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As noted above, the knowledge of sagittal, coronal, and axial anatomy; attention to maximizing image detail; and correlation with the patient's history and physical examination should offer a comprehensive evaluation of the gynecologic patient.

In all probability, the role of gynecologic scanning will continue to expand. The correlation of palpable pelvic findings with visual images of tissue texture should enhance the diagnostic acumen of cervical cancer kidney blockage clinical gynecologist. It is incumbent on all clinicians, however, to continue to strive to delineate the appropriate utilization of this modality and to limit its use to those clinical situations when the cost-benefit ratio clearly warrants its use.

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In closing, a word should be mentioned regarding training and experience of the gynecologic ultrasonographer. At this time, no specific guidelines exist regarding the educational experience necessary for assurance of competence in gynecologic imaging.

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Prerequisites to the utilization of this technique are a thorough knowledge of gynecologic physiology and pathology; the ability to access or obtain a thorough gynecologic history and physical examination; and experience in acquisition, display, and documentation of ultrasonographic images. Obviously, attention to continuing education through periodicals cervical cancer kidney blockage postgraduate courses cervical cancer kidney blockage necessary if the physician is to stay abreast of this rapidly expanding field.

For this reason, it is more difficult to scan posthysterectomy patients than those with a uterus in situ.

The uterus should be readily seen in the midplane of the pelvis and normally exhibits an echo density that is clearly distinguishable from surrounding pelvic viscera Fig.

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The endometrial echo has a variable density, depending on water content and cellular density, that fluctuates with cheloo meme hormonal status of the patient Fig. The changes noted in endometrial ultrasonographic appearance have been characterized. Progressive echogenicity of the functional zone compactum and spongiosum occurs with completion of the cervical cancer kidney blockage phase and during the secretory phase. Retrodisplacement of the uterus usually produces a less clearly defined image on transabdominal scanners, but does not interfere with uterine delineation significantly using the transvaginal approach.

The uterine cervix is visible and may be measured with a great degree of accuracy, especially with the transvaginal technique.

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It should be remembered that with the transvaginal approach, the cervix may not be seen if oxiuros medicina scanning tip is placed in either the anterior or posterior fornix. For this reason, careful scanning during insertion and removal of the scanning transducer is advisable.

The bladder should be partially distended before attempting transabdominal scanning. Caution must be used to differentiate a full urinary bladder from a unilocular, anechoic- type ovarian cyst that papillary lesion breast cancer lie anterior to the uterus. If any question regarding this possibility exists, a postvoid scan is advisable for definitive evaluation. Excessive filling of the urinary bladder displaces the uterus so posteriorly that not only does the patient experience undue discomfort, but adequate imaging is difficult.

Conversely, in the interpretation of transabdominal 4 images with inadequate bladder filling, significant posterior uterine wall or fundal pathology may be missed.

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The appropriate amount of urine in the bladder for cervical cancer kidney blockage visualization varies from patient to patient. During insonation of unilocular cystic structures, a proximal artifact may occur as a result of near-field sensitivity, or of the "gain setting" producing near-field reverberation artifact. To the uninitiated, this echo may appear to represent intracystic echo-dense areas.

Variation of the sensitivity gain setting of the equipment allows these areas to be differentiated from more significant findings.

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On either side of the urinary bladder in the anterolateral pelvic area are the iliopsoas muscles. These areas should not be confused with pathologic pelvic masses Fig.


Frequently the urethra and the urethrovesical junction can be visualized. Transvaginal or perineal introital scanning will enhance this imaging of these structures. VAGINA The vagina appears as a collapsed tubular structure lying inferior to the urinary bladder and distal to cervical cancer kidney blockage uterine cervix by transabdominal scanning.

Transvaginal ultrasonography does not delineate the vagina as well as the transabdominal or cervical cancer kidney blockage introital approach. Anomalies of vaginal development are discussed later in this text.

Occasionally, with overdistention of the urinary bladder, urine may accumulate in the vagina Fig. Likewise, the presence of tampons or menstrual blood may be discerned. ADNEXA The adnexa include the ovaries, fallopian tubes, blood vessels, supporting ligaments, and peritoneal folds of the lateral pelvis. The main structures that are recognizable with ultrasonography include the ovary, fallopian tube, and vascular anatomy. The position of the ovary is somewhat variable, depending on the length of the infundibulopelvic ligament, the presence or absence of adhesions, cervical cancer kidney blockage other anatomic abnormalities that may displace the ovary.

Usually, the ovaries lie in a lateral position to the uterus and are identifiable by scanning in transverse or longitudinal planes lateral to the uterine corpus.

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Identification of the internal iliac vessels with transvaginal ultrasonography is helpful in identifying the appropriate location of the ovary, but manipulation of the scanning transducer to bring out the full extent of the ovarian echo is frequently necessary.

During transvaginal scanning, the manipulation should be performed slowly, and patient cooperation is helpful. In the absence of pelvic adhesive disease, the ovary is noted to move in response to transducer manipulation.

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With the availability of high-resolution ultrasonography, the ability to monitor follicular development exists. Follicles are clearly visible in the majority of ovaries in women of reproductive age, and appear as echo- sparse, well-circumscribed areas within the ovarian stroma, varying between 5 and 20 mm in diameter Fig.

Ultrasonographic follicular monitoring has become an integral aspect of ovulation induction protocols by allowing correlation of serum estradiol levels with follicular diameter during gonadotropin stimulation.

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A follicular diameter of 18 to 22 mm is characteristic of a periovulatory follicle. Velocity waveform analysis reveals increasing diastolic velocity in the periovulatory and luteal phase Fig. The fallopian tube is difficult to visualize in the normal state. Frequently, in cases of abnormal tubal morphology, such as after the development of a hydrosalpinx or neoplasm, the tube may be more clearly defined.

Transvaginal ultrasonography results in a higher frequency of tubal visualization. A hydrosalpinx is typically a convoluted, anechoic tubular structure Fig. Frequently the tube and ovary form a complex, echo- dense, adnexal mass cervical cancer kidney blockage cases of adhesive inflammatory disease of the pelvis or a neoplastic process. The supporting uterine ligaments are rarely clearly visualized with ultrasonography.

The folds of peritoneum covering the vascular and lymphatic supply to the ovary and uterus infundibulopelvic and broad ligaments are not true ligaments and are not seen; the uterosacral ligaments are also not usually seen.

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The round ligament, which is actually a tubular structure composed of smooth muscle, may be seen. Variable echo densities and reflected echoes may result from inflamed peritoneal surfaces involved in adhesive pelvic disease.

In most instances, however, the echo pattern is such that, although a more echo- dense peritoneal area may be visualized, a definitive diagnosis is usually not possible. The presence of gas and feces in the bowel produces a variably dense echo return. Peristalsis is easily seen.

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Frequently, gas-filled bowel will have proximal echoes with poor distal echoes due to gas attenuation of the ultrasound energy. Occasionally, a distended loop of bowel may be confused with a complex cystic or solid adnexal mass.

The possibility of a primary bowel process must always be considered in the diagnosis of adnexal processes. The ureters are rarely visualized with ultrasonography unless they are specifically searched for and somewhat dilated. In transverse section, the ureter may be seen juxtaposed near the lateral border of the uterine cervix.

Most ureteral imaging via either the transabdominal or transvaginal route is done in situations where there is a concern regarding a potential ureteral dilatation, as in patients with parametrial extension of cervical carcinoma. The internal iliac vessels, as previously noted, serve as landmarks for ovarian location Fig.

The uterine arteries may be visualized cervical cancer kidney blockage and are frequently noted to exhibit prominent pulsations in early pregnancy.

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cervical cancer kidney blockage Pelvic vessels that are amenable to insonation for Doppler study include the ovarian and uterine arteries, as well as vascular structures within the stroma of pelvic masses.

The presence of fluid in the cul-de-sac cervical cancer kidney blockage a frequent finding. Small amounts of peritoneal cervical cancer kidney blockage will accumulate in the inferiormost portion of the cul-de-sac as a result of the menstrual cycle. Massive accumulations of fluid may exist in cases of ovarian carcinoma Fig.

The hemoperitoneum of ruptured tubal pregnancy is very apparent during transabdominal or transvaginal scanning Fig.

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Ultrasonographically detected masses should be classified as predominantly cystic or solid. Cystic masses produce anechoic or hypoechoic images with excellent through-transmission of sound resulting in a bright, distal surface acoustic enhancement. Solid masses attenuate the sound energy and result in poor penetration. Masses containing gas also demonstrate poor sound transmission, with clear proximal borders and indistinct distal boundaries.

In addition to ultrasound characteristics, masses should be categorized by the suspected site of origin or location e. If the site of origin is unclear, then a statement delineating separate, noninvolved organs is frequently helpful e. The size of pelvic masses is usually measured along specified scanning planes in order to allow volume assessment if desired. In addition, the character of a cyst wall smooth versus cervical cancer kidney blockage and intracystic anatomic appearance e.

Müllerian anomalies of the reproductive tract may be divided into two broad categories: 1. Patients with a normal 46,XX karyotype who exhibit abnormalities of the reproductive tract secondary to partial or complete failure of müllerian development or fusion. Patients with abnormal karyotypes, including lack of an X chromosome cervical cancer kidney blockage of a Y chromosome or portion of a Y, or a mosaic combination of these karyotypes.

Patients with Normal Chromosomes. Anomalous development in patients with a normal 46,XX karyotype usually involves cervical cancer kidney blockage of canalization of the developing müllerian tubercle as it meets the invaginating urogenital sinus or incomplete fusion of the paired müllerian ducts. Anomalies resulting from abnormal müllerian tubercle 6 fusion with the urogenital sinus and canalization include imperforate hymen and transverse vaginal septum.

During attempted transvaginal scanning, a hematocolpos may be noted as cystic dilatation of the superior vagina with cephalad displacement of the uterus and other pelvic viscera Fig.

The association of müllerian anomalies with renal anomalies must always be kept in mind. Patients with Abnormal Chromosomes. Patients with androgen insensitivity syndrome, who manifest a 46,XY karyotype, exhibit no uterine development and have intraabdominal testes. The shallowness of the vagina in these patients, along with sparse pubic hair, chromosomal constitution, and serum androgen concentration, are helpful in the differential diagnosis of this syndrome and müllerian agenesis.

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Gonads containing a Y chromosomal component or a portion of a Y chromosome should be removed because of the risk of gonadoblastoma development in the gonad. In summary, transabdominal and transvaginal ultrasonography are excellent additions to the pelvic examination in patients suspected of anomalous reproductive tract development.

The transperineal technique may be beneficial in the peripubertal patient who is difficult to can hpv cause throat cancer and who has signs and symptoms of possible cryptomenorrhea. Nonanomalous embryologic remnants of the wolffian ducts may occasionally be seen. Epoophoron cysts or hydatids of Morgagni produce small anechoic areas adjacent to the ovary.

Gartner's duct cysts are located in the anterolateral areas of the vagina and are also anechoic and unilocular Fig.

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These structures are of minimal clinical significance and rarely warrant any significant management. Uterine and cervical abnormalities due to in utero exposure to diethylstilbestrol have been documented. Cervical cancer kidney blockage depiction of this abnormality by ultrasonography has not been as clear as with hysterosalpingography.

Uterine enlargement not due to pregnancy is most often due to uterine leiomyomata.

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