13 Female Genital Tract

Female Genital Tract 441

Endometriotic Cysts

Thecomatosis

Inflammatory Adnexal Mass

Ovarian Carcinoma

Metastases

Pseudomyxoma Peritonei

Ovarian Tumors

(by Histological Criteria)

13

Female Genital Tract

Female Genital Tract

Fig. 13.3 Transverse scan of the uterine fundus: about 4 cm transverse diameter and about 2 cm sagittal diameter. BL = bladder.

Fig. 13.4 Uterine fundus, 29-year-old woman, transverse scan of the lower abdomen: normal echogenicity and size (cursors).

Fig. 13.5 Uterus (UT) in a dorso-inferior position of the bladder (BL), surrounded by ascites (A); also the retinaculi fixing the uterus to the lateral abdominal wall. The central echoic band is formed by the connecting halves of the endometrium.

■ Vagina

Ultrasound Morphology

The vagina is a flattened tube leading to the uterus. With its anterior and posterior walls composed of mucosal and muscular layers, the vagina appears as a thin, multilayered band in longitudinal and transverse ultrasound scans through the lower abdomen (Fig.13.6, Fig.13.7). The vagina may appear echogenic to hypoechoic, depending on the angle at which it is scanned. In some cases ultrasound can distinguish a high-level entry echo followed by the hypoechoic anterior wall, a bright luminal echo at the center, the hypoechoic posterior wall, and a bright exit echo. The lumen may also be hypoechoic, depending on the fluid and mucosal content of the vagina.

Masses

Fig. 13.6 Longitudinal scan of the vagina. UT = uterus; BL = bladder; V = vagina; R = rectum; FL = fluid in the cul-de- sac.

Fig. 13.7 Transverse scan of the vagina. BL = bladder; V = vagina; R = rectum.

Female Genital Tract

Vagina Masses

Abnormalities of Size or Shape Uterus

Fallopian Tubes Ovaries

Imperforate Hymen with Hematocolpos Vaginal Wall Cyst

Double Vagina, Septate Vagina Tampon

Vaginal Carcinoma

An imperforate hymen is rare (incidence 1/ 60 000) and does not become clinically apparent until puberty. With menarche, the patient experiences monthly lower abdominal pain and increasing malaise with an absence of menstrual bleeding. The blood pools in the vagina (hematocolpos) and may reflux into

the uterus (hematometra) or fallopian tubes (hematosalpinx). The pseudotumor may extend to the level of the umbilicus.

Hematocolpos. Ultrasound demonstrates an almost anechoic mass of variable size and extent in the vagina, located posterior and infe-

rior to the bladder. The uterus, which shows increased echogenicity, is displaced upward and is often barely detectable in its position above the mass (Fig.13.8).

Hematosalpinx. The fallopian tubes may also fill with blood, causing extension of the mass lateral to the bladder (see Fig.13.77).

Vagina

Malformations are somewhat rare and result from fusion anomalies of the müllerian ducts. In 40% of cases, malformations of the vagina are combined with anomalies of the kidneys and urinary tract.

When a double vagina is scanned with ultrasound, it initially appears thickened with a central, echogenic band. The two hypoechoic lumina can be distinguished when viewed in transverse section. Differentiation from a septate vagina is often difficult.

Only certain vaginal malformations are detectable by transabdominal scanning, and generally it is difficult to evaluate all malformations with ultrasound alone. A gynecological examination and additional tests (hysteroscopy and laparoscopy) are required.

A tampon appears caudal to the bladder as a very echogenic mass with indistinct margins and a posterior acoustic shadow (Fig.13.9). The nature of the mass is easily determined by questioning the patient.

Fig. 13.9 Intravaginal tampon (arrows) appears as an elongated, echogenic mass with an acoustic shadow (S). BL = bladder; UT = uterus.

The most frequent site of occurrence is the posterior fornix. Squamous cell carcinomas are the most common and tend to be locally invasive (rectum, uterus, bladder) and seed locoregional metastases (Fig.13.10).

Fig. 13.10 Vaginal/vulval carcinoma (T): hypoechoic mass infiltrating the rectum (R) and bladder (BL). VAG = vagina.