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Nongynecologic Applications of Transvaginal US¹

¹ From the Department of Medical Imaging, The Toronto Hospital, University of Toronto, 200 Elizabeth St, Toronto, Ontario M5G 2C4, Canada. Received January 7, 1999; revision requested February 15 and received March 21; accepted March 26. Address reprint requests to S.R.W.

View larger version (108K): [in a new window]   Figure 1a.   Acute appendicitis. (a) Suprapubic US image shows inflamed fat surrounding an abnormal loop of gut (arrows), which leaves the visualized field of view. The loop cannot be definitely confirmed as blind-ended. (b) Transvaginal US image helps confirm that the tubular area (ie, the appendix) is blind-ended (arrows).

View larger version (140K): [in a new window]   Figure 1b.   Acute appendicitis. (a) Suprapubic US image shows inflamed fat surrounding an abnormal loop of gut (arrows), which leaves the visualized field of view. The loop cannot be definitely confirmed as blind-ended. (b) Transvaginal US image helps confirm that the tubular area (ie, the appendix) is blind-ended (arrows).

View larger version (165K): [in a new window]   Figures 2, 3.   (2) Acute diverticulitis. Cross-sectional transvaginal US image of a thickened sigmoid colon shows an inflamed diverticulum as a shadowing echogenic focus projecting beyond the margin of the gut (arrow). (3) Diverticular abscess. A suprapubic US image (not shown) was inconclusive although findings were suggestive of inflammatory change. (a) Transvaginal US image shows an abscess as an ill-defined mass with multiple bright echoes representing gas (arrows). The abscess is adjacent to the margin of a loop of sigmoid colon (arrowheads). (b) CT scan helps confirm the gas-containing abscess (arrows). (c) Transvaginal US image shows a J-shaped catheter coiled within the abscess cavity. (d) CT scan obtained following US-guided transvaginal insertion of the drainage catheter helps confirm correct placement of the catheter within the abscess cavity.

View larger version (125K): [in a new window]   Figures 2, 3.   (2) Acute diverticulitis. Cross-sectional transvaginal US image of a thickened sigmoid colon shows an inflamed diverticulum as a shadowing echogenic focus projecting beyond the margin of the gut (arrow). (3) Diverticular abscess. A suprapubic US image (not shown) was inconclusive although findings were suggestive of inflammatory change. (a) Transvaginal US image shows an abscess as an ill-defined mass with multiple bright echoes representing gas (arrows). The abscess is adjacent to the margin of a loop of sigmoid colon (arrowheads). (b) CT scan helps confirm the gas-containing abscess (arrows). (c) Transvaginal US image shows a J-shaped catheter coiled within the abscess cavity. (d) CT scan obtained following US-guided transvaginal insertion of the drainage catheter helps confirm correct placement of the catheter within the abscess cavity.

View larger version (124K): [in a new window]   Figures 2, 3.   (2) Acute diverticulitis. Cross-sectional transvaginal US image of a thickened sigmoid colon shows an inflamed diverticulum as a shadowing echogenic focus projecting beyond the margin of the gut (arrow). (3) Diverticular abscess. A suprapubic US image (not shown) was inconclusive although findings were suggestive of inflammatory change. (a) Transvaginal US image shows an abscess as an ill-defined mass with multiple bright echoes representing gas (arrows). The abscess is adjacent to the margin of a loop of sigmoid colon (arrowheads). (b) CT scan helps confirm the gas-containing abscess (arrows). (c) Transvaginal US image shows a J-shaped catheter coiled within the abscess cavity. (d) CT scan obtained following US-guided transvaginal insertion of the drainage catheter helps confirm correct placement of the catheter within the abscess cavity.

View larger version (147K): [in a new window]   Figures 2, 3.   (2) Acute diverticulitis. Cross-sectional transvaginal US image of a thickened sigmoid colon shows an inflamed diverticulum as a shadowing echogenic focus projecting beyond the margin of the gut (arrow). (3) Diverticular abscess. A suprapubic US image (not shown) was inconclusive although findings were suggestive of inflammatory change. (a) Transvaginal US image shows an abscess as an ill-defined mass with multiple bright echoes representing gas (arrows). The abscess is adjacent to the margin of a loop of sigmoid colon (arrowheads). (b) CT scan helps confirm the gas-containing abscess (arrows). (c) Transvaginal US image shows a J-shaped catheter coiled within the abscess cavity. (d) CT scan obtained following US-guided transvaginal insertion of the drainage catheter helps confirm correct placement of the catheter within the abscess cavity.

View larger version (129K): [in a new window]   Figures 2, 3.   (2) Acute diverticulitis. Cross-sectional transvaginal US image of a thickened sigmoid colon shows an inflamed diverticulum as a shadowing echogenic focus projecting beyond the margin of the gut (arrow). (3) Diverticular abscess. A suprapubic US image (not shown) was inconclusive although findings were suggestive of inflammatory change. (a) Transvaginal US image shows an abscess as an ill-defined mass with multiple bright echoes representing gas (arrows). The abscess is adjacent to the margin of a loop of sigmoid colon (arrowheads). (b) CT scan helps confirm the gas-containing abscess (arrows). (c) Transvaginal US image shows a J-shaped catheter coiled within the abscess cavity. (d) CT scan obtained following US-guided transvaginal insertion of the drainage catheter helps confirm correct placement of the catheter within the abscess cavity.

View larger version (0K): [in a new window]   Figure 4a.   Permission to reprint this figure electronically was denied by the publisher. See print version.

View larger version (0K): [in a new window]   Figure 4b.   Permission to reprint this figure electronically was denied by the publisher. See print version.

View larger version (109K): [in a new window]   Figures 5, 6.   (5) Crohn disease with an enterovesical fistula. (a) Suprapubic US image shows a superficial abscess (a). A tract is seen running from the abscess to the bladder dome and appears as a thin, hypoechoic line (arrows). (b) Transvaginal US image shows the tract entering the bladder (arrows). There is evidence of marked mucosal edema (arrowheads). (6) Permission to reprint this figure electronically was denied by the publisher. See print version.

View larger version (115K): [in a new window]   Figures 5, 6.   (5) Crohn disease with an enterovesical fistula. (a) Suprapubic US image shows a superficial abscess (a). A tract is seen running from the abscess to the bladder dome and appears as a thin, hypoechoic line (arrows). (b) Transvaginal US image shows the tract entering the bladder (arrows). There is evidence of marked mucosal edema (arrowheads). (6) Permission to reprint this figure electronically was denied by the publisher. See print version.

View larger version (0K): [in a new window]   Figures 5, 6.   (5) Crohn disease with an enterovesical fistula. (a) Suprapubic US image shows a superficial abscess (a). A tract is seen running from the abscess to the bladder dome and appears as a thin, hypoechoic line (arrows). (b) Transvaginal US image shows the tract entering the bladder (arrows). There is evidence of marked mucosal edema (arrowheads). (6) Permission to reprint this figure electronically was denied by the publisher. See print version.

View larger version (136K): [in a new window]   Figure 7a.   Annular constricting carcinoma of the rectum. (a) Transrectal US image shows a rectal carcinoma end on as a black mass surrounding the narrowed lumen (arrows). The probe could not be advanced into the narrowed segment. (b, c) Long-axis (b) and cross-sectional (c) transvaginal US images of the rectum show nodular annular thickening of the rectal wall with total layer destruction. The lumen appears as a white central area (L), whereas the tumor appears black (arrows). Transvaginal US images are superior to transrectal images for assessing the length of annular lesions and the invasion of perirectal fat.

View larger version (152K): [in a new window]   Figure 7b.   Annular constricting carcinoma of the rectum. (a) Transrectal US image shows a rectal carcinoma end on as a black mass surrounding the narrowed lumen (arrows). The probe could not be advanced into the narrowed segment. (b, c) Long-axis (b) and cross-sectional (c) transvaginal US images of the rectum show nodular annular thickening of the rectal wall with total layer destruction. The lumen appears as a white central area (L), whereas the tumor appears black (arrows). Transvaginal US images are superior to transrectal images for assessing the length of annular lesions and the invasion of perirectal fat.

View larger version (142K): [in a new window]   Figure 7c.   Annular constricting carcinoma of the rectum. (a) Transrectal US image shows a rectal carcinoma end on as a black mass surrounding the narrowed lumen (arrows). The probe could not be advanced into the narrowed segment. (b, c) Long-axis (b) and cross-sectional (c) transvaginal US images of the rectum show nodular annular thickening of the rectal wall with total layer destruction. The lumen appears as a white central area (L), whereas the tumor appears black (arrows). Transvaginal US images are superior to transrectal images for assessing the length of annular lesions and the invasion of perirectal fat.

View larger version (125K): [in a new window]   Figure 8a.   Rectal carcinoma with transmural invasion of the wall and perirectal nodes in a 51-year-old woman with rectal bleeding that was originally thought to be related to hemorrhoids. (a) Transverse transvaginal US image of the rectum shows a hypoechoic tumor mass (m) involving the left lateral wall of the rectum (arrows). The tumor involves the mucosa between the 2-o'clock and 3-o'clock positions. (b) On a transvaginal US image of the rectum, a tumor seed (s) is seen separate from the primary tumor (m) in the rectovaginal septum.

View larger version (117K): [in a new window]   Figure 8b.   Rectal carcinoma with transmural invasion of the wall and perirectal nodes in a 51-year-old woman with rectal bleeding that was originally thought to be related to hemorrhoids. (a) Transverse transvaginal US image of the rectum shows a hypoechoic tumor mass (m) involving the left lateral wall of the rectum (arrows). The tumor involves the mucosa between the 2-o'clock and 3-o'clock positions. (b) On a transvaginal US image of the rectum, a tumor seed (s) is seen separate from the primary tumor (m) in the rectovaginal septum.

View larger version (143K): [in a new window]   Figure 9a.   Endometrioma of the rectal wall in a 47-year-old woman with dyspareunia. Long-axis (a) and cross-sectional (b) transvaginal US images of the rectum show a focal hypoechoic mass (M) involving and protruding from the outer layer of the rectal wall.

View larger version (139K): [in a new window]   Figure 9b.   Endometrioma of the rectal wall in a 47-year-old woman with dyspareunia. Long-axis (a) and cross-sectional (b) transvaginal US images of the rectum show a focal hypoechoic mass (M) involving and protruding from the outer layer of the rectal wall.

View larger version (146K): [in a new window]   Figure 10a.   Normal anal canal. (a) On a transverse transvaginal US image, the rectum (seen at the anorectal junction) has an oval, multilayered appearance. The outer black ring represents the muscularis propria (m). The puborectal muscle is echogenic and diverges anteriorly. (b) On a transverse US image, the normal anal canal appears round. The distance between the vaginal probe and the anal canal is greater than that between the probe and the rectum because of the depth of the perineal body. The internal anal sphincter (IS), which appears as a thick black ring, is continuous with the muscularis propria of the rectal wall. The external anal sphincter is echogenic and less well defined. (c) US image obtained with rotation of the end-fired transvaginal probe shows the anal canal in long axis. The anorectal junction (R) is on the left side of the image with the external opening on the right side. The thick black bands seen anteriorly and posteriorly represent the internal sphincter (IS).

View larger version (132K): [in a new window]   Figure 10b.   Normal anal canal. (a) On a transverse transvaginal US image, the rectum (seen at the anorectal junction) has an oval, multilayered appearance. The outer black ring represents the muscularis propria (m). The puborectal muscle is echogenic and diverges anteriorly. (b) On a transverse US image, the normal anal canal appears round. The distance between the vaginal probe and the anal canal is greater than that between the probe and the rectum because of the depth of the perineal body. The internal anal sphincter (IS), which appears as a thick black ring, is continuous with the muscularis propria of the rectal wall. The external anal sphincter is echogenic and less well defined. (c) US image obtained with rotation of the end-fired transvaginal probe shows the anal canal in long axis. The anorectal junction (R) is on the left side of the image with the external opening on the right side. The thick black bands seen anteriorly and posteriorly represent the internal sphincter (IS).

View larger version (124K): [in a new window]   Figure 10c.   Normal anal canal. (a) On a transverse transvaginal US image, the rectum (seen at the anorectal junction) has an oval, multilayered appearance. The outer black ring represents the muscularis propria (m). The puborectal muscle is echogenic and diverges anteriorly. (b) On a transverse US image, the normal anal canal appears round. The distance between the vaginal probe and the anal canal is greater than that between the probe and the rectum because of the depth of the perineal body. The internal anal sphincter (IS), which appears as a thick black ring, is continuous with the muscularis propria of the rectal wall. The external anal sphincter is echogenic and less well defined. (c) US image obtained with rotation of the end-fired transvaginal probe shows the anal canal in long axis. The anorectal junction (R) is on the left side of the image with the external opening on the right side. The thick black bands seen anteriorly and posteriorly represent the internal sphincter (IS).

View larger version (142K): [in a new window]   Figures 11-14.   (11) Scar tissue in the rectovaginal septum in a young woman with fecal incontinence following traumatic obstetric delivery. Transvaginal US image shows a defect in the hypoechoic black ring of the internal anal sphincter anteriorly from the 10-o'clock to the 12-o'clock position. A large mass of scar tissue (S) is seen expanding the rectovaginal septum and increasing the distance from the anal canal to the vaginal probe. (12) Tear of the anal sphincter in a 40-year-old woman with fecal incontinence following a fourth-degree tear at obstetric delivery. Transvaginal US image shows a deficiency in the hypoechoic black ring of the internal anal sphincter anteriorly at the 12-o'clock position. The tear in the external anal sphincter appears as a hypoechoic wedge in the normal echogenic muscle (arrows). (13) Permission to reprint this figure electronically was denied by the publisher. See print version. (14) Tear of the internal and external anal sphincters with loss of the perineal body. Transvaginal US image shows a large defect in the internal anal sphincter anteriorly between the 9-o'clock and 2-o'clock positions. The external anal sphincter is extremely thin anteriorly. There is virtually no rectovaginal septum or perineal body between the anal canal and the posterior wall of the vagina (arrows), which is outlined by the rim of a fluid-filled condom covering the transducer.

View larger version (156K): [in a new window]   Figures 11-14.   (11) Scar tissue in the rectovaginal septum in a young woman with fecal incontinence following traumatic obstetric delivery. Transvaginal US image shows a defect in the hypoechoic black ring of the internal anal sphincter anteriorly from the 10-o'clock to the 12-o'clock position. A large mass of scar tissue (S) is seen expanding the rectovaginal septum and increasing the distance from the anal canal to the vaginal probe. (12) Tear of the anal sphincter in a 40-year-old woman with fecal incontinence following a fourth-degree tear at obstetric delivery. Transvaginal US image shows a deficiency in the hypoechoic black ring of the internal anal sphincter anteriorly at the 12-o'clock position. The tear in the external anal sphincter appears as a hypoechoic wedge in the normal echogenic muscle (arrows). (13) Permission to reprint this figure electronically was denied by the publisher. See print version. (14) Tear of the internal and external anal sphincters with loss of the perineal body. Transvaginal US image shows a large defect in the internal anal sphincter anteriorly between the 9-o'clock and 2-o'clock positions. The external anal sphincter is extremely thin anteriorly. There is virtually no rectovaginal septum or perineal body between the anal canal and the posterior wall of the vagina (arrows), which is outlined by the rim of a fluid-filled condom covering the transducer.

View larger version (0K): [in a new window]   Figures 11-14.   (11) Scar tissue in the rectovaginal septum in a young woman with fecal incontinence following traumatic obstetric delivery. Transvaginal US image shows a defect in the hypoechoic black ring of the internal anal sphincter anteriorly from the 10-o'clock to the 12-o'clock position. A large mass of scar tissue (S) is seen expanding the rectovaginal septum and increasing the distance from the anal canal to the vaginal probe. (12) Tear of the anal sphincter in a 40-year-old woman with fecal incontinence following a fourth-degree tear at obstetric delivery. Transvaginal US image shows a deficiency in the hypoechoic black ring of the internal anal sphincter anteriorly at the 12-o'clock position. The tear in the external anal sphincter appears as a hypoechoic wedge in the normal echogenic muscle (arrows). (13) Permission to reprint this figure electronically was denied by the publisher. See print version. (14) Tear of the internal and external anal sphincters with loss of the perineal body. Transvaginal US image shows a large defect in the internal anal sphincter anteriorly between the 9-o'clock and 2-o'clock positions. The external anal sphincter is extremely thin anteriorly. There is virtually no rectovaginal septum or perineal body between the anal canal and the posterior wall of the vagina (arrows), which is outlined by the rim of a fluid-filled condom covering the transducer.

View larger version (119K): [in a new window]   Figures 11-14.   (11) Scar tissue in the rectovaginal septum in a young woman with fecal incontinence following traumatic obstetric delivery. Transvaginal US image shows a defect in the hypoechoic black ring of the internal anal sphincter anteriorly from the 10-o'clock to the 12-o'clock position. A large mass of scar tissue (S) is seen expanding the rectovaginal septum and increasing the distance from the anal canal to the vaginal probe. (12) Tear of the anal sphincter in a 40-year-old woman with fecal incontinence following a fourth-degree tear at obstetric delivery. Transvaginal US image shows a deficiency in the hypoechoic black ring of the internal anal sphincter anteriorly at the 12-o'clock position. The tear in the external anal sphincter appears as a hypoechoic wedge in the normal echogenic muscle (arrows). (13) Permission to reprint this figure electronically was denied by the publisher. See print version. (14) Tear of the internal and external anal sphincters with loss of the perineal body. Transvaginal US image shows a large defect in the internal anal sphincter anteriorly between the 9-o'clock and 2-o'clock positions. The external anal sphincter is extremely thin anteriorly. There is virtually no rectovaginal septum or perineal body between the anal canal and the posterior wall of the vagina (arrows), which is outlined by the rim of a fluid-filled condom covering the transducer.

View larger version (140K): [in a new window]   Figure 15a.   Ureteric calculus with edema. (a) Transvaginal US image shows a dilated ureter (U) and the edge of an obstructing stone. B = bladder. (b) US image obtained perpendicular to a shows the stone (calipers) with sharp acoustic shadowing and surrounding soft-tissue edema.

View larger version (122K): [in a new window]   Figure 15b.   Ureteric calculus with edema. (a) Transvaginal US image shows a dilated ureter (U) and the edge of an obstructing stone. B = bladder. (b) US image obtained perpendicular to a shows the stone (calipers) with sharp acoustic shadowing and surrounding soft-tissue edema.

View larger version (136K): [in a new window]   Figure 16a.   Transitional cell carcinoma of the bladder with a diverticulum. (a) Suprapubic US image shows a poorly filled bladder (b) with a left lateral diverticulum (d). (b) Transvaginal US image shows a carpet of tiny polyps arising from the wall of the bladder (b). Low-level echoes are seen within the diverticulum (d). (c) Transvaginal US image demonstrates tiny polyps on the wall of the diverticulum (arrows); these proved to be transitional cell carcinoma at histologic analysis.

View larger version (117K): [in a new window]   Figure 16b.   Transitional cell carcinoma of the bladder with a diverticulum. (a) Suprapubic US image shows a poorly filled bladder (b) with a left lateral diverticulum (d). (b) Transvaginal US image shows a carpet of tiny polyps arising from the wall of the bladder (b). Low-level echoes are seen within the diverticulum (d). (c) Transvaginal US image demonstrates tiny polyps on the wall of the diverticulum (arrows); these proved to be transitional cell carcinoma at histologic analysis.

View larger version (98K): [in a new window]   Figure 16c.   Transitional cell carcinoma of the bladder with a diverticulum. (a) Suprapubic US image shows a poorly filled bladder (b) with a left lateral diverticulum (d). (b) Transvaginal US image shows a carpet of tiny polyps arising from the wall of the bladder (b). Low-level echoes are seen within the diverticulum (d). (c) Transvaginal US image demonstrates tiny polyps on the wall of the diverticulum (arrows); these proved to be transitional cell carcinoma at histologic analysis.

View larger version (120K): [in a new window]   Figure 17a.   Transitional cell carcinoma of the bladder. (a) Transvaginal US image shows a partially filled bladder. A large tumor is seen projecting into the lumen. There is obvious extension of the tumor beyond the bladder wall (arrows). (b) CT scan helps confirm the tumor and the transmural spread.

View larger version (124K): [in a new window]   Figure 17b.   Transitional cell carcinoma of the bladder. (a) Transvaginal US image shows a partially filled bladder. A large tumor is seen projecting into the lumen. There is obvious extension of the tumor beyond the bladder wall (arrows). (b) CT scan helps confirm the tumor and the transmural spread.

View larger version (123K): [in a new window]   Figure 18a.   Unsuspected pheochromocytoma of the bladder wall in a woman with cardiac palpitations and a full urinary bladder. (a) Transvaginal US image obtained with the bladder moderately full shows a solid mass projecting from the bladder wall into the lumen. (b) Repeat US image obtained with the bladder virtually empty shows the mass as intramural with an intact overlying mucosa.

View larger version (134K): [in a new window]   Figure 18b.   Unsuspected pheochromocytoma of the bladder wall in a woman with cardiac palpitations and a full urinary bladder. (a) Transvaginal US image obtained with the bladder moderately full shows a solid mass projecting from the bladder wall into the lumen. (b) Repeat US image obtained with the bladder virtually empty shows the mass as intramural with an intact overlying mucosa.

View larger version (126K): [in a new window]   Figure 19a.   Endometrioma of the bladder in a 28-year-old woman with hematuria accompanying the menses. (a) Sagittal suprapubic US image of the bladder shows a mass (calipers) arising from the posterior wall of the bladder. (b) Transvaginal US image of a partially full bladder shows features of a solid intramural mass (m) with multiple superficial cysts.

View larger version (112K): [in a new window]   Figure 19b.   Endometrioma of the bladder in a 28-year-old woman with hematuria accompanying the menses. (a) Sagittal suprapubic US image of the bladder shows a mass (calipers) arising from the posterior wall of the bladder. (b) Transvaginal US image of a partially full bladder shows features of a solid intramural mass (m) with multiple superficial cysts.

View larger version (135K): [in a new window]   Figure 20a.   Purulent peritonitis of nongynecologic origin in a 37-year-old woman who presented with pelvic pain. (a) Sagittal midline pelvic US image shows a large fluid collection with fine internal strands (C) posterior to the uterus. B = bladder. (b) Transvaginal US image helps confirm the fluid collection in the pouch of Douglas (C) marginally surrounding a normal ovary with follicles.

View larger version (142K): [in a new window]   Figure 20b.   Purulent peritonitis of nongynecologic origin in a 37-year-old woman who presented with pelvic pain. (a) Sagittal midline pelvic US image shows a large fluid collection with fine internal strands (C) posterior to the uterus. B = bladder. (b) Transvaginal US image helps confirm the fluid collection in the pouch of Douglas (C) marginally surrounding a normal ovary with follicles.

View larger version (157K): [in a new window]   Figures 21-23.   (21) Peritoneal carcinomatosis of uncertain origin in an 84-year-old woman who presented with a small, palpable abdominal wall mass. Transvaginal US image through the pouch of Douglas shows grossly particulate ascites (A) with extensive seeding in the form of plaquelike thickening of the parietal peritoneum of the pelvic side wall (P). G = dilated loop of gut, U = uterus. (22) Visceral peritoneal carcinomatosis in a 74-year-old woman with recurrent ovarian carcinoma. Long-axis (a) and cross-sectional (b) transvaginal US images show a loop of small bowel. There is a mass (m) that is related to the serosal surface of the gut but does not involve the mucosal surfaces. (23) Peritoneal carcinomatosis in a patient with a history of hysterectomy and bilateral salpingo-oophorectomy for papillary serous carcinoma. Transvaginal US image through the pouch of Douglas shows a complex mass with multiple bright echogenic foci representing psammomatous calcifications. The diagnosis of peritoneal carcinomatosis was confirmed at surgery.

View larger version (150K): [in a new window]   Figures 21-23.   (21) Peritoneal carcinomatosis of uncertain origin in an 84-year-old woman who presented with a small, palpable abdominal wall mass. Transvaginal US image through the pouch of Douglas shows grossly particulate ascites (A) with extensive seeding in the form of plaquelike thickening of the parietal peritoneum of the pelvic side wall (P). G = dilated loop of gut, U = uterus. (22) Visceral peritoneal carcinomatosis in a 74-year-old woman with recurrent ovarian carcinoma. Long-axis (a) and cross-sectional (b) transvaginal US images show a loop of small bowel. There is a mass (m) that is related to the serosal surface of the gut but does not involve the mucosal surfaces. (23) Peritoneal carcinomatosis in a patient with a history of hysterectomy and bilateral salpingo-oophorectomy for papillary serous carcinoma. Transvaginal US image through the pouch of Douglas shows a complex mass with multiple bright echogenic foci representing psammomatous calcifications. The diagnosis of peritoneal carcinomatosis was confirmed at surgery.

View larger version (166K): [in a new window]   Figures 21-23.   (21) Peritoneal carcinomatosis of uncertain origin in an 84-year-old woman who presented with a small, palpable abdominal wall mass. Transvaginal US image through the pouch of Douglas shows grossly particulate ascites (A) with extensive seeding in the form of plaquelike thickening of the parietal peritoneum of the pelvic side wall (P). G = dilated loop of gut, U = uterus. (22) Visceral peritoneal carcinomatosis in a 74-year-old woman with recurrent ovarian carcinoma. Long-axis (a) and cross-sectional (b) transvaginal US images show a loop of small bowel. There is a mass (m) that is related to the serosal surface of the gut but does not involve the mucosal surfaces. (23) Peritoneal carcinomatosis in a patient with a history of hysterectomy and bilateral salpingo-oophorectomy for papillary serous carcinoma. Transvaginal US image through the pouch of Douglas shows a complex mass with multiple bright echogenic foci representing psammomatous calcifications. The diagnosis of peritoneal carcinomatosis was confirmed at surgery.

View larger version (132K): [in a new window]   Figures 21-23.   (21) Peritoneal carcinomatosis of uncertain origin in an 84-year-old woman who presented with a small, palpable abdominal wall mass. Transvaginal US image through the pouch of Douglas shows grossly particulate ascites (A) with extensive seeding in the form of plaquelike thickening of the parietal peritoneum of the pelvic side wall (P). G = dilated loop of gut, U = uterus. (22) Visceral peritoneal carcinomatosis in a 74-year-old woman with recurrent ovarian carcinoma. Long-axis (a) and cross-sectional (b) transvaginal US images show a loop of small bowel. There is a mass (m) that is related to the serosal surface of the gut but does not involve the mucosal surfaces. (23) Peritoneal carcinomatosis in a patient with a history of hysterectomy and bilateral salpingo-oophorectomy for papillary serous carcinoma. Transvaginal US image through the pouch of Douglas shows a complex mass with multiple bright echogenic foci representing psammomatous calcifications. The diagnosis of peritoneal carcinomatosis was confirmed at surgery.

View larger version (146K): [in a new window]   Figure 24a.   Benign encysted fluid in a 41-year-old woman with a history of myomectomy. (a) Sagittal suprapubic US image shows an elongated cystic mass (c) with septa extending out of the pelvis. b = bladder. (b) Transverse transvaginal US image shows the fluid conforming to the pelvic side wall and surrounding a normal right ovary (o) with a small follicle.

View larger version (147K): [in a new window]   Figure 24b.   Benign encysted fluid in a 41-year-old woman with a history of myomectomy. (a) Sagittal suprapubic US image shows an elongated cystic mass (c) with septa extending out of the pelvis. b = bladder. (b) Transverse transvaginal US image shows the fluid conforming to the pelvic side wall and surrounding a normal right ovary (o) with a small follicle.

View larger version (120K): [in a new window]   Figure 25a.   Pseudoaneurysm of the uterine artery in a 32-year-old woman with endometritis and left-sided pelvic pain. The patient had recently undergone cesarean section. (a) Transvaginal US image shows a complex, 5-cm-diameter mass in the right adnexal region (calipers) that could be mistaken for a bulky right ovary with a cyst. (b) Color Doppler US image shows the mass as vascular. The cursor is placed in an area of color aliasing and shows a pulsatile high-velocity jet at the entry point. (c) Color Doppler US image with the cursor moved to a uniform red area demonstrates high-velocity (60 cm/sec) flow with low pulsatility elsewhere within the mass.

View larger version (165K): [in a new window]   Figure 25b.   Pseudoaneurysm of the uterine artery in a 32-year-old woman with endometritis and left-sided pelvic pain. The patient had recently undergone cesarean section. (a) Transvaginal US image shows a complex, 5-cm-diameter mass in the right adnexal region (calipers) that could be mistaken for a bulky right ovary with a cyst. (b) Color Doppler US image shows the mass as vascular. The cursor is placed in an area of color aliasing and shows a pulsatile high-velocity jet at the entry point. (c) Color Doppler US image with the cursor moved to a uniform red area demonstrates high-velocity (60 cm/sec) flow with low pulsatility elsewhere within the mass.

View larger version (174K): [in a new window]   Figure 25c.   Pseudoaneurysm of the uterine artery in a 32-year-old woman with endometritis and left-sided pelvic pain. The patient had recently undergone cesarean section. (a) Transvaginal US image shows a complex, 5-cm-diameter mass in the right adnexal region (calipers) that could be mistaken for a bulky right ovary with a cyst. (b) Color Doppler US image shows the mass as vascular. The cursor is placed in an area of color aliasing and shows a pulsatile high-velocity jet at the entry point. (c) Color Doppler US image with the cursor moved to a uniform red area demonstrates high-velocity (60 cm/sec) flow with low pulsatility elsewhere within the mass.

View larger version (148K): [in a new window]   Figure 26a.   Tailgut cyst. (a) Transvaginal US image shows a cystic presacral mass (M) with multiple bright particles internally. R = rectum. (b) CT scan helps confirm the presacral mass (M) adjacent to the rectum.

View larger version (135K): [in a new window]   Figure 26b.   Tailgut cyst. (a) Transvaginal US image shows a cystic presacral mass (M) with multiple bright particles internally. R = rectum. (b) CT scan helps confirm the presacral mass (M) adjacent to the rectum.