51 dr ahmed esawy imaging oral board of female pelvis part i ultrasound

The Art of Radiology

3-dimensional coronal image of a unicornuate uterus.

2-dimensional image of a didelphic uterus with a gestational sac (arrow) in the left horn

2-dimensional transabdominal coronal view of a bicornuate uterus

3-dimensional coronal view of an arcuate shaped uterus

Hysterosalpingogram of an arcuate uterus

MRI of a bicornuate uterus. The arrows indicate two uterine horns.

3-dimensional coronal view of a septated uterus

NORMAL OVARY

MENOPAUSAL OVARY

The normal typical appearance of the infantile uterus

NORMAL OVARY

:Transverse US scan shows normal ovaries (arrows) with visible follicles

:appearence Uniform solid Baseline

Serial monitoring Day 9: Small Follicles Just Apparent. 

ECTOPIC.RING SIGN

.Tubal pregnancy circled in red, 4.5 mm fetal pole (between cursors) in green, pregnancy yolk sac blue

CASE

This is the peripheral component of the complex mass that was seen in the right adnexa. It appears to be an enlarged and heterogeneous right ovary with peripherally

displaced follicles - this is classical for torsion.

This is a normal appearance of the right ovary .

Color Doppler demonstrates normal flow within the right ovary

The left ovary is enlarged, has an abnormal gray scale appearance and appears heterogeneous .

There is scant internal and peripheral flow .

Gray-scale sagittal image reveals right ovary to be enlarged (7 cm) with peripheral follicles and areas of increased echogenicity

Color Doppler demonstrates no flow within the ovary .

Power Doppler confirms almost no flow in the ovary .

OVARIAN TORSION

OVARIAN TOSION

OVARIAN TOSION

OVARIAN TOSION

OVARIAN TOSION

OVARIAN TOSION

TORSION

There is a complex mass seen in the right adnexa. The right ovary is not seen separate from the

Spectral analysis demonstrates a normal arterial waveform. The venous waveform however, could not be obtained, implying that the venous supply is probably compromised .

The complex heterogeneous mass is again noted in the right adnexa. It is predominantly hypoechoic with a few cystic areas within the mass.

The contralateral left ovary appears normal and shows prominent follicles within .

This is the peripheral component of the complex mass that was seen in the right adnexa. It appears to be an enlarged and heterogeneous right ovary with peripherally displaced follicles - this is classical for torsion.

Case Isolated left tubal torsion

The uterus with the normal endometrial stripe is notedIsolated left tubal torsion

There is a hypoechoic structure seen in the left adnexa that appears cystic, contains low-level internal echoes,some debri and thin septae. The mass shows good posterior

enhancement. Isolated left tubal torsion

The cystic structure is noted again and shows very thin, barely perceptible walls. The patient had probe tenderness while scanning

this structure Isolated left tubal torsion

The cystic structure is noted again displaying the homogeneous low-level internal echoes Isolated left tubal torsion

Case Left ovarian torsion

This is a normal appearance of the right ovary .

Color Doppler demonstrates normal flow within the right ovary Left ovarian torsion

The left ovary is enlarged, has an abnormal gray scale appearance and appears heterogeneous. Left ovarian torsion

There is scant internal and peripheral flow. Left ovarian torsion

Case ovarain torsion Gray-scale sagittal image reveals right ovary to be enlarged (7 cm) with peripheral follicles and areas of increased

echogenicity

Color Doppler demonstrates no flow within the ovary .

Power Doppler confirms almost no flow in the ovary .

a) Transverse ultrasonography shows a solid right adnexal mass; b) Longitudinal ultrasonography shows a tubular right ovarian vein extending superiorly from the adnexal mass towards the inferior vena cava (IVC). c) Transverse ultra-sonography shows thrombus in the right ovarian

vein adjacent to the IVC. Blood flow was visible in the IVC on colour Dopplerbut not in the ovarian vein

a) CT through the lower abdomen shows low attenuation thrombus distending the right ovarian vein. b) CT at the level of the kidneys shows thrombus extending into the IVC. c) CT shows a solid adnexal mass adjacent to

the enlarged uterus . Post-partum ovarian vein thrombosis POVT

a) CT through the lower abdomen shows low attenuation thrombus distending the right ovarian vein. b) CT at the level of the kidneys shows thrombus extending into the IVC. c) CT shows a solid

adnexal mass adjacent to the enlarged uterus .

Multiple tiny follicles are seen scattered throughout the right ovary /PCO .

Multiple, small follicles are seen scattered in the right ovary/PCO .

Multiple follicles are seen scattered in the left ovary. A densely echogenic area showing significant posterior acoustic shadowing is noted in the ovarian stroma/PCO

This image shows an echogenic ovarian mass. The posterior margins of the mass are obscured. These features along with the calcification seen in the previous image are suggestive of an ovarian dermoid .

PCO

TOA

PYOSALPNIX

TOA

TOA

TOA after 1o days

PYOSALPNIX

left TOA The uterus appears normal. A large cystic mass is seen in the left adnexa which demonstrates homogeneous, low-level internal echoes. The left

ovary is not visualized separate from this mass .

The cystic mass has a smooth wall except for one loculated area that exhibits thick irregular walls. The medial wall of the locule demonstrated blood flow

on Doppler [not shown here] .

The complex adnexal cyst is noted again, demonstrating low level internal echoes. A thin septum is seen extending from the wall. The mass

appears to be contained within the left ovary (compressed ovarian tissue is seen around the entire periphery) .

The right ovary is seen in this image and exhibits a small cyst with septations .

The right ovary in a different plane shows multiple cystic areas, some of which are septated. The

rest of the ovarian tissue appears somewhat inhomogenous.

Pubic osteomyelitis with an abscessheterogeneous soft tissue mass is noted anterior-inferior to the urinary bladder in the region of

the symphysis pubis, indenting the bladder contour. The bladder wall appears thickened adjacent to the lesion. The uterus appear normal .

Pubic osteomyelitis with an abscessThe heterogeneous soft tissue mass is noted again in this parasagittal image. Irregular echogenic areas are noted caudal to the mass. These echogenic areas cause complete shadowing beneath

them

Pubic osteomyelitis with an abscessThis image shows the extent of the mass more clearly. The mass appears to involve the superficial soft tissues.

The irregular echogenic areas are also seen more prominently here

Pubic osteomyelitis with an abscessThe mass in this transverse view shows a hypoechoic center. This is suggestive of

necrosis .

Pubic osteomyelitis with an abscess Color Doppler shows some flow within the mass .

Pubic osteomyelitis with an abscess Color Doppler of the mass in a different plane

Left ovarian abscess and related IUCD in situ

The endometrial cavity shows a linear, high amplitude echo. This possibly represents a retained piece of the IUCD.

Left ovarian abscess and related IUCD in situ The linear echo within the endometrial cavity is noted again in this image

Left ovarian abscess and related IUCD in situ complex left adnexal cystic mass is noted. The mass is septated and the left ovary could not be identified separately from it .

Left ovarian abscess and related IUCD in situ The left sided cystic adnexal mass exhibits thick septations. The fluid within the mass shows inhomogeneous echoes within .

Left ovarian abscess and related IUCD in situ The septated cystic left adnexal mass is seen again. The thick septations appear quite

irregular, raising a suspicion for neoplasm

Left ovarian abscess and related IUCD in situ The transvaginal scan better demonstrates the internal characteristics of the complex mass in the left adnexa. The thick septae and the inhomogeneous echoes in the

different fluid compartments of the mass are better appreciated in this view

TVS of a cystic mass with a thick and irregular wall . This was an ovarian carcinoma

TOA

TOA after 1o days

HYDROSALPNIX

hydrolpnix

Adnexal mass reveals fluid debris level consistent with hydrosalpnix

SIMPLE UNILOCULAR CYST

Ultrasound: Benign ovarian cyst

FOLLICULAR CYST

A thin-walled cyst (C) with anechoic internal fluid and size larger than 2.5 cm meets the definition of a functioning ovarian cyst

FOLLICULAR CYST

FOLLICULAR CYST

FOLLICULAR CYST

CLC

MATURE CORPUS LUTEUM

SOLID CORPUS LUTEUM

CORPUS LUTEUM+SOLID LESION

SIMPLE CYST+SOLID CORPUS LUTEUM

THECA LUTEUN CYST

THECA LUTEUN CYST

Theca-lutein cysts replacing an ovary in a patient with a molar pregnancy. Despite their size these cysts are benign and usually resolve after treatment of the

underlying disease

PARAAOVARIAN CYSTS

PARAAOVARIAN CYSTS

PARAOVARIAN CYST

PARAOVARIAN CYST

SIMPLE UNILOCULAR CYST

HAEMORRHAGIC CYST

A thin-walled cyst (C) with anechoic internal fluid and size larger than 2.5 cm meets the definition of a functioning ovarian cyst

SIMPLE UNILOCULAR CYST

POSTMENOPAUSAL CYST

POSTMENOPAUSAL CYST

ENDOMETRIOMA

ENDOMETRIOMA

endometrioma

ENDOMETRIOMA

ENDOMETRIOSIS

ENDOMETRIOSIS

ENDOMETRIOSIS

ENDOMETRIOSIS

HGIC CYST(A)

HGIC CYST(B)

(A ) Hemorrhagic corpus luteumwithin the left ovary containing fibrin - , strands appearing as a web like complex of thin branching linear . ) ( , 6 , interface B Same patient as in A week later showing complete

regression.

Hgic cyst

HAEMORRHAGIC CYST

STIMULATED OVARY

STIMULATION WITH HORMONAL THERAPY

Dermiod cyst

Dermiod cyst

CT dermiod cyst

CYSTIC TERATOMA

Immature teratoma

DERMIOD-TERATOMA

DERMIOD-TERATOMA

DERMIOD-TERATOMA

DERMIOD-TERATOMA

DERMIOD-TERATOMA

DERMIOD-TERATOMA

DERMIOD-TERATOMA

BENIGN TERATOMA

CYSTIC TERATOMA

Mature cystic teratoma

DERMIOD-TERATOMA

THICK WALLED CYST

Ovarian fibroma

Fibriod cyst

Predominantly cystic right adnexal mass containing papillary excrescences. papillary serous tumour and fibroma

Doppler demonstrates low-impedance blood flow within the excrescences. papillary serous tumour and fibroma

3D pelvic sonography clearly demonstrated the internal papillations within the right adnexal mass. papillary serous tumour and fibroma

Endovaginal sonography of the left adnexal mass shows a solid lesion with moderate internal flow on color Doppler. The mass is adjacent to the uterus papillary serous tumour and fibroma

STIMULATED OVARY

STIMULATION WITH HORMONAL THERAPY

STIMULATED OVARY

STIMULATION WITH HORMONAL THERAPY

Sepated cystic masses ( A ) Transverse TAS showing cystic mass containing multiple thin internal septations , representing mucinous cystadenoma

Transverse TAS showing septated mass with echogenic material ( * ) in upper loculated area . The echogenic material was mucin within this

mucinous cystadenoma

The septated cystic left adnexal mass is seen again. The thick septations appear quite irregular, raising a suspicion for neoplasm

Sepated cystic masses ( A ) Transverse TAS szzzxhowing cystic mass containing multiple thin internal septations , representing mucinous cystadenoma . ( B ) Transverse TAS showing septated mass with echogenic material ( * ) in upper loculated area . The echogenic material

was mucin within this mucinous cystadenoma

Malignancy was suspected due to thickened septation ( arrow) within this mucinous cystadenocarcinoma

Serous cystadenocarcinoma

Benign cystadenoma

(G ) ) ( and axial H TVS shwing amultiloculated septated cystic mass with focal . wall thickening this represented a mucinous cystadenoma with one locule

containing thick mucinous material

A complex heterogeneous mass with cystic spaces within is noted filling the posterior cul de sac and displacing the uterus and broad ligaments anteriorly

TVA A complex right sided cystic mass is noted with the mass showing very thin septations .

Transvaginal scan demonstrating better the characteristics of the cystic mass in the pelvis .

Again seen is a cystic septated mass in the pelvis with no obvious mural

nodularity or solid components within

The cystic mass demonstrated in another view. The bands of weak echoes seen

crossing the larger cystic compartments are artifacts

Transverse TAS of complex predominantly cystic right – adnexal mass with calcific

focus ( arrow ) arising from tooth within this dermoid cyst

TVS of a pelvic mass in a woman with a renal transplant. This w as found to represent a luteal cyst with fluid surrounding adhesion Sagittal

(A ) ) ( and axial B TVS shwing a multiloculated septated cystic mass . with focal wall thickening this represented a mucinous cystadenoma

with one locule containing thick mucinous material

Complex predominantly cystic masses . ( A ) TVS of endometrioma ( curved arrow ) that contained echogenic clot located adjacent to mature follicle ( straight arrow}

TVS of tubovarian abscess. Abscess cavity was surrounded by ovarian tissue) * (

TVS of a hemorrhagic corpus luteum cyst with trosed left ovary

Transverse TAS showing cystic right – adnexal mass with septations or stands ( arrow ) .

representing an appendiceal abscess in a partum patient.

Cystic mass with small focus of solid tissue morphologically similar to a papillary excrescence ( arrowhead ) This mass was bening

TVS of a right ovary that contains two cystic masses ; one has a papillary excescence . This was a border – line ovarian cancer adjacent to a mature follicle

Complex predominantly cystic masses . ( A ) TVS of endometrioma ( curved arrow ) that contained echogenic clot located adjacent to mature follicle ( straight arrow

Predominantly cystic right adnexal mass containing papillary excrescences. papillary serous tumour and fibroma

Doppler demonstrates low-impedance blood flow within the excrescences. papillary serous tumour and fibroma

Cystic mass with small focus of solid tissue morphologically similar to a papillary excrescence ( arrowhead ) This mass was bening . ( L ) TVS of a right ovary that contains two cystic masses ; one has a papillary excescence . This was a border – line ovarian cancer adjacent to a mature

follicle

Complex predominently solid / dermiod cyst

TVS of granulosa cell tumour

Tvs of dermiod cyst with layer ofd dermiod sebum

TVS of haemorrhagic cyst

TAS of ovarian cystadenoma carcinoma

Magnified TAS of cul-de sac haemorrhage(arrow) resulting from ruptured ectopic pregnancy

TVS of a dermiod cyst contianin typical hair ball(arrow)

A-SOLID MASSES A-TAS enlarged right ovary(between cursor}with ecgogenic area consistent with haemorrahge due to ruptureds ovary

(B) same patient in A show intraperitoneal fluid due to ruptured ovary

Longitudanl TAS demonstrating solid area in culdesac(arrow)arising from torsed right ovary. Same patient in (A) with transverse TAS show normal left ovary(straight arrow)adgacent to

torsed right ovary(curved arrow)

Interligamentous fibriod appearing as solid pelvic mass

Myxomatous uterine tumor (Ilarge armw) arising from uterine fundus {curved arrow). (B) Same tumor . Ultrasound shows estent of tumor (*), which occupies entire abdomen.

TAS of a solid pelvic mass with calcifications (arrow) in elderly patient

Ovarian fibroma

Longitudinal TAS of pelvic kidney (arrow). Pelvocalvceal system accounts for central echogenicity

Magnified transverse TAS showing solid leti—adnexal mass jhcii ci’n cursor.). which represents a hemorrhagic corpus luteum cyst .

Longitudinal TAS ot solid teratoma with calcified areas

Magnified TAS of solid mass (between) representing hemorrhagic corpus luteum cyst

Sagittal and transverse TAS showing a 5 X 7 cm solid mass associated with ascites. This was ovarian cancer .

TVS of loculated fluid with peritoneal adhesions that mimic the appearance of

a cystadenoma.

TVS (A) and TAS (B) of a patient presenting with right lower quadrant pain. The T\’S shows a normal uterus. Compression TAS demonstrated a thickwalled appendix. This patient had

appendicitis at surgery

TVS of a patient following bowel surgery showing a peritoneal “pseudocvst’ or loculated fluid in the right lower quadrant `````

TAS through area of cuIde-sac showing intraperitoneal fluid

hemorrhagic corpus luteum (between cursors)

Long (A) and short (B) axes of fusiform mass in the right tower quadrant are consistent with a thickened appendix. Appendicitis was confirmed at surgery .

TVS of a walled-off appendiceal abscess adjacent to adhesed small bowel hops

TVS of solid mass containing ringlike interfaces. This was found to be a mucocoele

Frequency transvaginal color Doppler stinogram ( TV-CDS) showing low- impedance (pulsatility index of 0.6), low-veloctty (maximum systemic velocity l() cm s) flow in the wall of the corpus

luteum .

Amplitude TV-CDS shows ,more intraparenchyrnal vascularity than that with frequency-based TV-CDS

A complex heterogeneous mass with cystic spaces within is noted filling the posterior cul de sac and displacing the uterus and broad ligaments anteriorly

TVA A complex right sided cystic mass is noted with the mass showing very thin septations .

Transvaginal scan demonstrating better the characteristics of the cystic mass in the pelvis .

Again seen is a cystic septated mass in the pelvis with no obvious mural

nodularity or solid components within

The cystic mass demonstrated in another view. The bands of weak echoes seen crossing the

larger cystic compartments are artifacts

/Mature Cystic Ovarian Teratoma D ermoid Cyst