How Long Does It Take an Imaging Tech to Read Results of Trans Vaginal Ultrasound

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A transvaginal ultrasound offers an invaluable avenue of imaging of the female pelvic anatomy. It augments transabdominal ultrasound for a more than consummate evaluation of the ovaries, adnexa, uterus, neck, and surrounding pelvic regions. Typically, an ultrasound technician volition conduct the scanning and take images of the normal structures, with more dedicated images or cine clips obtained of aberrant anatomy, pathologic processes, or pregnancy. The images are read past a radiologist, guiding the treatment by an interprofessional team.

Objectives:

• Review the purpose of the transvaginal ultrasound.

• Explain how to perform the endovaginal ultrasound.

• Outline the utilities and limitations of the transvaginal ultrasound.

• Describe the basics of interpreting an endovaginal ultrasound past an interprofessional team.

Access complimentary multiple selection questions on this topic.

Introduction

Transvaginal ultrasound imaging of the female pelvic organs is unique in its power to closely visualize the organs that would otherwise exist difficult to see on transabdominal ultrasound. Additionally, different estimator tomography (CT), this is a more up-shut imaging modality without the utilization of ionizing radiation. There are many indications for this, both diagnostic and interventional. An ultrasound technician first conducts a transabdominal scan for a thorough exam and follows it with a transvaginal ultrasonographic test. Images are uploaded to a picture archiving and communication organisation or PACS system for the radiologist to interpret.

Adnexal/ovarian masses and cysts, endometrial pathologies, fibroids, pregnancy  (ectopic and intrauterine) every bit well as evaluation of developmental anomalies are a non-exhaustive list of indications that are ideally evaluated with ultrasound.

Anatomy and Physiology

The ability to properly evaluate the female pelvis sonographically requires proficiency in anatomy. An ultrasonographer volition always position the probe so that a marker that propagates on every prototype consistently indicates cephalad on sagittal imaging and correct side on transverse imaging. Start externally, the introitus gives way to the vaginal canal, which ends at the neck. The cervix has ii portions: the ectocervix, which protrudes out into the vagina, and the supravaginal portion connects with the uterus.[1]

The endocervical culvert connects the vagina and uterine cavity. Circumferentially to the cervix, the fornices are invaginations of the mucosa. A transvaginal ultrasound probe may be placed anteriorly, posteriorly, or on either side of the cervix by placement within the fornix. The posterior fornix creates the inferior edge of the Pouch of Douglas, while the anterior fornix borders the vesicouterine pouch inferiorly.

The external bone of the cervix gives rise to the endocervical culvert and terminates at the internal cervical os. This marks the entrance to the uterus. The fallopian tubes are located on either side of the uterus and are composed of three regions. The portion of the fallopian tube closest to the uterus is called the isthmus, followed by the ampullary segment and then the infundibulum. On the ends of the infundibulum, at that place are finger-like projections called fimbriae that move like cilia and are responsible for drawing an ovulated ovum into the fallopian tubes. The junction between the uterus and the fallopian tube is termed the cornu.[2]

The ovary is suspended to the pelvic sidewall by the infundibulopelvic ligament (suspensory ligament of the ovary), containing the ovarian vessels.[2] The utero-ovarian ligament extends from the uterus to the ovaries and carries a claret supply from the uterine artery.[3]

Indications

Indications for ultrasonographic evaluation of the female pelvis includes, but is non limited to the following:[4]

• Evaluation of pregnancy

• • Fetal evaluation

  • Intrauterine

  • Ectopic

  • Bootless process

• Infertility

• • Evaluation of crusade

  • Evaluation of treatment

• Abnormal uterine bleeding

• • Amenorrhea

  • Dysmenorrhea

  • Menorrhagia

  • Metrorrhagia

• Incontinence

• Presence of pelvic mass

• Presence of infection

• Evaluation of anomalous anatomy

• Aid in performing an interventional process

Other non-gynecologic entities may be evaluated equally well equally listed beneath:[5]

• Bladder:

• • Neoplasms

  • Calculi

  • Fistulas

  • Cystitis

• Urethra:

• Modest bowel

• Rectosigmoid colon

• Pelvic vasculature

• Adhesions

Contraindications

Contraindications to the transvaginal ultrasound are the following[4]:

1. Rupture of membranes in a meaning patient, as they are at an increased risk of chorioamnionitis

2. Imperforated hymen

3. Vaginal obstruction

4. Woman with no history of vaginal intercourse

5. Recent vaginal surgery

6. Lack of patient's consent

Contraindications in pregnant women are premature rupture of membranes and bleeding from placenta previa.

Equipment

• Ultrasound auto with a transvaginal ultrasound probe

• Ultrasound gel

• Probe Cover

• Table: The tabular array may exist specialized for patient placement in the lithotomy position with stirrups. If this specialized tabular array is unavailable, the patient may lie on a apartment table and accept a rolled towel or pillow nether her pelvis to allow for probe maneuverability.[4]

Personnel

An ultrasound technician conducts a transabdominal ultrasound and then follows with a transvaginal sonographic exam. Images are uploaded to a PACS system which is made available to the radiologist for review and interpretation. The paradigm quality and thoroughness of evaluation are largely dependent on the technician's proficiency and perspective to identify pathology and relay the images in a way that sufficiently allows the radiologist to interpret the ultrasound. A chaperone may be offered to the patient as this decreases misinterpretation or miscommunication during the exam.[6]

Preparation

The patient is asked to undress from the waist down and embrace themselves with a gown. Lying supine, transabdominal ultrasound is get-go performed. A full bladder is recommended as this displaces the adjacent bowel loops that would otherwise misconstrue the prototype and create an acoustic window, illuminating the organs behind it. Once completed, the patient is asked to empty their float. A disinfected transvaginal ultrasound probe is prepared by placing lubricant gel inside the tip of the probe cover and and so inserting the probe into it. Careful attention should exist made to eliminate any bubbles which may interfere with imaging quality every bit an antiquity.

Technique

The transvaginal transducer is inserted, with special attention beingness fabricated to the orientation of the image. A marking on the screen may be used to signal cephalad from caudad on sagittal imaging or correct from left on transverse imaging, though diverse protocols are institution-specific.

The probe is placed in the distal vagina or against the external cervical os. Irresolute the depth of the ultrasound probe will create a unlike focal signal and thus bring dissimilar areas inside view.[4] Sagittal imaging is obtained with side-to-side movements of the probe, from 1 adnexa to the other. Turning the probe to 90° will give u.s.a. a transverse/semi-coronal orientation.[4] The transverse on endovaginal imaging is more than of a coronal airplane, while the true transverse image is done transabdominally.[1] Subsequent imaging is performed past moving the probe inductive to posterior. A general survey is first performed as an initial evaluation by sweeping the probe from the midline to the lateral margins at the bilateral adnexa. The probe is then rotated 90° and swept in the anterior-posterior direction.[7] The cervix, internal os, endocervical canal, and occasionally the external os is imaged in both sagittal (long-axis) and transverse (short-axis) orientations.

The neck is commonly 2.5 to 3 cm and may be measured if at that place is an indication for it, such as recurrent second-trimester miscarriages in the setting of incompetent cervix.[1] Beneficial nabothian cysts may be seen here, which are small and anechoic. Concerning the uterus, size, orientation, contour irregularity, and myometrial design should be addressed. The length of the uterus is measured on sagittal orientation, from the fundus to the external cervical os if able to prototype. Transverse/semi-coronal images should too be obtained with anteroposterior and transverse diameters measured. Volume may be calculated from these values. An anteverted uterus, which is the most oftentimes seen presentation, rests its fundus forward on the float, best appreciated on sagittal imaging with the fundus oriented towards the top of the paradigm. A retroverted uterus displays a fundus that orients posteriorly towards the rectum. To see a retroverted uterus may not have whatsoever clinical significance, though it may exist associated with deep infiltrating endometriosis in the posterior cul-de-sac or abdominal adhesions, specially if information technology is fixed in this position.[eight] The myometrial pattern should exist homogeneous, and the uterine contour should be smooth. Heterogeneous parenchyma is not-specific though it may be attributable to adenomyosis or fibroids. Not all fibroids demand to be measured, but the ones that are measured should exist measured in at least ii dimensions.[eight] The location inside the layers of the uterus (subserosal, mucosal, submucosal) and which area of the uterus (left wall, fundus, lower segment, etc.) should be reported.

The endometrium, also referred to as the endometrial stripe, is delineated by its normal echogenic nature surrounded by the hypoechoic uterine myometrium. The thickest portion on true sagittal imaging should be measured. If the endometrial crenel has contents such every bit fluid or an intrauterine device, and so it should be documented.[8] The sum of the thickness of the two parallel endometrial lines is recorded as the endometrial thickness in these cases.[nine] Normal thickness varies for a premenopausal woman, which may be 3-5 mm during the proliferative phase of the cycle, with an upper limit of half dozen-12mm during the secretory stage. A maximum thickness of 5 mm is normal in a postmenopausal woman, even in women on hormonal replacement therapy or tamoxifen.[10] Endometrial irregularity, thickening, or cysts may be seen in the setting of adenomyosis. Endometrial thickness may besides provide clinically useful information. Saline-infused sonohysterography is a technique to augment visualization of the endometrial lining and crenel and evaluate fallopian tube patency.[11]

Ultrasonography is the best way to place the location of early on pregnancy in the setting of an elevated beta-hCG; all the same, a very early intrauterine pregnancy may be missed.[12] Furthermore, an ectopic pregnancy cannot be excluded. Hence a follow-up transvaginal ultrasound and b-hCG are advised [13]. An ectopic pregnancy may occur almost anywhere forth with the female reproductive arrangement; however, the majority (95%) implant within the fallopian tubes.[14]

The bilateral ovaries should exist measured in iii dimensions with the calculation of the volumes. Any masses or prominent cysts should be measured every bit well. Physiologic follicles in a reproductive-aged woman may be seen. Masses, dilated tubular structures, and other abnormalities should be evaluated in the adnexal regions.[fifteen] Notwithstanding, the fallopian tubes are not typically visualized if there is no pathology present.[7]

Dynamic imaging may exist performed past a sonographer via placing a hand over the lower abdomen, palpating, and observing the mobility of the internal organs in real-fourth dimension. "Slide sign" is when the organs motion relatively freely against one another. When they are more fixed during palpation, this is indicative of adhesions.[8] Additionally, regional sensitivity to probe maneuvers and anterior abdominal palpation may exist pertinent to place pathology.[7] Some other grade of dynamic imaging may exist performed by taking a cinematics-loop (video clip). When an expanse of interest is identified, a cine-clip volition let the interpreting radiologist to characterize pathology more accurately than static images alone. Some protocols have cine-clip imaging equally a part of their requirements.[xvi] The use of color doppler has many utilities. It tin can assess the vascularity of an identified lesion, appraise for hyperemic states such as infection, or assess for lack of flow, such equally in the case of ovarian torsion. When color doppler is utilized, this must exist mentioned in the reporting technique and findings.

Once the test is complete, the probe cover is removed, running water and soap are used to remove any gel. Afterward drying the probe, the utilization of a high-level disinfectant is recommended.[17]

Complications

Typically, at that place are no major complications with this procedure. The patient may experience some discomfort but should not feel any hurting.

Clinical Significance

Ultrasound is a tool that is widely available, relatively inexpensive, and timely, which makes information technology invaluable in evaluating emergency situations. 1 of these medical emergencies is ovarian torsion, in which there is twisting near the vascular pedicle of the infundibulopelvic ligament and utero-ovarian ligament.[15] Venous wave-forms are expected to initially become absent because vein walls are thinner and more compressible than their arterial counterparts.[xv]

Because of variability in blood menstruum appearance secondary to setting adjustment, the contralateral normal ovary should be compared.[15] The ovary will appear enlarged, and edematous and pelvic free fluid may be seen.[xv] A hallmark feature is the whirlpool sign, which is torsion at the infundibulopelvic ligament is evaluated in cross-department.[xviii]

Seeing some or all of these findings on ultrasound volition strongly advise ovarian torsion. However, at that place are a few caveats. Due to the dual blood supply from both the ovarian artery running through the infundibulopelvic ligament and the uterine artery from the abdominal aorta, a patient without symptoms may demonstrate an apparent lack of claret flow to the ovary.[15]

Furthermore, the ovary may alternate between beingness torsed and reconfigured to its original position, which ways that some of the aforementioned signs may non be nowadays at the time of the ultrasound.[fifteen] Direct visualization is the mainstay for diagnosis. An appropriate diagnosis of ovarian torsion is made near 84% of the time.[19] The shortcomings of this modality should exist known considering ultrasound alone may not be sufficient to make a diagnosis.

Enhancing Healthcare Team Outcomes

The proximity of the transvaginal ultrasound probe to the regions of involvement allows for better paradigm quality than its transabdominal counterpart.[iv] It operates with a higher frequency transducer (5 to 7.five MHz), resulting in less artifact. A higher frequency can only penetrate and then much through tissue, making it ideal in the transvaginal road.[xx] Additionally, there is marked difficulty in obtaining proper transabdominal sonographic images in an obese patient because of the amount of soft tissue the sound waves demand to traverse; the transvaginal probe volition bypass the pannus.[21]

The transabdominal counterpart operates at a lower frequency (around 3.5 MHz), assuasive for deeper signal penetration (every bit is required) at the expense of poorer resolution. The transabdominal ultrasound also allows more flexibility to image a larger field of view, such as in the setting of the loftier-positioned adnexa because the probe may be moved anywhere across the abdomen.[22]

Each modality has its forcefulness and shortcomings. Hence, the combination of the two methods provides more authentic evaluation and earlier detection of pathology.[23] [Level ii]

Review Questions

Figure

The semicircular region in the superior portion of the epitome indicates that this is a transvaginal ultrasound. This is a sagittal image (long centrality) of the uterus with the cephalad portion on the left as indicated by the LOGIC characterization. This is a retroflexed (more...)

Figure

This is a sagittal image of the left ovary. Physiologic follicles are noted. Contributed by Suraya Nahlawi, Do

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Source: https://www.ncbi.nlm.nih.gov/books/NBK572084/

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