Diagnostic ultrasound ( PDFDrive )

590 PART II Abdominal and Pelvic Sonography
A
B
FIG. 16.26 Pelvic Congestion Syndrome. Transverse TVS images, (A) without and (B) with color Doppler, of the left adnexa demonstrating
multiple large vascular structures consistent with varices.
partial absence of low in these veins. 205 Most patients respond
to anticoagulant and antibiotic therapy, and follow-up sonography
may show resolution of the thrombus and normal low by duplex
and color Doppler imaging.
Pelvic Congestion Syndrome
Pelvic congestion syndrome is a condition that consists of dilatation
of pelvic veins (pelvic varices) and reduced venous return
causing dull chronic pain that is exacerbated by prolonged
standing and relieved by lying down and elevating the legs.
Although venography remains the reference standard for diagnosis,
sonography can demonstrate an ovarian vein diameter of
greater than 5 to 10 mm with relux, uterine vein engorgement,
congestion of ovarian plexuses (tortuous and dilated pelvic venous
plexuses in the adnexa with individual varices measuring greater
than 5 mm in diameter, Fig. 16.26), illing of the pelvic veins
across the midline, or illing of vulvovaginal and thigh varicosities.
206 Dilated arcuate veins may also be seen crossing the
myometrium. Spectral Doppler evaluation of ovarian veins may
demonstrate reversed caudal low.
SONOGRAPHIC EVALUATION OF AN
ADNEXAL MASS IN ADULT WOMEN
Sonography in the setting of certain clinical features is oten
used to evaluate an ovarian/adnexal mass. Clinical features to
be considered when evaluating an adnexal mass include symptoms,
patient age, menstrual status, and family history. Comparison
with previous examinations, if available, is oten critical and may
save the patient a surgical intervention, since many of these
masses are hormonally driven and will resolve. A prior study
will also demonstrate if there has been any change in size or
internal characteristics.
When a mass is found by sonography, it should be characterized
by the following:
• Location (intraovarian or extraovarian)
• Size
• External contour (thin or thick walled and regularity of
borders)
• Internal consistency (cystic unilocular or multilocular with
or without solid components, predominantly solid, or solid)
Generally, ovarian masses are predominantly cystic, whereas
uterine masses are usually solid tumors, benign leiomyomas.
Even solid adnexal masses are usually exophytic or interligamentous
leiomyomas. Demonstrating a uterine origin by grayscale
and color Doppler is diagnostic and excludes a solid ovarian
tumor. Occasionally, it may be diicult to determine the exact
origin of the mass by sonography in which case MRI may be a
problem-solving tool.
In 2010 the Society of Radiologists in Ultrasound published
results of a consensus conference regarding the reporting and
follow-up needed for asymptomatic adnexal cysts (Table 16.3).
Use of these guidelines allows for decreased need for follow-up
of benign adnexal cysts. 207,208 he vast majority of ovarian masses
are functional in nature. Ovarian masses that are simple cysts
are almost always benign. In premenopausal asymptomatic
women, simple cysts or typical hemorrhagic cysts less than 5 cm
can be considered functional. he simple adnexal cyst less than
or equal to 1 cm in a postmenopausal woman is also very likely
benign. hese indings should be considered of no clinical signiicance
in asymptomatic women and do not require follow-up.
Simple cysts greater than 5 cm in premenopausal women are
also likely functional, but resolution should be conirmed with
a follow-up examination. In postmenopausal women, simple
cysts greater than 1 cm are most oten benign cystadenomas or
hydrosalpinges or paraovarian/paratubal cysts that demonstrate
no signiicant malignant potential. Cysts that are greater than
7 cm cannot be adequately evaluated sonographically for mural
nodules, so MRI or surgical evaluation is recommended. 28
Larger masses, especially those greater than 10 cm, and those
with solid components have a higher incidence of malignancy.
Solid ovarian masses that are not classic for ibromas are typically
surgically removed because of association with malignancy. Cystic