
Ultrasound Findings the endometrium and appears typically echo-
The gray-scale sonographic appearance of endo- genic, the differential diagnosis includes polyps
metrial cancer depends on the stage of disease. If and endometrial hyperplasia. A sonohysterogram
the tumor is confined to the endometrium and is very helpful as the initial workup for a thick-
small, the scan may reveal a thickened, heteroge- ened or ill-defined endometrium in a patient with
neous endometrium or even a normal-appearing abnormal or postmenopausal bleeding. The age,
endometrium if the tumor is very small. In post- history, and hormonal status of the patient are
menopausal patients who are bleeding, an endo- important factors to consider, but tissue sampling
metrial thickness greater than 4 mm (some use is necessary when malignancy is being consid-
greater than or equal to 5 mm) is considered ered. The differential diagnosis for a uterine mass
abnormal and requires further evaluation. Early- with irregular cystic areas and excessive vascular-
stage tumors are typically hyperechoic and may ity includes sarcoma and fibroids (see Uterine
have some but limited color flow within the endo- Sarcoma and also Fibroids). Because fibroids are
metrium. If the endometrium appears abnormal far more common than uterine cancers, a uterine
65
Section 1 Endometrial Carcinoma
mass may be mistaken for an atypical fibroid at Clinical Aspects and Recommendations
first scan. If a fibroid is unusual in appearance, it Endometrial cancer is typically treated with
is important to rescan the patient in a relatively total abdominal hysterectomy, bilateral
short time interval to evaluate growth of the salpingo-oophorectomy, and staging, which

lesion. Adenomyosis can give the myometrium a includes lymph node sampling. Further therapy
focal blotchy appearance, although the vascular- depends on the stage and type of tumor; it may
ity should differentiate adenomyosis from a involve gynecologic, radiation, and medical
cancer. oncologists.
2 1
B
Figure E2-1 Polypoid endometrial cancer. A, A solid isoechoic mass in the endometrium (calipers). B, Extensive
color flow displaying multiple, irregular vessels in the mass (arrows). C, A 3-D coronal rendering of the uterus after
saline had been introduced into the cavity. Note the tumor (arrows) at the fundus of the uterus, outlined by fluid.
66
Endometrial Carcinoma Section 1
B
Figure E2-2 A, Longitudinal view of the uterus in a patient with adenocarcinoma of the endometrium. Note the
thick and heterogeneous endometrium with ill-defined borders on the gray scale image. B, The color flow image
shows abundant vascularity (arrow) in the endometrium.
67
2
cavity
A B
C
Figure E2-3 A and B, Large echogenic endometrial cancer (calipers) invading the myometrium with only a small
component in the endometrial cavity. C, The color flow image shows the abundant vascularity in this aggressive
tumor.
Figure E2-4 Large endometrial cancer located within the endometrial cavity and involving approximately 50% of
the circumference of the endometrium. This mass is protruding into the cavity and outlined by endometrial fluid.
Note the intense vascularity evident on the color flow image.
68
Endometrial Carcinoma Section 1
A D
C
Figure E2-5 Two different patients with invasive endometrial cancer in the lower uterine segment and upper
cervix. A and B, A solid, homogeneous mass (arrows) that is very vascular and located in the lower uterine segment
and involving the upper portion of the cervix. C, The 3-D coronal view of the same mass showing its location in the
lower portion of the uterus as well as its irregular contour (arrows). D and E, A different patient with a similar
tumor (calipers) in the lower uterus/cervix. Note the disorganized abundant vascularity to the mass.
Videos
Video 1 on endometrial carcinoma is available
online.
Suggested Reading
Amant F, Moerman P, Neven P, Timmerman D, Van
Limbergen E, Vergote I. Endometrial cancer. Lancet.
2005;366:491-505.
Epstein E, Van Holsbeke C, Mascilini F, Måsbäck A,
Kannisto P, Ameye L, Fischerova D, Zannoni G,
Vellone V, Timmerman D, Testa AC. Gray-scale and
color Doppler ultrasound characteristics of endo-
E Figure E2-6 Endometrium of a 75-year-old asymp-

metrial cancer in relation to stage, grade and tumor
size. Ultrasound Obstet Gynecol. 2011;38:586-593.
Leone FP, Timmerman D, Bourne T, Valentin L,
tomatic woman who was on unopposed estrogen for Epstein E, Goldstein SR, Marret H, Parsons AK,
more than 10 years. Despite the absence of bleeding, Gull B, Istre O, Sepulveda W, Ferrazzi E,
this endometrium of 8 mm was considered heteroge- Van den Bosch T. Terms, definitions and measure-
neous and abnormal, prompting sampling. Stage Ib ments to describe the sonographic features of the
endometrial carcinoma was diagnosed, invading one endometrium and intrauterine lesions: a consensus
third of the way through the myometrium (invasion opinion from the International Endometrial Tumor
not detectable sonographically). Analysis (IETA) group. Ultrasound Obstet Gynecol.
2010;35:103-112.
Van den Bosch T, Coosemans A, Morina M, Timmer-
man D, Amant F. Screening for uterine tumours.
Best Pract Res Clin Obstet Gynaecol. 2012;26:
257-266.
70
Section 1
Endometrial Hyperplasia and the

Differential Diagnosis for Thick
Endometrium
Synonyms/Description 5 mm is normal; hence there is disagreement as to
Endometrial proliferation whether the upper limit of normal should be 4 or
Etiology
Endometrial hyperplasia refers to abnormal pro-
5 mm; however, the American College of Obstet-
rics and Gynecology states less than or equal to
4 mm is normal. It is important to evaluate the
E
liferation of endometrial glands and stroma, rep- endometrium in its entirety. If part of the endo-
resenting a spectrum of endometrial abnormalities metrium is obscured by fibroids, polyps, or ade-
ranging from benign overgrowth to precancerous nomyosis or if the margins are indistinct, saline
tissue. Endometrial hyperplasia can cause a dif- infusion sonohysterography can be used for fur-
fusely thickened endometrium or, less commonly, ther evaluation. There is no accepted normative
focal thickening within the cavity. data for the width of the endometrium in non-
bleeding postmenopausal patients. The sono-
Ultrasound Findings graphic appearance of the endometrial echo and
The sonographic appearance of endometrial color flow are important factors in detecting the
hyperplasia is a heterogeneous thickening of the presence of endometrial disease.
endometrial echo (lining). Endometrial hyper- Tamoxifen is a selective estrogen receptor
plasia may be circumferential, involving most of modulator used in the treatment and prevention
the endometrium or focal and nodular. In pre- of breast cancer. The estrogen receptor agonist
menopausal patients, optimal evaluation of the activity in the uterus caused by Tamoxifen has
endometrium is in the early follicular (prolifera- been associated with an increased risk of endo-
tive) phase when the lining is at its thinnest. metrial polyps, hyperplasia, and cancer when
Later in the menstrual cycle the endometrium used in postmenopausal women. In addition,
becomes topographically irregular, and the patients on Tamoxifen can have a very indistinct
appearance of endometrial hyperplasia may be endometrial/myometrial border that often
indistinguishable from the normal thickening results in the overestimation of the endometrial
that occurs during the luteal (secretory) phase. echo width. This is often caused by microcystic
There are no established values for the normal formation in the subendometrial region, which
width of the endometrial echo in premenopausal results in an irregular endometrial-myometrial
women. The sonographic texture of the endo- junction. These microcysts are glandular cystic
metrial echo is an important feature, and focal atrophy. Sonohysterography is very useful to
irregularities may be further delineated with delineate the true appearance of the endometrial
sonohysterography. surface itself.
In postmenopausal patients with bleeding, the
normal width of the endometrium in longitudinal Differential Diagnosis
view should measure less than or equal to 4 mm The differential diagnosis for a thickened endo-
and appear linear, with no focal irregularities. metrium is extensive, but generally includes endo-
Some authors report that a measurement less than metrial hyperplasia, polyps, fibroids (submucous),
71
Section 1 Endometrial Hyperplasia
endometrial cancer, retained products of concep- Adenomyosis; and Retained Products of Con-
tion, and adenomyosis. Patients with endometrial ception for more detail on each.
hyperplasia typically have a circumferentially
thickened endometrium. Unfortunately, endo- Clinical Aspects and Recommendations
metrial hyperplasia and cancer are indistinguish- Clinically there is a great difference between
able sonographically and require tissue sampling. endometrial evaluation in premenopausal and
Sonohysterography is crucial to differentiat- postmenopausal patients. In premenopausal
ing a focal lesion such as a polyp from a global patients who are still cycling, it is essential that
process such as hyperplasia or malignancy. Pol- sonographic evaluation be performed in the
yps are echogenic focal lesions, typically with a early follicular phase, when the endometrium is
feeder vessel, and often detectable without thinnest. In postmenopausal patients who are
sonohysterography. Submucous fibroids are not on hormone therapy, there is no “cycling,”
E typically rounded structures, more echolucent
than the surrounding endometrium and dis-
and sonographic evaluation may be carried out
at any time. The value of sonography in patients
placing the endometrial echo. Adenomyosis suspected of having endometrial hyperplasia is
may make the endometrial-myometrial junc- the high negative predicative value of a thin, dis-
tion indistinct, necessitating a sonohysterogram tinct endometrial echo when present. When a
to clarify. If a patient has had a recent preg- thin echo is not present, saline infusion sono-
nancy, retained products of conception should hysterography can help to differentiate between
be considered. Color flow Doppler may show global abnormalities, which can be sampled
extensive vascularity, further confirming the blindly, and focal abnormalities (polyps, focal
diagnosis. Please see the individual sections for tissue growth), which should be sampled under
Endometrial Carcinoma; Polyps, Endometrial; direct visualization (hysteroscopically).
72
Endometrial Hyperplasia Section 1
A B
C
Figure E3-1 Endometrial hyperplasia. A, A diffusely thickened endometrium. B and C, Images from the
sonohysterogram showing that the thickening is global.
A B
Figure E3-2 Differential diagnosis. A, A thickened endometrium. B, A 3-D image from the sonohysterogram
showing a focal lesion that was a large polyp.
73
Section 1 Endometrial Hyperplasia
E
1
A B
Figure E3-3 Differential diagnosis. A, A thickened and blotchy endometrium with a hint of a focal lesion. B, The
3-D coronal view shows the polyp without the need for a sonohysterogram.
74
Endometrial Hyperplasia Section 1
Figure E3-5 Differential diagnosis. Longitudinal

view of the endometrium of a postmenopausal
E
patient with bleeding. Note the focal nodular thick-
ening of the endometrium at the fundus (retroverted
uterus), with slight irregularity and loss of definition
1 of the endometrial-myometrial junction. The pathol-
ogy revealed papillary serous adenocarcinoma of the
endometrium.
B Goldstein RB, Bree RL, Benson CB, Benacerraf BR,

Bloss JD, Carlos R, Fleischer AC, Goldstein SR,
Figure E3-4 Differential diagnosis. A, A thick and Hunt RB, Kurman RJ, Kurtz AB, Laing FC, Parsons
irregular endometrium with many cystic spaces AK, Smith-Bindman R, Walker J. Evaluation of the
obscuring the endometrial-myometrial junction. woman with postmenopausal bleeding: Society of
This patient was on Tamoxifen, and the ultrasound Radiologists in Ultrasound-Sponsored Consensus
image was not sufficient to evaluate the endome- Conference statement. J Ultrasound Med. 2001;20:
trium. B, The sonohysterogram, which revealed that 1025-1036.
most of the cystic areas are in the subendometrial Goldstein SR. Modern evaluation of the endome-
region. trium. Obstet Gynecol. 2010;116:168-176.
Goldstein SR. Significance of incidentally thick endo-
metrial echo on transvaginal ultrasound in post-
menopausal women. Menopause. 2011;18:434-436.
Suggested Reading Goldstein SR. Sonography in postmenopausal bleed-
Ballard P, Tetlow R, Richmond I, Killick S, Purdie ing. J Ultrasound Med. 2012;31:333-336.
DW. Errors in the measurement of endometrial Mills AM, Longacre TA. Endometrial hyperplasia.
depth using transvaginal sonography in postmeno- Semin Diagn Pathol. 2010;27:199-214.
pausal women on tamoxifen: random error is Montgomery BE, Daum GS, Dunton CJ. Endometrial
reduced using saline instillation sonography. Ultra- hyperplasia: a review. Obstet Gynecol Surv. 2004;
sound Obstet Gynecol. 2000;15:321-326. 59(5):368-378.
75
Section 1
Endometriosis
Synonyms/Description The ground-glass texture of the cyst content is
Endometriosis signifies the presence of endome- very characteristic and makes 90% of endome-
trial tissue outside the endometrial cavity. These triomas easily recognizable. Some benign endo-
ectopic glands respond to the cyclical hormones, metriomas also have solid components (often
thus causing microscopic internal bleeding and echogenic) in the inner aspect of the cysts, but
pain during the course of the menstrual cycle. these are typically without discernible blood
This ectopic tissue bleeds episodically, causing flow and represent clot. When interrogating
E inflammation, adhesions, and scarring. These
ectopic glands can also react to hormones of
endometriomas with color Doppler, there is no
discernible flow in the cyst (only in the wall) and
pregnancy. there is usually no visible streaming of the low-
level echoes within the cyst, thus distinguishing
Etiology it from cystadenomas and other cysts. Patients
The exact cause of endometriosis is unknown with endometriomas often have adhesions so
and there are multiple theories. In addition, the that tubal disease in the form of a hydrosalpinx
true prevalence of this condition is also unclear or other signs of adhesive disease may be a com-
because endometriosis is not always symptom- mon finding.
atic. There does, however, appear to be a higher When the cyst wall is thickened and irregular,
incidence in women who are diagnosed with the possibility of malignancy, specifically endo-
infertility and pelvic pain. metrioid carcinoma, must be considered. Typi-
Endometriosis can occur in many forms, cally endometrioid carcinoma looks like an
including the formation of cysts known as endo- endometrioma but with internal solid nodular-
metriomas (chocolate cysts), which typically ity that contains abundant color Doppler flow.
develop in ovarian tissue. Endometriosis can In a study of 309 endometrioid cysts surgically
also occur in the uterus with the propagation of removed, 1.2% were classified as borderline, and
endometrial glands through the junctional zone 3.4% as invasive endometrioid tumors. Patients
into the myometrium, a condition known as with malignancies were typically older (median
adenomyosis (see Adenomyosis). Endometriosis 52 years) compared with those with benign cysts
can also take the form of small deep implants of (median 34 years). All of the malignant and bor-
endometrial tissue in many different places in derline tumors were characterized as having
the body, including the wall of the bladder, the solid components with evidence of color flow,
anterior abdominal wall, the bowel wall, and the compared with only 7.8% of the benign lesions.
uterosacral ligaments, as well as other pelvic
sites. Rarely, endometriosis can occur in distal Decidualized Endometrioma
sites such as the lung, potentially causing If the patient is pregnant, the endometrioma
hemoptysis. may become decidualized and have ultrasound
characteristics suggestive of a malignancy. The
Ultrasound Findings stromal transformation of endometrial cells
Endometrioma within the endometrioma can occur because of
The typical appearance of an endometrioma is high levels of progesterone in pregnancy. In
that of a unilocular cyst with homogeneous low- gravid patients, these cysts can contain internal
level echoes and through transmission of sound. solid nodularity with blood flow, and are
76
Endometriosis Section 1
indistinguishable from borderline or even frank have had abdominal surgery such as a prior
ovarian cancers sonographically. C-section or laparoscopy. Endometriosis of the
Therefore such cysts may potentially be bladder wall appears as a fusiform solid thicken-
watched with frequent serial ultrasounds before ing of the wall itself. If endometrial implants
making a final decision to remove the cyst during impinge on the ureter, the patient may have
the pregnancy. If the cyst remains unchanged, it chronic ureteral obstruction that is silent and
is unlikely to be malignant, and removal can be may lead to a nonfunctioning kidney.
planned after delivery. In patients who have had prior abdominal
surgery, endometriosis may present as a hard,
Deep Penetrating Bowel Wall and Pelvic solid mass in the anterior abdominal wall in the
Implants region of the scar. Little color flow may be pres-
Sonographically, deep implants of endometriosis ent, and the mass is often tender.
are small solid masses with little if any detectable
blood flow using color Doppler. The bowel wall Differential Diagnosis
E
implants are nodular and fusiform swellings of Endometrioma
one side of the bowel wall. This swelling is often Most endometriomas involve the ovary and have a
adherent to the back of the cervix, thus hindering characteristic appearance, which is a unilocular
any sliding of the uterus past the bowel on exam. cyst with homogeneous low-level echoes and no
Bazot reports a sensitivity and specificity of color flow. Some endometriomas can be multi-
78.5% and 95.2%, respectively, for detecting dis- locular or septate or have a thickened wall with
ease in that location, suggesting that ultrasound echogenic material. These cysts may be confused
(in experienced hands) is accurate in diagnosing with dermoids (echogenic area), cystadenomas
rectosigmoid endometriosis. Hudelist and col- (septations), or even malignancy if there is some
leagues report a sensitivity and specificity of 91% solid component. Color Doppler is essential to
and 98%, respectively, and positive likelihood interrogate these solid areas for blood flow. The
ratio and negative likelihood ratios of 30.4 and absence of flow may suggest a cystadenoma-
0.1, respectively, for detecting bowel wall endo- fibroma or endometrioma. If color flow is present,
metriosis using ultrasound. Although MRI can one must consider decidualized endometrioma
also detect implants of endometriosis, evidence (in pregnancy) versus a borderline or invasive
shows that pain-guided transvaginal ultrasound endometrioid carcinoma.
is likely more sensitive for detecting bowel Streaming is typically absent in endometrio-
involvement. mas when using Doppler. If the cyst has stream-
Implants in the rectovaginal septum are also ing echoes, a diagnosis other than endometriosis
nodular, small, rounded, solid structures best should be considered.
seen along the most distal portion of the cervix
and along the posterior fornix and upper vagina. Deep Penetrating Bowel Wall and Pelvic
Implants may also be found on the pelvic liga- Implants
ments such as the uterosacral ligaments and para Patients with deep bowel wall and pelvic endo-
pelvic regions. metrial implants are typically in a lot of pain
during the transvaginal examination, and the
Bladder Wall, Ureter, and Anterior Abdominal pelvic organs tend to be adherent to each other.
Wall Lesions (Also See Bladder Masses) It is important to try to move the uterus with the
Implants of endometriosis can occur practically vaginal probe to see if it slides past the anterior
anywhere; however, the more common areas of wall of the rectosigmoid and the ovaries. If these
involvement include the bladder wall, ureter, organs are stuck together in a patient with pain,
and anterior abdominal wall in patients who then endometriosis is likely. Other lesions
77
Section 1 Endometriosis
involving the bowel wall include inflammatory minimally invasive surgery in the form of lapa-
bowel disease or lymphoma; however, both of roscopy would be preferable to open laparot-
these diseases have diffuse (nonfocal) bowel omy although often the extent of adhesions
involvement without extensive adhesions or may make a minimally invasive approach dif-
focal pain (see Bowel Diseases). Solid implants ficult, if not impossible.
with color flow in the peritoneal cavity may indi-
cate carcinomatosis, although this is usually
accompanied by ascites.
LT O
Bladder Wall Lesions
Endometriosis of the bladder wall is usually well
contained within the wall and has little detect-
E able blood flow. The mucosal surface remains
smooth, unlike a transitional cell carcinoma,
which is a fungating vascular lesion of the muco-
2
sal surface.
Clinical Aspects and Recommendations

The three general categories that comprise the
clinical manifestations of endometriosis include
(1) pelvic pain, (2) infertility, and (3) pelvic mass. LT O
The goal of any therapy is to relieve the symp-
toms. There are so many different medical treat-
ments that decisions regarding management must
be individualized, taking into account severity of
symptoms, extent and location of the disease,
desire for future fertility, medication side effects,
surgical complication rates, and even cost.
Detailed treatment options are beyond the
scope of this section, but would include expect-
ant management, analgesia, various hormonal 1
medical therapies, surgical intervention, which
may be conservative and tissue sparing or Figure E4-1 Two views of a left ovarian endome-
definitive (total abdominal hysterectomy and trioma. Note the typical ground-glass sonographic
possible bilateral salpingo-oophorectomy), or texture of the cyst contents with a slightly irregular
combinations of these therapies. As always, wall.
78
E
A
Figure E4-2 Two views of an endometrioma involv-

ing the right ovary. Note that the internal texture is B
mixed with a hyperechoic area with shadowing, Figure E4-4 Patient with extensive endometriosis.
which may suggest a dermoid cyst in the differential A, A typical endometrioma with a thick and irregular
diagnosis. wall but no color flow demonstrated. B, The associ-
ated hydrosalpinx adjacent to the cyst.
Figure E4-3 Typical unilocular endometrioma. The

small, clear cyst compressed on one side is likely a
follicle.
79
E A
B
Figure E4-5 A, Cystic mass in a pregnant patient
showing an irregular and nodular inner wall with Figure E4-6 Transverse and longitudinal views of
cystic contents displaying low-level echoes. B, Image the anterior wall of the rectosigmoid, showing solid
showing blood flow in the solid areas, a finding that nodular masses compressing the lumen (arrows).
is worrisome for a malignancy. This mass was proved These are typical of endometriotic implants in the
to be a decidualized endometrioma at surgery. bowel wall. Note that the involved bowel is adjacent
to the back of the cervix and posterior fornix of the
vagina.
80
Bowel wall
Figure E4-7 Long segment of sigmoid involved with

endometriosis of the bowel wall on one side. Note E
the asymmetric thickening of the anterior wall. Figure E4-9 Three-dimensional multislide view of
the affected bowel wall showing the involved bowel
segment adjacent to the back of the cervix
(cephalad).
2 1
Figure E4-8 Focal area of involvement of the

rectovaginal septum, showing the typical fingerlike Figure E4-10 Small subcentimeter endometriotic
projections from the nodular wall toward the lumen implant along the posterior aspect of the cervix. Note
of the rectum. The rectum, upper vagina, and cervix that the free fluid in the cul-de-sac appears on the
were all adhered to each other, and the area was very outside of the implant rather than directly adjacent
tender during the scan. to the cervix.
RT post
Figure E4-11 Oblique view of the right cul-de-sac showing a small implant on the utero-sacral ligament in a
patient with extensive disease. This lesion was very tender.
81
Videos
Videos 1, 2, 3, 4, and 5 on endometriosis/endo-
metrioma are available online.
Suggested Reading
Koninckx PR, Ussia A, Adamyan L, Wattiez A,
1 Donnez J. Deep endometriosis: definition, diagno-
sis, and treatment. Fertil Steril. 2012;98:564-571.
2
Miranda-Mendoza I, Kovoor E, Nassif J, Ferreira H,
Wattiez A. Laparoscopic surgery for severe ureteric
endometriosis. Eur J Obstet Gynecol Reprod Biol.
Figure E4-12 Fusiform thickening of the bladder 2012 Dec; 165(2):275-279.
E wall in a patient with endometriosis of the bladder. Ozel L, Sagiroglu J, Unal A, Unal E, Gunes P, Baskent
E, Aka N, Titiz MI, Tufekci EC. Abdominal wall
endometriosis in the cesarean section surgical scar:
a potential diagnostic pitfall. J Obstet Gynaecol Res.
2012;38:526-530.
Poder L, Coakley FV, Rabban JT, Goldstein RB, Aziz S,
Chen LM. Decidualized endometrioma during
pregnancy: recognizing an imaging mimic of ovar-
ian malignancy. J Comput Assist Tomogr. 2008;32:
1 555-558.
Testa AC, Timmerman D, Van Holsbeke C,
Zannoni GF, Fransis S, Moerman P, Vellone V,
Mascilini F, Licameli A, Ludovisi M, Di Legge A,
2 Scambia G, Ferrandina G. Ovarian cancer arising
A
in endometrioid cysts: ultrasound findings.
B
Figure E4-13 Two views of a solid and tender lesion
in the anterior abdominal wall within a C-section
scar. B, A paucity of blood flow in the mass, typical of
endometriosis.
82
Section 1
Epidermoid Cyst
Synonyms/Description Clinical Aspects and Recommendations
Epidermal cyst or sebaceous cyst of the ovary Epidermoid cyst is usually detected as an inci-
Mature monophyletic teratoma dental finding on a pathology specimen, benign,
and rarely symptomatic.
Etiology
Epidermoid cysts are benign cysts, lined by
mature keratinizing squamous epithelium but
without hair (unlike dermoids). These lesions
represent less than 0.25% of all ovarian neo-
E
plasms. Two main theories exist regarding the
etiology: This may be a monophyletic variant of
a dermoid or teratoma with only the epithelial
component present, resulting in a highly differ-
entiated lesion. Alternatively, epidermoid cysts
may arise from epithelial cell nests in the ovary
similar to those seen in Brenner tumors. The
cysts can contain keratin and other sebaceous
material. There is a similar counterpart tumor
that occurs in the testes.
Ultrasound Findings
Epidermoid cysts are solid-appearing lesions
with heterogeneous and echogenic texture but
no internal color flow on Doppler evaluation.
The detectable blood flow is peripheral, suggest-
ing a cyst wall. Epidermoid cysts are not as echo-
genic as dermoids, making the appearance
nonspecific. The lack of flow inside is helpful in
this otherwise solid-appearing lesion.
Differential Diagnosis 1
The presence of a solid ovarian mass brings to
mind many diagnoses. The lack of internal blood
flow typical of the epidermoid cyst helps to narrow Figure E5-1 Two views of an ovarian epidermoid
the differential diagnoses to dermoid, endometri- cyst. Note the slightly echogenic but heterogeneous
internal sonographic texture.
oma, fibroma, or other benign solid ovarian tumor.
83
Section 1 Epidermoid Cyst
Suggested Reading
Fan LD, Zang HY, Zhang XS. Ovarian epidermoid
cyst: report of eight cases. Int J Gynecol Pathol.
1996;15:69-71.
Sheikh SS, Amr SS. Epidermoid cyst of the ovary.
J Obstet Gynaecol. 2003;23:213.
E
Figure E5-2 Color flow Doppler image of the same
epidermoid cyst showing only peripheral flow in the
capsule of the cyst.
84
Section 1
Fibroids
Synonyms/Description Intramural
Leiomyoma, myoma, fibromyoma, and uterine Fibroids are most commonly intramural and
fibroma occur within the confines of myometrium.
Etiology Submucosal
Fibroids are the most common benign pelvic A fibroid that protrudes into the endometrial
tumor in women. The prevalence in women age cavity is submucosal. These can occasionally be
50 and older is estimated at 80% in African pedunculated into the cavity and slide down into
Americans and up to 70% in Caucasians. Others the cervix as the uterus tries to expel it. Three-
have estimated a lower incidence (up to 50% of
perimenopausal women).
Myomas are thought to be monoclonal and
dimensional ultrasound and sonohysterography
can be very helpful in outlining the extent of the
submucosal component of the fibroid within the
F
originate from a single myocyte that undergoes cavity.
somatic mutation as it grows. Cytogenetic anom-
alies are found in 40% of fibroids. Estrogen and Subserosal
progesterone are known to stimulate the growth A fibroid that indents the serosal surface and
of fibroids. Although many fibroids are asymp- gives a bumpy appearance of the outside of the
tomatic, others may cause bleeding, pain, mass uterus is subserosal.
effect, urinary frequency, constipation, pregnancy
loss, and infertility. The presence of symptomatic Pedunculated
fibroids is the most common indication for A fibroid that has grown from a subserosal
hysterectomy. fibroid outward and remains tethered to the
uterus by a pedicle is considered pedunculated.
Ultrasound Findings Occasionally these can pick up vascularity from
Fibroids are typically solid masses, which are outside organs and become parasitic, no longer
sonographically hypoechoic or isoechoic with connected to the uterus, making the sonographic
the surrounding myometrium. They are well diagnosis more difficult.
circumscribed, with acoustic shadowing, often
with a pattern of stripes or swirls caused by Degenerating
these shadows. They can be calcified, often with Discrepancy between the rate of growth of the
a circumferential pattern of calcification. If they myoma and its blood supply can lead to an
degenerate, they can have central cystic por- infarction of part (most often the center) of the
tions. Color Doppler findings of fibroids are myoma. The degenerating fibroid has a variable
variable. Some fibroids have abundant flow manifestation, the most common being a donut-
and others scant; therefore there is no Doppler appearing mass with a cystic center and a thick
flow pattern specific to fibroids. Doppler is wall, located within the confines of the uterus.
helpful to map the blood flow to the fibroid. If The acute infarction leads to severe pain and is
it is pedunculated, it may be confused with an more common during pregnancy. Some degen-
ovarian mass. erating fibroids can mimic ovarian cystic masses,
Fibroids are further described by their location especially if they are pedunculated and multisep-
in the uterus. tate in appearance.
85
Section 1 Fibroids
Differential Diagnosis and uterine artery embolization. Symptom severity

The differential diagnosis of fibroids depends on and a desire to maintain uterine preservation are
the location and appearance of the uterine mass. factors in determining treatment choice.
A fibroid that contains cystic areas and abundant In patients desiring future fertility, uterine
blood flow may be indistinguishable sonograph- preservation is crucial, and either expectant man-
ically from a uterine sarcoma (see Sarcoma). agement or conservative surgery (myomectomy)
Follow-up scans showing aggressive growth, par- is employed. Increasingly, minimally invasive
ticularly in a postmenopausal patient, would techniques (transcervical resection, morcellation
suggest a malignancy. If the mass is ill-defined, it for selected submucous myomas, or laparoscopic
may represent an adenomyoma, which is similar surgery) would be preferred over traditional
in appearance to a fibroid, but has blurry or open abdominal myomectomy. Conservative
indistinct borders and is often seen in a setting of management of bleeding can often be accom-
adenomyosis (see Endometriosis). If the fibroid plished hormonally with combination contra-
is submucosal and more echogenic than usual, it ceptives (pills, patch, or vaginal ring), the
F
could be confused with an endometrial polyp. A levonorgestrel-releasing IUD, progestin-only
central blood supply with a feeding vessel and pills, tranexamic acid, and even nonsteroidal
cystic spaces would favor a polyp. A bumpy and anti-inflammatory drugs (NSAIDs) in some
asymmetric uterus may be confused with a Mül- patients. Preoperatively, GnRH agonists such as
lerian duct anomaly such as a unicornuate uterus leuprolide or danazol have been employed to
with a rudimentary horn forming a mass. Three- reduce uterine size. Some women close to meno-
dimensional ultrasound is essential for diagnos- pause may use such agents to eliminate bleeding
ing Müllerian duct abnormalities and the and reduce uterine size, thus allowing them to
position of fibroids within the uterus. drift into natural menopause, when symptoms
If the fibroid is pedunculated laterally, in the and bleeding will cease. In patients with severe
broad ligament, it may be difficult to distinguish symptoms of pelvic pressure, pain, bowel/blad-
it from a solid adnexal mass such as a fibroma or der complaints, or abnormal uterine bleeding,
Brenner tumor. Finding the ipsilateral ovary sep- hysterectomy will be definitive therapy. Other
arate from the mass is important to rule out such less invasive approaches such as high-frequency
entities. focused ultrasound (HiFUS) and uterine artery
embolization are also used.
Clinical Aspects and Recommendations Perimenopausal patient’s estradiol levels ini-
Fibroids are so common and variable in size and tially rise as women become anovulatory and
location that clinical management and recommen- produce multiple follicles, without any becom-
dations depend on many variables, such as age, ing dominant. This can result in temporary
parity, desire for future fertility, bleeding pattern, enlargement of fibroids before actual menopause
and hormonal status (e.g., premenopausal vs. post- and may concern clinicians. Although uterine
menopausal). In general, therapies for fibroids sarcomas may be difficult to distinguishsono-
include gonadotropin-releasing hormone agonists, graphically from very vascular fibroids, true leio-
hysterectomy or myomectomy (abdominal or trans- myomas are benign and do not undergo malignant
cervical), MRI-guided focused ultrasound surgery, degeneration.
86
Fibroids Section 1
F
Figure F1-1 3-D ultrasound showing an intramural fibroid in the right midbody of the uterus.
1
2
Figure F1-2 Pedunculated fibroid shown by the calipers.
87
Section 1 Fibroids
1
1
A C
D
B
Figure F1-3 Two cases of submucosal fibroids (2-D and 3-D coronal views). A and B, Small, almost completely
submucosal fibroid in the left side of the cavity best seen with 3-D. C and D, Larger fibroid, lower in the uterus and
50% submucoal. Three-dimensional imaging is necessary to map out the exact position of the fibroid within the
uterine cavity.
88
Fibroids Section 1
Figure F1-4 2-D and 3-D views of multiple submucoal fibroids throughout the uterus.
89
Section 1 Fibroids
F
B
C
Figure F1-5 Submucosal fibroids using sonohysterography for mapping. A, Simple 3-D coronal view. B, After
instilling saline into the cavity. C, Virtual hysteroscopy using the 3-D surface view.
90
Fibroids Section 1
1 D 10.94 cm
2 2 D 7.64 cm
Figure F1-7 Another case of a degenerating fibroid

showing very little blood flow. Note the uterus on the
right, adjacent to the mass.
Figure F1-6 Degenerating fibroid: Multiseptate mass

with peripheral blood flow. This atypical appearance
could be confused with an ovarian tumor or an
endometrioma. Finding a separate ovary as well as a
connection between the mass and the uterus is
essential to make the correct diagnosis.
91
Section 1 Fibroids
B C
Figure F1-8 A, Pedunculated submucosal fibroid prolapsing through the cervix (arrows). B, Color Doppler shows
feeding vessels. C, 3-D coronal view shows the position of the fibroid.
Suggested Reading Levy BS. Modern management of uterine fibroids.

American College of Obstetricians and Gynecolo- Acta Obstet Gynecol Scand. 2008;87:812-823.
gists. Alternatives to hysterectomy in the manage- Parker WH. Uterine myomas: management. Fertil
ment of leiomyomas. ACOG Practice Bulletin Steril. 2007;88:255-271.
No. 96. Obstet Gynecol. 2008;112:201. Stewart EA. Uterine fibroids. Lancet. 2001;357:293.
Evans P, Brunsell S. Uterine fibroid tumors: diagnosis Vitiello D, McCarthy S. Diagnostic imaging of
and treatment. Am Fam Physician. 2007;75: myomas. Obstet Gynecol Clin North Am. 2006:
1503-1508. 3385-3395.
Flake GP, Andersen J, Dixon D. Etiology and patho-
genesis of uterine leiomyomas: a review. Environ
Health Perspect. 2003;111:1037-1054.
92
Section 1
Fibroma (Ovarian), Thecoma,

and Fibrothecoma
Synonyms/Description the entire lesion. A pedunculated fibroid is the
Thecoma, fibroma, and fibrothecoma are all most likely differential diagnosis to mimic this
tumors belonging to the thecoma-fibroma group appearance. The finding of a normal ovary sepa-
of stromal tumors (per the World Health Organi- rate from the solid tumor can help to make that
zation classification of ovarian sex cord–stromal differentiation. Other solid ovarian tumors such
tumors). as teratomas, dysgerminomas, and some solid
malignancies are unlikely to cast a shadow and
Etiology
Thecoma-fibroma tumors are a closely related
tend to be more vascular throughout the lesion
than the fibroma/thecoma. F
group of benign tumors that arise from ovarian
stroma and are often difficult for the imager and Clinical Aspects and Recommendations
even pathologist to distinguish. The fibroma Larger lesions are sometimes associated with
contains spindle cells, and is the most common ascites and rarely even hydrothorax. Meigs’ syn-
type of sex cord-stromal tumor, accounting for drome (ascites and hydrothorax) occurs in 10%
6% of all ovarian tumors. They are usually of all cases and 40% of the time when the tumor
asymptomatic although they can be large. exceeds 10 cm in diameter.
The thecoma arises from theca (stroma) cells Similar to myomas they can sometimes have
and can produce estrogen, much like the granu- increased mitotic figures per 10 high-powered
losa cell tumors, thus sometimes presenting with fields. True ovarian fibrothecomas, however, are
abnormal uterine bleeding. Many of these extremely rare. Treatment generally consists of
tumors are a mixture of cell types and are called salpingo-oophorectomy. Occasionally, because
fibrothecoma. thecomas can produce estrogen and present with
postmenopausal bleeding, endometrial sam-
Ultrasound Findings pling is indicated.
Fibromas/thecomas are typically solid, rounded,
or oval ovarian lesions and may attain a large size
(fibroma) and have low to moderate vascularity.
Sonographically, fibromas tend to cast an intense
acoustic shadow, making it difficult to see beyond
the anterior surface of the tumor. They can also be
solid but “stripy,” with linear streaks appearing ver-
tically within the lesion. Vascularity is typically low
by color Doppler, but occasional lesions may be
more vascular, such as cellular fibromas. There can 1
be small cystic areas within the solid mass; how-

ever, large cystic components are extremely rare.
Differential Diagnosis Figure F2-1 Small fibroma indicated by the calipers.

These solid tumors cast intense acoustic shadows The lesion is almost invisible due to the intense
acoustic shadow cast by the front of the mass.
either as stripes or simply a global shadow from
93
Section 1 Fibroma (Ovarian), Thecoma, and Fibrothecoma
Right Right
Figure F2-2 Fibroma—typically oval, completely

solid but smooth mass.
Figure F2-4 Fibroma with more vascularity than
F
usually seen.
Left
LT
Left
Figure F2-5 Large fibroma with limited Doppler

color flow and linear vertical shadows down the
middle of the mass, typical of fibromas.
Figure F2-3 Fibrothecoma with and without

Doppler flow showing a typical solid mass with
internal shadowing and limited vascularity.
94
Fibroma (Ovarian), Thecoma, and Fibrothecoma Section 1
Suggested Reading
Chechia A, Attia L, Temime RB, Makhlouf T, Koubaa
A. Incidence, clinical analysis, and management of
ovarian fibromas and fibrothecomas. Am J Obstet
Gynecol. 2008;199:473.e1-4.
Conte M, Guariglia L, Benedetti Panici P, Scambia G,
1
Rabitti C, Capelli A, Mancuso S. Ovarian fibrothe-
coma: sonographic and histologic findings. Gyne-
col Obstet Invest. 1991;32:51-54.
Paladini D, Testa A, Van Holsbeke C, Mancari R, Tim-
merman D, Valentin L. Imaging in gynecological
disease (5): clinical and ultrasound characteristics
in fibroma and fibrothecoma of the ovary. Ultra-
sound Obstet Gynecol. 2009;34:188-195.
Yaghoobian J, Pinck RL. Ultrasound findings in the-
F
coma of the ovary. J Clin Ultrasound. 1983;11:
91-93.
Yen P, Khong K, Lamba R, Corwin MT, Gerscovich
EO. Ovarian fibromas and fibrothecomas. J Ultra-
sound Med. 2013;32:13-18.
Figure F2-6 Fibroma presenting as a large solid

ovarian mass in a pregnant woman. Note the mul-
tiple vertical linear stripes and poor vascularity of this
mass.
95
Section 1
Granulosa Cell Tumor

Synonyms/Description by color Doppler, indicating a high likelihood
Granulosa-theca cell tumor of malignancy.
Sex cord–gonadal stromal tumor These tumors typically produce hyperestro-
genemia, so patients are at increased risk for
Etiology development of endometrial hyperplasia or con-
Granulosa cell tumors (GCTs) are relatively rare comitant endometrial adenocarcinoma. Sono-
malignant neoplasms representing 3% of all graphically, there may be evidence of a thickened
ovarian cancers and 70% of tumors in the cate- endometrial lining.
gory of ovarian sex cord-stromal tumors. Gran-
ulosa cell tumors arise from a hormonally Differential Diagnosis
active component of the ovarian stroma that is Granulosa cell tumors are large tumors that can
responsible for estradiol production and hence be solid, solid/cystic, and cystic with multiple
G represents 80% of hormone-producing ovarian

tumors.
septations. They tend to be large and associated
with evidence of hyperestrogenemia such as
Granulosa cell tumor neoplasms are divided abnormal bleeding. The differential diagnosis is
into the rare juvenile form (5%) and the more vast and includes practically all large adnexal
common adult type, which typically occurs in masses that contain septations, solid compo-
perimenopausal or postmenopausal women. The nents, and vascularity. Other tumors such as
GCT is a slow-growing malignant tumor that typ- epithelial malignancies can have a similar

ically spreads locally in the peritoneum and in appearance. Fibromas tend to be predominantly
25% of patients recurs 5 to 10 years later, although solid with less blood flow than GCTs. Fibrothe-
sometimes decades after initial presentation. comas are also solid in appearance and can pro-
duce estrogen, similar to the GCT.
Ultrasound Findings
Granulosa cell tumors can present as cystic/sep- Clinical Aspects and Recommendations
tated or solid masses arising from the ovary. Postmenopausal or irregular bleeding is a common
In the study by Van Holsbeke and colleagues, presenting sign in the adult form of GCT, likely
almost all tumors had solid components; 52% because of exposure to estradiol, ultimately leading
were multilocular with solid areas, 39% were to endometrial hyperplasia or adenocarcinoma.
purely solid, 4% were unilocular with a solid The juvenile type of GCT may present with
component, and 4% were multilocular. Granu- precocious puberty or abdominal/pelvic pain as
losa cell tumors are typically large, with a median these can grow to large sizes.
diameter of 10.2 cm (range, 3.7 to 24.2cm) in The survival for GCT patients depends on stag-
this study. Only one mass was smaller than 5 cm, ing. The 10-year survival rates for stages 1, 2, and
and more than 50% were larger than 10 cm. 3/4 are 84% to 95%, 50% to 65%, and 17% to
Ascites was present in 22% of patients. Most of 33%, respectively. The management is surgical
the tumors had a high vascular content shown and depends on stage of disease.
96
Granulosa Cell Tumor Section 1
A
Left
LT
B
Figure G1-2 A and B, Large GCT with more solid
Figure G1-1 A and B, Large, heavily septated GCT
portions than cystic. B, Note the intense vascularity
with thick septae. B, The abundant vascularity in the
on color Doppler.
thick septae.
Suggested Reading Pectasides D, Pectasides E, Psyrri A. Granulosa cell

Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST. tumor of the ovary. Cancer Treat Rev. 2008;34:1-12.
CT and MR imaging of ovarian tumors with Schumer ST, Cannistra SA. Granulosa cell tumor of
emphasis on differential diagnosis. Radiographics. the ovary. J Clin Oncol. 2003;21:1180-1189.
2002;22:1305-1325.
97
Section 1
Hematometra and Hematocolpos

Synonyms/Description cystic mass in the pelvis often mistaken for a
Hydrometra and hydrocolpos degenerating fibroid or adnexal mass. If the Mül-
Pyometra and pyocolpos lerian duct anomaly is severe, the hematometra/
hydrometra may even be visible prenatally as an
Etiology intra-abdominal cystic mass in the fetus.
The most common etiology is cervical or vaginal
obstruction, resulting in a collection of blood, Hematocolpos/Hydrocolpos
pus, or fluid that distends the uterus or vagina. Obstruction within the distal vagina is usually
responsible for the development of a hematocol-
Hematometra/Hydrometra pos. If there is a backup of blood or fluid in the
Cervical stenosis can develop for multiple rea- vagina, this may extend into the uterine cavity
sons (treatment for cervical dysplasia, prior abla- and result in an associated hematometra.
tion, postmenopausal effect), blocking the Obstructions of the distal vagina are commonly
cervical canal and resulting in accumulation of owing to congenital Müllerian duct anomalies
fluid/blood in the uterine cavity. Advanced endo- such as a transverse vaginal septum or an imper-
H metrial cancer can either block the canal or pro-
duce copious amounts of fluid/blood filling the
forate hymen. Patients with congenital anoma-
lies of the vagina often have associated anomalies
uterine cavity. Many years ago, fluid in the endo- of the uterus; however, patients with vaginal
metrial cavity was considered a sonographic sign obstruction may not become symptomatic until
of cancer. More recently, Dr. Steven Goldstein menarche.
showed that it is not the intracavitary fluid that
conveys the risk of cancer, rather the appearance Ultrasound Findings
of the wall around the fluid. If the endometrium The sonographic appearance of a hematometra/
surrounding the fluid is smooth and thin, endo- hydrometra is the presence of fluid distending
metrial cancer is unlikely, whereas an irregular the uterine cavity. Similarly hematocolpos/
wall or mass protruding into the fluid indicates hydrocolpos is the presence of fluid in an
the presence of a tumor. obstructed vagina. The fluid often contains low-
Benign causes of hematometra include an level echoes much like the texture of an endome-
intracavitary fibroid or polyp in the cervix or trioma, indicating the presence of unclotted
lower uterine segment, and adhesions such as blood. The presence of more than a sliver of fluid
those encountered after an incomplete endome- in the uterus and/or vagina needs to be further
trial ablation. If the ablation seals the lower uter- investigated sonographically. Consider the
ine segment but leaves intact endometrium at patient’s history: Has the patient had an abla-
the fundus, cyclical hematometra with bilateral tion, and does she have cyclical symptoms? Is
hematosalpinges may result. Patients with Mül- there a known Müllerian duct anomaly? Did the
lerian duct anomalies who have a uterine dupli- patient become symptomatic at menarche or is
cation may have an obliterated horn, which will she asymptomatic? The ultrasound exam should
fill with blood and cause cyclical pain, typically include a 3-D evaluation of the uterine shape
presenting at puberty. This may pose a diagnostic looking for Müllerian uterine anomalies (see
dilemma if the uterine anomaly is not known, Müllerian Duct Abnormalities). The tubes
because these patients will present with a painful should be evaluated for the presence of fluid, to
98
Hematometra and Hematocolpos Section 1
determine if the obstruction has extended to the the ipsilateral ovary is normal sonographically,
fallopian tubes. The inner lining of the uterus then fluid in a rudimentary horn may be confused
(endometrial surface) should be evaluated care- with a degenerating fibroid or a hydrosalpinx. Rec-
fully for any masses indicating polyps or malig- ognizing the uterus as unicornuate using 3-D ultra-
nancy. The cervix should be assessed for the sound would be an important clue to the correct
presence of obstructing lesions such as fibroids diagnosis of a Müllerian duct abnormality. The
or large polyps. It may be difficult to see a small presence of such a uterine anomaly is also vital to
cervical carcinoma sonographically; however, making the correct diagnosis of an obstructed
the type of cervical lesion that obstructs the hemivagina. Otherwise the vaginal fluid could be
uterus is likely large enough to be visualized confused with a Gartner’s duct cyst or urethral
using a high-frequency transvaginal probe. diverticulum (see Vaginal Masses and also Bladder
The vagina is often easier to evaluate sono- Masses). The patient’s age, pain, and menstruation
graphically by placing the vaginal probe on the history are likely to be important factors in arriving
introitus and looking down the length of the at the correct diagnosis.
vagina and urethra (see Vaginal Masses and also
Bladder Masses). Any fluid collection along the Clinical Aspects and Recommendations
vagina may represent an obstructed hemivagina, The cause of the hematometra/hydrometra or
a finding often associated with congenital uterine hematocolpos/hydrocolpos will guide the man-
anomalies. agement. Patients who are asymptomatic and
simply have a small amount of clear intrauterine
Fluid inside a normal uterine cavity does not have
fluid with a normal endometrium do not require
treatment because this is not considered a clini- H
a differential diagnosis and is not always patho- cally significant finding. Pediatric patients are
logic. It is important to note that a small amount of likely to have Müllerian duct abnormalities that
clear fluid in a postmenopausal uterus is not abnor- need surgical intervention. Postmenopausal
mal. The different causes of hematometra/hydro- patients who are bleeding and have a fluid col-
metra (described in Etiology, earlier) are the more lection in the uterus require evaluation of the
diagnostically challenging step. The presence of cervix and endometrium to rule out malignancy.
fluid in an abnormal uterine cavity such as a rudi- Those with a previous ablation that somehow
mentary uterine horn can be confused with a cystic spared the fundus of the uterus are a challenge
adnexal mass, including those of ovarian origin. If and should be evaluated on an individual basis.
99
Section 1 Hematometra and Hematocolpos
Figure H1-1 A and B, Longitudinal and transverse

views of the uterus with fluid present in the cavity,
including the cervix. Note that the fluid has low-level
H echoes, which is characteristic of unclotted blood. This

was the result of an obstruction at the level of the
external os. C, Blood flow in the myometrium but no
flow within the uterine cavity.
Figure H1-3 Small amount of fluid in the uterine

cavity of an asymptomatic patient. With a normal-
Figure H1-2 Large hematometra. Note the large appearing endometrium, this is not considered to be
fluid collection filling the uterus with a closed cervix. clinically significant.
100
B
Figure H1-4 This is a patient post-endometrial ablation with pelvic pain. A, A transverse view through the uterine
fundus showing a hematometra (centrally). B, A dilated fallopian tube full of fluid (arrows) with debris consistent
with a hematosalpinx. The contralateral tube had the same appearance, suggesting that there is residual cycling
endometrium at the uterine fundus, above the level of the ablation.
101
Section 1 Hematometra and Hematocolpos
H B
C
Figure H1-5 Postmenopausal patient with endometrial cancer and a 5-week history of postmenopausal bleeding.
A and B, An endometrial mass (calipers) with abundant vascularity, located in the uterus and outlined by intracavi-
tary fluid. C, A 3-D rendered image of the uterine cavity distended with fluid, showing two separate irregular
masses in the endometrium and protruding into the cavity.
102
Suggested Reading
Goldstein SR. Postmenopausal endometrial fluid col-
lections revisited: look at the doughnut rather than
the hole. Obstet Gynecol. 1994;83:738-740.
Drakonaki EE, Tritou I, Pitsoulis G, Psaras K, Sfaki-
anaki E. Hematocolpometra due to an imperforate
hymen presenting with back pain: sonographic
diagnosis. J Ultrasound Med. 2010;29:321-322.
Shaked O, Tepper R, Klein Z, Beyth Y. Hydrometro-
colpos—diagnostic and therapeutic dilemmas.
J Pediatr Adolesc Gynecol. 2008;21:317-321.
Verma SK, Baltarowich OH, Lev-Toaff AS, Mitchell
DG, Verma M, Batzer F. Hematocolpos secondary
to acquired vaginal scarring after radiation therapy
for colorectal carcinoma. J Ultrasound Med. 2009;28:
949-953.
Figure H1-6 Translabial view of the vagina of a

young patient with a known complex Müllerian duct
abnormality. Note the obstructed hemivagina
containing fluid (arrows). H
103
Section 1
Hydrosalpinx
Synonyms/Description Hydrosalpinges are often accompanied by free
Fluid-filled, distended fallopian tube pelvic fluid, especially in acute pelvic inflamma-
tory disease or ectopic pregnancy. The presence
Etiology of a solid mass within a dilated tube, along with
A hydrosalpinx is a dilated fallopian tube filled a negative pregnancy test, may suggest fallopian
with fluid. A normal tube is not visible sono- tube carcinoma, although abundant vascularity
graphically; however, when a tube becomes would also usually be present.
obstructed, it distends and fills with fluid, giving Three-dimensional ultrasound is very helpful
it a sausage-like appearance. Infection is a major for demonstrating the course of the dilated tubes.
cause of hydrosalpinx, also called pelvic inflam- Once a volume is obtained, the complete cast of
matory disease (PID), in which the tube fills with the convoluted fallopian tube is easily seen using
pus in the acute phase of the disease (pyosal- the inverse mode. This technique enables the
pinx). In ectopic pregnancy, the tube can distend practitioner to view a cast of the entire cystic tube
and fill with blood (hematosalpinx) and have a previously hidden within the volume. The whole
similar appearance to a pyosalpinx. Tubal tor- tube is then demonstrated, even if the tube tra-
H sion presents with acute pain and a tender, dis-
tended tube. Scarring and adhesions in the pelvis
verses multiple planes.
can obstruct the tubes and allow them to fill with Differential Diagnosis
fluid, but this is more often found in asymptom- Most hydrosalpinges are tubular fluid collections
atic patients since it is not an acute process. This that do not conform to any single plane. There-
can also be seen in cases of severe endometriosis, fore with 2-D ultrasound, they can have the
or previous pelvic surgery. Rarely, tuberculosis appearance of a multiseptate cystic mass. The
and other infections can attack the pelvis and “spoke-wheel” walls and a separate ovary suggest
result in hydrosalpinx. the correct diagnosis; however, too often the
findings are nonspecific. Using standard 2-D
Ultrasound Findings sonography, the differential diagnosis includes
A hydrosalpinx has a typical sonographic appear- an ovarian neoplasm or a peritoneal inclusion
ance. Evaluation of the adnexa reveals a cystic, cyst. Volume (3-D) ultrasound with inverse
sausage-shaped, serpiginous, tubular mass. The mode is essential to connecting the cystic spaces
distended tube often has a characteristic “spoke- into a tubal architecture if the mass is a hydrosal-
wheel” pattern made up by the incomplete sep- pinx. The patient’s symptoms also play an impor-
tae of the tube. The tube can become redundant tant part in making the correct diagnosis. If a
and fold upon itself, giving the appearance of a patient presents with a cystic adnexal mass and
multiseptate cystic mass. If the adjacent ovary is severe pain, the differential diagnosis would
not clearly visualized, it is easy to suspect ovarian include pelvic inflammatory disease (signs of
pathology. If the hydrosalpinx is the result of pel- infection), an ectopic pregnancy (positive preg-
vic inflammatory disease, the tubal wall can nancy test), or tubal torsion. Chronic pain or
occasionally be thick and irregular, making the cyclic pain might indicate endometriosis. Ovar-
correct diagnosis more difficult. In the study by ian neoplasms are often asymptomatic, but so
Sokalska and colleagues (from the IOTA multi- are chronic hydrosalpinges.
center study), the sensitivity for the sonographic A right-sided adnexal mass can be confused
diagnosis of hydrosalpinx was 86%. with an appendiceal mucocele. A dilated ureter
104
Hydrosalpinx Section 1
can occasionally mimic a hydrosalpinx although filled with anechoic fluid, has thin walls, and the
the ureter typically peristalses. patient is asymptomatic, treatment is not typi-
cally required. Salpingectomy may be indicated
Clinical Aspects and Recommendations for infertile patients or those with prior ectopic
Most hydrosalpinges are found incidentally and pregnancies desiring to conceive. Acute pelvic
are asymptomatic. Treatment, if indicated, inflammatory disease will be treated with antibi-
focuses on the etiology. If the hydrosalpinx is otics, often intravenously.
Figure H2-1 Classic sonographic appearance of a simple hydrosalpinx in three different patients. Note that the
dilated tube is seen entirely in one plane, a rare finding.
105
Section 1 Hydrosalpinx
2
1
B
Figure H2-2 A, A 2-D sonographic image of the distal end of a hydrosalpinx, showing the typical “spoke-wheel”
appearance of the incomplete septae in a dilated tube. B, The 3-D inverse rendering of the same tube, demon-
strating the complete outer contour of the hydrosalpinx, including the bulbous blunted distal end seen in the 2-D
image.
106
Hydrosalpinx Section 1
Figure H2-3 Two- and three-dimensional images of a large hydrosalpinx. The 2-D image shows several individual
cysts; however, the 3-D image demonstrates that these cysts connect and represent a hydrosalpinx rather than
ovarian cysts.
Figure H2-4 Two-dimensional image of the left adnexa showing a normal ovary with a tubular multiseptate
cystic mass (calipers) lateral to the ovary. There are small “spoke-wheel” type incomplete septae within the cysts,
but the cysts do not appear to connect to each other. The 3-D image shows that these cystic components connect
into a long and narrow hydrosalpinx, confirming the diagnosis only suspected using 2-D ultrasound.
Figure H2-5 Large multiseptate cystic mass suspected to be a hydrosalpinx using 2-D ultrasound, but confirmed
107
with 3-D inverse mode.
Section 1 Hydrosalpinx
Suggested Reading
Sokalska A, Timmerman D, Testa AC, Van Holsbeke C,
Lissoni AA, Leone FPG, Jurkovic D, Valentin L.
Diagnostic accuracy of transvaginal ultrasound
examination for assigning a specific diagnosis to
adnexal masses. Ultrasound Obstet Gynecol.
2009;34:462-470.
Timor-Tritsch IE, Monteagudo A, Tsymbal T. Three-
dimensional ultrasound inversion rendering tech-
nique facilitates the diagnosis of hydrosalpinx. J
Clin Ultrasound. 2010;38:372-376.
Figure H2-6 Thick-walled large hydrosalpinx in a
patient with acute pelvic inflammatory disease. Note
the thick and irregular wall as well as the debris and
echogenic fluid in the tube consistent with a
pyosalpinx.
Figure H2-7 3-D images of a dilated tube containing

debris in a patient with acute pelvic pain. This was
proven to be torsion of the fallopian tube at surgery.
108
Section 1
Intrauterine Device Location, Abnormal

Synonyms/Description the IUD is much easier to see than the IUD itself,
Mirena especially when dealing with the non–copper–
ParaGard containing type. The shadow of the IUD often
IUD facilitates finding the IUD by following the
IUCD (intrauterine contraceptive device) shadow sonographically.
LARC (long-acting reversible contraception)
Etiology If an IUD is in the uterus, there is most often no
The uterus may be too small to accommodate an other diagnosis to consider. If there is a shadow-
intrauterine device (IUD) or the IUD may not ing structure in the uterus, however, other etiolo-
open normally because of placement or ana- gies can include an area of calcification from a
tomic abnormalities or it may become lodged in fibroid or endometrial scarring, or a foreign
the lower uterine segment/cervix. The IUD may body such as a laminaria. If a patient has an
become embedded in the myometrium. ultrasound immediately after an endometrial
biopsy or other instrumentation of the cavity, air
Ultrasound Findings left in the cavity can be very bright and echogenic
Three-dimensional ultrasound is crucial to deter- with a shadow, simulating an IUD. Generally,
mining the location of an IUD. Although the the IUDs are a typical shape that is recognizable
shaft of the IUD is visible using 2-D ultrasound,
it is often more difficult to see the relationship
and not usually confused with these other
conditions. I
between the arms of the IUD and the uterine cav-
ity, especially if the IUD did not open normally
or has become bent. Sometimes the shadow of
Figure I1-1 Mirena IUD in place. Figure I1-2 ParaGard IUD in place.
109
Section 1 Intrauterine Device Location, Abnormal
Clinical Aspects and Recommendations bleeding, a 3-D ultrasound should be done to

An abnormally located IUD can cause pelvic evaluate the position of the device in the uterus.
pain and bleeding, although this can also be an Malpositioned IUDs need to be removed to
incidental finding in an asymptomatic patient. If improve symptoms.
a patient with an IUD presents with pain or
I A B
C
Figure I1-3 A and B, Uncommon IUDs from foreign countries. C, A Lippes loop IUD, no longer on the market.
110
Intrauterine Device Location, Abnormal Section 1
C
B
Figure I1-4 A and B, Longitudinal and transverse views of an IUD lodged in the cervix. C, The 3-D coronal view
I
showing that the IUD is embedded in the upper cervical substance.
A B
Figure I1-5 A, A prominent IUD shadow, upside down in the region of the left cornu. B, Backing the ultrasound beam
in from the shadow reveals the exact position of the Mirena IUD, malpositioned across the top of the uterine cavity. 111
Section 1 Intrauterine Device Location, Abnormal
Right horn Left horn
IUD
Figure I1-8 This Mirena was inserted in a septate

uterus. It is lodged in the cervix as the septum
blocked its placement into the uterine cavity.
Figure I1-6 The uterus is too small to accommodate

an IUD; therefore, the IUD was not able to open.
Figure I1-9 Perforating IUD, half out the anterior

wall of the uterus. Note the puckering of the serosal
surface of the uterus.
Figure I1-7 The IUD is upside down, looking like an

anchor.
112
Intrauterine Device Location, Abnormal Section 1
Suggested Reading
Benacerraf BR, Shipp TD, Bromley B. 3D ultrasound
detection of embedded intrauterine contraceptive
devices—a source of pelvic pain and abnormal bleed-
ing. Ultrasound Obstet Gynecol. 2009;34:110-150.
Bonilla-Musoles F, Raga F, Osborne NG, Blanes J.
Control of intrauterine device insertion with three-
dimensional ultrasound: is it the future? J Clin
Ultrasound. 1996;24:263-267.
Lee A, Eppel W, Sam C, Kratochwil A, Deutinger J,
Bernaschek G. Intrauterine device localization by
three-dimensional transvaginal sonography. Ultra-
sound Obstet Gynecol. 1997;10:289-299.
Peri N, Graham D, Levine D. Imaging of intrauterine
contraceptive devices. J Ultrasound Med. 2007;
26:1389-1401.
Shipp TD, Bromley B, Benacerraf BR. The width of
the uterine cavity is narrower in patients with an
embedded intrauterine device (IUD) compared to
a normally positioned IUD. J Ultrasound Med.
Figure I1-10 Correct placement of Essure coils in 2010;29:1453-1456.
the interstitial portion of the tubes bilaterally. Valsky DV, Cohen SM, Hochner-Celnikier D, Lev-
Sagie A, Yagel S. The shadow of the intrauterine
device. J Ultrasound Med. 2006;25:613-616.
113
Section 1
Intravenous Leiomyomatosis
Benign metastasizing leiomyoma Pelvic malignancies separate from the uterus and
ovaries, such as sarcoma or lymphoma.
Etiology
This is caused by intravascular proliferation of a Clinical Aspects and Recommendations
smooth muscle, leiomyoma-like tumor, which is This is an extremely rare condition. The disease
noninvading locally, but grows within venous is usually asymptomatic and will often be dis-
channels of the uterus and pelvis as serpiginous covered incidentally on a chest x-ray. However,
tubular masses. This growth can be extensive and some patients will present with a cough, short-
occasionally even reach the inferior vena cava and ness of breath, or even chest pain. The ultimate
the right atrium, causing cardiac symptoms. In one diagnosis is based upon histologic findings of
study, 56% of patients with this condition had the extrauterine leiomyomas on bronchoscopic
previously had a hysterectomy for uterine fibroids. biopsy.
There are two possible etiologies for this rare When the disease is asymptomatic, expectant
tumor: (1) The tumor may originate from smooth management may be an option, although the
muscle in the vessel wall itself. (2) The tumor treatment of choice for symptomatic patients is
originates from a uterine leiomyoma, subse- removal of the intravascular tumors as well as
quently invading adjacent venous channels. hysterectomy/bilateral salpingo-oophorectomy.
I Ultrasound Findings
The tumor typically contains estrogen and pro-
gesterone receptors. Thus treatment with oopho-
These leiomyoma-like lesions are nodular, tubu- rectomy and medications that induce medical
lar, and serpiginous solid masses in the pelvis. menopause, such as GnRH agonists, aromatase
The intravascular location of these masses is not inhibitors, or even progestins, has been shown to
well seen sonographically. Color flow is typically result in tumor regression. Usually the lesions
visible within these masses. The characteristic will shrink or disappear after castration. Thus,
features are tubular solid masses, often bilateral, hormone replacement therapy is usually
following the course of pelvic veins. contraindicated.
114
Intravenous Leiomyomatosis Section 1
RT RT
RT
RT
I
Figure I2-1 Four different views of the serpiginous and tubular solid mass in the right side of the pelvis, which
was subsequently proven to be intravenous leiomyomatosis. There was abundant Doppler color flow in the mass.
Suggested Reading Kokawa K, Yamoto M, Yata C, Mabuchi Y, Umesaki N.

Andrade LA, Torresan RZ, Sales Jr JF, Vicentini R, De Postmenopausal intravenous leiomyomatosis with
Souza GA. Intravenous leiomyomatosis of the high levels of estradiol and estrogen receptor.
uterus. A report of three cases. Pathol Oncol Res. Obstet Gynecol. 2002;100:1124-1126.
1998;4:44-47. Lou YF, Shi XP, Song ZZ. Intravenous leiomyomato-
Diakomanolis E, Elsheikh A, Sotiropoulou M, Voul- sis of the uterus with extension to the right heart.
garis Z, Vlachos G, Loutradis D, Michalas S. Intra- Cardiovasc Ultrasound. 2011;24(9):25.
venous leiomyomatosis. Arch Gynecol Obstet. Low G, Rouget AC, Crawley C. Intravenous leiomyo-
2003;267:256-257. matosis with intracaval and intracardiac involve-
ment. AJR. 2012;265:971-974.
115
Section 1
Lymph Nodes, Enlarged

Lymphadenopathy
Etiology
Lymph nodes are common sites of metastatic 2
1
disease in gynecologic tumors and are an impor-
tant prognostic factor in these malignancies. For
example, the 5-year survival for a patient with
vulvar cancer and normal nodes is 90%, com-
pared with a patient with nodal disease, whose
5-year survival rate is 50%.
Ultrasound Findings
Normal lymph nodes (including pelvic) are typi-
cally oblong bean-shaped and small, with the
transverse diameter less than or equal to 10 mm.
They have a peripheral hypoechogenic band with a
hyperechogenic (fatty) hilum. The vascular pattern
of normal lymph nodes is characteristic, with the Figure L1-1 Normal lymph node. The normal lymph
feeding artery and vein coursing in and out from node is identified by calipers. Color flow to the node
the hilum. Lymph nodes containing tumor tend to (arrows) shows a single source of vessels along the
be enlarged, with an irregular border and loss of long axis of the small node.
normal sonographic architecture. They are rounded
in shape rather than oblong, and their blood-flow
pattern can become multifocal and disorganized.
L Differential Diagnosis
Sonographically, an enlarged lymph node appears
as a mass, and may be difficult to distinguish from
any other solid mass in the pelvis, unless the loca-
tion and pattern of blood flow suggest a lymph
node. The color flow pattern of a lymph node will
virtually always have a single vascular source.

Ultrasound may be the initial method of detec-
tion of abnormal pelvic lymph nodes. This find-
ing carries important prognostic and therapeutic Figure L1-2 Patient with chronic lymphocytic
implications and may help to stage disease in a leukemia. Transverse view of the pelvis in a patient
cancer patient. PET/CT and other imaging tech- with a full bladder showing bilateral solid masses
niques are likely to be used to further determine along the pelvic side walls indenting the sides of the
bladder.
extent of disease and treatment.
116
Lymph Nodes, Enlarged Section 1
Left
B
A
C
Figure L1-3 A, Magnified view of a left-sided mass seen transvaginally, showing a homogeneously solid mass
(calipers). This enlarged and abnormal node is rounded and wide, with loss of normal architecture. B, The same
mass is interrogated with color flow Doppler, showing that the blood flow into the mass originates from one side,
characteristic of a lymph node. C, The contralateral lymph node (seen here using 3-D color Doppler) is also
enlarged with abundant color flow.
Suggested Reading Gore RM, Newmark GM, Thakrar KH, Mehta UK, Ber- L
Fischerova D. Ultrasound scanning of the pelvis and lin JW. Pelvic incidentalomas. Cancer Imaging.
abdomen for staging of gynecological tumors: a 2010;10:S15-S26.
review. Ultrasound Obstet Gynecol. 2011;38:246-266.
Lai G, Rockall AG. Lymph node imaging in gyneco-
logic malignancy. Semin Ultrasound CT MRI.
2010;31:363-376.
117
Section 1
Metastatic Tumor to the Ovary

Synonyms/Description while the primary has not yet been discovered.
Secondary ovarian tumor Reportedly, up to 7% of ovarian lesions present-
Krukenberg tumor (originating mostly from the ing as primary ovarian malignancies are actually
gastrointestinal tract) metastatic in origin.
Metastatic tumors from nongastrointestinal
Etiology origin tend to be more solid and smaller than
Metastatic tumors to the ovary account for those from a gastrointestinal origin.
approximately 20% of ovarian malignancies.
The most common primary origins for meta- Differential Diagnosis
static disease to the ovary include colon, stom- Metastatic tumors to the ovary can have a similar
ach, breast, and the genitourinary tract, and less appearance to primary ovarian malignancies.
commonly, lymphoma and leukemia. Kruken- Both can be complex cystic and solid masses
berg tumor is a specific term, characteristically associated with ascites. The bubbly or frothy
used to describe metastatic colon or stomach appearance of the mass, often large and bilateral,
adenocarcinoma to the ovary, although breast is a feature that should raise suspicion for meta-
and other sites may be the primary. Spread of the static adenocarcinoma of the gastrointestinal
primary tumor to the ovaries may occur from tract rather than a primary ovarian cancer.
direct seeding or, more likely, via lymphatics. Often the smaller unilateral masses are
nonspecific-appearing and cannot be accurately
Ultrasound Findings diagnosed as a primary or secondary malig-
Metastases to the ovaries are bilateral in 60% to nancy. Abundant color flow is usually present in
80% of cases, especially when the primary malig- these malignant tumors, whether they are pri-
nancy originates from the stomach, colon, rectum, mary or secondary. The presence of abundant
or breast. color flow would make a benign etiology
Krukenberg tumors are bilateral in more than unlikely.
70% of cases. They are typically large masses con-
taining solid and cystic components. Frequently Clinical Aspects and Recommendations
the mass is multiloculated with a multitude of The prognosis of secondary ovarian tumors is typi-
small cystic compartments intermixed with solid cally poor; patients with gastric cancer metastatic
M areas, giving a frothy sonographic appearance.
More than 50% of Krukenberg tumors have asso-
to the ovaries usually succumb to the disease within
1 year. The treatment for malignancies that have
ciated ascites, especially when there is bilateral metastasized to the ovary varies according to the
disease. It is not uncommon to have the Kruken- primary tumor. Management may include a com-
berg tumor be the initial symptom or finding, bination of oncologic and surgical approaches.
118
Metastatic Tumor to the Ovary Section 1
A 1 D 15.20 cm
2 D 9.89 cm
B
Figure M1-1 A and B, Metastatic colon cancer to B
the ovary—Krukenberg tumor. Note the multiple tiny Figure M1-2 A and B, Adenocarcinoma of the
cystic areas and septations, giving a frothy appear- stomach metastatic to the ovary—Krukenberg tumor.
ance. B shows that part of the mass is solid. Note the large size of the tumor with multiple small
cystic areas within a solid matrix.
2
1 D 13.09 cm
2 D 12.55 cm
Figure M1-3 Colon cancer metastatic to the ovary.

Note the large size of the mass, which is typical.
119
Section 1 Metastatic Tumor to the Ovary
A B
Figure M1-4 A and B, Largely solid-appearing ovarian mass with some cystic areas as well as small punctate
calcifications. This tumor proved to be metastatic colon adenocarcinoma.
LTO
A B
C
Figure M1-5 A, B, and C Small echogenic mass with internal blood flow shown on Doppler examination (B and
C). This proved to be an adenocarcinoma originating from the appendix and metastatic to the ovary, first present-
ing as an adnexal mass.
Metastatic Tumor to the Ovary Section 1
1
B
Figure M1-6 Two different cases of metastatic
breast cancer to the ovary. Both are small tumors
that are largely solid, although A shows a small cystic
portion. Figure M1-7 Small solid ovarian mass with internal
blood flow. This was found to be metastatic angiosar-
coma of the ovary at surgery. The appearance is
nonspecific sonographically, although suspected to be
a malignancy.
Suggested Reading Koyama T, Mikami Y, Saga T, Tamai K, Togashi K. Sec-

Guzel AB, Gulec UK, Paydas S, Khatib G, Gumurdulu ondary ovarian tumors: spectrum of CT and MR
D, Vardar MA, Altintas A. Preoperative evaluation,
clinical characteristics, and prognostic factors of
nongenital metastatic ovarian tumors: review of 48
features with pathologic correlation. Abdom Imag-
ing. 2007;32:784-795.
Loke TKL, Lo SS, Chan CS. Case report: Krukenberg
M
patients. Eur J Gynaecol Oncol. 2012;33(5): tumours arising from a primary duodenojejunal
493-497. adenocarcinoma. Clin Radiol. 1997;52:154-155.
Jain V, Guptay K, Kudvay R, Rodrigues GS. A case of Yada-Hashimoto N, Yamamoto T, Kamiura S, Seino H,
ovarian metastasis of gall bladder carcinoma simu- Ohira H, Sawai K, Kimura T, Saji F. Metastatic ovar-
lating primary ovarian neoplasm: diagnostic pit- ian tumors: a review of 64 cases. Gynecol Oncol.
falls and review of literature. Int J Gynecol Cancer. 2003;89:314-317.
2006;16(suppl. 1):319-321.
121
Section 1
Mucinous Cystadenoma
Synonyms/Description invasive tumors, although this is a very subjective
One of the epithelial-stromal tumors containing finding.
mucoid material
Etiology The differential diagnosis includes any complex
Most mucinous cystadenomas are benign cystic mass of the adnexa. These diagnoses are
tumors, although 20% can be borderline (low numerous and include serous cystadenoma,
malignant potential) or malignant. Benign muci- cystadenofibroma, endometrioma, peritoneal
nous cystadenomas represent 20% to 25% of all inclusion cyst, degenerating fibroid, complex hy-
benign ovarian tumors and occur mostly during drosalpinx, and so on. It may not be possible to
the third to fifth decades. These mucinous tumors arrive at a specific diagnosis sonographically
are comprised most often of the mucin-producing when faced with a multiseptate cystic mass; how-
cell type similar to a cell type that lines the intes- ever, the characteristic finding to consider in a
tinal tract, although a minority of the tumors mucinous cystadenoma is the presence of low-
have endocervical-like mucin-producing cells. level echoes, much like an endometrioma but
Some tumors may contain both cell types. with multiple septations. Often a patient with
Borderline mucinous cystadenomas are of low endometriosis will be symptomatic and may
malignant potential and carry a 5-year survival have other sites of endometriotic implants that
prognosis of 95%. The less common borderline would differentiate it from a single asymptom-
the endocervical type has a worse prognosis and atic mass such as a cystadenoma. If a separate
higher recurrence rate than the intestinal type. For ovary can be found, the differential might in-
the borderline and invasive neoplasms, see else- clude non-ovarian diagnoses such as hydrosalpinx
where in this book. or peritoneal inclusion cyst.

Mucinous cystadenomas are multilocular in 50% Like any adnexal mass, mucinous cystadenomas
of cases, with solid components or papillary pro- may present with pelvic pain, especially during
jections in 40% of borderline and malignant activities such as intercourse, exercise, or defeca-
cases. The fluid inside the cystic area typically tion. However, most commonly they are asymp-
M contains low-level echoes much like an endome-
trioma; however, when interrogated with Dop-
tomatic and are appreciated on routine bimanual
pelvic examination or incidentally found at the
pler, the echoes stream compared with those in time of pelvic imaging for virtually any indica-
endometriomas, which usually do not. The dif- tion. Benign mucinous ovarian neoplasms can
ferent compartments of the cystic mass may differ become extremely large and thus come to surgi-
as to the texture of the echoes within, likely cal exploration. When they are multilocular,
secondary to different cell types within a single they may raise suspicion for malignancy. Increas-
tumor. When internal nodules with blood flow ingly, however, a minimally invasive approach
are present, the possibility of a borderline or inva- using laparoscopic surgery is favored over lapa-
sive malignancy must be considered. Typically, rotomy, especially to preserve ovarian function
borderline malignancies have fewer nodules and when the mass is considered benign. Although
less blood flow within them compared with less common, when unilocular and small, these
122
Mucinous Cystadenoma Section 1
masses can be treated expectantly. Tumor mark-

RT
ers such as CA125 are elevated in less than 50%
of malignant neoplasms, and thus would not be
expected to be extremely helpful in such cases. If
conservative management is undertaken, follow-
up sonographic surveillance at periodic intervals 1
is appropriate.
RT A 2
Dist 9.09 cm
Figure M2-1 Typical mucinous cystadenoma. Note B

the diffuse low-level echoes with multiple septations.
Figure M2-3 A and B, Multiseptate mucinous
cystadenoma with fine septations containing color
flow but no nodularity.
LT
Figure M2-4 Mucinous cystadenoma with low-level

Figure M2-2 Unilocular cystadenoma with typical echoes in one portion, typical of this type of tumor,
but somewhat coarse low-level echoes caused by the in which there are different echo textures in each
mucinous secretions. compartment.
123
Section 1 Mucinous Cystadenoma
Suggested Reading Achten R, Amant F, Vergote I, Timmerman D.

Caspi B, Hagay Z, Appelman Z. Variable echogenicity Ultrasound features of different histopathological
as a sonographic sign in the preoperative diagnosis subtypes of borderline ovarian tumors. Ultrasound
of ovarian mucinous tumors. J Ultrasound Med. Obstet Gynecol. 2005;26:644-650.
2006;25:1583-1585. Hart WR. Mucinous tumors of the ovary: a review. In
Fruscella E, Testa AC, Ferrandina G, De Smet F, Van J Gynecol Pathol. 2005;24:4-25.
Holsbeke C, Scambia G, Zannoni GF, Ludovisi M,
124
Section 1
Müllerian Duct Anomalies

Synonyms/Description when a rudimentary horn is present. They are
Congenital uterine anomalies also associated with preterm delivery.
Etiology Class III: Didelphic Uterus (5% of Uterine

Congenital anomalies of uterine shape occur in Anomalies)
3% to 4% of all women. The prevalence in These patients have a complete lack of fusion of
women with infertility and early miscarriage is the bilateral Müllerian ducts, resulting in two
up to 10%, and as high as 25% in those with totally separate uterine horns, each with its own
midtrimester pregnancy losses. Patients with endometrial cavity and cervix. The vagina also
uterine shape abnormalities have an increased contains a septum in 75% of cases. Uterine didel-
incidence of congenital renal anomalies such as phys is associated with spontaneous miscarriage
unilateral renal agenesis. The American Society rates of 32% to 52% and premature birth rates of
for Reproductive Medicine has developed the 20% to 45%.
following classification of uterine anomalies.
Class IV: Bicornuate Uterus (10% of Uterine
Class I: Agenesis of the Uterus, Cervix, and/or Anomalies)
Upper Vagina Incomplete fusion of the two Müllerian ducts leads
Includes women with Mayer-Rokitansky-Küster- to a concave dip in the serosal surface of the uterine
Hauser syndrome (incidence 1/5000). Patients fundus as well as a division of the endometrial
with this condition are born with no uterus, cer- cavity into two horns that connect near the cervix.
vix, or upper vagina. Bicornuate uteri are associated with spontaneous
abortion rates of 28% to 35% and premature
Class II: Unicornuate Uterus (20% of Uterine birth rates of 14% to 23%.
Anomalies)
This anomaly results from a lack of or incom- Class V: Septate Uterus (55% of Uterine
plete development of one of the two Müllerian Anomalies)
tubercles. This gives rise to only one complete When there is absence of normal resorption of
horn of the uterus with either total absence or the uterine septum after the two Müllerian ducts
hypoplasia of the contralateral horn (rudimen- have fused, the uterine cavity will be septate. The
tary horn). In 35% of cases, the unicornuate
uterus is isolated, but most are associated with
septum may be complete or partial (more com-
mon), but the serosal surface of the uterus
M
variable development of a contralateral rudimen- remains normal. A uterine septum is associated
tary uterine horn. Thirty-three percent of women with spontaneous abortion rates ranging from
with a unicornuate uterus have a noncavitary 26% to 94% and premature birth rates ranging
rudimentary horn (without endometrium), from 9% to 33%.
whereas 32% have a rudimentary horn with
endometrium present. This rudimentary horn Class VI: Arcuate Uterus
may or may not communicate with the “normal” This is considered a normal variant. With a nor-
hemiuterus. mal serosal surface, these uteri have a slight
Unicornuate uteri are associated with an early indentation of the fundal portion of the uterine
pregnancy loss rate of 41% to 62%, especially cavity that measures less than 1 cm in depth.
125
Section 1 Müllerian Duct Anomalies
Ultrasound Findings Differential Diagnosis

Before 3-D ultrasound, 2-D ultrasound was the The 3-D coronal view of the uterus is very accu-
first imaging modality to suspect a Müllerian rate, and there is usually no differential diagnosis
duct anomaly; however, MRI was needed to dis- when the image is adequate. It is sometimes diffi-
play the coronal view of the uterine cavity to cult to decide whether the uterus is arcuate or
make the correct diagnosis. Although the hys- partially septate, and admittedly the criteria are
terosalpingogram accurately depicts the shape of rather arbitrary, probably with some overlap
the uterine cavity, it provides no information clinically. The same is true for the borderline
about the outer contour of the uterus. A hystero- bicornuate uterus in which the serosal dip may
salpingogram cannot distinguish between a sep- not quite reach 10 mm.
tate and a bicornuate uterus. The unicornuate uterus may have a bizarre-
Currently, 3-D ultrasound can easily provide a looking rudimentary horn, which can mimic a
reconstructed coronal view of the uterus, dem- solid mass such as a fibroid. In such cases, the
onstrating both the shape of the endometrial presence of the unicornuate anatomy of the
cavity and the outer serosal/myometrial contour uterus should suggest the correct diagnosis of a
of the uterus. MRI is no longer necessary to diag- rudimentary horn.
nose the vast majority of uterine malformations.
The accuracy of both 3-D ultrasound and MRI Clinical Aspects and Recommendations
for diagnosing specific uterine malformations is All types of uterine anomalies are associated with
90% to 95%. renal anomalies. Women with a unicornuate
Once a 3-D image of the coronal view of the uterus have the highest prevalence of renal
uterine cavity is obtained, the anatomy of the anomalies, occurring in approximately 40%.
uterus can be observed easily. The uterus is septate Although all uterine anomalies are associated
if the septum extends 10 mm or more into the with a multitude of reproductive complications,
cavity from the midcornual line and the serosal the only type amenable to definitive treatment is
surface is normal. A septum that is shallow and the septate uterus. Hysteroscopic resection of a
extends less than 10 mm caudally defines an uterine septum is a relatively successful proce-
arcuate uterus. A bicornuate uterus has a serosal dure in expert hands. Removal of a uterine septum
indentation extending 10 mm or more caudally is not always necessary and should be based on
from the normal serosal surface, thus creating two the patient’s reproductive history and desires,
horns. The bicornuate uterus also has an obliga- the size of the septum, and consultation with
tory septum or partial septum, called a subseptum. experts in this area. Because all forms of uterine
Patients with Müllerian duct anomalies may have anomalies are associated with certain types of
two cervices (bicollis), which are visible using obstetric complications, these patients require
M 3-D reconstruction of the cervix. A uterine didel-
phys has two completely separate uterine horns
differing degrees of surveillance during preg-
nancy. Consultation or management by maternal-
that are located at opposite sides of the pelvis. fetal medicine experts should be considered.
These two horns are typically hard to image
simultaneously because of their distance from
each other.
126
Müllerian Duct Anomalies Section 1
Figure M3-1 The normal uterine cavity seen using

the 3-D coronal view. Note the triangular shape of
the uterine cavity and the rounded outer myometrial A
wall or serosal surface of the uterus.
Figure M3-2 Mayer-Rokitansky-Küster-Hauser

syndrome. Note the absence of the uterus and cervix
in the pelvis. The vaginal probe could only be
inserted part of the way into the vagina. The rest of
M
the vagina is not developed. B
Figure M3-3 A and B, Two different patients with
arcuate uteri. B shows the proper way to measure the
depth of the myometrial indentation. If the measure-
ment is 10 mm or more, then it is a septum. The
measurement was less than 10 mm, indicating an
arcuate uterus.
127
A B
D
Figure M3-4 Bicornuate uterus seen in 2-D and 3-D in two different patients. The 2-D image is a transverse view
M through the fundus of the uterus, showing two islands of endometrium and indicating a Müllerian anomaly. The
3-D image shows the typical bicornuate uterus with a deep indentation at the fundus, dividing the uterus into two
distinct horns. These horns merge in the lower uterine segment. Figures A and B are one patient and C and D are
another.
128
2.0 nm
* 1
B
Figure M3-5 A and B, Uterus didelphys. Note that the two uterine horns are widely separated and take on the
appearance of floppy rabbit ears on this 3-D coronal view.
M
2
Figure M3-6 3-D coronal view of a typical partial septum or subseptum. The calipers demonstrate the method of
measuring the depth of the septum.
129
A B
M D
C
Figure M3-7 A to D, Four different patients with partially septate uteri. Note the very different widths and
depths of the septae when comparing the appearance of these uteri. The smallest septum (A) measured 12 mm
and has an appearance similar to the arcuate uterus in Figure M3-3.
130
C
Figure M3-8 A partially septate or subseptate uterus. A is a 2-D transverse view, showing the typical two islands
of endometrium consistent with a Müllerian anomaly. B shows the preoperative 3-D coronal view of the partial
septum. C shows the postoperative result of the septal excision.
131
2
1
E
2.0 nm
1
M 3
C
Figure M3-9 Partially septate/subseptate uterus seen using 3-D and sonohysterography. A and B show the 3-D
volume displaying the partial septum. C to E show the sonohysterogram images of the same septum (C is a parallel
tomographic cut through the uterus). Note that the catheter is visible inside the left endometrial cavity.
132
B
Figure M3-10 Unicornuate uterus. A shows a unicornuate uterus seen with 2-D ultrasound. The anomaly is very
hard to detect on this view. B and C show the single uterine horn using 3-D ultrasound. The 3-D rendered coronal
view makes the anomaly obvious.
133
Figure M3-12 Unicornuate uterus with a small

rudimentary horn. Note that the rudimentary horn
contains a small cavity that connects to the rest of the
uterus but is tiny.
Bladder
B
Figure M3-11 A and B, Unicornuate uterus with a
noncommunicating rudimentary horn. A, The 2-D
M image suggests a septate uterus; however, the 3-D

coronal view (B) demonstrates the rudimentary horn
with an island of endometrium, which does not
connect with the rest of the cavity.
Figure M3-13 Obstructed hemivagina. This patient
had a didelphic uterus, and there was a fluid collec-
tion in the vaginal region. This is a view from the
perineum looking up into the vagina. Note the fluid
collection (arrows), indicating an obstructed
hemivagina.
134
Suggested Reading
Deutch TD, Abuhamad AZ. The role of 3-dimensional
ultrasonography and magnetic resonance imaging
in the diagnosis of Müllerian duct anomalies: a
review of the literature. J Ultrasound Med. 2008;27:
413-423.
Faivre E, Fernandez H, Deffieux X, Gervaise A, Fryd-
man R, Levaillant JM. Accuracy of three-dimensional
ultrasonography in differential diagnosis of septate
and bicornuate uterus compared with office hyster-
oscopy and pelvic magnetic resonance imaging.
J Minim Invasive Gynecol. 2012;19:101-106.
Ghi T, Casadio P, Kuleva M, Perrone AM, Savelli L,
Giunchi S, Meriggiola MC, Gubbini G, Pilu G,
Pelusi C, Pelusi G. Accuracy of three-dimensional
ultrasound in diagnosis and classification of
congenital uterine anomalies. Fertil Steril. 2009;
92:808-813.
Homer HA, Li TC, Cooke ID. The septate uterus: a
Figure M3-14 Complete septate uterus with an early review of management and reproductive outcome.
pregnancy in the left horn Fertil Steril. 2000;73:1-14.
Khati NJ, Frazier AA, Brindle KA. The unicornuate
uterus and its variants: clinical presentation, imag-
ing findings, and associated complications. J Ultra-
sound Med. 2012;31:319-331.
Troiano RN, McCarthy SM. Müllerian duct anoma-
lies: imaging and clinical issues. Radiology.
2004;233:19-34.
Woelfer B, Salim R, Banerjee S, Elson J, Regan L,
Jurkovic D. Reproductive outcomes in women with
congenital uterine anomalies detected by three-
dimensional ultrasound screening. Obstet Gynecol.
2001;98:1099-1103.
Figure M3-15 Shallow partial septum/subseptum in

a uterus that also contains a set of twins in the right
horn.
135
Section 1
Ovarian Calcifications
Synonyms/Description conceivably represent a small dermoid or just a
Echogenic foci or “bright spots” of the ovary scar, but is also likely not to be clinically signifi-
Most commonly thought to represent calcified cant. If there is an associated mass, the differen-
corpora albicans tial diagnosis includes many different ovarian
tumors either benign or malignant, and the pos-
Etiology sible diagnoses relate to the appearance and tex-
In a study by Brown and colleagues, small ovar- ture of the mass rather than the presence of small
ian calcifications (1 to 3 mm) were found in calcifications.
more than half of women examined with trans-
vaginal ultrasound who were scheduled to Clinical Aspects and Recommendations
undergo oophorectomy for unrelated diagnoses. Isolated punctate echogenic foci in an otherwise
The mean number of echogenic foci per ovary normal ovary are typically incidental findings.
was 8.7 (range, 1 to 30). In 23 ovaries with sono- No treatment is recommended for this benign
graphically detected echogenic foci, the location finding.
was peripheral in 17 ovaries, central in 1, and
both central and peripheral in 5. Histology iden-
tified a potential cause of the echogenic foci in
17 of the 23 ovaries (74%). The most frequent
sole histologic finding was a corpus albicans
with hemosiderin (26% of cases). Inclusion cysts
were also frequently seen along with a corpus
albicans. The foci were not associated with either
endometriosis or malignancy.
Brown and colleagues also studied larger calci-
fications on the ovary (greater than 5 mm; range,
5 to 13 mm) in patients with otherwise normal
ovaries who did not undergo surgery and found
that they were stable over time (mean, 3 years).
Figure O1-1 Normal-appearing ovary with multiple
Ultrasound Findings small peripheral punctate calcifications.
These are small echogenic foci, often without
acoustic shadowing, that usually appear along
the peripheral aspect of normal ovaries, espe- Suggested Reading
cially in older women. If there is an associated Brown DL, Frates MC, Muto MG, Welch WR. Small
O mass in the ovary and the calcifications are part
of the mass, they should be interpreted as such.
echogenic foci in the ovaries: correlation with
histologic findings. J Ultrasound Med. 2004;23:
307-313.
Differential Diagnosis Brown DL, Laing FC, Welch WR. Large calcifications
Ovaries that have small punctate echogenic foci in ovaries otherwise normal on ultrasound. Ultra-
without a mass are considered normal. A single sound Obstet Gynecol. 2007;29:438-442.
larger calcification without a mass could
136
Section 1
Ovarian Cancer (Epithelial)

Synonyms/Description papillary carcinoma of extra-ovarian origin, is
Ovarian carcinoma or adenocarcinoma considered a very aggressive cancer.
Etiology Ultrasound Findings

Ovarian cancer is the second most common Pattern recognition and Doppler features of an
(endometrial is number one) genital tract malig- ovarian mass are the most accurate method of
nancy (1% to 2% lifetime risk) and the most differentiating a malignant from a benign tumor
deadly (overall 5-year survival of 45%). Familial when performed by an experienced practitioner.
predisposition accounts for 5% to 10% of women In general, unilocular clear cysts with smooth
who develop ovarian cancer and is typically asso- borders, no nodularity, and absent internal blood
ciated with BRCA1 and BRCA2 gene mutations. flow are characteristic features of a benign mass.
Ovarian cancer is more prevalent with increasing Papillary projections with abundant blood flow,
age, usually occurring in postmenopausal women. large and irregular solid components, thick sep-
Most cancers are of the epithelial type, the most tations, and irregular walls are signs of malig-
common of these being serous cystadenocarci- nancy. These features are characteristic of all
noma (greater than 50%); the cell type compris- epithelial ovarian tumors; hence, it is not possi-
ing this tumor is very similar to that found in the ble to distinguish the exact tissue diagnosis sono-
fallopian tubes. Endometrioid adenocarcinoma graphically. Once the tumor is advanced, ascites
(15% to 20% of epithelial ovarian cancers) and and peritoneal seeding are common and easily
clear cell tumors of the ovary (6% of epithelial visualized sonographically.
tumors) are associated with pelvic endometriosis Color flow Doppler is very important to evalu-
and tend to occur in younger women. Mucinous ate the presence or absence of prominent vessels
adenocarcinoma (5% to 10% of epithelial tumors) within the solid areas of the tumor. Prior reports
is a mucin-producing tumor and resembles the suggested that spectral Doppler indices might be
intestinal or endocervical cell types. Other rarer helpful to distinguish malignant from benign
cell types include carcinosarcoma (epithelial and lesions. Although vessels in a malignant mass have
mesenchymal mixed tumor), transitional cell, a lower resistive index and abundant diastolic flow
squamous cell carcinoma, and Brenner tumors compared with those seen in benign masses, this
(see related sections elsewhere in the book). finding has not been helpful in premenopausal
Traditionally, ovarian cancer was thought to women. The corpus luteum is very vascular with a
arise de novo from the surface epithelium (meso- low resistive pattern similar to tumor vessels, mak-
thelium) of the ovary. However, there is recent evi- ing the spectral Doppler waveform potentially
dence that the most common ovarian cancer useful only in postmenopausal patients. The map-
originates from the fallopian tube. This precursor ping of blood vessels in the center of a mass is far
lesion, called serous intraepithelial tubal carci-
noma (STIC), is very similar to high-grade ovarian
more informative than the spectral Doppler wave-
form. More recently, some authors have suggested O
serous carcinoma. The current theory is that most using 3-D ultrasound with power Doppler to
of these tumors arise from a STIC in the fimbriated quantify the blood flow within the solid portions
end of the fallopian tube then spread to the ovary. of the tumor. Three-dimensional power Doppler
Even when the ovaries have been removed, a vascular indices used to quantify blood flow
patient can still develop primary peritoneal car- include the vascularization index, flow index, and
cinoma. This entity, known as serous surface vascularization-flow index. Although evaluating
137
Section 1 Ovarian Cancer (Epithelial)
the blood flow indices within a mass may be of have a similar, but imperfect accuracy. Either
some value, it does not seem to add substantially way, about 15% of benign and 10% of malignant
to the subjective sonographic assessment of the masses will be misdiagnosed. Furthermore there
mass by experienced practitioners. is no evidence that any other imaging modality
The International Ovarian Tumor Analysis performs better than ultrasound for the evalua-
(IOTA) multicenter group has devised and tested tion of ovarian masses.
several approaches to determining whether an
adnexal mass is malignant. Its five simple rules Differential Diagnosis
include five features suggestive of malignancy: M1, The differential diagnosis of solid or complex
irregular contour; M2, ascites; M3, 4+ papillations; ovarian masses is vast. The main goal of the
M4, irregular, multilocular, solid tumor with a ultrasound examination is to determine whether
largest diameter greater than or equal to 100 mm; the mass is suspicious for malignancy or almost
M5, strong vascularity. The group also compiled certainly benign. Once the mass is deemed to
five features suggestive of a benign mass: B1, uni- have malignant sonographic characteristics
locular; B2, solid components less than 7 mm in (thick septations, irregular walls, vascular nodu-
largest diameter; B3, acoustic shadows; B4, larity, or solid areas with abundant blood flow),
smooth, multilocular tumor; B5, no visible blood the differential diagnosis includes primary ovar-
flow. The presence of one or more of the M fea- ian tumors versus metastatic lesions to the ovary.
tures in the absence of any B feature conveys a The sonographic appearance of primary and
diagnosis of malignancy. If one or more B features secondary ovarian malignancies is very similar.
are present in the absence of any M feature, the Furthermore a tubal cancer also has an appear-
diagnosis is benign. If both M features and B fea- ance similar to an ovarian tumor, so the sono-
tures exist in the same mass, the diagnosis is graphic appearance does not help to differentiate
inconclusive. The group studied 1938 patients between these types of malignancies. A mass
with an adnexal mass of which 1396 (72%) were associated with ascites is worrisome for a malig-
benign, 373 (19.2%) had primary invasive can- nancy. A borderline ovarian tumor typically has
cers, 111 (5.7%) had borderline tumors, and 58 some sonographic characteristics of malignancy,
(3%) had metastatic tumors to the ovary. The M but the nodularity is often smaller and perhaps
and B rules gave definitive results in 77% of less vascular. A uterine tumor such as a sarcoma
masses. In the other 23% cases, pattern recogni- can be exophytic and mimic a malignant adnexal
tion by an expert was necessary to aid in the diag- mass. If the mass has indeterminant characteris-
nosis. These simple rules ultimately resulted in a tics such as some nodularity with limited blood
sensitivity and specificity for predicting a malig- flow, it could be a cystadenoma or cystadenofi-
nant mass of 92% and 96%, respectively. For com- broma. Although purely solid masses can be
parison, the corresponding sensitivity and epithelial cancers, they are more likely to be
specificity of subjective assessment by a specialist fibromas or teratomas or dysgerminomas
were 91% and 96%, respectively. The IOTA group because epithelial malignancies tend to have
also reported that serum CA125 does not improve some cystic component of varying sizes.
the diagnostic performance ultrasound models for
O diagnosis. There is recent evidence that serial

CA125 readings with attention to trends for an
The treatment of ovarian cancer usually includes
individual patient may be a better way to use the surgical debulking and chemotherapy. Once the
test than a single cutoff value. diagnosis is suspected, the patient is typically
In summary, ultrasound scoring by morpho- referred to a multidisciplinary team including
logic criteria and subjective reading by an expert gynecologic and medical oncologists.
138
Ovarian Cancer (Epithelial) Section 1
Figure O2-1 Seven-centimeter ovarian cancer.

Transvaginal view of the solid-appearing mass with
abundant vascularity with irregular, jagged vessels.
A B
Rt Ov-PS 9.66 cm/s
Rt Ov-ED 5.76 cm/s
E8 Rt Ov-S/D 1.68
Rt Ov-RI 0.40
Ov-PS
O
C Ov-ED
Figure O2-2 A to C, Ovarian cancer. Nine-centimeter ovarian cancer showing small cystic areas within a largely
solid mass with extensive vascularity. C shows the low resistive index of 0.4 using spectral Doppler. This abundant
diastolic flow is frequently seen in malignant tumors; however, the mere presence of disorganized blood vessels in
the center of the mass is the most important Doppler finding.
139
1
1 2
2 1
A B
C
Figure O2-3 Advanced ovarian cancer. A shows a large amount of ascites anterior to the uterus (calipers) on a
transverse view of the pelvis. B shows the large complex irregular mass (calipers), which was the ovarian tumor.
Note the surrounding ascites. C shows the extensive ascites surrounding bowel loops, higher up in the abdomen.
140
A
Figure O2-5 Serous cystadenocarcinoma in a
pregnant patient who presented for a routine 9-week
obstetric scan. Note the typical deranged and irregu-
lar branching vascularity within the nodule.
B
Figure O2-4 Clear cell carcinoma. A shows a largely
cystic tumor with areas of nodularity that are often
associated with endometriosis. B shows that the solid
nodules contain blood flow, which is a characteristic
of malignancy.
O
141
2
2
A B
C
Figure O2-6 A and B, Very large serous cystadenocarcinoma, almost completely solid with a few small internal
cysts. C shows the intense vascularity with typical disorganized tumor vessels.
142
RT
LT
A B
C
Figure O2-7 Bilateral papillary serous cystadenocarcinoma. A shows the right-sided lesion, which is predomi-
nantly cystic with several solid areas and a thick septum. B and C, The left-sided lesion is mostly solid with a small
cystic component.
143
RT
A B
C
Figure O2-8 A to C, Typical serous cystadenocarcinoma with a mostly solid texture and extensive disorganized
vascularity.
144
2 1
RT
C
Figure O2-9 Stage 1 ovarian cancer in a 73-year-old patient. A shows an enlarged left ovary with a subtle 1.5-cm
solid mass (calipers). B shows the normal (small) right ovary for comparison. C and D show the abundant blood
flow to the small tumor. Typically it is difficult to demonstrate blood vessels within a normal postmenopausal
ovary, making the flow pattern in the left ovary abnormal.
145
Campbell S. Ovarian cancer: role of ultrasound in

preoperative diagnosis and population screening.
Kaijser J, Bourne T, Valentin L, Sayasneh A, Van Hols-
beke C, Vergote I, Testa AC, Franchi D, Van Calster B,
Timmerman D. Improving strategies for diagnosing
ovarian cancer: a summary of the International Ovar-
ian Tumor Analysis (IOTA) studies. Ultrasound Obstet
Gynecol. 2013;41:9-20.
Sharma A, Apostolidou S, Burnell M, Campbell S,
Habib M, Gentry-Maharaj A, Amso N, Seif MW,
Fletcher G, Singh N, Benjamin E, Brunell C, Turner
A
G, Rangar R, Godfrey K, Oram D, Herod J, Wil-
liamson K, Jenkins H, Mould T, Woolas R, Mur-
doch J, Dobbs S, Leeson S, Cruickshank D, Fourkala
EO, Ryan A, Parmar M, Jacobs I, Menon U. Risk of
epithelial ovarian cancer in asymptomatic women
with ultrasound-detected ovarian masses: a pro-
spective cohort study within the UK collaborative
trial of ovarian cancer screening (UKCTOCS).
Timmerman D, Ameye L, Fischerova D, Epstein E,
Melis GB, Guerriero S, Van Holsbeke C, Savelli L,
Fruscio R, Lissoni AA, Testa AC, Veldman J, Ver-
B gote I, Van Huffel S, Bourne T, Valentin L. Simple
ultrasound rules to distinguish between benign
Figure O2-10 A and B, Primary extraovarian
and malignant adnexal masses before surgery:
peritoneal carcinoma. Arrows show the linear solid
prospective validation by IOTA group. BMJ.
mass coating the lateral side wall of the pelvis and
2010;341:c6839.
peritoneal cavity.
Timmerman D, Valentin L, Bourne TH, Collins WP,
Verrelst H, Vergote I. Terms, definitions and mea-
Videos surements to describe the sonographic features of
Video 1 on ovarian cancer (epithelial) is available adnexal tumors: a consensus opinion from the
online. International Ovarian Tumor Analysis (IOTA)
Group. Ultrasound Obstet Gynecol. 2000;16:500-505.
Suggested Reading Vang R, Shih EM, Kurman RJ. Fallopian tube precur-
Alcázar JL, Rodriguez D. Three-dimensional power sors of ovarian low- and high-grade serous neo-
Doppler vascular sonographic sampling for predict- plasms. Histopathology. 2013;62:44-58.
ing ovarian cancer in cystic-solid and solid vascular-
ized masses. J Ultrasound Med. 2009;28:275-281.
Ameye L, Valentin L, Testa AC, Van Holsbeke C, Domali
E, Van Huffel S, Vergote I, Bourne T, Timmerman D.
O A scoring system to differentiate malignant from

benign masses in specific ultrasound-based sub-
groups of adnexal tumors. Ultrasound Obstet Gynecol.
2009;33:92-101.
146
Section 1
Ovarian/Tubal Torsion
Synonyms/Description because venous flow may be obliterated, but
Adnexal torsion arterial flow may still be present. The ovary also
has a dual blood supply, which may confound
Etiology the Doppler findings. Doppler interrogation of
Torsion is defined as the twisting by at least one the twisted vascular pedicle may reveal a spiral
complete turn of the adnexa, ovary, or (rarely) the appearance of the vessels, referred to as the
tube only around the infundibulo-pelvic and tubo- “whirlpool” sign. A positive whirlpool sign has a
ovarian ligament, resulting in ischemia. It occurs high positive predictive value for diagnosing tor-
more frequently on the right side (70%), perhaps sion and should be part of the evaluation in a
because of a longer tubo-ovarian ligament on the symptomatic patient.
right. Approximately 15% of ovarian torsions occur The detection rate of torsion is reportedly only
in children. An increase in weight of the adnexa is between 46% and 74%, likely because of the
the primary risk factor for torsion, particularly with nonspecific findings associated with this entity
dermoid cysts and other mobile ovarian masses. and lack of expertise in recognizing them.
Ovarian cancer or endometriomas seldom cause Isolated tubal torsion is rare, and it typically
torsion because of lack of mobility of these lesions. mimics a hydrosalpinx such that differentiation
The incidence of ovarian torsion increases during between an uncomplicated hydrosalpinx and tubal
pregnancy, and ovarian stimulation is an addi- torsion is difficult. The whirlpool sign can be very
tional risk factor. helpful when considering tubal torsion.
Up to 26% of cases of torsion occur in patients
who have an apparently normal adnexa; therefore Differential Diagnosis
a leading ovarian mass is not always present. A patient with ovarian or tubal torsion typically
Paratubal cysts weighing down the tube can presents with fairly acute, worsening pelvic pain.
cause isolated torsion of the tube, although this This is often, although not always, accompanied
is rare compared with ovarian torsion. Occasion- by nausea, vomiting, and fever. The clinical dif-
ally a torsed fallopian tube is associated with a ferential diagnosis includes appendicitis, ureteral
hydrosalpinx. calculi, diverticulitis, colitis, ectopic pregnancy,
pelvic inflammatory disease, and ruptured or
Ultrasound Findings hemorrhagic ovarian cyst. The presence of an
An adnexal mass in a patient with pain should adnexal mass narrows the differential diagnosis
prompt consideration of adnexal torsion as a to a tubo-ovarian abscess (TOA), an ectopic
diagnosis. The typical appearance of a torsed pregnancy, a hemorrhagic cyst, or torsion. Color
ovary is a large, edematous ovary with multiple, Doppler may help because a TOA is associated
small, peripherally placed follicles and heteroge- with excessive blood flow caused by inflamma-
neous texture of the ovarian stroma. The ovary
may be very large and tender during the scan. If
tion, and an ectopic pregnancy can be excluded
by a negative pregnancy test. An inflamed O
color Doppler reveals no blood flow in the ovary, appendix can occasionally be confused with an
then the diagnosis of torsion can be made confi- adnexal mass; however, the tubular configuration
dently. The presence of flow, however, cannot be of the appendix should help to exclude ovarian
used to rule out adnexal torsion. Blood flow to torsion, and a normal ovary usually can be visu-
the ovary may be intermittent or diminished alized transvaginally.
147
Section 1 Ovarian/Tubal Torsion
Clinical Aspects and Recommendations will eventually result in necrosis of the ovary
Adnexal or ovarian torsion is a gynecologic sur- and/or fallopian tube. The longer surgical treat-
gical emergency, and quick diagnosis is essen- ment is delayed, the more severe the sequelae
tial. If the diagnosis is made early and normal because of increasing release of cytokines, which
blood flow is restored, the adnexa may be saved. can result in sepsis and more severe systemic
If the diagnosis is missed or delayed, ischemia sequelae.
FF2/E1
P5/E2
SRI II 5/CRI 5
RT SRI II 3
2
2
1 D 11.43 cm
A 1 D 10.07 cm
2 D 6.26 cm
B 2 D 7.23 cm
RT
C D
Figure O3-1 Adolescent girl with a 1-month history of pelvic pain. Endometriosis was the diagnosis initially given
before referral. A shows a large pelvic mass seen anterior to the uterus on a transabdominal scan (calipers). B to D
show various transvaginal views of the mass, which has both cystic and solid components. Note that there is
complete absence of blood flow to the ovary. The diagnosis of torsion was made based on these findings, and the
patient was taken to surgery.
148
Ovarian/Tubal Torsion Section 1
Twisted pedicle
A B
Twisted pedicle
C
Figure O3-2 Young, reproductive-age woman with a 2-day history of acute pelvic pain. Local diagnosis of ovarian
tumor was made. A shows the huge edematous ovary with a few peripheral follicles. B shows the edematous
twisted pedicle. C shows color Doppler of the whirlpool sign of the twisted pedicle.
149
2
1
2
A B
C
Figure O3-3 A, Transvaginal view of a huge pelvic mass with no blood flow. Note the severely edematous ovary
with a few peripheral follicles. B and C show the twisted vascular pedicle or positive whirlpool sign in 2-D and 3-D.
150
Ovarian/Tubal Torsion Section 1
53
* 45 3 2
2.0 mm
1
* 1
2 3 4
C O
Figure O3-4 Torsed fallopian tube. A shows a hydrosalpinx with a very thickened wall and debris within the tube.
B and C show 3-D of the tube, demonstrating the complex-appearing fluid and debris within the swollen tube. The
diagnosis of torsion was made at surgery.
151
Videos Servaes S, Zurakowski D, Laufer MR, Feins N, Chow

Video 1 on ovarian/tubal torsion is available JS. Sonographic findings of ovarian torsion in chil-
online. dren. Pediatr Radiol. 2007;37(5):446-451.
Valsky DV, Esh-Broder E, Cohen SM, Lipschuetz M,
Yagel S. Added value of the gray-scale whirlpool
Suggested Reading
sign in the diagnosis of adnexal torsion. Ultrasound
Boukaidi SA, Delotte J, Steyaert H, Valla JS, Sattonet C,
Bouaziz J, Bongain A. Thirteen cases of isolated
Vijayaraghavan SB, Senthil S. Isolated torsion of the
tubal torsions associated with hydrosalpinx in
fallopian tube: the sonographic whirlpool sign.
children and adolescents, proposal for conserva-
Ultrasound Med. 2009;28:657-662.
tive management: retrospective review and litera-
Wilkinson C, Sanderson A. Adnexal torsion—a multi-
ture survey. J Pediatr Surg. 2011;46:1425-1431.
modality imaging review. Clin Radiol. 2012;67:
Huchon C, Fauconnier A. Adnexal torsion: a litera-
476-483.
ture review. Eur J Obstet Gynecol Reprod Biol.
2010:1508-1512.
152
Section 1
Ovarian Vein Thrombosis

Septic pelvic thrombophlebitis (SPT) A tubular painful mass in the right lower quad-
rant can mimic appendicitis. The ultrasound
Etiology findings may be similar, although the appendix
Ovarian vein thrombosis is a rare but potentially is typically located more anteriorly in the abdo-
severe postpartum complication, occurring 80% men than is the ovarian vein, which is more
to 90% of the time on the right side, and with a dorsal. Doppler is also helpful in differentiat-
reported incidence of 1:600 to 1:2000 deliveries. ing these two diagnoses, as abundant color
Ovarian vein thrombosis can also occur in the flow is seen in the walls of the appendix and
immediate postoperative period after pelvic sur- ovarian vein thrombosis has little flow. Other
gery or in conjunction with pelvic infection or possible but less likely diagnoses when dealing
thrombophilias such as factor V Leiden muta- with a painful lower quadrant mass, especially
tion. Spontaneous ovarian vein thrombosis if left-sided, include ovarian torsion, broad lig-
without any of these predisposing conditions is ament fibroid, hydrosalpinx, and pelvic inflam-
exceedingly rare. matory disease. The presence of a separate
The ovarian veins are located in the retroper- ovary, location of the mass, and color Doppler
itoneum, anterior to the psoas muscle. The pattern are very helpful to arrive at the correct
right ovarian vein is longer than the left, and it diagnosis.
drains into the inferior vena cava below the
right renal vein. The left drains into the left Clinical Aspects and Recommendations
renal vein. Ovarian vein thrombosis should be considered
in postpartum patients who present with abdom-
Ultrasound Findings inal or flank pain (right more frequently) and
Ovarian vein thrombosis appears as a hypoechoic with fever, typically spiking, that is unresponsive
tubular mass cephalad to the ovary. Color Doppler to broad-spectrum antibiotics. These symptoms
typically shows an absence of flow within the mass. often mimic appendicitis, tubo-ovarian abscess,
The sensitivity, specificity, and accuracy of ovarian torsion, or broad ligament hematoma.
ultrasound with Doppler are reportedly 55.6%, Treatment is usually medical and may include
41.2%, and 46.2%, respectively. The sonographic parenteral broad-spectrum antibiotics with the
evaluation is often limited by overlying bowel addition of anticoagulant therapy.
gas because the ovarian vein is a retroperitoneal If untreated, ovarian vein thrombosis can lead
structure; therefore CT with contrast is often used to inferior vena cava and renal vein thrombosis,
to make a more definitive diagnosis. pulmonary thromboembolism, and sepsis.
153
Section 1 Ovarian Vein Thrombosis
2
A A
B
B
Figure O4-2 A and B, Longitudinal view of the right
Figure O4-1 A and B, Longitudinal and transverse external iliac containing multiple clots incidentally
views of the right ovarian vein showing a hypoechoic noted on a gynecologic scan. B shows color Doppler
mass with internal strandy echoes consistent with of the vein in the same projection, showing defects
internal organizing clot. No blood flow was identified within the color consistent with clot. The thrombosis
using Doppler color flow. was confirmed with contrast CT, and the patient was
anticoagulated.
Suggested Reading Sharma P, Abdi S. Ovarian vein thrombosis. Clin

Bilgin M, Sevket O, Yildiz S, Sharifov R, Kocakoc E. Radiol. 2012;67:893-898.
Imaging of postpartum ovarian vein thrombosis. Stafford M, Fleming T, Khalil A. Idiopathic ovarian
Case Rep Obstet Gynecol. 2012;2012:134603. vein thrombosis: a rare cause of pelvic pain—case
Dewdney SB, Benn T, Rimel BJ, Gao F, Saad N, Vedan- report and review of literature. Aust N Z J Obstet
tham S, Mutch DG, Zighelboim I. Inferior vena Gynaecol. 2010;50:299-301.
cava filter placement in the gynecologic oncology
patient: a 15-year institutional experience. Gynecol
O Oncol. 2011;121:344-346.
154
Section 1
Paratubal or Paraovarian Cysts

Synonyms/Description ovarian etiology is possible, especially if the cyst
Adnexal cyst, mesothelial or paramesonephric is not simple and unilocular.
cyst
Etiology Most paratubal or paraovarian cysts are inciden-
Paratubal and paraovarian cysts arise from the tal findings and asymptomatic. When patients
broad ligament. They constitute 10% of adnexal present with pelvic pain, the cysts may have
masses. They are usually benign but may rarely undergone hemorrhage, torsion, or rupture. If
(reportedly 2%) contain malignant or border- the cyst has thick septations, an irregular wall, or
line elements. nodularity, a neoplasm (cystadenoma, cystade-
Etiologies for paratubal cysts include mesosal- nocarcinoma, or borderline tumor) should be
pingeal cysts, hydatid cysts of Morgagni, and considered.
paratubal subserosal cysts arising from Mülle-
rian duct remnants, as opposed to paraovarian
cysts, which arise from mesonephric tubules
(Wolffian duct) and are mesothelial in origin.
Ultrasound Findings
Paratubal and paraovarian cysts are typically uni-
locular thin-walled adnexal cysts that are separate
from the ovaries. Paratubal cysts are usually farther
removed from the ovaries than paraovarian cysts,
which are usually adjacent to the ovary. These cysts
can (rarely) cause tubal or adnexal torsion or
undergo hemorrhage or rupture, resulting in severe A
pelvic pain. Occasionally paratubal or paraovarian
Left
cysts can have septations, nodularities, and excres-
cences, suggesting a malignancy (occurs in 2% of
such cysts).
The presence of a thin-walled, clear adnexal cyst
1
separate from the ovary is considered to be a
paratubal or paraovarian cyst. The differential
diagnosis may include a hydrosalpinx (although
the tubal wall is thicker than that of a cyst) or a
peritoneal inclusion cyst (usually contains mul-
P
B 1 D5.20 cm
tiple septations and takes on the shape of the
adjacent peritoneal surface). It is important to Figure P1-1 A and B, Two views of a simple para-
ovarian cyst
identify the ovary separately; otherwise, an
155
Section 1 Paratubal or Paraovarian Cysts
Kim JS, Woo SK, Suh SJ, Morettin LB. Sonographic

diagnosis of paraovarian cysts: value of detecting a
separate ipsilateral ovary. Am J Roentgenol.
1995;164:1441-1444.
Kiseli M, Caglar GS, Cengiz SD, Karadag D, Yilmaz
MB. Clinical diagnosis and complications of para-
tubal cysts: review of the literature and report of
1 uncommon presentations. Arch Gynecol Obstet.
2012;285:1563-1569.
Stein AL, Koonings PP, Schlaerth JB, Grimes DA,
d’Ablaing 3rd G. Relative frequency of malignant
parovarian tumors: should parovarian tumors be
Figure P1-2 Typical unilocular paratubal cyst. Note aspirated? Obstet Gynecol. 1990;75:1029-1031.
that there is no ovarian tissue visible. The ovary was Terek MC, Sahin C, Yeniel AO, Ergenoglu M,
totally separate from the cyst. Zekioglu O. Paratubal borderline tumor diagnosed
in the adolescent period: a case report and review
of the literature. J Pediatr Adolesc Gynecol.
Suggested Reading 2011;24:e115-e116.
Barloon TJ, Brown BP, Abu-Yousef MM, Warnock
NG. Paraovarian and paratubal cysts: preoperative
diagnosis using transabdominal and transvaginal
sonography. J Clin Ultrasound. 1996;24:117-122.
156
Section 1
Pelvic Congestion Syndrome

Varicose veins of the pelvis Clinically, pelvic congestion syndrome is charac-
terized by pelvic pain of at least 6 months dura-
Etiology tion. It often manifests during or after a pregnancy
Although the etiology of pelvic congestion syn- and worsens with subsequent pregnancies. Such
drome is unclear, it appears that gross dilatation, pain can be variable in its severity, but it is usu-
valve incompetence, and reflux of the ovarian ally described as a dull ache or heaviness. It
veins may be causal. Anatomic and/or hormonal increases premenstrually and is worsened with
factors may lead to insufficiency of the ovarian prolonged standing, postural changes, walking,
and/or internal iliac veins, resulting in peri- or activities that can increase intra-abdominal
ovarian pelvic varicosities. Such tubo-ovarian pressure. Occasionally it is worsened after inter-
varicoceles may be the female equivalent of tes- course. Classically it is unilateral and greater on
ticular varicoceles. the left side in most patients. It is virtually
unheard of in menopausal women, thus impli-
Ultrasound Findings cating the hormone estrogen in part of the
The ultrasound diagnosis is based on a subjec- pathogenesis.
tive impression of excessive venous channels in a There is no standard approach to treatment of
patient with dull and chronic pelvic pain made pelvic congestion syndrome. Ovarian cycle sup-
worse when standing. CT scans have also been pression with combination contraceptives,
used to detect these varicosities, but an ultra- GnRH agonists, or high-dose progestational
sound diagnosis is usually sufficient. The objec- agents has been employed. In the most severe
tive criteria include dilated ovarian veins greater cases refractory to medical management, embo-
than 4 mm in diameter, dilated and tortuous lization of ovarian veins can be performed.
arcuate veins communicating with pelvic vari- Rarely, hysterectomy and bilateral salpingo-
cose veins, and retrograde venous flow, particu- oophorectomy can be viewed as a last resort.
larly in the left ovarian vein.
The diagnosis of pelvic venous congestion is sug-
gested after all other causes of pelvic pain have
been excluded. Endometriosis is a common cause
of chronic pelvic pain that should be investigated
before implicating venous congestion as a final
diagnosis. Furthermore, there are patients with
large pelvic veins who have no pain at all and oth-
ers who barely make the subjective criteria for this
disorder but who complain of debilitating pain.
Certainly once a patient has been investigated for
other causes of pelvic pain, large, dilated, tortu-
P
ous pelvic varicosities with sluggish and occa- Figure P2-1 Color flow Doppler image showing
sional retrograde flow do suggest the diagnosis of excessive and large veins around the uterus in a
patient with characteristic dull but chronic pelvic pain.
pelvic venous congestion syndrome.
157
Section 1 Pelvic Congestion Syndrome
Suggested Reading Ignacio EA, Dua R, Sarin S, Harper AS, Yim D, Mathur
Beard RW, Reginald PW, Wadsworth J. Clinical fea- V, Venbrux AC. Pelvic congestion syndrome: diag-
tures of women with chronic lower abdominal nosis and treatment. Semin Intervent Radiol. 2008;25:
pain and pelvic congestion. Br J Obstet Gynecol. 361-368.
1988;95:153. Tu FF, Hahn D, Steege JF. Pelvic congestion syn-
Hobbs JT. The pelvic congestion syndrome. Br J Hosp drome-associated pelvic pain: a systematic review
Med. 1990;43:200. of diagnosis and management. Obstet Gynecol Surv.
2010;65:332-340.
158
Section 1
Pelvic Kidney
Synonyms/Description hydronephrotic kidney may be mistaken for an
Ectopic location of kidney—normal variant adnexal cystic mass such as an ovarian neoplasm
or hydrosalpinx (in the case of a dilated ureter).
Etiology Ectopic kidneys are associated with Müllerian
The incidence of pelvic kidney is reported as duct anomalies, which may further confuse the
being between 1 in 2200 and 1 in 3000. The nor- sonographic appearance of the other pelvic
mal human kidney migrates to the renal fossa organs.
from a pelvic location early in embryonic devel-
opment, typically before the 10th week of gesta- Clinical Aspects and Recommendations
tion. The congenital failure of this migration Pelvic kidneys are most often incidental and not
results in a pelvic kidney. Although a pelvic kid- clinically significant; however, they are associ-
ney is defined as a normal variant, it is associated ated with Müllerian duct anomalies, which can
with Müllerian duct anomalies such as uterine cause significant reproductive, mostly obstetric,
malformation (see Müllerian Duct Anomalies). complications. Therefore when an ectopic kid-
Pelvic kidney is the most common type of renal ney is identified in a patient of reproductive age,
ectopia and is typically clinically asymptomatic. sonographic evaluation of the reproductive tract,
However, ectopically located kidneys are at preferably 3-D, must be documented.
increased risk of urinary tract infection, stone Occasionally, ectopic kidneys can be diseased
formation, and trauma. and related to lower abdominal pain if there are
renal stones, hydronephrosis, or cysts or pyelo-
Ultrasound Findings nephritis. Rarely, renal masses such as malignan-
Pelvic kidneys that have a normal reniform cies have been identified in pelvic kidneys.
appearance can easily be recognized as an ecto-
pic kidney. It is important to check the corre-
sponding renal fossa to confirm the absence of
RT KID
the kidney in its normal location before diagnos-
ing a pelvic kidney. If there are cysts or fluid col-
lections associated with the pelvic kidney, the
correct diagnosis may be more challenging, and
it is crucial to consider the diagnosis of ectopic
kidney with hydronephrosis and hydroureter.
The patient may also have an associated uterine
anomaly, so a transvaginal gynecologic ultra-
sound should be included as part of the
evaluation.
An abnormal-appearing pelvic kidney may result
in misdiagnosis when there is hydronephrosis, Figure P3-1 Typical right pelvic kidney seen trans- P
large cystic structures, or stones. Ureteropelvic vaginally, adjacent to the vaginal probe. It is impor-
junction (UPJ) obstruction has been reported in tant not to mistake this structure for a solid pelvic
mass.
22% to 37% of ectopic kidneys. A cystic or
159
Section 1 Pelvic Kidney
Suggested Reading
RT
Cinman NM, Okeke Z, Smith AD. Pelvic kidney:
associated diseases and treatment. J Endourol.
2007;21:836-842. Review.
Debenedectis CM, Levine D. Incidental genitourinary
findings on obstetrics/gynecology ultrasound.
Ultrasound Q. 2012;28:293-298.
Hall-Craggs MA, Kirkham A, Creighton SM. Renal
and urological abnormalities occurring with Mül-
lerian anomalies. J Pediatr Urol. 2011;28:27-32.
Meizner I, Yitzhak M, Levi A, Barki Y, Barnhard Y,
Glezerman M. Fetal pelvic kidney: a challenge in
prenatal diagnosis? Ultrasound Obstet Gynecol.
Figure P3-2 Right pelvic kidney (arrows) with a 1995;5:391-393.
common malrotation, which resulted in mild Yildirim I, Irkilata HC, Aydur E, Zor M, Basal S, Gok-
hydronephrosis. tas S. Different clinical presentations of pelvic ecto-
pic kidneys: report of two cases and review of the
literature. Urologia. 2010;77:212-215. Review.
160
Section 1
Polycystic Ovaries
Synonyms/Description either ovary, the scan does not meet sonographic
Polycystic ovarian syndrome (PCOS) definition of PCO. Guidelines recommend the
Stein-Leventhal syndrome scan be repeated at another time (during ovarian
quiescence or in the next cycle).
Etiology
Polycystic ovarian syndrome (PCOS) is the most Differential Diagnosis
common endocrine disorder in women of repro- There is no differential diagnosis for a polycystic
ductive age, occurring in 4% to 6% of the female ovary when using the Rotterdam sonographic
population. PCOS is a complex of symptoms definition earlier on this page. Oral contracep-
often associated with obesity, type 2 diabetes, met- tives can make the ovaries appear polycystic,
abolic syndrome, and infertility. Historically there and normally functioning ovaries can also
had been a lack of consensus regarding the fea- appear polycystic. The ultrasound definition is
tures that define PCOS. In 2003 a consensus state- limited to the appearance of the ovaries. It is
ment was developed between the European and important to take a clinical history in addition
American reproductive societies, known as the to the ultrasound findings so as not to overdiag-
Rotterdam criteria, which standardized the defini- nose PCOS. For example, many adolescent
tion of PCOS. The diagnosis requires two of the women have irregular menses because their
following three findings: (1) oligo-ovulation or hypothalamic-pituitary-ovarian axis has not yet
anovulation, (2) clinical or biochemical signs of matured, and they may have many small
hyperandrogenism, (3) polycystic ovaries on ultra- follicles.
sound. It is important to note that the sonographic
appearance of the ovaries is not always required Clinical Aspects and Recommendations
for this diagnosis. The Rotterdam criteria clarify Ultrasound findings alone are not sufficient to
the difference between polycystic ovaries (PCO), diagnose or exclude PCOS in the absence of clin-
which is a diagnostic finding, and PCOS, which is ical information. Between 16% and 25% of the
a diagnosis affecting multiple organ systems. normal population have multicystic ovaries on
ultrasound, but only 4% to 6% of women have
Ultrasound Findings polycystic ovarian syndrome. Conversely, when
The Rotterdam sonographic definition of a PCO is ultrasound reveals normal-appearing ovaries in a
the presence of either 12 or more follicles measur- patient with oligo-ovulation or anovulation and
ing 2 to 9 mm in diameter or an ovary that has an hyperandrogenism, PCOS should be included in
increased ovarian volume defined as greater than the differential diagnosis.
10 cm3 (ovarian volume is calculated using simpli- Patients with PCOS who are overweight
fied formula for prolate ellipsoid = 0.5 × length × should be encouraged to lose weight through
width × thickness). Only one ovary with these find- diet and exercise. Drug therapies such as oral
ings is required with the following two exceptions. contraceptives or metformin can help with the
This definition does not apply to women tak- symptoms of PCOS. PCOS may increase the risk
ing oral contraceptives.
If there is evidence of a dominant follicle
for endometrial cancer, especially in patients
with prolonged amenorrhea, because of equally
P
(greater than 10 mm) or a corpus luteum on long episodes of unopposed estrogen.
161
Section 1 Polycystic Ovaries
Right ovary
1 3
A
1
A
3
1 D 4.06 cm
B 2 D 2.12 cm
3 D 3.67 cm
Figure P4-1 Measurements of the right (A) and left

(B) ovaries in a patient with PCOS with classic ultra-
sound findings.
Suggested Reading
Balen AH, Laven JSE, Tan SL, Dewailly D. Ultrasound
assessment of the polycystic ovary: international
consensus definitions. Hum Reprod Update. 2003;
9:505-514.
Polson DW, Wadsworth J, Adams J. Polycystic ovaries: B
a common finding in normal women. Lancet.
Figure P4-2 Typical polycystic ovary shown using
1988;1:870-872.
2-D ultrasound (A) and 3-D inverse mode (B), which
Wilson JF. In the clinic. The polycystic ovary syndrome.
shows all the individual follicles in the ovary.
Ann Intern Med. 2011; 154(3): ITC2-2-ITC2-15.
162
Section 1
Polyps, Endometrial
Synonyms/Description or in the proliferative/follicular phase of her
None cycle, a sonohysterogram may be necessary to
further define the finding. If there is a small mass
Etiology within the cavity, the differential diagnosis is
Endometrial polyps are relatively common intra- either a polyp or a submucosal fibroid. A polyp is
uterine lesions that are typically benign and usually more hyperechoic than the surrounding
often asymptomatic. Hyperplastic/proliferative endometrium, or it may be partly cystic. A fibroid
polyp is the most common type of polyp; it rep- is likely to have the same echotexture as the myo-
resents overgrowth of endometrial glands and metrium. Rarely, an adenomyoma can present as
stroma. Clinically they can be associated with an intracavitary mass (see Adenomyosis). It may
postmenopausal and abnormal uterine bleeding be difficult to differentiate a nonglobal endome-
as well as infertility. trial cancer, which appears polypoid, from a true
polyp.
Ultrasound Findings
The ultrasound appearance of endometrial pol- Clinical Aspects and Recommendations
yps varies depending on whether the patient is Postmenopausal patients with nonbleeding
premenopausal or postmenopausal. In premeno- polyps are not automatic candidates for polypec-
pausal women, the endometrium (especially in tomy. If it is removed, it should be done hystero-
the secretory/luteal phase) can be thick and het- scopically, because blind D&C often misses such
erogeneous, which often camouflages the polyps. focal lesions. Patients with abnormal or post-
In the proliferative/follicular phase or in postmenopausal bleeding are always candidates for
menopausal women, when the endometrium is removal of their polyps.
at its thinnest, the polyps may be more obvious Increasingly, it appears that patients with
because of their rounded contour and different asymptomatic polyps discovered incidentally
echotexture from the surrounding endometrium. need not have them automatically removed.
Polyps appear as hyperechoic or cystic lesions Fernandez-Parra and colleagues reported that
within the uterine cavity. In most cases, there is none of the 117 polyps removed in asymptom-
evidence of blood flow in the polyp, as seen by atic postmenopausal women were malignant.
color flow Doppler. The stalk of the polyp can Ferrazzi and colleagues report that there was one
often be identified by Doppler, revealing a single- endometrial cancer (less than 0.1%) in a polyp
vessel pattern and thus highlighting the connec- among 1152 asymptomatic postmenopausal
tion between the polyp and the underlying women in a multicenter trial. Furthermore, Ger-
endometrium. ber and colleagues report that the detection of
A sonohysterogram is very helpful when eval- endometrial cancer in asymptomatic postmeno-
uating the endometrial cavity because polyps pausal patients does not confer a better outcome
may not be discernible from the rest of the endo- compared with cancer patients presenting with
metrium unless outlined by fluid. abnormal uterine bleeding. Finally, operative
hysteroscopy in such postmenopausal patients is
associated with a small but significant incidence
P
When the endometrium is thickened and hetero- of complications (e.g., perforation, false channel,
geneous and the patient is either postmenopausal anesthesia problems).
163
Section 1 Polyps, Endometrial
B
Figure P5-1 A, Patient with thickened endometrium. B shows that when saline is introduced into the endome-
trial cavity, the polyps become visible (calipers on largest one).
164
Polyps, Endometrial Section 1
B
D
Figure P5-2 A, Thickened heterogeneous endometrium with focal echogenic area within the cavity. B and C show
the smooth-walled polyp outlined by fluid during the sonohysterogram. D shows the blood flow to the polyp using
color Doppler.
165
A C
B
Figure P5-3 Two different patients with small 10-mm polyps seen in 2-D and 3-D at the fundus of the uterus.
Note the characteristic smooth, round appearance of the polyps. A and B show the polyps with 2-D and 3-D
transvaginal sonography. C and D show the polyp of a different patient using sonohysterography and color
Doppler.
166
1
2
B
Figure P5-4 A and B, Small polyp (calipers) identified on 2-D transvaginal sonography. The diagnosis is confirmed
by the presence of blood flow with a single-vessel pattern. C shows blood flow to a polyp in a different patient,
demonstrating the similar vascular pattern.
167
POLYP
1
2
B
Figure P5-5 A and B, Tiny cystic polyp seen using
2-D and 3-D ultrasound, mimicking an early preg-
nancy. The patient was postmenopausal.
B
Figure P5-6 Sonohysterography with 3-D ultrasound
P
is an excellent way to demonstrate polyps. A and B
show two different patients with polyps.
168
A C
D
Figure P5-7 A to D, Very large polyp shown in standard 2-D (A), sonohysterography (B), and 3-D sonography with
saline in the uterine cavity outlining the polyp (C and D).
Suggested Reading Gerber B, Krause A, Müller H, Reimer T, Külz T, Kundt

Fang L, Su Y, Guo Y, Yingpu Sun Y. Value of 3-dimen- G, Friese K. Ultrasonographic detection of asymp-
sional and power Doppler sonography for diagno- tomatic endometrial cancer in postmenopausal
sis of endometrial polyps. Ultrasound Med. 2013;32: patients offers no prognostic advantage over symp-
247-255. tomatic disease discovered by uterine bleeding. Eur
Fernandez-Parra J, Rodriguez Oliver A, Lopez Criado S, J Cancer. 2001;37:64-71.
Parrilla Fernandez F, Montoya Ventoso F. Hystero- Goldstein SR. Sonography in postmenopausal bleed-
scopic evaluation of endometrial polyps. Int J Gynae- ing. J Ultrasound Med. 2012;31:333-336.
col Obstet. 2006;95:144-148. Lieng M, Istre O, Qvigstad E. Treatment of endome-
Ferrazzi E, Zupi E, Leone FP, Savelli L, Omodei U, trial polyps: a systematic review. Acta Obstet Gynecol.
2010;89:992-1002.
P
Moscarini M, Barbieri M, Cammareri G, Capobi-
anco G, Cicinelli E, Coccia ME, Donarini G, Fiore S,
Litta P, Sideri M, Solima E, Spazzini D, Testa AC,
Vignali M. How often are endometrial polyps malig-
nant in asymptomatic postmenopausal women? A
multicenter study. Am J Obstet Gynecol. 2009;200:235.
169
Section 1
Premature Ovarian Failure

Synonyms/Description follicular phase. In a study by Sokalska and Val-
Early menopause entin, spanning 2 years before to 2 years after
Ovarian insufficiency menopause, uterine size and left and right ovar-
ian volumes decreased by 22%, 45%, and 20%,
Etiology respectively. Two years before menopause, the
Premature ovarian failure (POF) occurs in total number of follicle-like cysts varied from 0
women under the age of 40 and is characterized to 5, and 2 years after menopause they varied
by amenorrhea, hypoestrogenism, and elevated from 0 to 2.
gonadotropins. It affects an estimated 1% of
women, including 0.1% under age 30. Most Differential Diagnosis
cases of POF are idiopathic. There are theories The ultrasound should not be interpreted with-
that POF is the result of follicular depletion, out knowing the clinical setting. There is no real
accelerated follicular atresia, or other follicular differential diagnosis when seeing a normal but
dysfunction. There are rare genetic and chromo- small uterus and ovaries, and there is no specific
somal causes, which generally involve the X sonographic diagnosis for POF.
chromosome. Other causes of POF include auto-
immune oophoritis, chemotherapy or radiation, Clinical Aspects and Recommendations
and surgical removal of the ovaries. Even a sim- The clinical symptoms of POF are similar to those
ple hysterectomy can lead to premature ovarian of menopause, but because onset is earlier, the
failure secondary to vascular disruptions. result is an increased risk of menopause-associated
conditions such as osteoporosis and cardiovascu-
Ultrasound Findings lar disease, among others. It is important that data
The ultrasound findings in POF are indistin- derived on hormone therapy for menopausal
guishable from menopause. The ovaries tend to patients (average age 51.4) not be blindly applied
be small and comma-shaped, sometimes hard to to women with POF. This is a unique population
locate. The uterus may also be small and will with an abnormal cessation of ovarian function,
typically have a thin endometrial echo. These and hormone therapy in this condition has not
findings are nonspecific, and there is a large been well studied. Adding replacement therapy
overlap between the normal appearance of the until approximately age 50 will simply bring these
pelvis in postmenopausal patients and pre- patients back to appropriate hormone levels com-
menopausal patients, especially early in the pared with their cohorts.
170
Premature Ovarian Failure Section 1
Suggested Reading
Kokcu A. Premature ovarian failure from current per-
spective. Gynecol Endocrinol. 2010;26:555-562.
Maclaran K, Horner E, Panay N. Premature ovarian
failure: long-term sequelae. Menopause Int.
1
2010;16:38-41.
Michalakis K, Coppack SW. Primary ovarian insuffi-
ciency: relation to changes in body composition
and adiposity. Maturitas. 2012;71:320-325.
Sokalska A, Valentin L. Changes in ultrasound mor-
phology of the uterus and ovaries during the meno-
pausal transition and early postmenopause: a 4-year
longitudinal study. Ultrasound Obstet Gynecol.
A 1 D 1.25 cm 2008;31:210-217.
B 1 D 1.81 cm
2 D 1.04 cm
Figure P6-1 A and B, Typical comma-shaped small

ovary (calipers) seen in patients with premature
ovarian failure as well as menopause.
171
Section 1
R Retained Products of Conception

Synonyms/Description sensitivity, specificity, negative predictive value,
RPOC and positive predictive value of 94%, 67%, 95%,
Retained placenta and 65%, respectively. Of the patients with
Incomplete abortion pathologically confirmed retained products of
conception, five had focal increased vascularity
Etiology without a mass, but none had a mass without
Retained products of conception (RPOC) may focal increased vascularity.
occur following an abortion, a vaginal delivery,
or even after a Cesarean section. This obstetric Differential Diagnosis
complication most commonly results in pro- When observing a vascular mass in the endome-
longed or excess vaginal bleeding and has also trium, it is important to determine the clinical
been associated with endometritis. The retained history. The sonographic appearance alone may
tissue may include a portion of the placenta suggest a large polyp or an abnormal endome-
(such as a succenturiate lobe) or tissue from a trium such as hyperplasia or endometrial cancer.
pregnancy not completely evacuated. If the vascularity in the lesion is dramatic, an
AVM may be suspected, although primary uter-
Ultrasound Findings ine AVMs are exceedingly rare. If the patient is
Retained products of conception typically appear postpartum or if there has been a recent preg-
as an echogenic, vascular mass with ill-defined nancy loss, the diagnosis is retained products of
borders, centrally located within the endometrial conception until proved otherwise.
cavity. The mass may contain areas of fluid but is
largely solid. Color Doppler often shows an Clinical Aspects and Recommendations
alarming amount of vascularity, which has been In patients who have had a first trimester preg-
described as mimicking an arteriovenous malfor- nancy loss or termination, the presence of vascu-
mation (AVM); however, this resolves completely larity may be helpful in predicting the success of
after evacuation of the retained products. The expectant management for RPOC. In the study by
sonographic appearance of the retained tissue Casikar and colleagues, the absence of color flow
can have characteristics of placenta, especially if was predictive of successful expectant management
the patient is postpartum. If the patient had an with a sensitivity, specificity, positive predictive
early pregnancy loss or termination, the tissue is value, negative predictive value, and positive
more often echogenic with small cystic areas. likelihood ratio of 90.3%, 37.5%, 89%, 40.9%,
Abundant vascularity is a characteristic feature of and 1.445, respectively. There was no correlation
most types of retained products of conception. between the volume of the retained products and
Durfee and colleagues report that an endome- the success of expectant management.
trial mass is the most sensitive (79%) and spe- Active management includes both surgical
cific (89%) sonographic finding in patients with and medical options. Medical management
retained products of conception. None of the with misoprostol, a prostaglandin agonist, is a
patients in their study with this diagnosis had a relatively new tool. Treatment with misoprostol
completely normal scan. for retained products from early pregnancy fail-
Regarding vascularity, Atri and colleagues ure showed a greater than 90% success rate in
report that the presence of focal vascularity had women presenting with localized abdominal
172
Retained Products of Conception Section 1
pain, Rh-negative blood type, or a combination symptomatic bleeding or acute hemorrhage

of active bleeding and nulliparity. Thus, in a
select group, the decision to pursue expectant,
require surgical management with dilation and
curettage (D&C). In these patients, swift action
R
medical, or surgical management depends on is needed to remove the cause of bleeding since
multiple factors, including patient preference. such patients can rapidly develop disseminated
Patients presenting with hemodynamically intravascular coagulopathy (DIC).
A B
C
Figure R1-1 Typical case of RPOC after an incomplete first trimester pregnancy loss. A and B (gray-scale views)
show the ill-defined margins of the endometrium at the fundus with irregular cystic spaces. The color Doppler in C
shows that these spaces are blood vessels in this very vascular case of RPOC.
173
Section 1 Retained Products of Conception
A C
D
Figure R1-2 A to D, The uterine cavity contains an echogenic mass, filling the cavity (A) and extending to the
edge of the endometrium, blurring the margins (B, calipers). C shows the abundant color flow at the site of the
RPOC. D shows the 3-D appearance of the same case, demonstrating an asymmetric enlargement and deformity of
the left fundus/cornu, representing the RPOC.
174
Retained Products of Conception Section 1
R
1
A B
C
Figure R1-3 A to C, Sclerotic RPOC, 6 months after a term delivery (2-D, Doppler, and 3-D images). Note the
complex-appearing vascular mass involving the endometrium. If this were seen in a postmenopausal patient with
bleeding, the appearance would be consistent with endometrial cancer. The history of a symptomatic postpartum
patient enabled the correct diagnosis of longstanding RPOC (sclerotic on pathologic examination).
175
Section 1 Retained Products of Conception
Figure R1-4 Patient with an endometrial polyp.

Note the similarity to the RPOCs. This patient had
never been pregnant
Videos
Videos 1 and 2 on retained products of contracep-
tion are available online.
Figure R1-5 Rare case of spontaneous AVM unre-
Suggested Reading lated to pregnancy. The entire uterus is replaced by
Atri M, Rao A, Boylan C, Rasty G, Gerber D. Best pre- cystic areas on gray-scale imaging. Color flow Doppler
dictors of grayscale ultrasound combined with shows abnormal vessels reaching to the serosa and
color Doppler in the diagnosis of retained products involving much of the myometrium. The pattern and
of conception. J Clin Ultrasound. 2011;39:122-127. clinical history were very different in this nulliparous
Casikar I, Lu C, Oates J, Bignardi T, Alhamdan D, patient.
Condous G. The use of power Doppler colour scor-
ing to predict successful expectant management in
women with an incomplete miscarriage. Hum
Reprod. 2011;27:669-675.
Creinin MD, Huang X, Gilles J, Barnhart K, Westhoff
C, Zhang J. Medical management of early preg-
nancy failure. Obstet Gynecol. 2006;107:901-907.
Durfee SM, Frates MC, Luong A, Benson CB. The
sonographic and color Doppler features of retained
products of conception. J Ultrasound Med. 2005;
24:1181-1186.
176
Section 1
Scarred Uterus and Asherman’s

Syndrome S
Intrauterine adhesions or synechiae In patients with Asherman’s syndrome, the endo-
metrial echo is difficult to see, with irregular bor-
Etiology ders and disruptions of the endometrial lining in
Most cases of intrauterine adhesions result from multiple areas. There may also be small, focal,
trauma to the endometrium, primarily from dila- cystic-like areas containing blood within the endo-
tion and curettage (D&C) procedures. Patients metrial cavity, trapped by the adhesions. Using
most at risk for developing Asherman’s syndrome 3-D ultrasound, the outline of the endometrial
are those undergoing D&C postpartum for retained cavity is irregular, shaggy, and distorted. Linear
products of conception, incomplete spontaneous adhesions are usually seen, traversing the endome-
abortion (SAB), or therapeutic abortion (TAB). trium, leaving small islands of endometrial echo.
Intrauterine synechiae can occur after any proce- The most accurate method for diagnosing Ash-
dure or process that causes trauma to the normal erman’s syndrome is sonohysterography, in which
endometrium. Examples in addition to those dis- saline is injected into the uterine cavity through a
cussed include abdominal or hysteroscopic myo- small catheter threaded through the cervix. In
mectomy, hysteroscopic septoplasty, and previous severe cases, it may not be possible to distend the
placenta accreta, among others. Synechiae are con- cavity at all, thus confirming the diagnosis of
nective tissue bands that disrupt the endometrium, extensive adhesions. The adhesions may be seen
causing a lack of distention of the uterine cavity. sonographically traversing the cavity in patients
They are associated with recurrent pregnancy loss when saline can distend the cavity even slightly.
and infertility.
Schenker and Margalioth studied 1856 cases Differential Diagnosis
of Asherman’s syndrome and showed that preg- The clinical history is essential in making the
nancy was the main predisposing factor in 90.8% diagnosis of Asherman’s syndrome. A likely sce-
of the patients, with 66.7% of cases occurring nario is a patient presenting with infertility and
after D&C for SAB or TAB, 21.5% after postpar- amenorrhea whose history is significant for a
tum D&C, 2% after Cesarean section, and 0.6% D&C following her last pregnancy.
after evacuation of trophoblastic disease. The ill-defined endometrial echo may suggest
These results appear to show that the endome- the diagnosis of adenomyosis, although in that
trium is most vulnerable to developing Asher- case the uterus is typically globular and asym-
man’s syndrome during the hypoestrogenic state metric, which is not usually a feature of Asher-
immediately after pregnancy. man’s syndrome. Fibroids or polyps can also
Asherman’s syndrome may also occur after distort the endometrium, but these patients typi-
endometrial ablation. These procedures aim to cally complain of excess bleeding, unlike patients
destroy the basalis layer of the endometrium to with intrauterine adhesions, who are more likely
decrease menstrual bleeding. If synechiae occur, to present with amenorrhea or oligomenorrhea.
it makes subsequent evaluation of any abnormal It is remotely possible that a thick synechia
bleeding extremely difficult. could be confused with a uterine septum, although
177
Section 1 Scarred Uterus and Asherman’s Syndrome
it is unlikely because of the asymmetry of adhe- typically treated with hysteroscopic lysis of
sions compared with septa. adhesions, sometimes with intrauterine “stent-
ing,” followed by treatment with sequential
S
estrogen and progesterone therapy to repair the
Patients with significant Asherman’s syndrome endometrium.
are usually infertile and amenorrheic. They are
B
Figure S1-2 A and B, 2-D and 3-D views of a
B severely scarred (arrows) endometrium in a patient
who had recurrent SABs and D&C’s.
Figure S1-1 A and B, Two 3-D coronal views of a
patient with Asherman’s syndrome. Note the echolu-
cent linear jagged structures (adhesions; arrows)
traversing the endometrial cavity.
178
Scarred Uterus and Asherman’s Syndrome Section 1
B
Figure S1-3 A, 3-D coronal view of the shaggy endometrial cavity in a patient with Asherman’s syndrome and
infertility. B is a similar view of the same uterus after hysteroscopic surgery for lysis of the adhesions. Note that
the margins of the endometrium are sharper and smoother than preoperatively.
179
Section 1 Scarred Uterus and Asherman’s Syndrome
S
1
A
B
C
Figure S1-4 A to C, 2-D, multiplanar, and 3-D rendering of the uterine cavity in a patient who had an
endometrial ablation because of excessive vaginal bleeding. Note the irregular outline and severe scarring of the
margins of the cavity; this should not be confused with a partial septum.
180
Scarred Uterus and Asherman’s Syndrome Section 1
Suggested Reading
Berman JM. Intrauterine adhesions. Semin Reprod
Med. 2008;26:349-355.
Knopman J, Copperman AB. Value of 3D ultrasound
in the management of suspected Asherman’s syn-
drome. J Reprod Med. 2007;52:1016-1022.
S
Schenker JG, Margalioth EJ. Intrauterine adhesions: an
updated appraisal. Fertil Steril. 1982;37:593-610.
Yu D, Wong YM, Cheong Y, Xia E, Li TC. Asherman
syndrome—one century later. Fertil Steril. 2008;89:
759-779.
B
Figure S1-5 A and B, Two different patients with
uterine synechiae seen during a sonohysterogram.
Note the fluid outlining the adhesion within the
uterine cavity. These adhesions are similar in appear-
ance to a uterine septum, although correctly diag-
nosed because of asymmetry.
181
Section 1
Schwannoma
S Synonyms/Description often with central hemorrhage and infarction.
Schwann cell tumor The appearance is nonspecific, making the correct
diagnosis by imaging difficult. The large masses
Etiology often displace normal retroperitoneal structures
Schwannomas are peripheral nerve sheath tumors such as the kidney and ureter without invading
composed of Schwann cells, which produce them.
myelin that covers and insulates nerve fibers.
Schwannomas can occur in isolation or may be Differential Diagnosis
associated with neurofibromatosis type I (previ- The differential diagnosis includes any solid or
ously known as von Recklinghausen’s disease). complex vascular mass that is large, posterior
Nerve sheath tumors can occur anywhere (retroperitoneal), and displacing other organs.
along the peripheral nervous system, with only This includes sarcomas, lymphomas, neurofibro-
3% of Schwannomas arising in the retroperito- mas, metastatic disease, renal cell carcinoma, and
neum and pelvis. Retroperitoneal Schwannomas other retroperitoneal tumors. When present in
tend to be very large when detected because they the pelvic area (presacral), they may be confused
are usually asymptomatic or associated with with degenerating fibroids, although the lack of a
nonspecific symptoms, thus delaying diagnosis. uterine stalk should argue against a fibroid.
Malignant peripheral nerve sheath tumors are
even more rare and are classified as sarcomas. Clinical Aspects and Recommendations
Schwannomas are typically benign and only
Ultrasound Findings treated when symptomatic. Malignant Schwan-
Schwannomas are typically solid, hypoechoic, nomas are classified as sarcomas and typically
and well encapsulated, sometimes with cystic are very aggressive. These are managed by multi-
areas and calcifications. They can grow large, up disciplinary teams, which include surgeons,
to 20 cm in diameter, and tend to be vascular, oncologists, and other specialists.
182
Schwannoma Section 1
Left
1 S
A B 2
C
Figure S2-1 A, Large, predominantly solid tumor with an irregular cystic component, located high in the adnexa,
just below the inferior pole of the left kidney. B and C show two different views of the mass, demonstrating the
smooth outer border and the solid texture with cystic spaces.
Suggested Reading Kudo T, Kawakami H, Kuwatani M, Ehira N, Yamato

Daneshmand S, Youssefzadeh D, Chamie K, Boswell H, Eto K, Kubota K, Asaka M. Three cases of retro-
W, Wu N, Stein JP, Boyd S, Skinner DG. Benign peritoneal schwannoma diagnosed by EUS-FNA.
retroperitoneal schwannoma: a case series and World J Gastroenterol. 2011;17:3459-3464.
review of the literature. Urology. 2003;62:993-997.
Habib T, Hamdi JT, Hussain W, Almiamini W, Hamdi
K, Wani AM, Al Zeyani NR. Presacral schwannoma
treated as irritable bowel syndrome. BMJ Case Rep.
2010; 2010:pii.
183
Section 1
Serous Cystadenoma
S Synonyms/Description compartments compared with a serous cystade-
An epithelial-stromal cystic tumor containing noma. An endometrioma typically has character-
serous fluid istic homogeneous low-level echoes. Serous
cystadenomas and some cystadenofibromas can
Etiology be virtually indistinguishable.
Serous cystadenomas are the most common type
of epithelial-stromal tumors. They are lined with Clinical Aspects and Recommendations
cells similar to those lining the fallopian tubes, sug- Cysts that are symptomatic, growing over several
gesting that the origin may be tubal rather than cycles, or extremely large are typically managed
ovarian. These cysts can become very large, although surgically. The type of surgery and route will
not typically as large as mucinous cystadenomas, depend on multiple factors, such as the patient’s
and up to 20% are bilateral. Most (70%) are benign, age, reproductive stage, size of the mass, and benign
whereas 5% to 10% have borderline malignant versus nonbenign appearance of the mass.
potential, and 20% to 25% are frankly malignant,
although there is no indication that benign serous
tumors transform into malignant ones. Left ovary
Ultrasound Findings
Serous cystadenomas are typically thin-walled
unilocular cysts, although they can also be multi-
locular. They are filled with serous fluid, which is
usually clear or may contain tiny particles.
Although less common, a borderline or malignant
tumor must be considered (see elsewhere in the
book for more information on borderline and
malignant ovarian tumors) in cysts with solid
components or nodules, especially if blood flow is A
detected with color Doppler.
The differential diagnosis includes any adnexal
cystic mass such as a mucinous cystadenoma,
cystadenofibroma, endometrioma, peritoneal
inclusion cyst, degenerating fibroid, or hydrosal-
pinx. When unilocular, or simple, they are virtu-
ally indistinguishable from functional type
follicular cysts. The presence of a separate ovary
may be helpful to focus on non-ovarian etiolo- B
gies such as a hydrosalpinx, degenerating fibroid,
or even paraovarian cysts. A mucinous cystade- Figure S3-1 A and B, Unilocular serous cystad-
noma is more likely to be multicystic, displaying enoma of the left ovary. Note that there are no solid
areas or nodularity.
varying sonographic textures within the different
184
Serous Cystadenoma Section 1
Suggested Reading
Maheshwari V, Tyagi SP, Saxena K, Tyagi N, Sharma R,
Aziz M, Hameed F. Surface epithelial tumours of
the ovary. Indian J Pathol Microbiol. 1994;37:75-85.
Sujatha VV, Babu SC. Giant ovarian serous cystade-
noma in a postmenopausal woman: a case report.
S
Cases J. 2009;2:7875.
Figure S3-2 Serous cystadenoma with small areas

of nodularity but no internal blood flow. This is
indistinguishable sonographically from a
cystadenofibroma.
B
Figure S3-3 A and B, Small paraovarian serous
cystadenoma. Similar to Figure S2-2, this lesion has
some mural irregularities but without detectable
blood flow.
185
Section 1
Struma Ovarii
S Synonyms/Description Up to 17% of patients with benign struma
Monodermal, highly specialized mature cystic ovarii may have ascites. Struma ovarii may be
teratoma comprised of ectopic thyroid tissue associated with a contralateral dermoid or other
types of teratoma.
Etiology There are no specific sonographic features that
Struma ovarii is an extremely rare condition. It is help distinguish malignant from benign struma
defined as the presence of thyroid tissue com- ovarii tumors.
prising greater than 50% of the cellular compo-
nent in an ovarian tumor, virtually always a Differential Diagnosis
teratoma. Struma ovarii is a mature teratoma Struma ovarii can mimic a dermoid cyst, although
and accounts for approximately 3% of all ovar- presence of Doppler flow in the solid portions is
ian teratomas. It is usually benign, although 5% very helpful to distinguish a struma ovarii from a
have malignant components that can occasion- dermoid. Because struma ovarii can be solid,
ally metastasize. Tumors may have features of a solid and cystic, or completely cystic with or with-
multinodular goiter, with colloid nodules and out septations, the appearance is nonspecific and
hyperplastic changes. These tumors can vary in makes a precise diagnosis almost impossible.
size, but most are greater than 5 cm at diagnosis. Struma ovarii can also masquerade as an endo-
metrioma, other types of teratomas, or essentially
Ultrasound Findings any ovarian malignancy, depending on the degree
The typical sonographic appearance of struma of flow demonstrated by Doppler.
ovarii is similar to that of a dermoid cyst with
one or more echogenic nodules known as struma Clinical Aspects and Recommendations
pearls. Although the echogenic nodules in der- They are most commonly seen in reproductive-
moids have no evidence of color flow on Dop- age women; however, incidence peaks between
pler interrogation, the struma pearl may be quite the ages of 40 and 60. The possible presence of
vascular, which is a valuable clue to the correct struma ovarii should be suspected in a woman
diagnosis. Sonographically, most cases of struma with hyperthyroidism who has no goiter and
ovarii are nonspecific in appearance and are minimal thyroid uptake of radioactive iodine.
largely solid or have both cystic and solid por- Even among such women, however, true struma
tions. Less commonly, the tumor is predomi- ovarii is rare.
nantly or entirely cystic, although most of these Treatment of hyperthyroidism associated with
are multilocular. Occasionally, struma ovarii will struma ovarii consists primarily of surgical exci-
have a unilocular cystic appearance, making a sion, mainly because of the risk of carcinoma. In
specific sonographic diagnosis difficult. those patients who are symptomatic or have sub-
Doppler is very helpful in detecting struma stantial serologic evidence of hyperthyroidism,
ovarii because most are vascular and demonstrate use of an antithyroid drug for 4 to 6 weeks before
more blood flow than typically seen in a dermoid surgery is recommended. The cyst should be
cyst. removed surgically.
186
Struma Ovarii Section 1
Figure S4-2 Struma ovarii presenting as a large,

solid, heterogenous mass with several areas of relative
increase in echogenicity. Note the presence of blood
flow in the mass.
B
Figure S4-1 A, Small echogenic mass whose appear-
ance suggests a dermoid. B, Doppler color flow with
moderate vascularity in the mass, a characteristic of
struma ovarii.
187
Section 1 Struma Ovarii
SAG RT 1
S
2
COR RT
1
B
C
Figure S4-3 A to C, Struma ovarii presenting as a large 8-cm cystic mass with a few septations. The cystic portions
have dense, homogeneous echoes and no blood flow. Although the pattern of internal echoes might suggest an
endometrioma, the internal echoes are too coarse.
Suggested Reading Saba L, Guerriero S, Sulcis R, Virgilio B, Melis G,

Coyne C, Nikiforov YE. RAS mutation-positive follic- Mallarini G. Mature and immature ovarian terato-
ular variant of papillary thyroid carcinoma arising mas: CT, US and MR imaging characteristics. Eur J
in a struma ovarii. Endocr Pathol. 2010;21:144-147. Radiol. 2009;72:454-463.
Doganay M, Gungor T, Cavkaytar S, Sirvan L, Zalel Y, Seidman DS, Oren M, Achiron R, Gotlieb W,
Mollamahmutoglu L. Malignant struma ovarii with Mashiach S, Goldenberg M. Sonographic and clin-
a focus of papillary thyroid cancer: a case report. ical characteristics of struma ovarii. J Ultrasound
Arch Gynecol Obstet. 2008;277:371-373. Med. 2000;19:857-861.
Manini C, Magistris A, Puopolo M, Montironi PL.
Cystic struma ovarii: a report of three cases. Patho-
logica. 2010;102:36-38.
188
Section 1
T-Shaped Uterus
Synonyms/Description A normal uterine cavity is triangular or V-shaped,
T-shaped uterus refers to the imaging appearance
of a T rather than a triangular-shaped endome-
with the three apices being the two cornua and the
junction of the lower uterine segment and the T
trial cavity cervix (level of internal os). When the uterus is
T-shaped, there is a waist in the sides of the triangle
Etiology such that the corpus of the endometrial cavity is
Diethylstilbestrol (DES) is a synthetic estrogen that narrowed and takes on the shape of a T rather than
was widely prescribed to pregnant women from a V. The outer myometrial surface of the uterus
the late 1940s until 1970 to prevent miscarriage. (the serosal surface) is typically unaffected.
An estimated 1 million to 1.5 million women
received DES during their pregnancies, and this Differential Diagnosis
ultimately affected the reproductive organs of 35% The differential diagnosis of a T-shaped uterine
to 69% of their female offspring. The daughters of cavity relates more to the cause, such as Asherman’s
women treated with DES developed congenital syndrome and uterine scarring versus congenital
malformations of the uterus, cervix, and vagina as anomaly (see Scarred Uterus and Asherman’s Syn-
well as adenosis and (rarely) clear cell adenocarci- drome and also Müllerian Duct Anomalies).Occa-
noma of the vagina. The T-shaped uterus is the sionally a fibroid can press on the uterine cavity,
most common and characteristic deformity of creating the appearance of a T shape because of the
the uterus resulting from the prenatal exposure location of the fibroid. Other congenital Müllerian
to DES and is highly associated with infertility duct abnormalities are usually characteristic, such
and recurrent miscarriage. as a septate or unicornuate uterus, and quite differ-
Initially, the term “T-shaped uterus” was ent from a T-shaped cavity.
reserved for the DES daughters with the character-
istic uterine cavity shape. More recently, patients Clinical Aspects and Recommendations
with multiple D&Cs or hysteroscopic procedures Women found to have a T-shaped endometrial
can develop endometrial scarring that can be very cavity are best managed by specialists in infertility,
similar in appearance and outcome to the con- hysteroscopic surgery, and high-risk obstetrics.
genital T-shaped uterus. Sometimes a patient may Fernandez and colleagues studied 97 infertile
have recurrent miscarriages and D&Cs with a sub- women who had T-shaped uteri, and 49.5% of
sequent diagnosis of T-shaped uterus as a result of them became pregnant after metroplasty. For
Asherman’s syndrome. Whether those patients these patients, the pregnancy rate increased from
had a congenital T-shaped uterus or acquired 0% to 73%, and their miscarriage rate fell from
extensive scarring that distorted the endometrial 78% to 27% (p = 0.05). For all 57 pregnancies in
cavity often cannot be determined. 48 women, the preterm delivery rate was 14%,
the term delivery rate was 49%, and the live birth
Ultrasound Findings rate was 63%.
The exact shape of the uterine cavity is usually not In another study by Katz and colleagues, which
discernible on a standard 2-D ultrasound. The included eight patients with T-shaped uteri and
coronal view of the uterus, usually reconstructed recurrent miscarriage, hysteroscopic surgery resulted
from a 3-D volume, is necessary to evaluate the in four term pregnancies in three women, one
shape of the uterus and endometrial cavity. ectopic pregnancy, and no abortions.
189
Section 1 T-Shaped Uterus
Figure T1-2 Classic T-shaped uterus in a DES

daughter who was never able to conceive.
Figure T1-1 3-D image of a T-shaped uterus in a

patient with recurrent miscarriage. Note the lack of
triangular shape of the lateral walls of the endometrial
cavity. Instead, the lateral walls are pulled inward to
create a T configuration, thus narrowing the cavity. The
outer uterine surface, however, is normally shaped, as is
expected with this diagnosis.
190
T-Shaped Uterus Section 1
Suggested Reading
Fernandez H, Garbin O, Castaigne V, Gervaise A,
Levaillant JM. Surgical approach to and reproduc-
tive outcome after surgical correction of a T-shaped
uterus. Hum Reprod. 2011;26(7):1730-1734.
Katz Z, Ben-Arie A, Lurie S, Manor M, Insler V. Benefi-
cial effect of hysteroscopic metroplasty on the
reproductive outcome in a ‘T-shaped’ uterus. Gyne-
col Obstet Invest. 1996;41(1):41-43.
T
van Gils AP, Tham RT, Falke TH, Peters AA. Abnor-
A malities of the uterus and cervix after diethylstil-
bestrol exposure: correlation of findings on MR
and hysterosalpingography. AJR Am J Roentgenol.
1989;153(6):1235-1238.
B
Figure T1-3 A and B, 2-D and 3-D images of the
uterus in a patient with multiple D&Cs. Note that
although the shape is slightly T-shaped, the main
abnormality is scarring (arrows) and irregularity of
the left cornu with asymmetry of the shape of the
uterine cavity.
191
Section 1
Tarlov Cysts
T Perineural cysts Treatment is undertaken for symptomatic
patients with perineural cysts and may involve
Etiology surgery with sacral laminectomy and cyst
These perineural cysts are of unknown etiology removal. Microsurgical cyst fenestration and CT-
and arise in sacral nerve roots, in an extradural guided percutaneous cyst aspiration have also
location and communicate with the thecal sac. been undertaken, but the fluid tends to reaccu-
They are seen on pelvic ultrasound when they mulate after aspiration.
extend through adjacent foramina with erosion
of the bone. These cysts are often multiple and
bilateral. They are usually an incidental finding
on asymptomatic patients, although they may
cause pelvic or lower back pain.
Ultrasound Findings
The sonographic appearance of Tarlov cysts
includes cystic masses (often bilateral) in the 1
posterior part of the pelvis, fixed to the pelvic
side wall. Careful scanning will reveal that the
uterus and ovaries are separate from these masses, 2
which lie along the posterior pelvic side wall.
Tarlov cysts are avascular on color Doppler.
1
It is important to visualize the ovaries separately
from these cysts; otherwise, it is easy to mistake
them for endometriomas, hydrosalpinges, ecto-
pic pregnancy, lymphadenopathy (lymphoma),
2
or retroperitoneal sarcoma. These entities all
have the sonographic appearance of complex
cystic masses, often bilateral and sometimes
solid-looking because of their internal echoes.
Because Tarlov cysts are found in the posterior
compartment of the pelvis, the practitioner needs
to consider this diagnosis and seek out separate Figure T2-1 Bilateral posterior adnexal masses—
proven Tarlov cysts in two different patients.
ovaries to arrive at the correct diagnosis.
192
Tarlov Cysts Section 1
T
A
RT O
Figure T2-3 MRI in a different patient—typical

appearance of Tarlov cyst extending anteriorly from
neural foramina. (With permission J Ultrasound Med.
1994;13:803-805.)
Suggested Reading
H’ng MW, Wanigasiri UI, Ong CL. Perineural (Tarlov)
cysts mimicking adnexal masses: a report of three
cases. Ultrasound Obstet Gynecol. 2009;34:230-233.
McClure MJ, Atri M, Haider MA, Murphy J. Perineural
B cysts presenting as complex adnexal cystic masses
Figure T2-2 The same patient as in the top image of on transvaginal sonography. AJR Am J Roentgenol.
Figure T2-1. A, Note the lack of blood flow in the 2001;177:1313-1318.
mass. B shows the normal ovary anterior to the mass. Mummaneni PV, Pitts LH, McCormack BM, Corroo
JM, Weinstein PR. Microsurgical treatment of
symptomatic sacral Tarlov cysts. Neurosurgery. 2000;
47:74-78.
Raza S, Klapholz H, Benacerraf BR. Tarlov cysts: a
cause of bilateral adnexal masses on pelvic sonog-
raphy. J Ultrasound Med. 1994;13:803-805.
193
Section 1
Theca Lutein Cyst

Synonyms/Description presence of bilateral symmetric, anechoic cysts
T Hyperreactio luteinalis with the characteristic spoke-wheel appearance

in a pregnant patient is virtually pathognomonic
Etiology for theca lutein cysts.
Theca lutein cysts are benign, functional cysts of
pregnancy. They are usually multiple, bilateral, Clinical Aspects and Recommendations
and large. The exact etiology is unknown but is Theca lutein cysts are functional cysts, which are
associated with high circulating levels of (or an usually asymptomatic and spontaneously resolve
increased sensitivity to) human chorionic gonad- during pregnancy or in the postpartum period.
otropin (hCG), the “hormone of pregnancy.” Intervention is only indicated if they become
They are typically seen in patients with tropho- symptomatic and conservative management is
blastic disease, with multiple pregnancy, or who not an option. These masses increase the risk of
have undergone infertility treatment (ovarian ovarian torsion; if suspected, they require imme-
stimulation followed by pregnancy). Up to 50% diate surgical management. Theca lutein cysts
of patients with molar pregnancies and 10% of can occur in patients with gestational tropho-
patients with choriocarcinoma develop theca blastic disease, in which the treatment should be
lutein cysts. Occasionally, theca lutein cysts can based on the trophoblastic tumor rather than the
occur in pregnancies associated with large pla- accompanying cysts.
centas, such as those affected with diabetes or Rh
sensitization. Rarely, they can also occur in nor-
mal, singleton pregnancies.
Right
Ultrasound Findings
Theca lutein cysts are large, usually bilateral,
adnexal masses that consist of many thin-walled
smaller cystic components, giving them the
appearance of a “spoke wheel.” The cystic com-
ponents are typically anechoic, although focal 2
hemorrhage can occur, demonstrated as internal 1
echoes. Bilateral, multiple, predominantly clear,

large cysts in a pregnant patient should be highly 1 D 15.13 cm
suggestive of theca lutein cysts. Color Doppler 2 D 6.23 cm
should be considered to exclude torsion since Figure T3-1 Markedly enlarged right ovary in a
these patients are at increased risk. pregnant patient previously treated with ovulation-
induction drugs. The contralateral ovary was similar
Differential Diagnosis in appearance. Note that a few of the cystic spaces
Although there is a vast differential diagnosis, contain clots consistent with focal areas of
hemorrhage.
including many benign ovarian tumors, the
194
Theca Lutein Cyst Section 1
2
1
T
1 2
A B
2
1
1 2
C
Figure T3-2 A to C, Multiple views of the ovaries of a patient with spontaneous theca lutein cysts during
pregnancy.
Suggested Reading Suzuki S. Comparison between spontaneous ovarian

Amoah C, Yassin A, Cockayne E, Bird A. Hyperreactio hyperstimulation syndrome and hyperreactio
luteinalis in pregnancy. Fertil Steril. 2011;95:24-29. luteinalis. Arch Gynecol Obstet. 2004;269:227-229.
Holsbeke C, Amant F, Veldman J, de Boodt A, Mer-
man P, Timmerman D. Hyperreactio luteinalis in a
spontaneously conceived singleton pregnancy.
195
Section 1
Tube Carcinoma, Primary Fallopian

Synonyms/Description that it may be tubal, but in most cases the ovary is
T Tubal carcinoma/malignancy not seen separately. Although hydrosalpinges

have a characteristic appearance of incomplete
Etiology septa and a spoke-wheel pattern, tubal cancers
Primary fallopian tube carcinoma (PFTC) is typically have a large solid component obscuring
among the rarest gynecologic malignancies, any distinctive features of the tube. Most patients
accounting for 0.3% of all gynecologic cancers, with tubal cancer are presumed preoperatively
and is usually seen in postmenopausal women. to have an ovarian malignancy; thus it is rare to
There is recent evidence that the majority of high- make the correct diagnosis prospectively. In a
grade, papillary serous cancers involving the ovary study by Slanetz and colleagues, only 3 of 20
may actually originate in the fallopian tube, then patients were correctly diagnosed sonographi-
spread to the ovary. There is a precursor lesion of cally with primary tubal cancer, whereas the oth-
the fallopian tube called serous intraepithelial ers were presumed to be of ovarian origin. These
tubal carcinoma (STIC) that is similar to high- authors also report that the fallopian tube can be a
grade ovarian serous adenocarcinoma. Recent site for metastatic disease from distant primaries.
research suggests that many ovarian cancers origi-
nate from a STIC in the fimbriated end of the fal- Differential Diagnosis
lopian tube. Histologically, up to 90% of tubal The differential diagnosis for tubal cancer is sim-
cancers are adenocarcinomas, most of which are ilar to the one for ovarian cancer. The sono-
serous adenocarcinomas. A minority of cases are graphic finding of a complex solid and cystic
endometrioid and clear cell adenocarcinoma. mass with abundant color flow Doppler and
The risk factors for tubal cancer are similar to shaggy borders suggests a malignancy. Whether
ovarian, including the inheritance of the BRCA 1 the mass is a tubal, ovarian, or metastatic tumor
and BRCA 2 gene mutations. Approximately 15% is indeterminate sonographically. Rarely, there
to 45% of women with fallopian tube cancer are are benign masses that can mimic a tubal or
positive for one of these two mutations. Although ovarian cancer, such as cystadenofibromas or
the symptoms are nonspecific and may include cystadenomas, with small solid excrescences that
pain and bleeding, tubal cancer has historically may suggest a malignancy. There can also be
been associated with a characteristic watery vagi- unusual-appearing degenerating fibroids or
nal discharge. The Latzko triad includes serosan- complex endometriomas with irregular borders
guineous discharge, colicky pelvic pain, and a that occasionally simulate a cancer. Generally,
mass. Although this triad of symptoms is consid- tubal cancers tend to be large, multilocular,
ered characteristic of tubal cancers, it occurs in partly solid, and vascular when discovered, mak-
only 15% of affected patients. ing the diagnosis of a malignancy likely.

The sonographic appearance of tubal carcinoma The treatment of tubal cancer is similar to the
is very similar to ovarian cancer. There is usually treatment of ovarian cancer. This typically
a complex but largely solid adnexal mass with includes surgical debulking by a gynecologic
cystic components and abundant blood flow. oncologist and referral for medical treatments
The mass may be sausage-shaped, suggesting guided by specialized oncologists.
196
Tube Carcinoma, Primary Fallopian Section 1
LT
LT
1 T
2
A B
C
Figure T4-1 Three views of a large tubal carcinoma. A and B show the tubular or sausage shape of the solid mass
and the prominent vascularity within. C is an image taken from the distal end of the same mass, showing several
cystic components typical of the complex appearance of tubal cancers.
RT
RT
Figure T4-2 Large papillary serous carcinoma of the fallopian tube showing the sausage shape of the solid mass
and abundant internal vascularity. This tumor had little if any cystic component.
Section 1 Tube Carcinoma, Primary Fallopian
Right
RT
1 Right
2
Figure T4-4 Small complex adnexal mass in a
postmenopausal patient. The appearance of a solid
Figure T4-3 Two views of a tubal adenocarcinoma
mass with cystic spaces is nonspecific but consistent
that is predominantly cystic, with thick septa, a
with a malignancy. This tubal carcinoma contains a
thick wall, and areas of internal nodularity. The
small tubular cystic space (arrows) suggesting its tubal
appearance of this mass is indistinguishable from an
origin (only appreciated in retrospect).
ovarian cancer but was proved tubal at surgery.
Suggested Reading Seidman JD, Zhao P, Yemelyanova A. “Primary peri-

Chan A, Gilks B, Kwon J, Tinker AV. New insights toneal” high-grade serous carcinoma is very likely
into the pathogenesis of ovarian carcinoma: time metastatic from serous tubal intraepithelial carci-
to rethink ovarian cancer screening. Obstet Gynecol. noma: assessing the new paradigm of ovarian and
2012;120:935-940. pelvic serous carcinogenesis and its implications
Haratz-Rubinstein N, Russell B, Gal D. Sonographic for screening for ovarian cancer. Gynecol Oncol.
diagnosis of fallopian tube carcinoma. Ultrasound 2011;120:470-473.
Obstet Gynecol. 2004;24:86-88. Slanetz PJ, Whitman GJ, Halpern EF, Hall DA, McCar-
Huang WC, Yang SH, Yang JM. Ultrasonographic man- thy KA, Simeone JF. Imaging of fallopian tube
ifestations of fallopian tube carcinoma in the fim- tumors. Am J Roentgenol. 1997;169:1321-1324.
briated end. J Ultrasound Med. 2005;24:1157-1160.
Ko ML, Jeng CJ, Chen SC, Tzeng CR. Sonographic
appearance of fallopian tube carcinoma. J Clin
Ultrasound. 2005;33:372-374.
198
Section 1
Tubo-Ovarian Abcess and Pelvic

Inflammatory Disease
Synonyms/Description and debris. The walls are irregular, and the tubes T
Pelvic infection are elongated and tortuous with abundant blood
Pelvic abcess flow on color Doppler examination. Milder
Pyosalpinx infections may result in thickening of the tube
without the presence of fluid (salpingitis). These
Etiology thickened tubes are very tender during the trans-
Pelvic inflammatory disease (PID) is an ascending vaginal ultrasound examination.
pelvic infection causing inflammation of the A TOA is usually a solid, cystic or complex
upper genital tract, including cervicitis, endome- multiseptate mass, most often hypoechoic with
tritis, salpingitis, pelvic peritonitis, and occasion- areas of mixed echogenicity and thick septa.
ally resulting in development of a tubo-ovarian Adhesions form within the pelvis, causing the
abscess (TOA). Inflammation damages the fallo- tubo-ovarian complex to be adherent to nearby
pian tubes, leading to infertility, ectopic pregnancy, bowel, giving the appearance of a large, complex,
and chronic pelvic pain. Acutely, the fallopian adnexal mass with indistinct borders. Abundant
tubes swell and become congested, leading to sal- blood flow is typical on Doppler studies.
pingitis and potentially pyosalpinx if the tube fills
with pus. Untreated PID may progress from Differential Diagnosis
inflammation of the tubo-ovarian complex to the The sonographic appearance of PID and TOA is
formation of a tubo-ovarian abscess (TOA). nonspecific, and the differential diagnosis
Most cases of PID are sexually transmitted and includes diseases that can cause complex hydro-
caused by Chlamydia trachomatis, Neisseria gonor- salpinges and pain. These include ectopic preg-
rhoeae, or other similar causative agents. Pelvic nancy (there must be a positive pregnancy test),
inflammatory disease can also occur as a result of extensive endometriosis (typically a patient with
a gynecologic or abdominal procedure or sur- chronic, cyclic pelvic pain), and tubal carcinoma
gery, as well as tuberculosis and appendicitis. (typically asymptomatic). Patients with PID and
TOA are usually febrile and appear quite ill;
Ultrasound Findings therefore the clinical setting is an important part
Ultrasound is very sensitive for detecting ovar- of evaluating a patient with a complex multisep-
ian and tubal involvement of PID (sensitivity tate tubo-ovarian mass.
of 90% and 93%, respectively). When infected,
the uterus enlarges and the echogenicity of the Clinical Aspects and Recommendations
endometrium becomes heterogeneous and PID and TOAs are infections of the upper repro-
blotchy. The endometrial cavity often contains ductive tract, usually sexually transmitted but
small amounts of echogenic fluid (exudate). occasionally polymicrobial; therefore, treatment
The outer border of the uterus is often indis- is with antibiotics. The choice of antibiotics
tinct, with loss of clear separation between the depends on the source of infection. The diagnosis
uterus and adnexa. of PID is more of a clinical diagnosis than one
Inflamed fallopian tubes are typically thick based on ultrasound findings. Clinicians are
walled and dilated, filled with echogenic fluid taught to maintain a low threshold for suspecting,
199
Section 1 Tubo-Ovarian Abcess and Pelvic Inflammatory Disease
diagnosing, and treating PID because long-term assisted by ultrasound findings. TOAs may be
complications are more common if treatment is more chronic and the diagnosis better assisted by
delayed. Easily obtainable sensitive pregnancy the presence of complex adnexal masses as well as
tests have helped quickly exclude possible ectopic clinical signs, symptoms, and laboratory findings.
pregnancy in patients who present with lower Antibiotics or surgical intervention may be indi-
abdominal pain. Appendicitis and ovarian torsion cated, but specific recommendations are beyond
T are part of a clinical differential and may be the scope of this book.
SRI II 5/C
Right
A B
C
Figure T5-1 Very large pyosalpinx in a very sick patient with severe PID. A and B show the 2-D view of the very
large pyosalpinx. The distal end of the tube is filled with a large amount of echogenic fluid. The rest of tube is
more narrow and folded upon itself (calipers and arrows). C is a 3-D rendering of the entire dilated tube (arrows).
200
Tubo-Ovarian Abcess and Pelvic Inflammatory Disease Section 1
RT SAG 2 1
2
T
A
RV RT
A
B
Figure T5-2 A and B, Acute PID with a very dilated
tube in a patient later found to have a TOA. Note that
the tubal wall is thick and edematous with multiple
cystic spaces (pockets of pus) inside.
B
Figure T5-3 Tubo-ovarian abscess in two different
patients. A shows a large complex cystic mass with
irregular borders and septations in a patient with
severe PID. Note that the borders of the mass are
indistinct and blurry because of the surrounding
edema. Although the sonographic appearance of the
mass is nonspecific, the setting of a septic patient
helps to make the diagnosis more definitive. B shows
a completely solid adnexal mass containing small
linear echoes throughout, consistent with an air-
containing abscess.
201
Section 1 Tubo-Ovarian Abcess and Pelvic Inflammatory Disease
Suggested Reading
RT ADNEXA
Chappell CA, Wiesenfeld HC. Pathogenesis, diagno-
sis, and management of severe pelvic inflamma-
tory disease and tuboovarian abscess. Clin Obstet
1 Gynecol. 2012;55:893-903.
Cicchiello LA, Hamper UM, Scoutt LM. Ultrasound
2 evaluation of gynecologic causes of pelvic pain.
T Obstet Gynecol Clin North Am. 2011;38:85-114.
Crossman SH. The challenge of pelvic inflammatory
A disease. Am Fam Physician. 2006;73:859-864.
Ghiatas AA. The spectrum of pelvic inflammatory dis-
ease. Eur Radiol. 2004;14(suppl):E184-E192.
LT Kamaya A, Shin L, Chen B, Desser TS. Emergency
1 gynecologic imaging. Semin Ultrasound CT MRI.
2008;29:353-368.
Kim MY, Rha SE, Oh SN, Jung SE, Lee YJ, Kim YS,
Byun JY, Lee A, Kim MR. MR imaging findings of
2
hydrosalpinx: a comprehensive review. Radiograph-
ics. 2009;29:495-507.
Soper DE. Pelvic inflammatory disease. Obstet Gyne-
col. 2010;116:419-428.
B Varras M, Polyzos D, Perouli E, Noti P, Pantazis I,
Figure T5-4 A and B, Salpingitis in two different Akrivis CH. Tubo-ovarian abscesses: spectrum of
patients. Note the elongated and straight swollen- sonographic findings with surgical and pathologi-
appearing tubes (calipers). Both patients had local- cal correlations. Clin Exp Obstet Gynecol.
ized pain in the area of the tube. For the patient in A, 2003;30:117-121.
the diagnosis of pyosalpinx was confirmed at laparos-
copy. The second patient improved with antibiotics.
202
Section 1
Ureteral Stone
Synonyms/Description associated ipsilateral hydronephrosis and flank
Renal stone pain. Partial obstruction of the distal ureter may
Kidney stone also cause asymmetry of the ureteral jets in the
Nephrolithiasis bladder (seen best using color Doppler in the
Etiology
urinary bladder).
U
Renal and ureteral stones are typically calcium Differential Diagnosis
stones (calcium oxalate, calcium phosphate, or Patients with flank pain who are scheduled for
mixed calcium oxalate and phosphate). A minor- pelvic ultrasound should also have a cursory
ity (20%) of stones are uric acid, cystine, and stru- examination of the ipsilateral kidney. If there is
vite in origin. They become especially symptomatic evidence of hydronephrosis, the ultrasound
when they travel down the ureter and become examination should include a careful look at the
lodged, causing a blockage in the flow of urine. course of the ureter, including the junction of
the distal ureter and the bladder, which is best
Ultrasound Findings done transvaginally. If there is a stone at the UVJ,
Sonography is very useful in visualizing stones at there is essentially no differential diagnosis.
the ureteropelvic junction (UPJ), the ureterovesi- Occasionally there may be other disease pro-
cal junction (UVJ), the renal pelvis, and in the cesses in that location, such as a bladder mass or
kidney itself, although stones are harder to see endometriosis, causing constriction of the distal
when located in the mid ureter. Patlas and col- ureter and mimicking the symptoms of a stone
leagues reported a sensitivity and specificity of (see Bladder Masses).
95% and 93%, respectively, for diagnosing ure-
teral calculi, although unfortunately a majority Clinical Aspects and Recommendations
of urologists are still ordering CT scans for the Patients with ureteral stones have extreme,
workup of renal colic. Stones lodged in the distal crampy flank pain, with tenderness at the costo-
ureter are easily seen sonographically either vertebral angle (CVA). Most patients (90%) have
transabdominally through a full bladder, or even gross or microscopic hematuria. The treatment
better transvaginally. Ureteral calculi are echo- for ureteral stones requires referral to a urologist,
genic foci with acoustic shadowing, seen within who may remove or break up (i.e., lithotripsy)
the lumen of a dilated ureter. There is usually the stone if spontaneous passage does not occur.
203
Section 1 Ureteral Stone
Suggested Reading
Ackerman SJ, Irshad A, Anis M. Ultrasound for pelvic
pain II: nongynecologic causes. Obstet Gynecol Clin
North Am. 2011;38:69-83.
Masarani M, Dinneen M. Ureteric colic: new trends in
diagnosis and treatment. Postgrad Med J. 2007;83:
469-472. Review.
1
Patlas M, Farkas A, Fisher D, Zaghal I, Hadas-
Halpern I. Ultrasound vs CT for the detection of
U
ureteric stones in patients with renal colic. Br J Radiol.
2001;74:901-904.
A
B
Figure U1-1 A shows a stone (calipers) lodged in the
distal ureter of a patient with flank pain. Note that the
stone has a posterior acoustic shadow and is located
at the distal end of the dilated, fluid-containing
ureter. B shows the kidney on the ipsilateral side with
moderate hydronephrosis.
204
Section 1
Uterine Sarcoma
Synonyms/Description Endometrial stromal sarcomas represent approx-
Many different types of uterine sarcoma, includ- imately 10% of uterine sarcomas and typically
ing but not limited to carcinosarcoma, adenosar- present with vaginal bleeding and pelvic pain in
coma, leiomyosarcoma, and endometrial stromal women 40 to 55 years of age.
sarcoma
Ultrasound Findings
U
Etiology Uterine sarcomas usually present as large uterine
Uterine sarcomas are rare tumors of mesenchy- masses that may be difficult to distinguish from
mal origin, representing approximately 5% of all fibroids. They can be polypoid with cystic spaces
uterine malignancies. and ill-defined borders. They often involve the
They are classified into three groups according endometrium, at least in part, and may prolapse
to their source: or extend through the endocervical canal. This
1. Mixed epithelial and mesenchymal tumors, type may be mistaken for a submucosal degener-
which include carcinosarcomas. These were ating fibroid or an endometrial polyp. The
previously termed malignant mixed Mülle- appearance of a vascular, intraluminal mass can
rian tumors (MMMTs) and adenosarcomas. also mimic endometrial adenocarcinoma. Dop-
2. Smooth muscle tumors, which are pler usually shows abundant blood flow as is
leiomyosarcomas common in malignancies. The diagnosis of a sar-
3. Endometrial stromal tumors, which include coma may be suspected if the mass is irregular
endometrial stromal sarcoma and high-grade with disorganized cystic areas and especially if
undifferentiated sarcoma the mass is rapidly growing and very vascular.
Carcinosarcoma is the most common, account- Leiomyosarcomas are typically difficult to distin-
ing for 50% of all uterine sarcomas. It is typi- guish from highly vascular benign leiomyomas
cally diagnosed in the sixth decade and often by imaging alone.
presents with postmenopausal bleeding. The
presentation and risk factors are similar to endo- Differential Diagnosis
metrial adenocarcinoma. It is an aggressive The differential diagnosis for a large uterine mass
tumor with extrauterine spread to lymph nodes with irregular cystic areas includes a degenerat-
or beyond found in 30% of patients at initial ing fibroid and an adenomyoma. These typically
diagnosis. do not grow and do not have the abundant blood
Adenosarcoma is a less aggressive tumor than flow seen in a sarcoma. Endometrial cancers can
carcinosarcoma. It tends to be smaller and con- also grow to a large size and look like a sarcoma;
fined to the uterus at presentation and has a however, endometrial cancers are typically less
more favorable prognosis. aggressive and usually present at an earlier stage
Leiomyosarcoma is the second most common with abnormal bleeding. Because fibroids are far
uterine sarcoma, occurs mostly in the fifth decade more common than sarcomas, a uterine mass
of life, and accounts for almost 40% of cases. may be mistaken for an atypical fibroid at first
These tumors are not thought to arise from exist- scan. If a fibroid is unusual in appearance, it is
ing myomas. They generally present with the important to rescan the patient in a relatively
same symptoms attributed to enlarging fibroids short time interval to evaluate growth of the
and rapid growth of the uterus. lesion.
205
Section 1 Uterine Sarcoma
Clinical Aspects and Recommendations The treatment for uterine sarcomas depends
Five-year overall survival for patients with stage 1 on the type of tumor and the extent of disease.
to 2 uterine carcinosarcoma is 44% to 74%. The Uterine sarcomas are relatively rare and should
survival for women with stage 1 to 2 leiomyosar- be managed at specialized centers because treat-
coma is 52% to 85%. ments are typically multimodal and evolving.
Endometrial stromal sarcoma has the best prog- Recurrence rates are relatively high compared
nosis, with a 90% 5-year survival rate in women with other types of gynecologic malignancies.
with stage I disease. Survival is poor in patients with
stage III to IV disease for all types of sarcomas.
U
206
Uterine Sarcoma Section 1
A
U
E
Figure U2-1 A, Adenosarcoma presenting as a mass (arrows) protruding through the cervical canal. Note the
small cystic areas within the solid matrix of the mass. B and C show abundant color flow with a large stalk origi-
nating from the uterine fundus. D and E show a 3-D image of the vasculature of the mass as it attempts to pass
through the cervix.
207
Section 1 Uterine Sarcoma
U B
D
Figure U2-2 Endometrial stromal sarcoma. A, Note that the solid mass (arrows) is largely intraluminal; however,
the color flow images (B and C) show abundant blood flow coming from the uterine fundus where the borders of
the mass are ill-defined. D is a 3-D rendered image of the endometrial cavity showing a sharp border on one side
but no real border (arrows) at the right fundus where the tumor appears to reach the serosa.
Suggested Reading Wu TI, Yen TC, Lai CH. Clinical presentation and diag-
Seddon BM, Davda R. Uterine sarcomas—recent nosis of uterine sarcoma, including imaging. Best
progress and future challenges. Eur J Radiol. 2011; Pract Res Clin Obstet Gynaecol. 2011;25(6):681-689.
78(1):30-40. Xue WC, Cheung AN. Endometrial stromal sarcoma
Shah SH, Jagannathan JP, Krajewski K, O’Regan KN, of uterus. Best Pract Res Clin Obstet Gynaecol.
George S, Ramaiya NH. Uterine sarcomas: then and 2011;25(6):719-732.
now. AJR Am J Roentgenol. 2012;199(1):213-223.
208
Section 1
Vaginal Masses
Synonyms/Description vagina or vesicovaginal septum. These are usu-
None ally solid rounded masses that are well encapsu-
lated and not particularly vascular. Implants of
Etiology endometriosis are commonly found in the recto-
The most common vaginal masses are benign. vaginal septum or along the posterior wall of the
bladder, and may indent or involve the vaginal
Vaginal Cysts wall. Malignant masses in the vagina are very
Vaginal wall cysts tend to be embryologic in
nature and often asymptomatic. These cysts
rare. Metastatic spread (such as lymphoma or
melanoma) accounts for the most common
V
include Gartner’s duct cysts, Müllerian cysts, malignant masses in the vagina, followed by pri-
epithelial inclusion cysts (ectopic epithelium), mary squamous cell carcinoma. Primary vaginal
urethral diverticula, and cysts resulting from a cancers represent only 1% to 2% of all gyneco-
blocked gland Bartholin duct cyst) or obstructed logic malignancies, and 85% of these primary
Müllerian duct anomaly. A complete vaginal vaginal malignancies are squamous cell carci-
septum will typically be diagnosed during men- noma. Other rare primary vaginal cancers include
arche when a hematometra develops from the adenocarcinoma, melanoma, lymphoma, and
obstructed menstrual flow (see Hematometra sarcomas.
and Hematocolpos). Gartner’s duct cysts are Postoperative or radiation changes may result
remnants of the mesonephric ducts and are in vaginal lesions secondary to inflammation
most often discovered incidentally. They are and fibrosis. Fistulas between the vagina and rec-
located along the anterolateral aspect of the tum can present with vaginal symptoms.
vagina and are typically clear unilocular cysts.
Bartholin’s glands are mucus-secreting glands Ultrasound Findings
in the posterolateral aspect of the vaginal open- The best way to evaluate the vagina sonographi-
ing, near the rectum. Bartholin’s duct cysts result cally is by placing a high-frequency transducer
from blockage of the duct and swelling from (such as the transvaginal probe) on the perineum
accumulated secretions. and by looking down the vagina, rectum, and
Kondi-Pafiti and colleagues studied 40 cases urethra simultaneously. Once the vaginal probe
of benign vaginal cysts. Of these, 12 cases were is actually inserted into the vagina, it will bypass
Müllerian cysts (30.0%), 11 were Bartholin’s duct any vaginal pathology, and the vaginal findings
cysts (27.5%), 10 were epidermal inclusion cysts will be obscured and undetectable.
(25.0%), 5 were Gartner’s duct cysts (12.5%), 1 A 3-D acquisition taken from the perineum is
was an endometrioid cyst (2.5%), and 1 was an important to generate the coronal view of the
unclassified cyst (2.5%). Mean patient age was floor of the pelvis. Using that reconstructed view,
35 years (range 20 to 75). Most of the patients the vagina, urethra, and rectum can be seen in
(31 cases, 77.5%) were asymptomatic, and the cross-section and their relationship with one
Bartholin’s duct cyst was the more frequently another evaluated. This view can demonstrate
symptomatic. the location of the mass within the floor of the
pelvis, specifically showing the relationship of
Vaginal Solid Masses the mass to the vagina, urethra, and rectum. This
Fibroids may occur in the vagina, originating reconstructed view of the pelvic floor is also
from the smooth muscle cells of the anterior ideal to demonstrate defects in the vaginal wall
209
Section 1 Vaginal Masses
such as fistulas (see Figure V1-9), and is increas- be a Bartholin’s duct cyst and has only peripheral
ingly being used in urogynecology. Similar to color flow. The most common rounded and focal
any other pelvic mass, the appearance of the vag- solid mass (with limited color flow) is a fibroid
inal mass, such as gray-scale texture, contour, in the vaginal wall.
and degree of vascularity using color flow Dop- Although vaginal cysts are usually benign,
pler, provides clues as to the diagnosis. The loca- most solid vaginal masses with abundant color
tion of the mass is also important, keeping in flow tend to be malignant. The appearance of the
mind that masses in the anterior compartment solid mass is not useful to determine the specific
may be urologic and those in the posterior com- tissue diagnosis, as sarcomas, lymphomas, and
partment may be gastrointestinal. The vagina, other lesions look similar to one another. Malig-
urethra, and rectum are in close proximity to nant vaginal masses are typically completely
one another, sharing walls that may be affected solid, abundantly vascular, and irregular in con-
V by the mass. Refer to the differential diagnosis
section that follows for a description and com-
tour. They may extend into the surrounding tis-
sues such as the pelvic side walls.
parison of these masses and their sonographic
appearance. Clinical Aspects and Recommendations
The treatment of vaginal masses depends on
Differential Diagnosis the diagnosis. Benign cysts are treated depending
A clear and asymptomatic cyst in the lateral wall on the patient’s symptoms. Asymptomatic Gart-
of the vagina is likely to be a Gartner’s duct cyst. ner’s duct cysts are typically monitored with
Fluid (or blood) in a hemi-hematocolpos sec- follow-up ultrasounds, whereas a symptomatic
ondary to a vaginal septum typically has low- Bartholin’s duct cyst requires drainage or marsu-
level echoes indicating unclotted blood, much pialization. Urethral diverticula may be found
like an ovarian endometrioma. A complex cyst incidentally or when they become symptomatic,
with solid elements seen anterior to the vagina and are usually managed by a urogynecologist or
suggests a urethral diverticulum. When the lesion urologist. Treatment of malignant vaginal masses
is symptomatic, peripheral color flow may be depends on the specific type of malignancy and
seen, owing to inflammation. A complex cyst in usually involves a multidisciplinary team includ-
the posterior-lateral wall of the vagina is likely to ing gynecologic and medical oncology.
210
Vaginal Masses Section 1
Urethra
Vagina
V
Rectum
B
Figure V1-1 A and B, 3-D reconstructed view of the floor of the normal pelvis, showing the urethra, vagina, and
rectum en face. B demonstrates the multiplanar view of the pelvic floor, showing the acquisition planes. The 3-D
volume was acquired from the perineum and sweeping side to side. The A plane in the upper left-hand corner
shows the acquisition view looking straight down the vagina. The B plane shows the same view at right angles
from the A plane. The C plane is the reconstructed view of the floor of the pelvis, which is crucial to evaluating the
perineal structures, including the length of the vagina and its relationship to neighboring structures.
211
Urethra
2 Cyst
V
1
Rectum
A B
Figure V1-2 A and B, Gartner’s duct cyst: Long axis view looking down the vagina from the perineum, showing a
clear unilocular cyst just posterior to the urethra. B is a 3-D reconstructed image of the pelvic floor, showing that
the cyst is located along the left side of the vagina.
212
A B
Vagina
C
Figure V1-3 Urethral diverticulum. A and B, 2-D view of a complex cystic mass with irregular borders and
internal debris. Note that the vascularity is only in the peripheral aspect of the mass. The mass was located ante-
rior to the vagina and lateral to the urethra. The patient was quite symptomatic, particularly upon voiding. C, 3-D
reconstructed view of a different case of a urethral diverticulum. Note the complex, multicystic mass anterior to
the vagina where the urethra should be. The exact location of the urethra is obscured and likely encapsulated by
this cystic mass, which was quite symptomatic.
213
Mass
Vagina
Rectum
V A
Figure V1-5 Vaginal fibroid. Magnified view of a
small, rounded, solid mass in the wall of the vagina.
Urethra
Vagina
Mass
Rectum
B
Figure V1-4 Bartholin’s duct cyst. (A) 2-D and (B) 3-D
views of a heterogeneous solid mass located antero-
lateral to the rectum. Note that the interior of the
mass has no discernible blood flow.
214
Posterior
RT Buttock
1
A 1 D 10.03 cm
2 D 6.49 cm
B
Posterior
V
C
Figure V1-6 A to C, Leiomyosarcoma. Multiple views of a solid and very vascular mass located along the right
side of the vagina and extending posteriorly toward the right buttock.
215
A
V Figure V1-8 Vaginal lymphoma. Long axis view from
the perineum, looking down the vagina, showing a
lobulated irregular vascular mass extending the
Urethra entire length of the vagina.
Vagina
Mass
Rectum
B
Figure V1-7 A and B, Myxoid spindle cell sarcoma.
Very vascular, lobulated and irregular solid mass
along the lateral and posterior aspect of the vagina.
Note that the mass has a fingerlike extension into the
surrounding side wall, indicating the aggressive
behavior of the tumor.
216
Suggested Reading
Dai Y, Wang J, Shen H, Zhao RN, Li YZ. Diagnosis of
female urethral diverticulum using transvaginal
contrast-enhanced sonourethrography. J Int Urogy-
Rectum
necol. January 31, 2013. [Epub ahead of print].
Elsayes KM, Narra VR, Dillman JR, Velcheti V, Hameed
O, Tongdee R, Menias CO. Vaginal masses: mag-
Bladder netic resonance imaging features with pathologic
correlation. Acta Radiol. 2007;48:921-933.
Fletcher SG, Lemack GE. Benign masses of the female
periurethral tissues and anterior vaginal wall. Curr
Urol Rep. 2008;9:389-396.
V
Hwang JH, Oh JM, Lee NW, Hur JY, Lee KW, Lee KJ.
A Multiple vaginal Müllerian cysts: a case report and
review of literature. Arch Gynecol Obstet.
2009;280:137-139.
Kondi-Pafiti A, Grapsa D, Papakonstantinou K, Kairi-
Vassilatou E, Xasiakos D. Vaginal cysts: a common
pathologic entity revisited. Clin Exp Obstet Gynecol.
2008;35:41-44.
Vagina
Rectum
B
Figure V1-9 A and B, Recto-vaginal fistula. 2-D and
3-D views of the perineum looking down the vagina
in a patient with Crohn’s disease who had clinical
evidence of a fistula. Arrows demonstrate the loca-
tion of the fistula, which was identified first on the
3-D reconstruction (B) and then recognized on
standard 2-D imaging (A). An MRI done the same day
had been read as negative.
217

Section 2
Normal Pelvic Ultrasound

and Common Normal
Variants

Section 2
Normal Pelvic Ultrasound and

Common Normal Variants
The Normal Pelvic Ultrasound: How to Do It just anterior to the uterus. If the bladder is not
and What to See distended, gentle pressure can be applied to
Knowledge of the normal anatomy and tech- the abdominal wall with the transducer to
niques for scanning the female pelvis are essen- push the bowel away and narrow the distance
tial for detecting pelvic disease. The complete between the probe and the pelvic organs. If
pelvic sonogram is done in two parts. In most the uterus is large or contains fibroids, the TA
cases, these include the transabdominal followed approach may provide the best view and mea-
by the transvaginal evaluation. Decades ago, surements of the uterus. This perspective may
the transabdominal pelvic ultrasound was per- even improve after the bladder is emptied. It
formed using a full bladder to visualize the pel- is important to image the endometrial lining
vic organs by pushing the bowel out of the way. as well as ensure that the fundus of the uterus
Although on occasion filling the patient’s blad- has been fully imaged. Looking just above the
der may be helpful, the transabdominal scan is uterus is often necessary to detect any masses
very effective even if the bladder is not com- in the lower abdomen, when they are too
pletely distended. If the uterus is anteverted, it is cephalad to be visualized transvaginally.
typically well seen whether or not the bladder is 2. The adnexa are evaluated, providing slight
full. A retroverted uterus may be difficult to visu- pressure on the lower abdominal organs to
alize with an empty bladder; however, it will be improve visibility. This gentle pressure can
seen well transvaginally. Hence it is no longer displace the bowel and better visualize the
necessary to obligate patients to fill their blad- adnexal regions. The ovaries themselves may
ders for pelvic ultrasound, assuming that the not be identified until the transvaginal por-
transvaginal scan is also performed. If for some tion of the scan; however, the overall evalua-
reason the patient is to be scanned with a full tion of the right and left lower quadrants
bladder (e.g., if the patient declines the intravagi- often requires a TA view in patients in whom
nal scan), it is important not to overdistend the there an ovary or mass located high in the
bladder, thus compressing the pelvic organs pelvis or lower abdomen.
against the sacrum. The technique for performing the transvaginal
The pelvic scan should typically include a (TV) scan (Figure II-2):
transvaginal component after the transabdomi-
1. Proper disinfection of the transvaginal probe
nal scan unless contraindicated or declined by the
is essential preceding each use, and should be
patient. If the patient is not a candidate for the
performed in accordance with the standard
transvaginal approach, the scan can be performed
guidelines recommended by each institution
transrectally (see technique that follows).
(hospital) or probe manufacturer. Following
The technique for performing a transabdominal
disinfection, the probe is rinsed with water to
(TA) scan (Figure II-1):
remove any residual chemicals and wiped
1. The uterus is imaged both longitudinally and clean. It is then inserted into a probe cover
transversely using a 3- to 8-MHz abdominal that typically contains coupling gel. Finally
transducer. If the bladder is full, it can be the tip of the probe is lubricated before its
used as an acoustic window because it lies insertion into the vagina. If the scan is being
221
Section 2 Normal Pelvic Ultrasound and Common Normal Variants
A B
C D
Figure II-1 Transabdominal scan (TA). A and B show a longitudinal and transverse view of the uterus seen
transabdominally through a distended bladder. Calipers show the measurements of the uterus. C and D show the
normal ovaries, also seen transabdominally.
done for infertility and the patient is a candi- The technique for performing the transrectal
date for insemination, it is crucial not to use (TR) scan (Figure II-3):
a gel that may be harmful to the sperm, and
water or saline can be utilized in these spe- 1. After emptying her bladder, the patient is
cial circumstances. placed in the Sims position, on her side with
2. The TV scan is typically done with an empty her legs tucked toward her abdomen or main-
bladder (except for rare instances in which tained in a dorsolithotomy position.
the bladder itself is to be evaluated); there- 2. The transvaginal transducer is prepared in
fore, the patient should empty her bladder the same way as for TV scan, and inserted
just before initiating the TV scan. into the rectum by the physician or sonog-
3. The vaginal probe can be introduced into the rapher. The insertion is done very slowly,
vagina by a physician, a sonographer, or the with steady but gentle pressure, and under
patient herself, whichever is most appropri- direct visualization of the rectum (sono-
ate and comfortable for the patient. In cer- graphically), thus giving time for the sphinc-
tain cases, a chaperone may be necessary, ter to relax. One can also perform a digital
especially if the physician or sonographer rectal exam preceding the probe insertion to
is male. relax the sphincter muscle and gauge the
222
Normal Pelvic Ultrasound and Common Normal Variants Section 2
A B
C
Figure II-2 Transvaginal scan (TV). A demonstrates the transvaginal view of a normal anteverted uterus seen
longitudinally. B shows a similar view of a normal retroverted uterus. Note that in both cases the body of the
uterus is at right angles to the ultrasound beam. C shows an axial uterus that is hard to image well transvaginally
because of its vertical orientation away from the ultrasound beam.
direction of the rectum. In the Sims position,

when the cervix is visualized and approxi-
mately half of the shaft of the probe is inside
the rectum, the patient is then carefully
turned onto her back while trying not to dis-
lodge the probe. With the patient supine,
the pelvic landmarks become similar to
those seen transvaginally, and the protocol is
the same.
Protocol for Intracavitary Scan

The Vagina
To assess the vagina, it is important to visualize
Figure II-3 Transrectal scan. The uterus is seen the entire length of the vagina from the introi-
longitudinally in the same orientation as if the probe tus, before placing the vaginal probe inside
were in the vagina. The scan is being done transrectally (Figure II-4, A and B). Once the probe is inside
on a virginal patient.
the vagina, the vaginal walls and surrounding
223
Urethra
Vagina
Rectum
B C
Figure II-4 The perineum. A shows a longitudinal scan of the floor of the pelvis looking from the introitus, down
the length of the vagina. B and C show the 3-D volume acquisition with the axial reconstructed transverse view of
the pelvic floor. The reconstructed view shows the urethra, vagina, and rectum in transverse section.
structures are no longer visible. An attempt to for any polyps, fibroids or masses (Figure II-5).
visualize them on the way out of the vagina is Color Doppler is helpful to detect abnormal
hampered by the introduction of air with the blood flow or a feeder vessel if a polyp or mass
initial placement of the probe; hence if the is suspected. Small cysts in the wall of the cer-
clinical problem involves the vagina, it must be vix are usually nabothian cysts, also referred to
evaluated with a perineal scan before placing as cervical inclusion cysts, and typically are
the probe inside. With the probe on the ignored on a sonogram. Evaluating the outer
perineum, a 3-D volume can be acquired and contour of the cervix is important to look for
reconstructed to show the floor of the pelvis, implants of endometriosis along the posterior
the anterior and posterior compartments of the outer surface of the cervix and in the upper
pelvis (Figure II-4, B and C). This enables the portion of the rectovaginal septum (see
practitioner to assess the relationships between Endometriosis).
the urethra, vagina, and rectum and any mass
or cyst that may be present (see Vaginal Masses). The Uterus
As the vaginal probe is placed in the vagina,
The Cervix there is direct visualization of the length of the
The appearance, size, and symmetry of the cer- vagina down to the cervix, which is typically at
vix are evaluated as well as the cervical canal right angles to the vagina (Figures II-2 and II-6).
224
A B
Figure II-5 The cervix. A shows a transvaginal longitudinal view of the normal cervix showing a normal endocer-
vical canal. B demonstrates a nabothian cyst (arrow) located in the cervix of a postmenopausal patient. These are
of no clinical significance and typically are not mentioned in the ultrasound report.
Once the cervix is located, the cul-de-sac is seen

posteriorly (Figure II-7) and the rest of the uterus
is visualized longitudinally. The evaluation of
the uterus includes the uterine orientation, loca-
tion of the endometrium, and symmetry of the
myometrium. If the uterus is anteverted or retro-
verted, it will be seen at right angles (horizontal)
to the ultrasound beam and be easily examined
(see Figure II-2). If the uterus is axial, it will be
oriented parallel and heading away from the
ultrasound beam and be much more difficult to Figure II-6 Long axis view of the uterus and cervix,
image (see Figure II-2). In such cases the endo- typical of the first landmark to visualize when
metrial cavity may be better seen TA. The mea- performing a vaginal ultrasound.
surements of the uterus that are done
longitudinally include the uterine length from
the fundus to the cervix (external os), and the
width from the anterior to posterior uterine sur-
faces, perpendicular to the length. The width of
the uterus is measured in the transverse view,
with the uterus viewed in short axis. These mea-
surements can be done either TA or TV (see Figures
II-1 and II-8).
The texture of the myometrium is evaluated
for contour changes, heterogeneity, masses,
bulges, and cysts. Fibroids or other masses must
be measured in at least two dimensions. It is impor-
tant to determine the location of fibroids within
the uterus such as whether it is submucosal, intra- Figure II-7 Longitudinal scan though the uterus
mural, subserosal or pedunculated (see Fibroids). and cervix showing a small amount of free fluid
Postmenopausal women may have extensive cal- (arrows) in the cul-de-sac, which is a normal finding,
particularly in premenopausal patients.
cification of the arcuate arteries, which is not
225
1
1
A B
Figure II-8 A and B, Measurements of the uterus done transvaginally.
associated with any gynecological abnormalities

(Figure II-9).
The endometrium should be assessed for its
appearance, thickness, and focal irregularities
or disruptions (Figure II-10). The presence of
fluid in the endometrial cavity should be
evaluated; if fluid is present, it should be noted
whether it outlines any focal or diffuse abnor-
malities, defects, or masses protruding into the
cavity. The endometrium should be measured
in the midline on a longitudinal image where
the axis of the uterus is perpendicular to the
Figure II-9 Transverse view of the uterus in a
ultrasound beam (Figure II-11). Any rotation
postmenopausal patient who has multiple arcuate
of the uterus may artificially widen this mea- artery calcifications (arrows). These are not consid-
surement; therefore, the axis of the probe ered of clinical significance.
should mimic the axis of the uterus. If there is
fluid in the endometrial cavity, the endometrial
measurement can be obtained by measuring
the single width anterior and posterior portions be very helpful to further delineate the lesion
of the endometrium separately. A small amount (see Figure II-11, C).
of anechoic fluid is not considered to be an The appearance of the endometrium varies
abnormal finding, and is more commonly seen with the phases of the menstrual cycle. In the
in postmenopausal patients. Regardless of early proliferative phase, it is very thin, echo-
what the endometrial echo measures, it is genic, and linear (Figure II-12). During the pro-
essential to evaluate the endometrium in its liferative phase, the endometrium gradually
entirety, looking for focal abnormalities or thickens. Closer to the time of ovulation (mid-
irregularities. The endometrial echo may be cycle), the endometrium typically develops a
normal on one side of the uterus and have a characteristic trilaminar appearance with a thin
focal lesion on the other. When finding an linear echogenic line at the center, flanked by an
endometrial abnormality, color Doppler can echolucent rim and surrounded by an echogenic
226
A B
Figure II-10 A and B, The normal endometrium seen transvaginally both in longitudinal and transverse
sections, showing no irregularities or focal lesions.
1
1
A 1 D 0.66 cm B 1 D 0.16 cm
C
Figure II-11 The measurement of the endometrial echo is done in a midline longitudinal section of the uterus
with the transverse axis of the uterus identical to the axis of the transducer to obtain the true sagittal view of the
uterus. A and B show the measurements done on a premenopausal and postmenopausal patient, respectively.
C shows the presence of a focal polyp with a feeder vessel demonstrated using color Doppler. The rest of the
endometrium was less than 4 mm in this postmenopausal patient with bleeding.
227
Figure II-14 Transvaginal view of the normal luteal

Figure II-12 Transvaginal view of a normal uterus in phase endometrium, which has a homogeneous,
the early proliferative phase, showing a very thin, lobular, and thickened sonographic appearance.
echogenic, and linear endometrium.
measurements done in the early proliferative

phase are an accurate representation of the cav-
ity. There are no true normative data of the mea-
surement of the endometrium in premenopausal
patients, and endometrial abnormalities are
detected by the presence of focal abnormalities
and asymmetry. Patients who have had an endo-
metrial ablation may have a markedly heteroge-
neous appearance of the myometrium and
endometrial-myometrial junction, making any
Figure II-13 Transvaginal view of the uterus in a meaningful measurement or characterization
patient who is midcycle and about to ovulate. Note impossible. The region of the endometrium typi-
the trilaminar pattern of the endometrial echo, with cally looks puckered and the surrounding myo-
a thin linear echogenic line at the center surrounded metrium mottled in these patients (Figure II-16).
by a lucent rim, which is further encircled by an In postmenopausal patients who are not bleed-
echogenic basilar layer. ing, there are no accepted normative data for the
width of the endometrium. The sonographic
appearance of the endometrium and the presence
basilar layer (Figure II-13). The endometrium of any abnormal color flow are far more impor-
further thickens in the secretory or luteal phase tant factors in detecting abnormalities of the endo-
and takes on a more homogeneous, lobular, and metrium. In postmenopausal patients who are
thickened appearance, which is normal before bleeding, the width of the endometrium is useful
menstruation (Figure II-14). in the initial evaluation. If it measures less than or
In patients who are not cycling, the endome- equal to 4 mm and appears linear, echogenic, and
trium should maintain a constant appearance straight, further testing is not typically indicated in
and is typically thin and homogeneous (Figure a low-risk patient unless bleeding recurs (Figure
II-15). The measurement of the endometrial II-17). There is disagreement as to whether the
echo is not as important as the appearance and upper limit of normal should be 4 or 5 mm; how-
texture of the endometrium. The width can ever, the American College of Obstetrics and Gyne-
change dramatically during the cycle, and only cology recommends that greater than 4 mm
228
when there is any perceived abnormality on

standard 2-D evaluation. The coronal view of
the uterus is key to detecting Müllerian duct
anomalies, abnormally located IUDs, submu-
cous fibroids, and polyps (see individual sec-
tions) (Figure II-19). If a sonohysterogram is
performed, acquiring a 3-D volume during the
saline infusion is invaluable for a comprehen-
sive evaluation of the endometrial cavity offline
(Figure II-20). The patency of the fallopian tubes
can also be tested by injecting air mixed with
saline into the uterine cavity and watching the
echogenic air bubbles travel through the tubes in
Figure II-15 Transvaginal view of the endometrium real-time (hysterosalpingo- contrast sonography,
in a patient on oral contraception, showing a thin or HyCoSy).
linear endometrium, which is typical of patients who
are not cycling. The Adnexa
To evaluate the adnexa transvaginally, it is best to
begin at the level of the uterine fundus in the
transverse section. One can then follow the tubo-
ovarian ligament out laterally toward the ovary.
In most patients the ovary is located at the end of
the tubo-ovarian ligament along the pelvic side
wall and iliac vessels. Patients who have had pelvic
surgery, endometriosis, or pelvic inflammatory
disease tend to have ovaries that are in unpredict-
able locations and more difficult to find because
of adhesions. Postmenopausal ovaries are small,
lack folliculogenesis, and thus are difficult to
identify in some cases (Figure II-21). In patients
who had a hysterectomy, the ovaries are particu-
Figure II-16 Transvaginal view of the uterus of a larly hard to identify because of the lack of refer-
patient who has undergone an endometrial ablation. ence usually provided by the uterus. The
Note the characteristic puckered look of the
practitioner can use his or her free hand to press
endometrium that is indistinct and unmeasurable.
on the patient’s lower abdomen while scanning
The surrounding myometrium is mottled and blotchy.
transvaginally much like a bimanual examina-
tion. This maneuver often shifts the abdominal
warrants further evaluation (see Endometrial organs so that the ovary can appear from behind
Hyperplasia and the Differential Diagnosis for a loop of bowel. Asking the patient to perform
Thick Endometrium and also Endometrial Carci- the Valsalva maneuver will also accomplish similar
noma). If part of the endometrium is obscured by results when trying to find hidden ovaries. If the
fibroids, polyps, or adenomyosis, or if the margins uterus is enlarged by fibroids or adenomyosis,
are indistinct, saline infusion sonohysterography ovaries can be undetectable sonographically. In
can be a useful adjunct for further evaluation such cases one must still evaluate the adnexa
(Figure II-18). carefully to rule out masses.
Volume imaging of the uterus (3-D) is a very The ovaries are measured in three dimensions
helpful adjunct to 2-D ultrasound, especially (width, length, and depth), in two planes that
229
A B
C
Figure II-17 A shows a transvaginal view of the typical paper-thin, echogenic endometrium in a postmenopausal
patient. B and C show a small amount of fluid in the endometrial cavity of a postmenopausal patient, which is not
considered clinically significant in the presence of a thin endometrium (calipers).
A B
Figure II-18 A and B, Normal sonohysterogram seen both in 2-D and 3-D coronal reconstruction. Note the saline
in the endometrial cavity outlining a thin and smooth lining.
230
C
Figure II-19 3-D volume acquisitions of the uterus are essential to generate the reconstructed coronal view of the
uterus. A shows the multiplanar display of the volume acquisition. B shows the reconstructed coronal view of the
uterus and cavity showing a normal shape. Note that even the interstitial portions of the tubes can be visualized.
C shows the normal positioning of an IUD within the uterine cavity.
are at right angles to each other (Figure II-22). Color Doppler ultrasound is often helpful to
Women who are cycling typically have one or determine whether an adnexal cyst or lesion is
more follicles on each ovary (up to 2.5 to 3 cm vascular. An intense circular vascular pattern
in largest diameter), particularly if examined indicates a corpus luteum, which is a normal
midcycle (Figure II-23; also see the section on finding in a cycling woman. Other masses with
ovarian cysts). Postmenopausal women should abundant central blood flow may be worrisome
not normally have ovarian cysts, although a for malignancy.
small clear cyst less than or equal to 10 mm is
considered clinically insignificant. The Cul-de-sac
It is also important to evaluate the entire The cul-de-sac should be evaluated for the pres-
adnexal area, including the pelvic side wall, to ence of masses or free fluid behind the cervix.
identify any abnormal fluid collection or masses. This is an area that is often affected by deep pen-
The fallopian tubes are not usually seen unless etrating endometriosis in the anterior wall of the
abnormal or outlined by free fluid. rectosigmoid (see Endometriosis). Masses in this
231
Figure II-20 Multiplanar display of the 3-D volume

acquisition done during a sonohysterogram.
Note that all three orthogonal views are seen
simultaneously. One can navigate through the
saved volume at a review station after the patient
has left.
area may include fibroids, an enlarged ovary, a

bowel lesion, or a presacral mass.
Part of the evaluation of the cul-de-sac should B
include testing the mobility of the uterus. The
Figure II-21 A and B, Transvaginal view of the right
uterus can be moved slightly by gently pushing on
and left ovary in a postmenopausal patient. Note the
the cervix with the vaginal probe in the vagina. If typical comma shape of the ovary, which is thin
the cul-de-sac is frozen by adhesions or endome- rather than fat and rounded, as seen
triosis, the uterus will not glide past the anterior premenopausally.
wall of the rectosigmoid as it normally should.
Nongynecologic Organs
We must not forget that the uterus, ovaries, and
fallopian tubes are not alone in the female pelvis.
There are multiple loops of small and large bowel
as well as the appendix, the ureters, lymph nodes,
blood vessels, and sacrum. It is important to 2
keep these organs in mind when performing 3
pelvic ultrasound because not all masses and
fluid collections are attributable to the uterus
and adnexa (see related sections).
In conclusion, ultrasound is well known and 1
accepted as the chosen method of imaging the
female pelvis for practically all indications. The
sonographic armamentarium at our disposal is
Figure II-22 Transvaginal view of a normal ovary
vast and includes gray scale, 3-D volume imaging,
showing the correct method of measuring the ovary.
color Doppler mapping, introduction of saline
232
into the uterus, extended-field-of-view images,

and so on. Ultrasound techniques are versatile,
operator dependent, and vary with patient body
habitus, previous surgery, and the anatomy of
each individual patient.This differentiates sonog-
1 raphy from other forms of cross-sectional imag-
ing, which are standardized. Performing quality
ultrasound includes deciding what images are
2 needed, acquiring quality images, and finally
interpreting them. The well-trained and experi-
enced sonologist and/or sonographer can resolve
A
the vast majority of gynecologic problems with
ultrasound imaging.
B
Figure II-23 Transvaginal view of a normal ovary in
two different patients. A shows the normal ovary as
the dominant follicle is maturing mid-cycle. B shows
multiple follicles in a patient taking Clomid for the
treatment of infertility.
233

Section 3
Case Studies for Review

Directions: For each case study in this section, review the provided information and images and suggest
a diagnosis. Actual results for each case may be found at the end of the section on pp. 264-265.

Section 3
Case 1
This adnexal mass was found in a 33-year-old patient who was asymptomatic.
237
Section 3 Case Studies for Review
Case 2
This 48-year-old nulliparous patient had a long history of pelvic pain and dyspareunia,
worse at the time of menses.
238
Case Studies for Review Section 3
Case 3
This 57-year-old patient was referred for a second opinion of a right ovarian cyst dis-
covered on an ultrasound at a different institution.
239
Case 4
This patient presented for a scan to evaluate the uterus due to infertility. These are
images of both ovaries. The uterus was normal.
240
Case 5
This 66-year-old patient with breast cancer is being treated with Tamoxifen. She was
referred for a sonohysterogram for evaluation of a “thickened endometrium” seen on
an ultrasound done elsewhere.
241
Case 6
This 72-year-old woman presented with pelvic pain on urination and urinary urgency.
242
Case 7
This 36-year-old patient had a recent spontaneous abortion but has had persistent
heavy bleeding for the past 3 weeks.
243
Case 8
This 32-year-old patient presented with cyclic dysuria and pelvic pain.
244
Case 9
This pelvic mass was present in the cul-de-sac of an asymptomatic 44-year-old patient.
The ovaries could not be clearly identified.
245
Case 10
This 69-year-old postmenopausal patient with a retroverted uterus presented with a
history of recent vaginal bleeding.
246
Case 11
This 27-year-old woman presented with a very large pelvic mass and ascites.
247
Case 12
This postmenopausal patient presented with several hours of right lower quadrant
pain. The scan was done transvaginally.
248
Case 13
This 56-year-old postmenopausal woman had not had a pelvic exam for decades. She
was brought in by her family for a prolonged history of vaginal bleeding.
249
Case 14
This 37-year-old patient has a history of choriocarcinoma that was successfully treated
5 years ago. Recently, she was treated for a missed abortion with a D&C and was being
seen for persistently elevated serum beta-HCG. After a second D&C procedure, the
levels continued to rise and this ultrasound was done.
250

251
Case 15
This 28-year-old pregnant woman had a routine obstetrical ultrasound. This right
ovarian mass was noted incidentally at 18 weeks.
252
Case 16
This 36-year-old patient had a positive pregnancy test and vaginal bleeding.
253
Case 17
This 66-year-old patient had dull, chronic pelvic pain. The transvaginal ultrasound
shows bilateral avascular posterior pelvic masses.
254
Case 18
This is an asymptomatic right adnexal mass in a 32-year-old patient. Images include
both transabdominal and transvaginal views.
255
Case 19
This 44-year-old woman presented with chronic severe pelvic pain. The uterus and
ovaries were normal sonographically.
256
Case 20
This 37-year-old patient was referred because of a pelvic mass seen on other imaging.
257
Case 21
This cystic structure was an incidental finding on a transabdominal pelvic ultrasound
done on a 77-year-old woman.
258
Case 22
This 48-year-old patient complained of pelvic pain, and the top two images were
obtained. The patient returned 3 weeks later, and the bottom two images were obtained.
259
Case 23
This 64-year-old woman was sent for an ultrasound because of a family history of
ovarian cancer.
260
Case 24
This 33-year-old patient complained of irregular bleeding.
261
Case 25
This 51-year-old patient had a recent colonoscopy and subsequently developed pelvic
pain and fever several days after the procedure.
262
Case 26
This 25-year-old woman presented with an enlarged uterus on physical examination.
The first image (top left) is a transabdominal view of the pelvis. The other images
were taken transvaginally.
263
Case 1 Answer: This mass was mistaken for Case 9 Answer: Degenerating fibroid. The
an ovarian fibroma but was proven to be a appearance of this mass was nonspecific and
mature teratoma at surgery. more suggestive of an ovarian lesion. The
correct diagnosis was not suspected preoper-
Case 2 Answer: Endometriosis involving atively because this appearance is atypical for
the back of the cervix and anterior wall of a fibroid, even with degeneration.
the recto-sigmoid. There was severe focal
tenderness at the site of the abnormality Case 10 Answer: This is a thickened endo-
during the scan. metrium, worrisome for malignancy. The
final pathologic diagnosis was grade 2
Case 3 Answer: Mucocele of the appendix. endometrial adenocarcinoma. Note the
Note the onion skin–like texture of the inter- vascular mass involving the endometrium
nal contents of the lesion. A separate right and invading the anterior myometrium as
ovary that appeared normal was documented. well as the echogenic fluid within the cavity
Case 4 Answer: Bilateral cystadenomas of (blood).
low malignant potential (borderline tumor). Case 11 Answer: Dysgerminoma measuring
Note that these masses with abundant color 20 cm × 12 cm.
flow are worrisome for malignancy.
Case 12 Answer: Acute appendicitis. Note
Case 5 Answer: The initial scan suggested a that the appendix has a cystic area in its tip
polyp due to the thick, heterogeneous, and and is surrounded by very echogenic tissue,
cystic central endometrial echo. When saline which represents inflammation of the sur-
was infused into the uterine cavity, the muco- rounding fat. A separate, normal right ovary
sal surface appeared thin, compatible with was clearly identified.
atrophy. The cystic areas are sub-endome-
trial, which is typical of the Tamoxifen effect Case 13 Answer: Large cervical carcinoma.
and represents glandular cystic atrophy. The first image (top left) shows the measure-
ment of the endometrium, and the second
Case 6 Answer: Urethral diverticulum. The image (top right) shows the calipers on the
scans were all done from the perineum, look- cervical mass. Note the extreme vascularity.
ing down the length of the urethra and
vagina. The location of the diverticulum is Case 14 Answer: Intramural choriocarci-
best seen on the 3-D reconstructed view of noma. The tumor was confined to the myo-
the perineum and forms a semilunar shape metrium and not contiguous with the
around the anterior aspect of the urethra. endometrial cavity. The patient was treated
with chemotherapy to no avail and eventu-
Case 7 Answer: Retained products of concep- ally underwent a hysterectomy for definitive
tion. Note the extreme vascularity, which is therapy. The tissue typing of the tumor was
very common when the abortion is incom- different from the original choriocarcinoma,
plete. This vascularity will resolve completely consistent with a second, primary choriocar-
after a D&C. cinoma as opposed to a recurrence.
Case 8 Answer: Endometriosis of the poste- Case 15 Answer: Decidualized endometrioma.
rior bladder wall and anterior aspect of the
uterus. Note the mass-like thickening of the Case 16 Answer: Left cornual pregnancy.
floor of the bladder (calipers) with involve- Note how the 3-D coronal image best dem-
ment of the wall of the uterus underneath. onstrates the location of the pregnancy.
264
Case 17 Answer: Tarlov’s cysts along the ante- seen to retract 3 weeks later. In addition, the
rior aspect of the sacrum bilaterally. The nor- blood flow was only seen peripherally.
mal ovaries were identified separately.
Case 23 Answer: Fibrothecoma of the ovary.
Case 18 Answer: Right dermoid cyst. Note the solid texture with limited blood
flow as well as the multiple vertical shadow-
Case 19 Answer: Nodular, deep-penetrating
ing stripes (Venetian blind appearance) char-
endometriosis of the anterior wall of the
acteristic of fibromas.
recto-sigmoid, behind the distal end of the
cervix. The cul-de-sac was frozen with endo- Case 24 Answer: (Hint: The patient had a
metriotic implants. positive pregnancy test). Complete molar
pregnancy. Note that without the complete
Case 20 Answer: Serous cystadenoma of low
history, the sonographic appearance could
malignant potential (borderline tumor).
be confused with an endometrial polyp or
Note the few internal mural nodules con-
other endometrial process.
taining neovascularity seen by color flow
Doppler. Case 25 Answer: Pelvic inflammatory disease
with pyosalpinx. This was thought to be a com-
Case 21 Answer: Bladder diverticulum. Note
plication resulting from a micro-perforation
the connection to the bladder on the bottom
during a colonoscopy and was treated with
image.
broad-spectrum antibiotics.
Case 22 Answer: Hemorrhagic cyst with
Case 26 Answer: Large dermoid located
retracting clot over the course of 3 weeks.
above the uterine fundus. The location of the
Note that the initial scan suggested a solid
dermoid likely simulated an enlarged uterus
mass, but this was an avascular clot and was
clinically; however, the uterus was normal.
265

Index
A Appendiceal mucocele (Continued) Bowel diseases (Continued)
Abdominal pregnancies, 58. See also Ectopic recommendations for, 11 gastrointestinal stromal tumors (GISTs), 27
pregnancies. synonyms for, 11 inflammatory bowel diseases, 26
Abdominal wall lesions, anterior, 77–78. See also ultrasound findings for, 11, 12f lymphomas, 27
Endometriosis. Appendicitis, 26. See also Bowel diseases. synonyms for, 26
Abnormal intrauterine device (IUD) locations, Arcuate uterus, 125. See also Müllerian duct ulcerative colitis, 26
109–113 anomalies. ultrasound findings for, 26–27, 28f–30f
clinical aspects of, 110 Asherman's syndrome, 177–181 BRCA 1/BRCA 2, 196
differential diagnosis for, 109 clinical aspects of, 178 Brenner tumors, 32–33. See also Tumors.
etiology of, 109 differential diagnosis for, 177-178 clinical aspects of, 32
recommendations for, 110 etiology of, 177 differential diagnosis for, 32
synonyms for, 109 recommendations for, 178 etiology of, 32
ultrasound findings for, 109 retained products of conception (RPOC) and, recommendations for, 32
Abortion, incomplete, 172. See also Retained prod- 177. See also Retained products of concep- synonyms for, 32
ucts of conception (RPOC). tion (RPOC). ultrasound findings for, 32, 32f
Abscesses, tubo-ovarian (TOAs), 199–202 synonyms for, 177 Bright spots, ovarian, 136. See also Calcifications,
clinical aspects of, 199–200 T-shaped uterus and, 189. See also T-shaped ovarian.
differential diagnosis for, 199 uterus.
etiology of, 199 ultrasound findings for, 177, 178f–180f C
vs. pelvic inflammatory disease (PID), 199–200 Asymptomatic ovarian tumors, 32. See also Calcifications, ovarian, 136
recommendations for, 199–200 Brenner tumors. clinical aspects of, 136
synonyms for, 199 Atrophic endometrium, 14 differential diagnosis for, 136
ultrasound findings for, 199, 200f–202f clinical aspects of, 14 etiology of, 136
Adenocarcinomas, colon, 27. See also Bowel differential diagnosis for, 14 recommendations for, 136
diseases. etiology of, 14 synonyms for, 136
Adenomyomas, 3. See also Adenomyosis. recommendations for, 14 ultrasound findings for, 136, 136f
Adenomyosis, 1–7 synonyms for, 14 Carcinomas
adenomyomas and, 3 ultrasound findings for, 14, 14f adenocarcinomas, colon, 27
clinical aspects of, 3–4 Atrophy, endometrial, 14. See also Atrophic endometrial, 65–70
differential diagnosis for, 3 endometrium. ovarian, 137–146. See also Epithelial ovarian
etiology of, 3 cancer.
generalized, 3 B primary fallopian tube (PFTCs), 196–198
recommendations for, 3–4 Benign entities serous intraepithelial tubal carcinomas (STICs),
synonyms for, 3 bladder masses, 15. See also Bladder masses. 137
ultrasound findings for, 3, 4f–6f cystic mesotheliomas, 8. See also Adhesions. tubal, 196
Adenosarcomas, 205. See also Uterine sarcomas. germ cell tumors, 56. See also Dermoid cysts. Carcinosarcomas, 205. See also Uterine
Adhesions, 8–10 metastasizing leiomyomas, 114. See also Intrave- sarcomas.
clinical aspects of, 8 nous leiomyomatosis. Cervical masses, 34–38. See also Masses.
differential diagnosis for, 8 ovarian tumors, 32. See also Brenner tumors. clinical aspects of, 35
etiology of, 8 Bicornuate uterus, 125. See also Müllerian duct differential diagnosis for, 35
intrauterine, 177. See also Asherman's syndrome. anomalies. etiology of, 34
recommendations for, 8 Bladder masses, 15–20. See also Masses. recommendations for, 35
synonyms for, 8 clinical aspects of, 16 synonyms for, 34
ultrasound findings for, 8, 9f–10f differential diagnosis for, 16 ultrasound findings for, 34, 35f–38f
Adnexa, intracavity scan protocols, 221, 229–231, etiology of, 15 Cervical pregnancies, 58. See also Ectopic
232f recommendations for, 16 pregnancies.
Adnexal cysts, 155. See also Paratubal and para- synonyms for, 15 Cervix, intracavity scan protocols, 20f, 224, 225f
ovarian cysts. ultrasound findings for, 15, 16f–20f Cesarean section (C-section) scar defects, 39–42
Adnexal torsion, 147–152 Bladder wall lesions, 77–78. See also Lesions. clinical aspects of, 39
clinical aspects of, 148 Borderline ovarian tumor, 21–25 differential diagnosis for, 39
differential diagnosis for, 147 clinical aspects of, 21 etiology of, 39
etiology of, 147 differential diagnosis for, 21 recommendations for, 39
recommendations for, 148 etiology of, 21 synonyms for, 39
synonyms for, 147 recommendations for, 21 ultrasound findings for, 39, 40f–41f
ultrasound findings for, 147, 148f–151f synonyms for, 21 CL. See Corpus luteum (CL).
Agenesis, 125. See also Müllerian duct anomalies. ultrasound findings for, 21, 22f–25f Clear cysts, 48–50. See also Cysts.
Anatomy, normal, 221–223 Bowel diseases, 26–31 clinical aspects of, 48–49
Anomalies, Müllerian duct, 125–135. See also Mül- adenocarcinomas, colon, 27 differential diagnosis for, 48
lerian duct anomalies. appendicitis, 26 etiology of, 48
Anterior abdominal wall lesions, 77–78. See also colon cancer, 27 postmenopausal, 48
Endometriosis. Crohn's disease, 26 premenopausal, 48
Appendiceal mucocele, 11–13 diverticulitis, 26–27 recommendations for, 48–49
clinical aspects of, 11 duplication cysts, 27 synonyms for, 48
differential diagnosis for, 11 endometriosis, rectosigmoid colon, 26 ultrasound findings for, 48, 49f–50f
etiology of, 11 etiology of, 26 Colitis, ulcerative, 26. See also Bowel diseases.
Page numbers followed by f indicate figures.
267
Index
Colon adenocarcinomas, 27. See also Bowel Conditions (Continued) Dermoid cysts (Continued)
diseases. tumors etiology of, 53
Colon cancer, 27. See also Bowel diseases. Brenner, 32–33 recommendations for, 53–54
Conditions granulosa cell (GCTs), 96–97 synonyms for, 53
abscesses, tubo-ovarian (TOAs), 199–202 metastatic to ovaries, 118–121 ultrasound findings for, 53, 54f–55f
adenomyosis, 1–7 uterus, T-shaped, 189–191 DES. See Diethylstilbestrol (DES).
adhesions, 8–10 vein thrombosis, ovarian, 153–154 Didelphic uterus, 125. See also Müllerian duct
bowel diseases, 26–31 Congenital uterine anomalies, 125. See also anomalies.
calcifications, ovarian, 136 Müllerian duct anomalies. Diethylstilbestrol (DES), 189
carcinomas Cornual pregnancies, 58. See also Ectopic Diffuse bladder wall thickening. See Bladder
endometrial, 65–70 pregnancies. masses
primary fallopian tube (PFTCs), 196–198 Corpus luteum (CL), 43–47 Disinfection, probes, 221–222
Cesarean section (C-section) scar defects, clinical aspects of, 44 Distended fluid-filled fallopian tubes, 104. See also
39–42 differential diagnosis for, 43–44 Hydrosalpinx.
corpus luteum (CL), 43–47 etiology of, 43 Diverticula, urethral, 15. See also Bladder masses.
cystadenofibromas, 51–52 recommendations for, 44 Diverticulitis, 26–27. See also Bowel diseases.
cystadenomas synonyms for, 43 Duplication cysts, 27. See also Bowel diseases.
mucinous, 122–124 ultrasound findings for, 43, 44f–47f Dysgerminomas, 56–57
serous, 184–185 Crohn's disease, 26. See also Bowel diseases. clinical aspects of, 56
cysts C-section scar defects. See Cesarean section differential diagnosis for, 56
clear, 48–50 (C-section) scar defects. etiology of, 56
dermoid, 53–55 Cul-de-sac, intracavity scan protocols, 225f, recommendations for, 56
epidermoid, 83–84 231–232 synonyms for, 56
paraovarian, 155–156 Cystadenofibromas, 51–52 ultrasound findings for, 56, 57f
paratubal, 155–156 clinical aspects of, 51
peritoneal inclusion, 8–10 differential diagnosis for, 51 E
Tarlov, 192–193 etiology of, 51 Early menopause, 170. See also Premature ovarian
theca lutein, 194–195 recommendations for, 51 failure (POF).
dehiscence, uterine, 39–42 synonyms for, 51 Ectopic kidney, 159. See also Pelvic kidney.
dysgerminomas, 56–57 ultrasound findings for, 51, 51f–52f Ectopic pregnancies, 58–64
edema, massive, 147–152 Cystadenomas clinical aspects of, 59
endometriosis, 76–82 mucinous, 122–124 differential diagnosis for, 59
endometrium, atrophic, 14 clinical aspects of, 122–123 etiology of, 58
fibroids, 85–92 differential diagnosis for, 122 recommendations for, 59
fibromas etiology of, 122 synonyms for, 58
cystadenofibromas, 51–52 recommendations for, 122–123 ultrasound findings for, 58–59, 60f–64f
ovarian, 93–95 synonyms for, 122 Edema, massive, 147–152
fibrothecomas, 93–95 ultrasound findings for, 122, 123f clinical aspects of, 148
hematocolpos, 98–103 serous, 184–185 differential diagnosis for, 147
hematometra, 98–103 clinical aspects of, 184 etiology of, 147
hematuria, 15–20 differential diagnosis for, 184 recommendations for, 148
hydrosalpinx, 104–108 etiology of, 184 synonyms for, 147
hyperplasia, endometrial, 71–75 recommendations for, 184 ultrasound findings for, 147, 148f–151f
intrauterine device (IUD) locations, abnormal, synonyms for, 184 Endometrial atrophy, 14. See also Atrophic
109–113 ultrasound findings for, 184, 184f–185f endometrium.
leiomyomatosis, intravenous, 114–115 Cystic mesotheliomas, benign, 8. See also Endometrial carcinomas, 65–70. See also
lymph nodes, enlarged, 116–117 Adhesions. Carcinomas.
masses Cystic teratomas, mature, 53. See also Dermoid cysts. clinical aspects of, 66
bladder, 15–20 Cysts differential diagnosis for, 65–66
cervical, 34–38 clear, 48–50 etiology of, 65
vaginal, 209–218 dermoid, 53–55 recommendations for, 66
mucocele, appendiceal, 11–13 duplication, 27 synonyms for, 65
Müllerian duct abnormalities, 125–135 epidermoid, 83–84 ultrasound findings for, 65, 66f–70f
ovarian cancer nonfunctional, 43 Endometrial hyperplasia, 71–75
borderline, 21–25 paraovarian, 155–156 clinical aspects of, 72–75
epithelial, 137–146 paratubal, 155–156 differential diagnosis for, 71–72
pelvic inflammatory disease (PID), 199–202 peritoneal inclusion, 8–10 etiology of, 71
pelvic kidney, 159–160 Tarlov, 192–193 recommendations for, 72–75
polycystic ovaries, 161–162 theca lutein, 194–195 synonyms for, 71
polyps, endometrial, 163–169 vaginal, 209 Endometrial polyps, 163–169
pregnancies, ectopic, 58–64 clinical aspects of, 163
premature ovarian failure, 170–171 D differential diagnosis for, 163
retained products of conception (RPOC), Decidualized endometriomas, 76–77. See also etiology of, 163
172–176 Endometriosis. recommendations for, 163
sarcomas, uterine, 205–208 Deep penetrating bowel wall/pelvic implants, synonyms for, 163
Schwannomas, 182–183 77–78. See also Endometriosis. ultrasound findings for, 163, 164f–169f
stones, ureteral, 203–204 Degenerating fibroids, 85. See also Fibroids. Endometrial proliferation, 71. See also Endometrial
struma ovarii, 186–188 Dehiscence, uterine, 39–42 hyperplasia.
syndromes clinical aspects of, 39 Endometrial stromal tumors, 205. See also Uterine
Asherman's, 177–181 differential diagnosis for, 39 sarcomas.
pelvic congestion, 157–158 etiology of, 39 Endometriomas, 76–77. See also Endometriosis.
thecomas, 93–95 recommendations for, 39 Endometriosis, 76–82
thick endometrium, differential diagnosis, synonyms for, 39 bladder masses and, 15. See also Bladder masses.
71–75 ultrasound findings for, 39, 40f–41f clinical aspects of, 78
torsion Dermoid cysts, 53–55. See also Cysts. differential diagnosis for, 77–78
ovarian, 147–152 clinical aspects of, 53–54 etiology of, 76
tubal, 147–152 differential diagnosis for, 53 of myometrium, 3. See also Adenomyosis.
268
Index
Endometriosis (Continued) Entities (Continued) Fibromas (Continued)

recommendations for, 78 pelvic inflammatory disease (PID), 199–202 cystadenofibromas, 51–52
of rectosigmoid colon, 26. See also Bowel pelvic kidney, 159–160 differential diagnosis for, 93
diseases. polycystic ovaries, 161–162 etiology of, 93
synonyms for, 76 polyps, endometrial, 163–169 ovarian, 93–95
ultrasound findings for, 76–77, 78f–82f pregnancies, ectopic, 58–64 recommendations for, 93
of uterus, 3. See also Adenomyosis. premature ovarian failure, 170–171 synonyms for, 93
Endometrium retained products of conception (RPOC), ultrasound findings for, 93, 93f–95f
anatomy, normal, 221–223 172–176 Fibromyomas, 85. See also Fibroids.
atrophic, 14 sarcomas, uterine, 205–208 Fibrothecomas, 93–95
clinical aspects of, 14 Schwannomas, 182–183 clinical aspects of, 93
differential diagnosis for, 14 stones, ureteral, 203–204 differential diagnosis for, 93
etiology of, 14 struma ovarii, 186–188 etiology of, 93
recommendations for, 14 syndromes recommendations for, 93
synonyms for, 14 Asherman's, 177–181 synonyms for, 93
ultrasound findings for, 14, 14f pelvic congestion, 157–158 ultrasound findings for, 93, 93f–95f
intracavity scan protocols, 224–229, 227f–228f thecomas, 93–95 Fluid-filled distended fallopian tubes, 104. See also
thick, differential diagnosis, 71–75 thick endometrium, differential diagnosis, Hydrosalpinx.
Enlarged lymph nodes, 116–117 71–75 Focal bladder lesions, 15. See also Bladder masses.
clinical aspects of, 116 torsion
differential diagnosis for, 116 ovarian, 147–152 G
etiology of, 116 tubal, 147–152 Gastrointestinal stromal tumors (GISTs), 27. See
recommendations for, 116 tumors also Bowel diseases.
synonyms for, 116 Brenner, 32–33 GCTs. See Granulosa cell tumors (GCTs).
ultrasound findings for, 116, 116f–117f granulosa cell (GCTs), 96–97 Generalized adenomyosis, 3. See also
Entities metastatic to ovaries, 118–121 Adenomyosis.
abscesses, tubo-ovarian (TOAs), 199–202 uterus, T-shaped, 189–191 Germ cell tumors. See also Tumors.
adenomyosis, 1–7 vein thrombosis, ovarian, 153–154 benign, 56. See also Dermoid cysts.
adhesions, 8–10 Epidermoid cysts, 83–84. See also Cysts. malignant, 56. See also Dysgerminomas.
bowel diseases, 26–31 clinical aspects of, 83 GISTs. See Gastrointestinal stromal tumors (GISTs).
calcifications, ovarian, 136 differential diagnosis for, 83 Granulosa cell tumors (GCTs), 96–97. See also
carcinomas etiology of, 83 Tumors.
endometrial, 65–70 recommendations for, 83 clinical aspects of, 96
primary fallopian tube (PFTCs), 196–198 synonyms for, 83 differential diagnosis for, 96
Cesarean section (C-section) scar defects, 39–42 ultrasound findings for, 83, 83f–84f etiology of, 96
corpus luteum (CL), 43–47 Epithelial ovarian cancer, 137–146. See also Ovar- recommendations for, 96
cystadenofibromas, 51–52 ian cancer. synonyms for, 96
cystadenomas clinical aspects of, 138 ultrasound findings for, 96, 97f
mucinous, 122–124 differential diagnosis for, 138 Granulosa-theca cell tumors, 96. See also Granu-
serous, 184–185 etiology of, 137 losa cell tumors (GCTs).
cysts recommendations for, 138 Gynecologic ultrasound
clear, 48–50 synonyms for, 137 of entities
dermoid, 53–55 ultrasound findings for, 11, 137–138, abscesses, tubo-ovarian (TOAs), 199–202
epidermoid, 83–84 139f–145f adenomyosis, 1–7
paraovarian, 155–156 Epithelial-stromal cystic tumors, 184. See also adhesions, 8–10
paratubal, 155–156 Serous cystadenomas. bowel diseases, 26–31
peritoneal inclusion, 8–10 calcifications, ovarian, 136
Tarlov, 192–193 F carcinomas, endometrial, 65–70
theca lutein, 194–195 Fallopian tubes carcinomas, primary fallopian tube (PFTCs),
dehiscence, uterine, 39–42 anatomy, normal, 221–223 196–198
dysgerminomas, 56–57 fluid-filled distended, 104. See also Cesarean section (C-section) scar defects,
edema, massive, 147–152 Hydrosalpinx. 39–42
endometriosis, 76–82 intracavity scan protocols, 223–232. See also corpus luteum (CL), 43–47
endometrium, atrophic, 14 Intracavity scan protocols. cystadenofibromas, 51–52
fibroids, 85–92 Fibroids, 85–92 cystadenomas, mucinous, 122–124
fibromas clinical aspects of, 86 cystadenomas, serous, 184–185
cystadenofibromas, 51–52 degenerating, 85 cysts, clear, 48–50
ovarian, 93–95 differential diagnosis for, 86 cysts, dermoid, 53–55
fibrothecomas, 93–95 etiology of, 85 cysts, epidermoid, 83–84
hematocolpos, 98–103 intramural, 85 cysts, paraovarian, 155–156
hematometra, 98–103 pedunculated, 85 cysts, paratubal, 155–156
hematuria, 15–20 recommendations for, 86 cysts, peritoneal inclusion, 8–10
hydrosalpinx, 104–108 submucous, 85 cysts, Tarlov, 192–193
hyperplasia, endometrial, 71–75 subserosal, 85 cysts, theca lutein, 194–195
intrauterine device (IUD) locations, abnormal, synonyms for, 85 dehiscence, uterine, 39–42
109–113 ultrasound findings for, 56, 85, 91f dysgerminomas, 56–57
leiomyomatosis, intravenous, 114–115 Fibromas edema, massive, 147–152
lymph nodes, enlarged, 116–117 bladder, 15. See also Bladder masses. endometriosis, 76–82
masses cystadenofibromas, 51–52 endometrium, atrophic, 14
bladder, 15–20 clinical aspects of, 51 endometrium, thick (differential diagnosis),
cervical, 34–38 differential diagnosis for, 51 71–75
vaginal, 209–218 etiology of, 51 fibroids, 85–92
mucocele, appendiceal, 11–13 recommendations for, 51 fibromas, ovarian, 93–95
Müllerian duct abnormalities, 125–135 synonyms for, 51 fibrothecomas, 93–95
ovarian cancer ultrasound findings for, 51, 51f–52f hematocolpos, 98–103
borderline, 21–25 ovarian hematometra, 98–103
epithelial, 137–146 clinical aspects of, 93 hematuria, 15–20
269
Index
Gynecologic ultrasound (Continued) Hyperplasia, endometrial (Continued) Leiomyomatosis, intravenous, 114–115

hydrosalpinx, 104–108 differential diagnosis for, 71–72 clinical aspects of, 115
hyperplasia, endometrial, 71–75 etiology of, 71 differential diagnosis for, 115
intrauterine device (IUD) locations, abnor- recommendations for, 72–75 etiology of, 114
mal, 109–113 synonyms for, 71 recommendations for, 115
leiomyomatosis, intravenous, 114–115 ultrasound findings for, 71, 73f–75f synonyms for, 114
lymph nodes, enlarged, 116–117 Hyperplastic polyps, 163 ultrasound findings for, 114
masses, bladder, 15–20 Hyperreactio luteinalis, 194. See also Theca lutein Leiomyosarcomas, 205. See also Uterine sarcomas.
masses, cervical, 34–38 cysts. Lesions
masses, vaginal, 209–218 anterior abdominal wall, 77–78. See also
mucocele, appendiceal, 11–13 I Endometriosis.
Müllerian duct abnormalities, 125–135 Implants, deep penetrating bowel wall/pelvic, bladder wall, 77–78
ovarian cancer, epithelial, 137–146 77–78. See also Endometriosis. focal bladder, 15
ovarian tumor, borderline, 21–25 Inclusion cysts, peritoneal, 8–10. See also Cysts. LMPs. See Low malignant potential tumors
pelvic inflammatory disease (PID), 199–202 Incomplete abortion, 172. See also Retained prod- (LMPs).
pelvic kidney, 159–160 ucts of conception (RPOC). Locations, intrauterine devices (IUDs), 109–113.
polycystic ovaries, 161–162 Infections, pelvic, 199. See also Pelvic inflamma- See also Abnormal intrauterine device (IUD)
polyps, endometrial, 163–169 tory disease (PID). locations.
pregnancies, ectopic, 58–64 Inflammatory bowel diseases, 26. See also Low malignant potential tumors (LMPs), 21. See
premature ovarian failure, 170–171 Bowel diseases. also Borderline ovarian tumor.
retained products of conception (RPOC), Insufficiency, ovarian, 170. See also Premature Lymph nodes, enlarged, 116–117
172–176 ovarian failure (POF). clinical aspects of, 116
sarcomas, uterine, 205–208 International Ovarian Tumor Analysis (IOTA) differential diagnosis for, 116
Schwannomas, 182–183 multicenter group, 138 etiology of, 116
stones, ureteral, 203–204 Intracavity scan protocols, 221–223 recommendations for, 116
struma ovarii, 186–188 adnexa, 221, 229–231, 232f synonyms for, 116
syndrome, Asherman's, 177–181 cervix, 20f, 224, 225f ultrasound findings for, 116, 116f–117f
syndrome, pelvic congestion, 157–158 cul-de-sac, 225f, 231–232 Lymphomas, bowel, 27. See also Bowel diseases.
thecomas, 93–95 endometrium, 224–229, 227f–228f
torsion, ovarian, 147–152 myometrium, 225–226 M
torsion, tubal, 147–152 techniques for, 221–223 Malignant germ cell tumors, 56. See also
tumors, Brenner, 32–33 probe disinfection, 221–222 Dysgerminomas.
tumors, granulosa cell (GCTs), 96–97 transabdominal (TA) scans, 221–223, 222f Malignant mixed Müllerian tumors (MMMTs),
tumors, metastatic to ovaries, 118–121 transrectal (TR) scans, 222, 223f 205–208. See also Uterine sarcomas.
uterus, T-shaped, 189–191 transvaginal (TV) scans, 221–223, 223f Masses
vein thrombosis, ovarian, 153–154 uterus, 221, 222f–223f, 224–229, 225f–226f appendiceal, 11. See also Appendiceal
normal pelvic scans and variants, 219–234 vagina, 223–224, 224f mucocele.
anatomy, normal, 221–223 Intramural fibroids, 85. See also Fibroids. bladder, 15–20
intracavity scan protocols, 223–232. See also Intrauterine adhesions, 177. See also Asherman's cervical, 34–38
Intracavity scan protocols. syndrome. vaginal, 209–218
nongynecologic organs, 232–233 Intrauterine device (IUD) locations, abnormal, Massive edema, 147–152
quality-related considerations of, 232–233 109–113 clinical aspects of, 148
techniques, 221–223. See also Techniques. clinical aspects of, 110 differential diagnosis for, 147
differential diagnosis for, 109 etiology of, 147
H etiology of, 109 recommendations for, 148
hCG. See Human chorionic gonadotropin recommendations for, 110 synonyms for, 147
(hCG). synonyms for, 109 ultrasound findings for, 147, 148f–151f
Hematocolpos. See Hematometra and ultrasound findings for, 109 Mature teratomas
hematocolpos. Intravenous leiomyomatosis, 114–115 cystic, 53. See also Dermoid cysts.
Hematometra and hematocolpos, 98–103 clinical aspects of, 115 monophyletic, 83. See also Epidermoid cysts.
clinical aspects of, 99 differential diagnosis for, 115 Menopause, early, 170. See also Premature ovarian
differential diagnosis for, 99 etiology of, 114 failure (POF).
etiology of, 98 recommendations for, 115 Mesothelial cysts, 155. See also Paratubal and
recommendations for, 99 synonyms for, 114 paraovarian cysts.
synonyms for, 98 ultrasound findings for, 114 Mesotheliomas, benign cystic, 8. See also
ultrasound findings for, 97f, 98–99, 100f–102f IOTA. See International Ovarian Tumor Analysis Adhesions.
Hematuria, 15–20 (IOTA) multicenter group. Metastasizing leiomyomas, benign, 114. See also
clinical aspects of, 16 IUD locations. See Intrauterine device (IUD) Intravenous leiomyomatosis.
differential diagnosis for, 16 locations, abnormal. Metastatic tumors to ovaries, 118–121. See also
etiology of, 15 Tumors.
recommendations for, 16 K clinical aspects of, 118
synonyms for, 15 Kidney, pelvic, 159–160 differential diagnosis for, 118
ultrasound findings for, 15, 16f–20f clinical aspects of, 159 etiology of, 118
Human chorionic gonadotropin (hCG), 194 differential diagnosis for, 159 recommendations for, 118
Hydrocolpos, 98. See also Hematometra and etiology of, 159 synonyms for, 118
hematocolpos. recommendations for, 159 ultrasound findings for, 118, 119f–121f
Hydrometra, 98. See also Hematometra and synonyms of, 159 Mirena intrauterine device (IUD), 109.
hematocolpos. ultrasound findings for, 159, 159f–160f See also Intrauterine device (IUD) locations,
Hydrosalpinx, 104–108 Kidney stones, 203. See also Ureteral stones. abnormal.
clinical aspects of, 105 Mixed epithelial and mesenchymal tumors, 205.
differential diagnosis for, 104–105 L See also Uterine sarcomas.
etiology of, 104 Latzko triad, 196 MMMTs. See Malignant mixed Müllerian tumors
recommendations for, 105 Leiomyomas, 85 (MMMTs).
synonyms for, 104 benign metastasizing, 114. See also Intravenous Monodermal highly specialized mature cystic
ultrasound findings for, 104, 105f–108f leiomyomatosis. teratomas, 186. See also Struma ovarii.
Hyperplasia, endometrial bladder, 15. See also Bladder masses. Monophyletic teratomas, mature, 83. See also
clinical aspects of, 72–75 fibroids, 85–92. See also Fibroids. Epidermoid cysts.
270
Index
Mucinous cystadenomas, 122–124. See also Ovarian insufficiency, 170. See also Premature PFTCs. See Primary fallopian tube carcinomas
Cystadenomas. ovarian failure (POF). (PFTCs)
clinical aspects of, 122–123 Ovarian metastatic tumors, 118–121. See also Meta- PID. See Pelvic inflammatory disease (PID)
differential diagnosis for, 122 static tumors to ovaries. Placenta, retained, 172. See also Retained products
etiology of, 122 Ovarian pregnancies, 58. See also Ectopic of conception (RPOC).
recommendations for, 122–123 pregnancies. POF. See Premature ovarian failure (POF)
synonyms for, 122 Ovarian sebaceous cysts, 83. See also Epidermoid Polycystic ovarian syndrome (PCOS), 161–162
ultrasound findings for, 122, 123f cysts. clinical aspects of, 161
Mucocele, appendiceal, 11–13. See also Appendi- Ovarian torsion, 147–152 differential diagnosis for, 161
ceal mucocele. clinical aspects of, 148 etiology of, 161
Müllerian duct anomalies, 125–135 differential diagnosis for, 147 recommendations for, 161
classification of, 125 etiology of, 147 synonyms for, 161
etiology of, 125 recommendations for, 148 ultrasound findings for, 161, 162f
synonyms for, 125 synonyms for, 147 Polyps
ultrasound findings for, 126, 127f–135f ultrasound findings for, 147, 148f–151f endometrial, 163–169
Myomas, 85. See also Fibroids. Ovarian vein thrombosis, 153–154 clinical aspects of, 163
Myometrium clinical aspects of, 153 differential diagnosis for, 163
endometriosis of, 3. See also Adenomyosis. differential diagnosis for, 153 etiology of, 163
intracavity scan protocols, 225–226 etiology of, 153 recommendations for, 163
recommendations for, 153 synonyms for, 163
N synonyms of, 153 ultrasound findings for, 163, 164f–169f
Nephrolithiasis, 203. See also Ureteral stones. ultrasound findings for, 56, 153, 154f hyperplastic, 163
Nonfunctional cysts, 43. See also Corpus luteum (CL). Ovaries, polycystic, 161–162. See also Polycystic proliferative, 163
Nongynecologic organs, 232–233 ovarian syndrome (PCOS). Postmenopausal clear cysts, 48. See also Clear
Normal anatomy, 221–223 cysts.
Normal pelvic scans and variants, 219–234 P Pregnancies, ectopic, 58–64
anatomy, normal, 221–223 ParaGard intrauterine device (IUD), 109. clinical aspects of, 59
intracavity scan protocols, 221–223 See also Intrauterine device (IUD) locations, differential diagnosis for, 59
adnexa, 221, 229–231, 232f abnormal. etiology of, 58
cervix, 20f, 224, 225f Paramesonephric cysts, 155. See also Paratubal and recommendations for, 59
cul-de-sac, 225f, 231–232 paraovarian cysts. synonyms for, 58
endometrium, 224–229, 227f–228f Paraovarian cysts. See Paratubal and paraovarian cysts ultrasound findings for, 58–59, 60f–64f
myometrium, 225–226 Paratubal and paraovarian cysts, 155–156. See also Pregnancy of unknown location (PUL), 58. See
ovaries, 229–231, 232f–233f Cysts. also Ectopic pregnancies.
perineum, 18f, 223–224 clinical aspects of, 155 Premature ovarian failure (POF), 170–171
uterus, 221, 222f–223f, 224–229, 225f–226f differential diagnosis for, 155 clinical aspects of, 170
vagina, 223–224, 224f etiology of, 155 differential diagnosis for, 170
nongynecologic organs, 232–233 recommendations for, 155 etiology of, 170
quality-related considerations of, 232–233 synonyms for, 155 recommendations for, 170
techniques, 221–223 ultrasound findings for, 155, 155f–156f synonyms for, 170
probe disinfection, 221–222 PCOS. See Polycystic ovarian syndrome (PCOS) ultrasound findings for, 170, 171f
transabdominal (TA) scans, 221–223, 222f Pedunculated fibroids, 85. See also Fibroids. Premenopausal clear cysts, 48. See also Clear cysts.
transrectal (TR) scans, 222, 223f Pelvic abscesses, 199. See also Pelvic inflammatory Primary fallopian tube carcinomas (PFTCs),
transvaginal (TV) scans, 221–223, 223f disease (PID). 196–198. See also Carcinomas.
Pelvic congestion syndrome, 157–158 BRCA 1/BRCA 2 and, 196
O clinical aspects of, 157 clinical aspects of, 196
Organs, nongynecologic, 232–233 differential diagnosis for, 157 differential diagnosis for, 196
Ovarian calcifications, 136. See also Calcifications, etiology of, 157 etiology of, 196
ovarian. recommendations for, 157 Latzko triad and, 196
Ovarian cancer synonyms for, 157 recommendations for, 196
borderline, 21–25 ultrasound findings for, 157, 157f serous intraepithelial tubal carcinomas (STICs)
clinical aspects of, 21 Pelvic infections, 199. See also Pelvic inflammatory and, 196
differential diagnosis for, 21 disease (PID). synonyms for, 196
etiology of, 21 Pelvic inflammatory disease (PID), 199–202 ultrasound findings for, 196, 197f–198f
recommendations for, 21 clinical aspects of, 199–200 Probe disinfection, 221–222
synonyms for, 21 differential diagnosis for, 199 Proliferation, endometrial, 71. See also Endome-
ultrasound findings for, 21, 22f–25f etiology of, 199 trial hyperplasia.
epithelial, 137–146 recommendations for, 199–200 Proliferative polyps, 163
clinical aspects of, 138 synonyms for, 199 PUL. See Pregnancy of unknown location (PUL).
differential diagnosis for, 138 vs. tubo-ovarian abscesses (TOAs), 199 Pyocolpos, 98. See also Hematometra and
etiology of, 137 ultrasound findings for, 199, 200f–202f hematocolpos.
recommendations for, 138 Pelvic kidney, 159–160 Pyometra, 98. See also Hematometra and
synonyms for, 137 clinical aspects of, 159 hematocolpos.
ultrasound findings for, 11, 137–138, 139f–145f differential diagnosis for, 159
International Ovarian Tumor Analysis (IOTA) etiology of, 159 Q
multicenter group and, 138 recommendations for, 159 Quality-related considerations, 232–233
metastatic tumors, 118–121 synonyms of, 159
Ovarian cysts, clear, 48. See also Clear cysts. ultrasound findings for, 159, 159f–160f R
Ovarian failure, premature, 170–171. See also Pelvic varicose veins, 157. See also Pelvic conges- Rectosigmoid colon, endometriosis of, 26. See also
Premature ovarian failure (POF). tion syndrome. Bowel diseases.
Ovarian fibromas, 93–95 Peritoneal inclusion cysts, 8–10 Renal stones, 203. See also Ureteral stones.
clinical aspects of, 93 clinical aspects of, 8 Retained placenta, 172. See also Retained products
differential diagnosis for, 93 differential diagnosis for, 8 of conception (RPOC).
etiology of, 93 etiology of, 8 Retained products of conception (RPOC),
recommendations for, 93 recommendations for, 8 172–176
synonyms for, 93 synonyms for, 8 Asherman's syndrome and, 177–178. See also
ultrasound findings for, 93, 93f–95f ultrasound findings for, 8, 9f–10f Asherman's syndrome.
271
Index
Retained products of conception (Continued) Struma ovarii (Continued) T-shaped uterus (Continued)
clinical aspects of, 172–173 recommendations for, 186 diethylstilbestrol (DES) and, 189
differential diagnosis for, 172 synonyms for, 186 differential diagnosis for, 189
etiology of, 172 ultrasound findings for, 186, 187f–188f etiology of, 189
recommendations for, 172–173 Submucous fibroids, 85. See also Fibroids. recommendations for, 189
synonyms of, 172 Subserosal fibroids, 85. See also Fibroids. synonyms for, 189
ultrasound findings for, 172, 173f-176f Syndromes ultrasound findings for, 189, 190f–191f
RPOC. See Retained products of conception Asherman's, 177–181 Tubal carcinomas, 196. See also Primary fallopian
(RPOC) pelvic congestion, 157–158 tube carcinomas (PFTCs).
polycystic ovarian syndrome (PCOS), 161 Tubal pregnancies, 58. See also Ectopic
S Synechiae, 177. See also Asherman's syndrome. pregnancies.
SAB. See Spontaneous abortion (SAB), incomplete. Tubal torsion, 147–152
Sarcomas, uterine, 205–208 T clinical aspects of, 148
classification of, 205 TA scans. See Transabdominal (TA) scans. differential diagnosis for, 147
clinical aspects of, 206 TAB. See Therapeutic abortion (TAB). etiology of, 147
differential diagnosis for, 205 Tarlov cysts, 192–193. See also Cysts. recommendations for, 148
etiology of, 205 clinical aspects of, 192 synonyms for, 147
recommendations for, 206 differential diagnosis for, 192 ultrasound findings for, 147, 148f–151f
synonyms for, 205 etiology of, 192 Tubo-ovarian abscesses (TOAs), 199–202
ultrasound findings for, 205, 207f–208f recommendations for, 192 clinical aspects of, 199–200
Scar defects, Cesarean section (C-section), 39–42. synonyms for, 192 differential diagnosis for, 199
See also Cesarean section (C-section) scar ultrasound findings for, 192, 192f–193f etiology of, 199
defects. Techniques, 221–223 vs. pelvic inflammatory disease (PID), 199–200
Schwann cell tumors. See Schwannomas. probe disinfection, 221–222 recommendations for, 199–200
Schwannomas, 182–183 transabdominal (TA) scans, 221–223, 222f synonyms for, 199
clinical aspects of, 182 transrectal (TR) scans, 222, 223f ultrasound findings for, 199, 200f–202f
differential diagnosis for, 182 transvaginal (TV) scans, 221–223, 223f Tumors
etiology of, 182 Teratomas bladder, 15
recommendations for, 182 cystic, 53. See also Dermoid cysts. Brenner, 32–33
synonyms of, 182 mature gastrointestinal stromal (GISTs), 27
ultrasound findings for, 182, 183f monodermal highly specialized cystic, 186. germ cell, benign vs. malignant, 56
Sebaceous cysts of ovary, 83. See also Epidermoid See also Struma ovarii. granulosa cell (GCTs), 96–97
cysts. monophyletic, 83. See also Epidermoid cysts. low malignant potential (LMPs), 21
Septate uterus, 125. See also Müllerian duct Theca lutein cysts, 194–195. See also Cysts. metastatic to ovaries, 118–121
anomalies. clinical aspects of, 194 stromal. See Stromal tumors
Septic pelvic thrombophlebitis (SPT), 153. See also differential diagnosis for, 194 transitional cell. See Transitional cell tumors.
Ovarian vein thrombosis. etiology of, 194 TV scans. See Transvaginal (TV) scans.
Serous cystadenomas, 184–185. See also human chorionic gonadotropin (hCG) and, 194
Cystadenomas. recommendations for, 194 U
clinical aspects of, 184 synonyms for, 194 Ulcerative colitis, 26. See also Bowel diseases.
differential diagnosis for, 184 ultrasound findings for, 194, 194f–195f Ultrasound, gynecologic
etiology of, 184 Thecomas, 93–95 of entities
recommendations for, 184 clinical aspects of, 93 abscesses, tubo-ovarian (TOAs), 199–202
synonyms for, 184 differential diagnosis for, 93 adenomyosis, 1–7
ultrasound findings for, 184, 184f–185f etiology of, 93 adhesions, 8–10
Serous intraepithelial tubal carcinomas (STICs), fibrothecomas, 93–95. See also Fibrothecomas. bowel diseases, 26–31
137. See also Epithelial ovarian cancer. recommendations for, 93 calcifications, ovarian, 136
Sex-cord-gonadal stromal tumors, 96. See also synonyms for, 93 carcinomas, endometrial, 65–70
Granulosa cell tumors (GCTs). ultrasound findings for, 93, 93f–95f carcinomas, primary fallopian tube (PFTCs),
Simple cysts, 48. See also Clear cysts. Therapeutic abortion (TAB), 177 196–198
Solid masses, vaginal, 209. See also Vaginal cysts. Thick endometrium, differential diagnosis, 71–75 Cesarean section (C-section) scar defects,
Spontaneous abortion (SAB), incomplete, 172. See Thrombosis, ovarian vein, 153–154 39–42
also Retained products of conception (RPOC). clinical aspects of, 153 corpus luteum (CL), 43–47
SPT. See Septic pelvic thrombophlebitis (SPT) differential diagnosis for, 153 cystadenofibromas, 51–52
STICs. See Serous intraepithelial tubal carcinomas etiology of, 153 cystadenomas, mucinous, 122–124
(STICs) recommendations for, 153 cystadenomas, serous, 184–185
Stones, ureteral, 203–204 synonyms of, 153 cysts, clear, 48–50
clinical aspects of, 203 ultrasound findings for, 56, 153, 154f cysts, dermoid, 53–55
differential diagnosis for, 203 TOAs. See Tubo-ovarian abscesses (TOAs) cysts, paraovarian, 155–156
etiology of, 203 Torsion, ovarian/tubal, 147–152 cysts, paratubal, 155–156
recommendations for, 203 clinical aspects of, 148 cysts, peritoneal inclusion, 8–10
synonyms for, 203 differential diagnosis for, 147 cysts, Tarlov, 192–193
ultrasound findings for, 203, 204f etiology of, 147 cysts, theca lutein, 194–195
Stromal tumors recommendations for, 148 dehiscence, uterine, 39–42
cystadenomas synonyms for, 147 dysgerminomas, 56–57
mucinous, 122–124 ultrasound findings for, 147, 148f–151f edema, massive, 147–152
serous, 184–185 TR scans. See Transrectal (TR) scans. endometriosis, 76–82
fibromas, ovarian, 93–95 Transabdominal (TA) scans, 221–223, 222f endometrium, atrophic, 14
fibrothecomas, 93–95 Transitional cell tumors endometrium, thick (differential diagnosis),
gastrointestinal (GISTs), 27 of bladder, 15. See also Bladder masses. 71–75
thecomas, 93–95 of ovaries, 32. See also Brenner tumors. fibroids, 85–92
World Health Organization (WHO) classifica- Transrectal (TR) scans, 222, 223f fibromas, ovarian, 93–95
tion of, 93 Transvaginal (TV) scans, 221–223, 223f fibrothecomas, 93–95
Struma ovarii, 186–188 T-shaped uterus, 189–191 hematocolpos, 98–103
clinical aspects of, 186 Asherman's syndrome and, 189. See also Asher- hematometra, 98–103
differential diagnosis for, 186 man's syndrome. hematuria, 15–20
etiology of, 186 clinical aspects of, 189 hydrosalpinx, 104–108
272
Index
Ultrasound, gynecologic (Continued) Ultrasound, gynecologic (Continued) Uterus

hyperplasia, endometrial, 71–75 normal pelvic scans and variants, 219–234 anatomy, normal, 221–223
intrauterine device (IUD) locations, abnor- anatomy, normal, 221–223 endometriosis of, 3. See also Adenomyosis.
mal, 109–113 intracavity scan protocols, 223–232. See also intracavity scan protocols, 221, 222f–223f,
leiomyomatosis, intravenous, 114–115 Intracavity scan protocols. 224–229, 225f–226f
lymph nodes, enlarged, 116–117 nongynecologic organs, 232–233
masses, bladder, 15–20 quality-related considerations of, 232–233 V
masses, cervical, 34–38 techniques, 221–223. See also Techniques. Vagina
masses, vaginal, 209–218 Unicornuate uterus, 125. See also Müllerian duct anatomy, normal, 221–223
mucocele, appendiceal, 11–13 anomalies. intracavity scan protocols, 223–224, 224f
Müllerian duct abnormalities, 125–135 Ureteral stones, 203–204 Vaginal cysts, 209. See also Vaginal masses.
ovarian cancer, epithelial, 137–146 clinical aspects of, 203 Vaginal masses, 209–218. See also Masses.
ovarian tumor, borderline, 21–25 differential diagnosis for, 203 clinical aspects of, 210
pelvic inflammatory disease (PID), 199–202 etiology of, 203 cysts, 209
pelvic kidney, 159–160 recommendations for, 203 differential diagnosis for, 210
polycystic ovaries, 161–162 synonyms for, 203 etiology of, 209
polyps, endometrial, 163–169 ultrasound findings for, 203, 204f recommendations for, 210
pregnancies, ectopic, 58–64 Urethral diverticula, 15. See also Bladder masses. solid masses, 209
premature ovarian failure, 170–171 Uterine cancer, 65. See also Endometrial carcinomas. synonyms for, 209
retained products of conception (RPOC), Uterine dehiscence, 39–42 ultrasound findings for, 209, 211f–217f
172–176 clinical aspects of, 39 Varicose veins, pelvic, 157. See also Pelvic conges-
sarcomas, uterine, 205–208 differential diagnosis for, 39 tion syndrome.
Schwannomas, 182–183 etiology of, 39 Vein thrombosis, ovarian, 153–154
stones, ureteral, 203–204 recommendations for, 39 clinical aspects of, 153
struma ovarii, 186–188 synonyms for, 39 differential diagnosis for, 153
syndrome, Asherman's, 177–181 ultrasound findings for, 39, 40f–41f etiology of, 153
syndrome, pelvic congestion, 157–158 Uterine fibromas, 85. See also Fibroids. recommendations for, 153
thecomas, 93–95 Uterine sarcomas, 205–208 synonyms of, 153
torsion, ovarian, 147–152 classification of, 205 ultrasound findings for, 56, 153, 154f
torsion, tubal, 147–152 clinical aspects of, 206
tumors, Brenner, 32–33 differential diagnosis for, 205 W
tumors, granulosa cell (GCTs), 96–97 etiology of, 205 World Health Organization (WHO) classifica-
tumors, metastatic to ovaries, 118–121 recommendations for, 206 tions, 93
uterus, T-shaped, 189–191 synonyms for, 205
vein thrombosis, ovarian, 153–154 ultrasound findings for, 205, 207f–208f
273



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Yvette S. Groszmann, MD, MPH

GYNECOLOGIC ULTRASOUND: A PROBLEM-BASED APPROACH ISBN: 978-1-4377-3794-3

Library of Congress Cataloging-in-Publication Data

Benacerraf, Beryl R., author.

Executive Content Strategist: Helene Caprari

Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to the late Robert F. Porges, MD,

I would like to dedicate this to my parents, Dr. Roberto Groszmann

Beryl R. Benacerraf Steven R. Goldstein Yvette S. Groszmann

I Section 2 NORMAL PELVIC ULTRASOUND

Recurrent Pregnancy Loss—Possible Ultrasound Findings

Appendiceal Mucocele Video 1 Endometriosis/Endometrioma Video 3

Adenomyoma Clinical Aspects and Recommendations

Suggested Reading Maheshwari A, Gurunath S, Fatima F, Bhattacharya S.

A Adhesions (Peritoneal Inclusion Cyst)

Figure A3-2 Low-grade mucinous cystadenoma.

Figure A3-1 Two different patients both suspected

Figure A3-4 Pseudomyxoma peritonei. Note the

Figure A3-3 Nonspecific appendiceal mass proved

Differential Diagnosis Clinical Aspects and Recommendations

Figure B1-1 Transitional carcinoma of the bladder.

Suggested Reading Wong-You-Cheong JJ, Woodward PJ, Manning MA,

Borderline Ovarian Tumor

Figure B2-1 A papillary serous cystadenoma with

Figure B2-6 The unusually solid appearance of a

Figure B3-3 Appendiceal abscess, seen transvagi-

Figure B3-7 Lymphoma. Note the marked thicken-

Figure B3-9 Colon cancer. Note the complex mass

Figure B3-10 Rectal duplication cyst, originally

Etiology Differential Diagnosis

Ultrasound Findings Clinical Aspects and Recommendations

Figure B4-2 Longitudinal view of a Brenner tumor

Suggested Reading Hermanns B, Faridi A, Rath W, Füzesi L, Schröder W.

Differential Diagnosis arising or metastasizing deep in the cervix. A bulky

Figure C1-4 Small endocervical polyp with single feeder vessel.

Figure C1-6 Cervical lymphoma. Note the large

Suggested Reading Sahdev A. Cervical tumors. Semin Ultrasound CT MR.

Cesarean Scar Defect

Figure C2-4 Dehiscence of the C-section scar in a

Corpus Luteum and Hemorrhagic Cyst

C from a neoplasm. Sometimes, the retracting

Figure C3-5 Fluid debris level in an acutely hemor-

Postmenopausal Differential Diagnosis

Suggested Reading Washish A, Elsayes K. Ovarian cystadenofibroma: a

salpingo-oophorectomy is an acceptable treat-

Figure D1-3 Predominantly cystic dermoid mimick-

Figure D1-1 Dermoid. Large mass with typical

Figure D1-4 Unusual but characteristic appearance

Figure D1-2 Dermoid. Typical heterogeneous

Figure D1-5 Cystic mass with typical echogenic

Suggested Reading Kim SH, Kang SB. Ovarian dysgerminoma: color

a thin rim of myometrium. If there is myome- An ectopic pregnancy can masquerade as a

showing the proximity of the cornual ectopic sac to

E Figure E2-6 Endometrium of a 75-year-old asymp-

Endometrial Hyperplasia and the

Figure E3-5 Differential diagnosis. Longitudinal

B Goldstein RB, Bree RL, Benson CB, Benacerraf BR,

Clinical Aspects and Recommendations

Figure E4-2 Two views of an endometrioma involv-

Figure E4-3 Typical unilocular endometrioma. The

GYNECOLOGIC ULTRASOUND: A PROBLEM-BASED APPROACH ISBN: 978-1-4377-3794-3

I Section 2 NORMAL PELVIC ULTRASOUND