Diagnostic ultrasound ( PDFDrive )

566 PART II Abdominal and Pelvic Sonography
course with the suspensory (infundibulopelvic) ligament and
the utero-ovarian ligament. he lymph vessels of the ovary
accompany the ovarian artery to the lateral aortic and periaortic
lymph nodes. Coursing superior and adjacent to the utero-ovarian
ligament that arises from the uterine cornu posteriorly to the
tubes and attaches to the inferior aspect of the ovary in the
utero-ovarian ligament is the ovarian branch of the uterine artery.
Derived from the main ovarian artery and the ovarian branch
of the uterine artery are numerous arterioles extending to the
capsule of the ovary and small penetrating arteries within the
ovary itself. he ovarian blood supply may vary from ive to six
branches that penetrate the capsule to two large branches with
multiple twigs. 2
Although not considered part of the adnexal structures, the
rectouterine recess (posterior cul-de-sac) is oten involved in
adnexal processes. It is the most posterior and inferior relection
of the peritoneal cavity and is located between the rectum and
vagina and is also known as the pouch of Douglas. he posterior
fornix of the vagina is closely related to the posterior cul-de-sac
and is separated by the thickness of the vaginal wall and the
peritoneal membrane. he cul-de-sac is a potential space, and
because of its location, it is frequently the initial site for intraperitoneal
luid collection. As little as 5 mL of luid has been
detected by TVS. 3
Technique
he standard examination of the pelvic adnexa is included in
the routine pelvic sonogram and is composed of the traditional
TAS combined with the TVS, frequently using color and spectral
Doppler. TAS uses a distended bladder as window to pelvic
structures for a global view and may be advantageous when
ovaries are high in the pelvis, outside of the ield of view of the
TVS probe. However, using TAS, visualization of pelvic organs
may be limited because of attenuation from the body wall and
the distance from the area of interest of the transducer. As a
result, it is not oten possible to use higher frequency transducers
and beneit from their inherent higher axial and lateral resolution.
TVS gives a more detailed evaluation of adnexal architecture
using higher frequency transducers at closer proximity to pelvic
structures and should be used whenever feasible. Still, TVS should
not be performed in premenarchal patients, in the majority of
virginal patients, or in any patient who does not willingly consent
to vaginal examination. Because TVS is typically performed,
routine bladder distention is not required unless there is a reason
for additional TAS images, or unless the woman declines vaginal
scanning. Initial imaging with TAS is performed using the patient’s
bladder distention at presentation followed by a full TVS. When
TVS is not going to be performed, then we require a full bladder
for best visualization of the uterus, endometrium, and adnexa.
TVS with abdominal compression is a valuable technique for
improving adnexa visibility. Abdominal pressure with one hand,
while holding the transducer with the other hand, is used to
displace bowel, bring structures closer to the transducer, and
identify focal areas of tenderness. he pressure of the transducer
between two adjacent structures in the pelvis can be used to
determine if they move together or slide past each other as separate
entities. his is oten referred to as the “sliding organ sign.”
Examples of the value of this technique include its use to conirm
that an adnexal mass is unattached to the ovary or a mass is
ovarian and not uterine in origin.
Spectral and color and power Doppler are routinely used to
characterize vascularity to the ovaries and fallopian tubes, helping
to narrow the diferential considerations. his is especially useful
when there is suspicion of neoplasia or in patients presenting
with pelvic pain with diagnostic considerations that include pelvic
inlammatory disease (PID), ovarian torsion, or functional cysts.
Because color or power Doppler signal may be produced artifactually,
it is important to always conirm low by demonstrating a
spectral waveform.
Normal Sonographic Appearance of the
Ovary and Fallopian Tube
he ovary can be quite variable in position and may be located
high in the pelvis or in the cul-de-sac because of the laxity of
the ligamentous attachments. Uterine location inluences the
position of the ovaries. he normal ovaries are usually identiied
laterally or posterolaterally to the antelexed midline uterus.
When the uterus lies to one side of the midline due to exogenous
pressure by a mass or a normal variant, the ipsilateral ovary
oten lies superior to the uterine fundus. In a retrolexed uterus,
the ovaries tend to be located laterally and superiorly, near the
uterine fundus. When the uterus is enlarged, the ovaries may
be displaced more superiorly and laterally. Ater hysterectomy,
the ovaries tend to be located more medially and directly superior
to the vaginal cuf. A common location of the ovaries, especially
in nulliparous patients, is Waldeyer fossa. In this location, the
ellipsoid coniguration of the ovary has its craniocaudad axis
paralleling the internal iliac vessels, which lie posteriorly and
serve as a helpful reference (Fig. 16.3). Waldeyer fossa is also
bounded by the obliterated umbilical artery anteriorly, the ureter
posteriorly, and the external iliac vein superiorly. Superiorly or
extremely laterally placed ovaries may not be visualized by the
TVS approach because they may be outside of the ield of view
of the TVS probe.
Because of the variability in shape, ovarian volume has been
considered the best method for determining ovarian size. he
volume measurement is based on the formula for a prolate ellipse
(0.523 × length × width × height). In women of reproductive
age, a normal ovary may have a volume as large as 22 mL. Cohen
et al. 4 assessed 866 normal ovaries by TAS and reported a mean
ovarian volume of 9.8 ± 5.8 mL, with an upper limit of 21.9 mL. 4
Another study of 406 patients with normal ovaries used TVS
and reported a mean ovarian volume of 6.8 mL, with an upper
limit of 18.0 mL. 5 here is no signiicant parity-related change
in ovarian volume in premenopausal women. 6
Punctate echogenic foci are commonly seen in an otherwise
normal-appearing ovary (Fig. 16.4). Many are tiny (1-3 mm)
nonshadowing foci, usually multiple and peripherally located,
although they can be difuse. Kupfer et al. 7 examined ive patients
with peripherally distributed echogenic ovarian foci who subsequently
underwent bilateral oophorectomy for other clinical
indications. All 10 ovarian specimens showed multiple surface
epithelial inclusion cysts and associated psammomatous