UTERUS

• ISLAMABAD INSTITUTE OF SONOGRAPHY

ANATOMY

Anterior relations (from above to downwards)

• Utero vesical pouch of peritoneum
• U.B
• Urethra
Posterior relations (from above to downwards)
• Recto uterine pouch of peritoneum
• containing bowel loops
• Rectovaginal fascia perineal body rectum anus
ANATOMY

LATERAL RELATIONS (FROM ABOVE TO DOWNWARDS)

• Fallopian tubes.
• Ovaries.
• Broad ligament.
• Ureter.
• Uterine artery.
• Pelvic fascia.
• Small pelvic muscles: obturator internus and
levator ani.
PATIENT PREPARATION

• Adequately filled urinary bladder displaces the gas filled

intestinal loops laterally
• Provides an acoustic window
• Adequately filled urinary bladder just covers uterine
fundus
• Overdistended urinary bladder elongates uterus
• Under distended urinary bladder obscure findings
EFFECT OF UB ON UTERUS
CYST APPEARS AS UB
POSITION
ANTEVERTED.
Body of uterus is bent anteriorly on the long axis of vagina.
ANTEFLEXED
Body of uterus is bent anteriorly on the long axis of cervix,
at the level of internal os.
RETROVERTED
Body of uterus is bent posteriorly on the long axis of vagina.
RETROFLEXED
Body of uterus is bent posteriorly on the long axis of cervix,
at the level of internal os.
POSITION
RETROVERTED UTERUS ANTEVERTED UTERUS
POSITION
RETOVERTED UTERUS RETOVERTED
RETROFLEXED UTERUS
PROBE POSITIONING FOR TRANSVERSE
SCAN OF UTERUS.
PROBE POSITIONING FOR LONGITUDINAL
SCAN OF UTERUS
USE THE FULL URINARY BLADDER AS AN
ACOUSTIC WINDOW TO ANGLE ACROSS
TO THE OVARY.
INDICATIONS FOR SCAN

• Pain in lower abd

• Mass in lower abd
• Abnormal uterine bleeding
• Abnormal vaginal discharge
• Evaluation of menstrual disorders
• Evaluation of the cause of amenorrhea; both
primary and secondary
• Evaluation of infertility and sub fertility
• Localization of IUCD
• Detection of congenital anomalies
• Postpartum evaluation
 SIZE
Prepubertal uterus:
• 30 mm (L.S) x 20 mm (T.S) x 20 mm (A.P)
• The body of uterus and cervix are of similar length, so that ratio is 1:1.
• Postpubertal / premenopausal:
• After puberty, body grows more and the ratio b/w body and cervix is
2:1.
• Nulliparous:
• 70mm(l.S) x 30mm (A.P) x 50mm (trans).
• Multiparous:
• Measures 15 mm (on average) more in all directions as compared to
nulliparous uterus.
• Post menopausal
• Uterine body and cervix are of same length so that ratio is 1:1
HOW TO MEASURE ANTEVERTED UTERUS
HOW TO MEASURE RETROVERTED
RETROFLEXED UTERUS
• TO measure uterine length
accurately , we start
measuring from fundus till
lower uterine segment,the
level at which uterus is
flexed ( 1 ) .Then second 1

measurement starting from 2

lower uterine segment till

internal os ( 2 ).Then add
both measurements
• Total uterine length = 1 + 2
7 YRS OLD CHILD UTERUS
 SHAPE & CONTOUR
Prepubertal:
Tubular in shape.
Postpubertal / premenopausal:
Pear shaped anteverted, anteflexed.
Globular retroverted, retroflexed.
Postmenqpausal:
Remains pear shaped.
Contour..............Smooth and well defined.
MYOMETRIUM

• Normal myometrium...
• Homogenous and hypoechoic.
• " This texture of normal myometrium is consistent:
• In body of uterus and cervix through out all age groups.
PROMINENT NORMAL SUB SEROSAL VEINS
 ENDOMETRIUM

• Appears as central linear echogenicity.

• The thickness of endometrium depends upon:
Age of patient.
Menstrual phase
• Premenopausal: up to 10-12mm.
• Postmenopausal:
• 5 mm.......If no HRT
• Up to 8 mm......If taking HRT
 MENSTRUAL CYCLE CHANGES:
Menstrual phase (day 1 -5 )
Endometrial thickness is 1 -4 mm and appears as thin linear
echogenicity
Proliferative phase (day 6-13)
In early proliferative phase endometrial thickness is 1 -4 mm and
appears as thin linear echogenicity however in late proliferative phase
endometrium appears as three line sign
• Myometrial-endometrial interface.
• Endometrial-endometrial interface.
• Endometrial-myometrial interface.
Secretory phase (day 14-28)
Endometrial thickness is 9-12 mm and appears thick and homogeneously
echogenic.
 ENDOMETRIUM IN DIFFERENT PHASES OF CYCLE

Early
Mensturating Proliferative
Phase Phase

Secretory
Proliferative
Phaase
Phase
Late
HOW TO MEASURE ENDOMETRIAL THICKNESS

PROLIFEARTIVE PHASE SECRETORY PHASE

HOW TO MEASURE ENDOMETRIUM WITH FLUID IN
ENDOMETRIAL CAVITY
 VAGINA

• Seen in the midline

• Behind the lower part of a full urinary bladder
• It contains a midline, linear, bright echo produced by
the apposition of anterior and posterior vaginal walls.
CONGENITAL ANOMALIES OF UTERUS
BICORNUATE UTERUS
FUSION DEFECT
No fusion:
Uterus didelphys
• 2 uterine bodies
• 2 cervices
• 2 vaginas
Partial fusion:
Bicornuate uterus
• 2 uterine bodies,
• 1 cervix
• 1 vagina
BICORNUATE UTERUS

• Two separate endometrial cavities in upper part with

no intervening myometrium.
• Two separate endometrial cavities joined by a band of
myometrium slightly lower down.
• Single endometrial cavity in lower part.
• Single cervix.
• Single vagina.
INCOMPLETE RESORPTION OF SEPTUM

• Septate uterus

• Sub septate uterus

• Anomalies caused by incomplete resorption of the

septum are most common.
SEPTATE UTERUS

• Two separate endometrial cavities joined by a

intervening myometrium through out the length
• Two cervix
• Two vagina
SUB SEPTATE UTERUS
• 2 separate endometrial cavities joined by band of
myometrium
• Single endometrial cavity in lower part
• Single cx
• Single vagina
CONGENITAL ANOMALIES OF UTERUS
BICORNUATE UTERUS DIDELPHYS UTERUS
IUCD
It is recognized as an echogenic linear structure within the
cavity of uterine body with dense acoustic shadowing.

MULTILOAD MIRENA
IUCD
 DISPLACED IUCD
• The distance of IUCD from the upper end of endometrium should be less then 5 mm.
• The distance of IUCD from the pole of fundus should be less then 20 mm.
• An increase in these distances suggests that IUCD is displaced toward the cervix
and provides inadequate contraception
DISPLACED IUCD
EMBEDDED IN MYOMETRIUM
PERFORATED INTO THE
ADJACENT CUL DE SAC
IUCD WITH GESTATIONAL SAC
PATHOLOGIES
Mvometrium:
• Uterine fibroid,
• Adenomyosis
Endometrium:
• D/D of thick endometrium
Endometrial hyperplasia
Polyps
Endometrial carcinoma
• D/D of fluid in the endometrial cavity
Endometria, hydrometra,pyometra, haematometra
Cervix:
Cervial fibroid
FIBROIDS
• Leiomyomas usually appear as well-defined, solid, concentric,
hypoechoic masses that cause a variable amount of acoustic
shadowing.
• Refraction artifacts resulting from tissue density interfaces and
fibroid textures often aid in identification of fibroids
• Location :
intramural
submucosal
Intracavitary
subserosal
Exophytic / pedunculated
cervical
SONOGRAPHIC APPEARENCE

• Generally round, smooth, well circumscribed, solid in

appearance hypoechoic relative to normal myometrium.
Other features:
• Attenuation of ultrasound beam
• Centrally anechoic
• Because of necrosis and cystic degeneration..
• Echogenic with acoustic shadowing suggesting calcification
FIBROIDS
INTRAMURAL SUBMUCOSAL
FIBROIDS
SUBSEROSAL INTRACAVITARY
FIBROIDS
EXOPHYTIC EXOPHYTIC PEDUNCULATED
HOW TO LOCALIZE ISOECHOIC FIBROID
CALCIFIED FIBROIDS
CALCIFIED FIBROID
NECROSIS IN FIBROID
FIBROID WITH PREGNANCY
FIBROID MIMICKING DUPLICATED UTERUS
NECROTIC FIBROID RESEMBLING
GESTATIONAL SAC
ADENOMYOSIS
• Foci of endometrium are present inside myometrium, which
undergo same cyclical changes as the normal endometrium
causing dysmenorrehea.
• Also called "endometrium interna"
• Focal / diffuse benign invasion of myometrium by endometrium
Types
• Focal adenomyosis = "adenomyoma"
• Diffuse adenomyosis resulting in smooth uterine enlargement
• Focal adenomyoma is difficult to differentiate from a fibroid
 ADENOMYOSIS
• Variable sonographic findings are observed
[Link] globular uterus
[Link] wall thickening
[Link] myometrial echotexture
4. Subendometrial and myometrial cysts
5. Loss of endomyometrial interface causing indistinct
myometrium/pseudowidening of endometrium
TVS and MR pelvis should be suggested
ADENOMYOSIS
ADENOMYOSIS
ADENOMYOSIS
ADENOMYOSIS
ADENOMYOSIS
ENDOMETRIUM
SONOGRAPHIC EVALUATION OF A THICK
ENDOMETRIUM NEEDS CORRELATION WITH

• Age of patient.
• Phase of the menstrual cycle.
• Pregnancy .
• Any peri menopausal abnormal uterine bleeding.
• Any postmenopausal bleeding
D/D OF THICK ENDOMETRIUM

• Secretory phase of a normal menstrual cycle.

• Decidual reaction of an intrauterine or extrauterine
pregnancy.
• Rpoc's.
• Endometrial polyp.
• Endometrial hyperplasia.
• Endometrial carcinoma.
ENDOMETRIAL POLYP
Sonological appearance of endometrial polyps is
• Well defined
• Oval or round
• Homogeneous
• Polypoid lesion
• Isoechoic or echogenic to the endometrium with
preservation of the endometrial-myometrial interface.
• There is usually a well-defined vascular pedicle within the
stalk.
DIFFERENCE BETWEEN POLYP AND
INTRACAVITARY FIBROID
ENDOMETRIAL POLYP
ENDOMETRIAL HYPERPLASIA
Endometrial hyperplasia s the common cause of abnormal uterine
bleeding in both perimenopausal and postmenopausal age group.
Atypical hyperplasia is precancerous.
Histologically:
Simple, sometime complex and atypical indistinguishable
sonographically
SONOGRAPHICALLY:
Perimenopausal >8 mm
Postmenopausal >5 mm
• Should be evaluated by transvaginal color doppler and biopsy.
ENDOMETRIAL HYPER PLASIA
 ENDOMETRIAL CARCINOMA
• Commonest uterine malignancy.
• Usually present as postmenopausal bleeding in the age group b/w
55-65.
Sonographically:
• Uterine enlargement.
• Thick endometrium > 5 mm.
• Heterogeneous echogenicity and echotexture with irregular outline
of the endometrium
• Associated with hydrometra, pyometra or hematometra carcinoma
blocks the cavity.
THICKENED ENDOMETRIUM
Vaginal bleeding In 54 And 77 Yrs Old patients
ENDOMETRIAL CARCINOMA
THICK ENDOMETRIAL CYSTS DUE TO
TAMOXIFEN
D/D OF FLUID IN THE ENDOMETRIAL CAVITY
• Ovulatory phase of a normal menstrual cycle
• True gestational sac
• Pseudo gestational sac of ectopic pregnancy
• Post abortal and postpartum status
• Endometritis chronic PID
Hydrometra:
Outflow obstruction in prepubertal state
Hematometra:
Outflow obstruction in post pubertal state
Pyometra:
Cervical stenosis due to cervical carcinoma
HEMATOCOLPOS
 PELVIC INFLAMMATORY DISEASE
• Consists of:
 Endometritis
 Salpingitis
 Tubovarian mass,
 To abscess,
 Pelvic fluid collections in cul de sac,
 Diffuse peritonitis.
• Clinically : acute & chronic (tuberculous)
presenting as
Chronic pelvic pain, discharge, dysparunia,infertility
 ENDOMETRITIS
Sonographically:
1) Early cases:
Normal appearance
2) Advanced:
• There is uterine enlargement, with ill defined endometrial
echos.
• Dilated fluid filled endometrial cavity with debris level.
D/D OF FLUID IN POUCH OF DOUGLUS
• Small quantity of fluid at the time of ovulation.
• Ruptured ectopic pregnancy.
• Ruptured ovarian cysts.
• Acute PID with pus in cul de sac.
• Chronic PID (tuberculous: fluid with thick adhesions).
 CERVIX

• Nebothian cysts
• Cervical fibroids
• Cervical carcinoma
 CERVICAL CARCINOMA
• 6th most common cause of death in women.
• 3rd most common uterine malignancy.
• Presents in the perimenopausal age group b/w 45-55.
• Sonographically:
1) Solid mass with irregular margins and heterogeneous
appearance
2) Pyometra or hematometra due to outflow obstruction.
POST MENOPAUSAL : FLUID DUE TO
CERVICAL STENOSIS
 VAGINA

• Gartner duct cyst

• Hematocolpos
• Vaginal fibroid
GARTNER'S DUCT CYST
• Mesonephric duct in the female obliterates to form the
gartner's duct.
• When this obliteration is incomplete, a cyst is formed,
in the lateral vaginal wall.
• Asymptomatic or present with pain, swelling and
dysparunia.
NORMAL AIR IN POST PARTUM UTERUS