My talk on Adnexal USG at Varanasi AICOG 2012

1. Dr.Sameer Dikshit

3. • When evaluating the adnexa, attempt should be first
made to identify the ovaries
• Once identifies, they should be used as reference point
• Ovaries should be examined in 2 orthogonal planes
• Ovaries may not be identified in cases before and after
puberty

4. • The normal fallopian tubes are not identified
• If any pathology is seen, size and sonographic nature of
the lesion should be documented
• Spectral , color and power doppler examination should
be performed
• Finally cul-de-sac should be examined posterior to the
uterus

5. • Ovaries • Pelvic vessels
• Fallopian Tubes • Vestigial Structures
• Broad Ligament

6. • Bowel
• Fluid in pouch of Doughlas

7. • Pelvic Kidneys
• Pelvic Spleen

8. • Ovaries • Pelvic vessels
• Fallopian Tubes • Vestigial Structures
• Broad Ligament

9. • Bowel
• Fluid in pouch of Doughlas

19. • Ring of fire in ectopic
pregnancy

20. • Is a mass present?
• Is this the same mass which a clinician feels?
• Is the mass, a cause of pain?

21. • Cystic
• Complex
• Solid

22. Completely Cystic Multiple Septate
Physiological Ovarian Endometrioma Cystadenoma
Cysts
Cystadenomas Multiple follicular cysts
Hydrosalpinx
Endometriomas
Parovarian Cyst
Hydatid Cyst of Morgagni

23. Predominantly cystic Predominantly solid
Cystadenomas Cystadenocarcinoma
Tubo-ovarian abscess Germ Cell Tumor
Ectopic Pregnancy
Cystic Teratomas

24. Uterine Extrauterine
Leiomyoma Ovarian tumor
Uterine Sarcoma, Carcinoma

26. • Peripheral
ovarian
tissue

27. • Peripheral
ovarian
tissue

28. • No rim of ovarian
tissue
• Probe pressure to
separate ovary
and the cyst

29. • Larger than mature
follicle
• Between 3-8 cm
• Thin walls
• No septation
• No solid structures

30. • Usually unilateral
• Usually regresses in 2
cycles
• If it persists after 3
cycles, then it is not
functional

31. • Central area of
low level echoes
• Lacy reticular
pattern
• Occasionally
septations

32. • Reabsorption of blood
in corpus
hemorrhagicum
• Usually less than 4 cm
• May accompany Intra
Uterine Pregnancy

33. • No
demonstrable
central flow
• Ring of Fire

34. • Fusiform anechoic
structure
• Tapers towards the
uterus
• No peristalsis

35. • Complex internal
appearance

36. • Typical
endometrioma is
a unilocular cyst
with
homogeneous low
level echogenicity

37. • Ground glass
echogenicity

39. • Mucinous
• Hemorrhagic Corpus Cystadenoma
Luteum
• Granulosa Tumours
• Dermoid cyst
• Tubo Ovarian Abscess

40. • Clear fluid

41. • Thick septations
• Low internal
echoes

43. • Complex mass
• Predominantly
solid mass with
echogenic
internal echoes

45. • Papillations

46. • Diameter >4 cm
• Ascites
• Thick wall or thick
septum >3 cm
• Fixed mass
• Papillations

47. • Serous
Cystadeno-
carcinoma
• Inner wall
papillations

48. • Hydrosalpinx

49. • Rapid vascularization in malignant masses
• Tumor vessels lack smooth muscles
• Malignant masses have AV connections

50. • IOTA (International Ovarian Tumor Analysis group)
consensus statement
• Scoring
• No blood flow Score 1
• Minimal blood flow Score 2
• Moderate blood flow Score 3
• Highly vascular Score 4
• Score of 3 or more Highly suggestive of malignancy

51. • RI < 0.6
• PI < 1.0

52. • Movement of particulate matter within fluid due to energy
transfer when ultrasound wave is directed to it
• Hold the transducer still and then view movement of
particles AWAY from the transducer
• Can be demonstrated in cysts with fluid containing low
level echogenicity

53. • Presence of acoustic streaming means that the fluid is
less viscous
• Thus, it is not seen in Endometriomas
• Used as a test to distinguish endometriomas

54. • Standardization of sonographic description of ovarian
tumours

55. Inner Wall Papillations
Contents

56. • Age • Irregular internal cyst
• Personal history of walls
ovarian cancer • Presence of purely solid
• Largest diameter of the tumor
lesion • Color score
• Largest diameter of • Presence of acoustic
largest solid component shadows
• Presence of ascites • Current Hormonal
• Presence of flow in therapy
papillary projections • Pain during examination

58. • Score > 9  suspicious of malignancy
• Additional risk factors
• Mean diameter > 10 cm
• Bilaterality
• Presence of ascites
• RI < 0.6
• Serum CA 125 >35 IU/mL

60. • 1 point each for • Total score= 0 U=0
• Unilocular • Total score=1 U=1
• Solid areas
• Total score=>2 U=3
• Bilateral
• Ascites
• Intra abdominal Mets

61. • Pre-Menopausal  M=1
• Post-Menopausal  M=3

62. • RMI 1 (Jacobs)= U X M X CA-125

64. RMI score Risk
<25 Low
25-250 Moderate
>250 High

66. • Pelvic Congestion Syndrome postulated as cause of
chronic pelvic pain
• Venography is the gold standard
• However, ultrasound can still be used for diagnosis

67. • Dilated ovarian vein > 5 mm
• Tortuous veins around ovary and uterus (> 5mm)
• Venous plexus crossing from one side to another
• Change of flow direction with Valsalva maneuver
• Increase in size of veins with Valsalva maneuver

73. • Enlargement of the
ovary
• Abnormal ovarian
position anterior to
the uterus
• Free fluid in the
pouch of Doughlas

74. • Coiling for blood
vessels on 2D and
colour Doppler