Answer key

a. The top of the screen is inferior on the patient.

• b.

  The uterus is anteverted with the fundus directed anteriorly (screen left on Fig. 4 ).

• c.

  The uterus is neither anteflexed nor retroflexed.

a. The posterior segment, though superior relative to the transducer

• b.

  The anterior segment, though superior relative to the transducer. If the uterus was retroverted/retroflexed, the opposite segments would be 
at the top and bottom of the screen on the sagittal plane.

a. This is transperineal in a ML sagittal plane. The image is as if looking up the patient from the distal urethra, starting inferiorly. Therefore, the top of the screen is inferior. The bottom of the screen is superior. Screen left is anterior. Screen right is posterior.

• b.

  This is transperineal of a cut 
90 degrees to the A plane (orthogonal to the A plane at the dot as if looking anteriorly from behind the urethra); therefore, the cut is coronal of the urethra. The top of the screen is inferior.

• c.

  This is transperineal of a cut coronal to the dot seen on the A plane, as if looking from 
one side of the urethra to the other (green line); therefore, 
the cut is a transverse cut of the urethra. Screen left is anterior. Screen right is posterior. Screen top is the patient’s left. The bottom of the screen is the patient’s right.

• d.

  Superior

• e.

  Superior

• f.

  Anterior

• g.

  Right

Because the mesh is posterior to the CRP location.

The transducer should be angled anteriorly toward the patient’s head by bringing the handle down to bring the fundus into view of this anteverted uterus.

Though thin, there are distinct 
layers—the hyperechoic basal layer (a), the hypoechoic functional layer (b), and the hyperechoic central cavity (c)—created by the two apposing walls of the central cavity. Therefore, this demonstrates the early proliferative phase. The endometrium is often erroneously called a “stripe” but, because it changes by the day in appearance, that term should be removed from reporting descriptive terminology. There are other cases at other phases presented in this workbook.

The letter “d” is pointing to a loop of small bowel in cross-section (as if it is coming at you).

No. It should be moved up to the uterus level. This would improve the resolution of the anatomy at this level. Additionally, the depth of view for the image could be improved by decreasing the field of view, since half the screen is imaging bowel and our area of interest is the uterus.

The uterus is retroverted.

This is the anterior segment directed back posteriorly.

Inferior

Superior

Posterior

Anterior

The transducer should be angled posteriorly toward the patient’s feet to bring the fundus into view of this retroverted uterus.

The endometrial segments are more obscured on this image. Though the functional component is now thickened, there remain three distinct layers—the outer hyperechoic basal layer (gold), the now thickened functional layer, isoechoic to the basal layer (green), and the hyperechoic central cavity (red)—created by the two apposing walls of the central cavity; therefore, this demonstrates the late secretory phase.

The CRP (red dot) on the B plane is placed on the left lateral echogenic focus; therefore, the A plane is sagittal at that left side with the white dot CRP corresponding to that same echogenic focus. The light blue dot CRP is the coronal cut through the uterus at that same level and the rendered image demonstrates the hyperechoic foci at the bilateral isthmus locations, proving the coil is correctly placed.

The perspective for this image is as if one is looking from posterior to anterior of the pelvic floor at a transverse cut of the urethra and mesh. The patient’s right side is on the left of the screen.

c. Unless the entire volume set is present, the relative location of the mesh as compared to the urethral segments would not be known.

The mesh is located at the proximal urethra. Since the urethra is only 
3–4 cm long and a small mesh placement difference can alter the effectiveness of the urethral/bladder function, the level should be reported on all cases.

A curvilinear, hyperechoic structure is visualized posterior and lateral to the urethra, consistent with history of former SPARC sling placement. Of note, the symmetric sling is located at the proximal (not mid) urethra in close proximity to the bladder neck.

• A small, round hyperechoic structure is seen in the posterior, proximal urethral wall on sagittal view, and is also visualized on coronal view and with 3D reconstruction. This does not change throughout the exam, suggesting the possibility of a foreign body such as a suture in the posterior urethral muscularis.

a. Myometrium

• b.

  IUD stem

• c.

  IUD strings

• d.

  Cornua

Measurements can be made using the calipers along the side of the images. The uterus is enlarged measuring 5.7 × 11.8 × 8.3 cm. The normal uterine volume changes throughout the menstrual cycle and ranges from 70 to 200 cm ³ . The formula to calculate volume is the prolate ellipsoid volume calculation, which is L × W × H × 0.52; therefore, the volume of this uterus is enlarged at 290.3 cm ³ .

b. The posterior/fundal myoma displaces the endometrium anteriorly giving the false impression of anteflexion.

c

d

c

a. 1. Inferior

• 2.

  Left

• 3.

  Superior

• 4.

  Right

1. Inferior

• 2.

  Posterior

• 3.

  Superior

• 4.

  Anterior

The most likely etiology of the complex primarily cystic appearing mass is a hemorrhagic follicular cyst with a dependent clot. While it looks large on the screen, it measures very small at 1.5 × 0.885 × 1.38 cm with a volume of 0.9526 cm ³ . The patient was re-examined 6 weeks later at which time it all had 
resolved.

a. 2.3 × 1.5 cm. This ovary appears within normal limits in size.

• b.

  4.1 × 3.6 cm. This ovary appears enlarged.

• c.

  No. The right ovary has a normal echo pattern. The left ovary demonstrates a diffuse heterogeneous dense appearing echo pattern.

a. Yes, the ovarian contour is smooth.

• b.

  No, the contour is circumferentially irregular.

a. Normal small follicles are seen.

• b.

  There is a paucity of follicles seen.

Though there is a normal circumferential flow pattern around one small follicle, most of the ovary has inconsistent vascularity.

RI is an additional tool that when abnormally low, less than 0.4, may raise the index of suspicion for quickly forming hypervascularized tissue, such as a neoplasm. The RI in this case was high at 0.61, decreasing, but not eliminating, the concern for malignancy.

c. The right ovary was resected. At pathology, the sonographic bulky, enlarged, and dense area of the left ovary was found to be a dysgerminoma with corresponding abnormal vascularity.

The acquisition sweep was ML sagittal, as seen on the A plane.

The CRP is seen at the mid posterior vaginal wall.

The CRP could be moved to the screen left at mid-urethra on the A plane, which would move through the volume on the orthogonal B and C planes. Alternatively, the CRP could also be moved towards screen left on the C plane to the mid-urethra.

There is no evidence of avulsion, although there are several aspects of the volume set that would have improved visualization of the entire PVM complex had the following three instrumentation steps been taken. First, the A plane could have been rotated to the left on the screen by shifting the Z-axis knob. Second, the C plane screen right side could have been rotated upward also with the Z-axis knob to enhance symmetry of the 3D rendered image. Third, if the green line of reference was moved up on the screen (inferior on the body), it would have added the final aspect of the PVM attachment at the pubic rami.

a. The typical sonographic venous appearance is one of low visibility, generally measuring 1–2 mm. AP diameter > 5 mm is considered abnormal.

• b.

  Normal vessels likely increase in diameter with Valsalva and resume normal size at rest. Dilated venous structures with Valsalva may demonstrate increased AP diameter, as seen on Fig. 31 , where the diameter (gold lines) measures 6.5 mm with Valsalva. This same increase in diameter may be accomplished when a patient has prolonged periods of standing up or heavy lifting.

• c.

  Pelvic Congestion Syndrome

• d.

  This appearance of diffusely 
dilated vessels is indicative of pelvic congestion syndrome, which has a prevalence of 39%. It is associated with an increasingly incompetent ovarian vein varices that results in reduced venous clearance and stasis. As the venous dilatation worsens, the vessels become diffusely tortuous as flow becomes retrograde. Patients may describe the fullness as if their “bottom is going to fall out” and occurs more frequently in multiparous patients for unclear reasons. The patient’s chronic pelvic pain will usually reflect the degree of dilatation seen sonographically.

  • When dilated, abnormal venous structures can be serpiginous in contour and unilateral or bilateral. Other imaging, including CT and MRI, also well visualize the altered dilated vasculature with this condition.

The uterus is anteverted.

b

Using the calipers along the side of the images, the smooth-walled central cavity lesion measures 
4.3 × 1.8 × 2.5 cm.

Doppler Color Flow pattern is the key to the diagnosis. The transverse image demonstrates a single anterior feeder vessel entering centrally ( Fig. 33 ), the finding c/w a large endometrial polyp as opposed to the typical peripheral vascularity of a myoma.

• The patient was undergoing evaluation for infertility, the polyp was resected, and the patient became pregnant 2 months later.

a. Endometrial lesions are found on all three cases, ranging from × to 40 mm, some originating from the anterior, some from the posterior, and some from both aspects of the endometrium.

• b.

  Fig. 35 demonstrates a single lesion seen on both planes.

• c.

  It demonstrates increased internal central, not peripheral, vascularity within each lesion.

• d.

  Yes. A thin basal layer is seen only, except the abnormal segments.

• e.

  No, the vascularity is a qualitative sample of vessel presence.

• f.

  Yes

c

Hydrosalpinx

The sweep plane (A) is midline sagittal.

e

The IAS disruption is from 9 to 
1 OC, with elevation of the central mucosa toward the defect.

c

a. It is circumferentially smooth.

• b.

  Yes

• c.

  This is called “posterior acoustic enhancement,” also known as “enhanced through transmission,” indicating little absorption of sound as it traveled through the lesion by the increased echogenicity beyond the lesion.

a. The septae seen are variable in thickness.

It would be incorrect to call this lesion a “cyst.” It is complex primarily solid in appearance with diffuse low-level echogenicity and multiple thick and thin septae noted.

b

a

a. Bladder

• b.

  Vagina

• c.

  Rectum

• d.

  Urethra

c. Best seen on the C plane.

a

It measures 5 × 10 × 10 mm.

a. Both (red arrows)

• b.

  Small rectocele at the distal posterior vaginal/rectal interface

• c.

  Left pubovisceralis muscle complex

Neither image is right or wrong.

a. Endometrial functional layer

• b.

  Endometrial basal layer

• c.

  Central cavity wall

• d.

  Extra-uterine transverse cut of bowel loop

c

b

a. The uterus is anteverted.

• b.

  The uterine echo pattern is diffusely heterogeneous and appears unlike the normal uterus.

a

a. Typically, however, flow pattern of this condition appears randomly scattered.

c. It is not uncommon to find concomitant leiomyomata; however, no demonstrable myomatous lesions are seen in this patient.

Using the calipers along the side of the image, the transverse width measures 10 cm.

• a.

  The normal nulliparous uterine transverse width measures approximately 4–5 cm.

• b.

  i. The lesion is central in location, within the endometrial cavity.

  • ii.

    The lesion is irregular and multilobular in contour.

  • iii.

    The lesion is oblong and multilobular in shape, with the widest aspect at the transverse plane.

  • iv.

    The echo pattern is complex primarily solid in echo pattern, with a rim of hypoechogenicity around most aspects of the mass, except the left lateral aspect where the lesion appears to be contiguous with the myometrium (gold arrows). All is thought to be within the endometrial cavity.

b

d

d

The volume measures 6.523 cm ³ when calculated manually, which correlates with the volume on the image of 6.568 cm ³ done at the time of the exam.

• This demonstrates that measurements can trustfully be calculated post exam using the prolate ellipsoid formula from two planes; therefore, one can measure the L × H × W × 0.52 to obtain the parameters and volume. This assumes one does not measure, say, the transverse width twice instead of the AP diameter; so, one must be sure what the directions are on each plane.

a and e. Describe the mass as anechoic, indicating it is simple, with a smooth though irregular border extending toward the patient’s left side. The ultimate diagnosis requires histochemical assessment.

The volume of this ovary is measured on Fig. 56 and is markedly increased at 154 mL (cm ³ ).

a. Smooth

• b.

  Bilobular

• c.

  Heterogeneous

Both and, cumulatively, markedly increased.

RI = 0.2

• The RI of this ovary is abnormal. Sometimes, a benign process changes flow patterns to have a low RI. A typical corpus luteum, for example, has a low RI as it develops quickly. A malignant lesion tends to quickly form new vessels also with a low RI; so, in the context of imaging, a first exam often elicits a referral for a repeat exam in the presence of a mass with a low RI.

• It is crucial to repeat the imaging exam in enough time for a potential corpus luteum to resorb. It is reasonable to schedule after 8 weeks or at least two full menstrual cycles. Rushing to repeat another exam prior to that time may result in continued concerning 2D findings, Color Power Doppler, and abnormal spectral waveform patterns.

• These findings persisted on repeat exam and she underwent surgical removal of the mass. The pathologic diagnosis for this lesion was a borderline tumor.

a. They are the right and left 
pubovisceralis muscle complex, which is most optimally seen at the midlevel.

• b.

  Screen left on a transverse cut is right on the patient, as if looking “up” the patient (from inferior to superior).

• c.

  It is widely disrupted from 8 to 2 OC (green arrows), with elevation of the central mucosa (CM) toward the defect.

3.38 × 2.69 cm

More

2D EV imaging of the IAS and perianal tissue demonstrates a disruption from 8 to 2 OC at the midlevel IAS, as seen by the presence of the pubovisceralis muscle complex posterior and lateral to the IAS. Anterior to the disruption is a poorly demarcated heterogeneous perianal soft tissue area with irregular contour, and a central area measuring approximately 3.4 × 2.69 cm. Multiple punctate echogenic foci are noted within this central soft tissue area. 2D Color Power Doppler elicits diffusely increased vascularity throughout this area. 3D volume render demonstrating profound accumulated increased vascularity ( Fig. 65 ).

• Findings are c/w a perianal 
abscess extending from a severe IAS disruption and vaginal tear.

• Over the next 8 weeks, the patent was treated medically with various antibiotics and the abscess gradually reduced in size and the patient slowly improved.

b

Yes, the stem is central.

No. Though the stem is central ( Fig. 67 ), the arm extends beyond the cavity into the left myometrium ( Fig. 68 ).

It is at the mid IAS by demonstration of the adjacent pubovisceralis muscle (PVM) complex. All quadrants of the IAS are measured, demonstrating relative symmetry with the central mucosa.

a. Central mucosa (CM)

• b.

  Left pubovisceralis muscle (PVM) complex

• c.

  Internal anal sphincter (IAS)

Label E is the patient’s right side and F is left as if you are looking inferiorly to superiorly.

No. The absence of the pubic and anterior/lateral PVM makes this diagnosis inconclusive. To be complete, another 3D volume sweep needs to be performed with an angulation of the line of interest from symphysis to the puborectalis level wide enough sweep angle to include all anatomy anteriorly to posteriorly. This is usually accomplished with the CRP moved to symphysis and the plane rotated on the Z-axis.

Appreciating the 90-degree planes’ yin-yang appearance of an acutely formed hemorrhagic clot is related to knowing what direction is where on each plane of an EV image. When a clot forms, it lies at the dependent portion of the hemorrhage at the dependent portion of the patient in a layer/layer (fluid/fluid) pattern. So, if the patient is lying down, the dependent aspect is inferior (always at the top of the screen when the exam is EV). What is seen in the sagittal versus transverse plane is related to the side locations. In the sagittal plane, screen left is anterior (screen right posterior) and in the transverse plane, screen left is the right side of the patient (screen right is the left side of the patient).

• Fig. 72 a is labeled with correct directions on the patient as related to each aspect of the clot of the sagittal and transverse plane.

a. Yes. The typical normal ovary measures 1 × 2 × 3 cm with a volume of approximately 3.12 mL (cm ³ ). Globally, this ovary measures 1.5 × 2 cm.

• b.

  The contour of the ovary is smooth in appearance; the hyperechoic subcomponent is eccentric yet also smooth in contour within the ovary.

• c.

  If her last menstrual period (LMP) was 1 week ago, her ovary would be in the follicular phase and demonstrate several small follicles. No follicles, normal or abnormal, are seen within the ovary on these cuts; however, if a higher-frequency transducer could have been used, there may have been a few small follicles visualized.

a

Too high

c

It is not entirely visualized by transperineal imaging due to distal apposition of the mucosa and possible minimal transducer compression; however, the urethra appearance is typical.

This is an example of how important assessing anatomy in two planes is, especially in the presence of what may be perceived to be an abnormality. The finding is not uncommon in a partially full bladder.

a. Indistinct

• b.

  Endometrial periphery

• c.

  16 mm

• d.

  23 mm

• The endometrium appears thickened with a smooth contour and a relatively homogeneous echo pattern. The anteroposterior (AP) diameter measures 23 mm, whereas the typical measurement would be 5–7 mm at the early proliferative phase. The endometrial layers are indistinct with the isoechoic thin basal layer noted peripherally only at the lower endometrium. The basal layers are being measured by the calipers at 1.5 and 1.7 mm.

Focal peripheral vessels extend centrally into the endometrial mass.

c

a. The typical bladder wall thickness is 1.5–2.76 mm.

• When the bladder is distended, it should not measure more than 3 mm.

• When the bladder is empty, it should not measure more than 5 mm.

• This bladder thickness is 
abnormal, ranging 6.1–6.3 mm.

• b.

  The AP thickness at the arrow measures 8 mm.

  • Etiologies for increased bladder wall thickness may include chronic UTI/ infectious cystitis, bladder outlet obstruction, neurogenic bladder, and cystitis from radiation or chemotherapy exposure, and others.

The transabdominal examination approach is infinitely variable with individualized angulation necessary in order to optimize assessment of the uterus.

a. B, C, and D are EV images as 
evidenced by empty bladder, closer approach to the anatomy, and improved resolution. Image A is a transabdominal image.

• b.

  No. Image A demonstrates the measurement of the uterine length suboptimally, and the bladder is not full enough to completely see the uterine fundus. Unless the transducer lines of sight are perpendicular to 
the endometrium, it will not be 
optimally assessable even if the uterus is measurable.

• c.

  C. The cervical canal is well demarcated because the curvilinear transducer’s lines of sight are hitting both interfaces perpendicularly.

• d.

  Correct answer is B, C, and D images. B is secretory phase, C is early proliferative phase, and D is secretory phase.

a. Angled anteriorly. Bring handle down.

• b.

  Move halfway out of the vagina and angle slightly anteriorly.

• c.

  Move out of the vagina and anteriorly from the vaginal introitus on the perineum to be directly in front of the urethra.

• d.

  Move out of vagina, angle perpendicularly [90 degrees to the anal sphincter complex (ASC)] on the vaginal posterior wall (yellow line) toward ASC (unless anorectal transducer is utilized).

a. Anteriorly, with the transducer toward the patient’s head, handle down.

• b.

  Posteriorly, with the trans­­ducer toward the patient’s feet, handle up.

• c.

  Post-menses; the two very thin hyperechoic basilar layers are apposing each other with no visible functional layers.

• d.

  Secretory; the functional and basilar layers are isoechoic, relative to each other, and slightly hyperechoic, relative to the myometrium.

a. It measures 10.9 × 14.8 × 14.3 mm.

• b.

  Round

• c.

  It appears isoechoic to the vagina with several peripheral hyperechoic curvilinear echoes with and without posterior acoustic shadow. Isoechoic structures are difficult to see, so the calcifications can be helpful to get the examiner on the right pathway toward locating lesions.

a. It is posterior.

• b.

  It is posterior and inferior.

The B plane, relative to the patient’s body , is coronal through the center reference point (CRP), and the C plane is axial through the CRP.

It is not seen on the B plane because the coronal cut (90 degrees, or perpendicular, at the red line on the A plane) is posterior to the urethra.

10 × 10 mm

d. Myomas can have a range of echogenicity and calcifications.

a. What to report: The bladder luminal wall contour is irregular and diffusely jagged in contour with markedly abnormal thickening, measuring 9.3 mm. Remember, the maximal wall thickness of a partially full bladder should be 5 mm or less.

Bladder

a. The caliper units along the right side of the Color Power Doppler of Fig. 92 are 0.5 cm increments, with every two lines measuring 1 cm units. The left (normal) labium ( Fig. 90 ) measures 2.69 × 1.43 × 2.96 cm with a volume of 5.48 cm ³ . The right (swollen) labium ( Fig. 92 ) measures approximately 3.5 × 2.5 × 2.25 cm with a volume of 10.23 cm ³ , calculated by using the prolate ellipsoid formula of (L × W × H × 0.523); therefore, one can confidently say that the right labium is about twice the size of normal.

• b.

  Diffuse. What to report: Color Power Doppler demonstrates a diffuse markedly increased pattern of flow of the enlarged right labium, indicating an extensive inflammatory process, especially as seen cumulatively on the profoundly increased vascularity of the 3D rendered images. Follow-up exams demonstrated gradual reduction of the hypervascularity with antibiotic treatment.

b. The surrounding posterior and lateral pubovisceralis muscle complex (Label C) is the adjacent midlevel internal anal sphincter (IAS) landmark.

a. Sagittal

• b.

  Transverse (axial) at the mid-internal anal sphincter (IAS) (see gold arrows at PVM complex on both A and B planes).

• c.

  Coronal

• d.

  The CRP should be moved screen left on the A plane, which is proximal on the ASC, to just before the anal angle (red *).

Parallel. In this case, abnormal vessels can be clearly visualized in a parallel pattern anterior and posterior to the endometrium on the sagittal images (screen left, top, and bottom). When the transducer is turned 90 degrees to a transverse cut, those vessels can be seen entering into the central area of an endometrial lesion in the zoomed transverse plane 
(blue arrows, screen right, top, and bottom). This indicates a classic 
endometrial polyp appearance. The lesion is surrounded by a thin isoechoic post-menses basal layer component (gold arrow) of the endometrium on the transverse cut.

e

a. 11–12 o’clock (OC)

• b.

  11–1 OC

Both. Note that the normally round central mucosa extends towards the defect on both images.

Though B demonstrates a portion of the PVM (gold arrow), the sector width during the exam was set wider for A (blue arrow).

It would be better. A higher-
frequency transducer has higher resolution images.

b

a. Disruption is from 10 to 2 OC.

• b.

  There is an elevation of the central mucosa (CM) toward the defect.

• c.

  False. The perianal tissue is abnormally distorted and heterogeneous, suggesting the presence of scarred tissue.

a

e

a. Widens

• b.

  Both

• c.

  No

• d.

  No

• e.

  Yes

a. No.

• b.

  Inferiorly

• c.

  No. The bladder has an irregular bilobular bulky appearance that expands with Valsalva. It prolapses inferiorly. There is no evidence of enterocele.

A

a. Yes. It appears to extend through the cuff.

• b.

  It lies directly adjacent to the left ovary but is hard to tell if they are adhered on the initial image. With manual lower pelvic compression, the two structures separated on real time.

a. Sagittal midline

• b.

  Transverse mid-uterus

• c.

  Coronal of uterine body

The A image is always the sweep plane, but what plane that is will be determined by the examiner in how they hold the transducer. Midsagittal is the standard cut for the sweep plane in uterine assessment and the typical sweep angle is about 75 degrees to capture the whole uterus with the slowest sweep speed setting to obtain the highest resolution. The center reference point (CRP) indicates the location at which the B plane is cut at 90 degrees, or perpendicular (transverse cut) to the A plane, and C plane is coronal to the A plane and a coronal cut of the uterus.

The C plane is the only view that shows the entire IUD in this case. Since the coronal C plane is not seen on the 2D vaginal approach, unless the uterus is in a neutral position, seeing the entire IUD on one plane may not be possible.

The coronal C plane is most reliable if the original sweep plane is midline sagittal.

It is pointing to a commonly seen nabothian cyst.

No. Only the stem is within the cavity. Note that the left arm is extending into the left portion of the myometrium. Only identifying the presence of the stem will often miss this diagnosis.

Posterior

Each horizontal-to-horizontal distance caliper along the side of each image is 1 cm. Each horizontal-to-dot distance is 0.5 cm. The left ovary is enlarged, measuring 4.2 × 4.2 × 4.3 cm using the markers on the side of each image, with a 
volume of 40.38 cm ³ (using the prolate ellipsoid volume formula of L × W × H × 0.52. This was acquired from the calipers along the image of the 3D volume set. Remember, normal ovarian measurements should be around 1 × 2 × 3 cm with a volume of × cm ³ .

c. The only anechoic components of this ovary are a few peripheral follicles. Otherwise, the ovary demonstrates diffuse low to midlevel echoes, a thick partial vertical septum, and a solid round component at the inferior aspect of the abnormal appearing ovary.

All three RIs are abnormally low at 0.20, 0.22, and 0.26. Remember, normal RI for the ovary should be above 0.4. Added concern is raised for malignancy when septae demonstrate increased vascularity, as is seen here. At surgical pathology, this mass was found to be a borderline tumor.

Each line-to-dot distance is 0.5 cm; so, one can appreciate the distance of the mesh from the perineum at about 1.5 cm. The purpose of this image and cine loop is to demonstrate how mesh can be well seen with a high-frequency transducer. To determine the location of the mesh, relative to the urethra would be better presented with a 3D volume set; however, it is evident that the surgical mesh placement is too distal.