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(Radiographics. 1999;19:S179-S200.)
© RSNA, 1999

PELVIC IMAGING

Nongynecologic Applications of Transvaginal US1

Nizar Damani, MB,BS, FFR(RCSI), FRCR, 2 and Stephanie R. Wilson, MD, FRCP

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.


   Abstract
Top
 Abstract
INTRODUCTION
 GASTROINTESTINAL APPLICATIONS
 URINARY TRACT APPLICATIONS
 PERITONEAL APPLICATIONS
 VASCULAR APPLICATIONS
 MISCELLANEOUS APPLICATIONS
 CONCLUSIONS
 References
 
Transvaginal ultrasonography (US) is a noninvasive, readily available imaging technique that has greatly enhanced diagnostic sensitivity and accuracy for both gynecologic and nongynecologic disease. High-frequency US probes placed in the vagina allow high-resolution assessment of all the pelvic viscera, including portions of the gut and urinary tract. In addition, they allow visualization of the peritoneum of the pelvic pouch and the pelvic side walls without interference from bowel gas or adipose tissue. Evaluation of these areas requires a modified US technique that includes the use of the highest-frequency probes with angulation of the transducer to allow assessment of the region of interest. In women of childbearing age, the similarity of symptoms in gynecologic and gastrointestinal tract disease in particular underscores the potential utility of transvaginal US, which may, for example, help differentiate appendicitis in a pelvic appendix from pelvic inflammatory disease. Transvaginal US may also help determine the correct course of therapy, thereby improving patient management. Other indications for transvaginal US include assessment for pelvic appendicitis and diverticulitis, rectal and perianal complications of Crohn disease, and ureteric and bladder calculi and tumors as well as evaluation of the anal sphincters in women with fecal incontinence. Transvaginal US is also superior to routine US in the detection and characterization of ascites and peritoneal disease. Transvaginal US examination should include the entire pelvic cavity and contents, especially in women at risk for pelvic sepsis or peritoneal disease.

Index Terms: Bladder, diseases, 83.214, 83.3192 • Bladder neoplasms, 83.321, 83.328 • Gastrointestinal tract, diseases, 70.262, 75.273, 751.291, 757.40, 791.3196 • Gastrointestinal tract, neoplasms, 70.30 • Pelvic organs, diseases, 85.20, 85.30 • Pelvic organs, US, 85.12989 • Peritoneum, abnormalities, 791.3196 • Peritoneum, fluid, 791.77 • Ultrasound (US), utilization, **.129893 • Ureter, calculi, 82.811


   INTRODUCTION
Top
 Abstract
 INTRODUCTION
GASTROINTESTINAL APPLICATIONS
 URINARY TRACT APPLICATIONS
 PERITONEAL APPLICATIONS
 VASCULAR APPLICATIONS
 MISCELLANEOUS APPLICATIONS
 CONCLUSIONS
 References
 
The value of transvaginal ultrasonography (US) in gynecologic diagnosis is well recognized. Less familiar is its potential diagnostic value in other organ systems. Transvaginal ultrasonography (US) with high-frequency US probes provides excellent resolution. Placement of these probes in the vagina close to the uterus and ovaries allows imaging without interference from interposed bowel gas or attenuation of the US beam by adipose tissue. The placement of the US probe in proximity to the region of interest and the high resolution of the transducers have led to many improvements in diagnosis involving the gynecologic organs. However, such improvements also apply to many other anatomic areas that can be accessed from the vaginal vault (1). These include portions of the urinary tract (distal ureters, bladder, urethra) and gastrointestinal tract (pelvic small bowel loops, sigmoid colon, rectum, anal canal, pelvic appendix), the peritoneum of the pelvic pouch, the pelvic vasculature, and the soft tissues of the retroperitoneum and pelvic side wall.

Since the introduction of transvaginal US at our institution, we have steadily increased the number of applications for this procedure. Some endeavors have proved particularly useful and are now part of our imaging protocol. In some cases, transvaginal US has largely replaced other US examinations (eg, transanal US in anal sphincter evaluation). In other areas, the addition of transvaginal US has led to marked improvement in our diagnostic capability while increasing the number of US procedures required. In some patients, definitive US findings have led to the institution of appropriate therapy following US without the need for further imaging (eg, computed tomography [CT], magnetic resonance imaging), which might otherwise be necessary if the US findings were equivocal or negative.

In this article, we describe and illustrate the spectrum of nongynecologic (ie, gastrointestinal, urinary tract, peritoneal, vascular) applications of transvaginal US with emphasis on those applications having the greatest impact on patient care.


   GASTROINTESTINAL APPLICATIONS
Top
 Abstract
 INTRODUCTION
 GASTROINTESTINAL APPLICATIONS
URINARY TRACT APPLICATIONS
 PERITONEAL APPLICATIONS
 VASCULAR APPLICATIONS
 MISCELLANEOUS APPLICATIONS
 CONCLUSIONS
 References
 
Indications for routine abdominal and pelvic US in the investigation of gut disease include suspected acute appendicitis (2) and acute diverticulitis (3) as well as complications of Crohn disease (4). Although routine US generally has excellent diagnostic sensitivity and specificity (2–4), it may yield negative or misleading results in patients in whom the pathologic process is located deep in the pelvis. However, the addition of transvaginal assessment to a routine pelvic US examination in these patients may allow accurate diagnosis with differentiation of gastrointestinal from gynecologic disease.

Diagnosis may be especially problematic in women of childbearing age because nonspecific signs and symptoms including pelvic pain, fever, and a pelvic mass may be associated with a gynecologic condition or an inflammatory process related to the bowel (5). Patient treatment is significantly improved by correct noninvasive diagnosis with avoidance of unnecessary laparotomy and institution of appropriate therapy (6).

Evaluation of the gut with transvaginal US requires appreciation of both normal and abnormal US appearances of the gut as well as the appearances of inflamed perienteric fat, phlegmon, and abscess. At cross-sectional US, the normal gut wall appears as a series of alternating echogenic and hypoechoic concentric rings corresponding to the histologic layers of the wall ("gut signature") (7,8). Gut wall thickness in healthy patients varies with luminal distention but is generally 3 mm or less for both the small and large intestines. The collapsed rectum may appear slightly thicker. Alterations in the gut signature may include focal or diffuse wall thickening with or without wall layer preservation.

Inflammation of the perienteric fat is one of the most easily recognized and frequent manifestations of inflammatory processes in the gastrointestinal tract. Its identification at CT is well documented as a valuable indicator of a local inflammatory process even in the absence of other findings (9). Its US appearance may be less familiar but is equally valuable as an aid to diagnosis. At US, inflamed fat appears as a uniformly echogenic "mass effect," often with increased vascularity at color Doppler US. A phlegmon appears as a focal area of hypoechogenicity with irregular margins within an area of inflamed fat, whereas an abscess manifests as a fluid collection with or without gas bubbles within a mass (8).

Acute Appendicitis
Transabdominal US is reported to have a sensitivity of 80%–94% in the detection of appendicitis when the appendix is identified as a blind-ended, noncompressible, aperistaltic tubular structure with a gut signature arising from the base of the cecum (10). The diameter of an inflamed appendix is generally greater than 6 mm (10). False-negative diagnoses are usually due to either an unusual position or incomplete visualization of the appendix (10). This is particularly true when the appendix has a retrocecal or pelvic location. A retrocecal appendix can be seen at coronal US performed with the transducer parallel to the iliac wing to optimize visualization posterior to the cecum (11). In contrast, a pelvic appendix, which extends medially into the pelvis toward the pouch of Douglas, is best depicted at transvaginal US in most women (Fig 1).



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  		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).

 


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  		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).

 
As with routine US, identification of the appendix at transvaginal US as a blind-ended, aperistaltic tubular structure constitutes a positive diagnosis for acute appendicitis. A threshold diameter of 6 mm, above which acute appendicitis is likely to be present, is equally diagnostic regardless of transducer placement. Compression of the appendix and confirmation that the appendix originates from the base of the cecum are often difficult with transvaginal probes. However, the high-resolution assessment of the appendix makes these limitations seem unimportant. Discontinuity in the echogenic submucosa of the appendix is suggestive of mural necrosis and impending perforation (12). Inflamed adjacent mesenteric or omental fat is seen with extension of the inflammation to the serosal surface. If perforation occurs, a localized periappendiceal fluid collection or abscess may be seen.

Appendicitis of a pelvic appendix is relatively uncommon, accounting for only 21% of cases (13); however, it is also the type of appendicitis that is most frequently confused with gynecologic disease and consequently misdiagnosed (14). Furthermore, coexistent gynecologic disease may be present in a patient with acute appendicitis and may lead to an incorrect diagnosis if some of the findings are missed or misinterpreted. Therefore, we recommend transvaginal US for women of childbearing age with fever, pelvic pain, or a pelvic mass whenever gynecologic and gastrointestinal disease cannot be clearly differentiated at routine transabdominal and pelvic US.

Acute Diverticulitis
Acute diverticulitis typically manifests at clinical examination with left lower quadrant pain and tenderness, elevated white blood cell count, and fever (15). The diagnosis is readily confirmed with cross-sectional CT or US (3,16). Because most affected patients are in the 5th or 6th decade of life or older, confusion with gynecologic disease with resulting misdiagnosis occurs much less frequently than in acute appendicitis. Nonetheless, we have encountered many premenopausal as well as postmenopausal women who were not previously suspected of having acute diverticulitis that was demonstrated at transvaginal US: In the vast majority of these patients, gut disease was not evident at routine transabdominal US. As with appendicitis, this occurs when the diseased segment of the colon is located deep within the true pelvis.

At US, acute diverticulitis is associated with thickening of long segments of the gut wall with prominence of the outer hypoechoic layer (muscularis propria) (3,17). Inflamed diverticula manifest as bright echogenic foci with acoustic shadowing that usually project beyond the wall of the thickened gut (3) (Fig 2). Localized perforation is accompanied by inflammation of the perienteric fat, phlegmon, and abscess formation (Fig 3).



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  		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.

 


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  		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.

 


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  		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.

 


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  		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.

 


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  		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.

 
Optimal guidance for drainage of a deep pelvic abscess is often achieved with transvaginal techniques (18) (Fig 3). The procedure is performed with the patient supine with the legs widely separated as for all transvaginal examinations. A transvaginal probe equipped with a biopsy guide is placed in the vagina such that the most direct approach to the abscess is identified. The guidance path must avoid all of the pelvic organs and vascular structures. A long coaxial needle is advanced through the guide into the abscess, and fluid is aspirated to confirm the presence of pus. A decision is then made, often based on the size of the abscess, as to whether drainage can be accomplished with US alone or if fluoroscopy is required. Contrast material may be injected into the abscess and fluoroscopy used to confirm encapsulation of the fluid. A J wire is then advanced through the needle into the abscess, after which the probe, the guide, and the needle are removed. The tract is dilated to the appropriate size, and a drain is inserted.

Depending on the size of the abscess, simple aspiration may be preferable to drainage because transvaginal drainage procedures are painful for the patient. In considering this procedure, one must weigh the advantage of accessibility against the need for significant analgesia and sedation.

Crohn Disease
Crohn disease is a chronic, granulomatous inflammatory process that affects the gastrointestinal tract. The disease is characterized by multiple remissions and exacerbations and is diagnosed most often in young patients (19). US does not involve the use of ionizing radiation and can help assess the mural and extramural abnormalities in Crohn disease and help identify patients in whom the need for surgery or intervention would justify the use of CT (4,20).

Gut wall thickening (21) (Fig 4), inflammation of the mesenteric fat, mesenteric lymphadenopathy, strictures, and fistulas can all be appreciated at US (23,24). In addition, inflammatory masses can be characterized as abscess or phlegmon. As with other gastrointestinal diseases, Crohn disease involvement of parts of the gut in the true pelvis lends itself to transvaginal evaluation (25). Furthermore, the high prevalence of perianal disease in patients with Crohn disease makes transvaginal US an optimal and usually painless technique for characterizing this pathologic condition in women. In contrast, transrectal and transanal US are often less helpful and may cause the patient considerably more discomfort.



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  		Figure 4a.   Permission to reprint this figure electronically was denied by the publisher. See print version.

 


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  		Figure 4b.   Permission to reprint this figure electronically was denied by the publisher. See print version.

 
Imaging evaluation of the sigmoid colon and pelvic small intestine is performed with routine transvaginal technique, whereas perianal disease and Crohn disease of the rectum require a modified approach. The extreme proximity of the rectum and anal canal to the vagina allows use of a higher-frequency probe (up to 10 MHz) than is used in routine transvaginal procedures (5.0–7.5 MHz). The rectum is visualized by elevating the examining hand toward the symphysis pubis to achieve extreme angulation of the probe in a posterior direction. This will usually allow evaluation of the region of the rectosigmoid and of the more cephalic part of the rectum itself. Gradual withdrawal of the transvaginal probe while maintaining the posterior angulation will allow progressive visualization of the entire rectum and ultimately the anal canal. Rotation of the transducer 90° will produce both longitudinal and cross-sectional images. The anal canal itself is often better seen with a side-fired biplane transvaginal probe than with the more traditional end-fired probe. Evaluation of perianal fistula is accomplished with a combined transvaginal and transperineal approach, which allows examination of the tract from its point of origin in the gut to its cutaneous opening. In most patients, a transvaginal probe can be used for the entire examination.

Gut wall thickening in Crohn disease is usually symmetric with partial or total loss of the gut signature, findings that indicate transmural edema, inflammation, or fibrosis. Like inflamed fat from any other cause, inflamed perienteric fat in Crohn disease manifests as an echogenic mass effect (9). Complications of Crohn disease such as strictures manifest as luminal narrowing. Fistula formation is seen as a hypoechoic linear tract, often containing gas bubbles, between the involved organ and the gut. Rectovaginal and enterovesical fistulas in particular are seen much more clearly at transvaginal US than at routine US (Figs 5, 6). Palpation of the abdomen at the time of the procedure may prove helpful by causing gas to percolate through the fistula, thus making the fistula easier to detect because the bright bubbles of gas outside the lumen of the gut are readily appreciated at US.



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  		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.

 


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  		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.

 


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  		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.

 
Neoplasms
Detection of gastrointestinal neoplasms is a very uncommon indication for US. However, many primary as well as secondary neoplasms, including those of the rectosigmoid colon and even of the small intestine, may be seen at transvaginal US depending on their locations relative to the vaginal vault. Transrectal imaging is the most efficient noninvasive method of evaluating rectal cancer preoperatively (26). However, staging accuracy may be enhanced with transvaginal imaging, which provides more adequate visualization of rectovaginal space infiltration and lymph node enlargement (27,28) (Figs 7, 8). Furthermore, transvaginal imaging may improve assessment of stenosing rectal cancers that are inaccessible to the transrectal probe. Although transvaginal imaging cannot always help visualize all the rectal wall layers or their neoplastic infiltration, we have achieved better results in preoperative staging of rectal cancer in women by combining transrectal and transvaginal imaging.



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  		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.

 


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  		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.

 


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  		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.

 


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  		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.

 


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  		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.

 
Differential diagnosis of gut wall masses includes mesenchymal tumor, lymphoma, gut metastasis, and adenocarcinoma. If present, the tumor can be seen as focal mural thickening or as a localized, round, solid, hypoechoic or heterogeneous intra- or extraluminal mass. Identification of specific layer involvement may be helpful in differential diagnosis. For example, adenocarcinoma demonstrates mucosal involvement in contrast to both mesenchymal tumors and gut wall metastases, which more commonly involve the outer layers of the gut wall. On magnified views, mesenchymal tumors are often seen to have outgrown their blood supply and demonstrate ulceration and necrosis (29). Annular carcinoma manifests as a pseudokidney or target sign at US, with the black outer margin representing the thickened gut wall and the white inner region representing the gut lumen (28). Nonneoplastic masses may also involve the gut wall and mimic a primary or secondary neoplasm. Transvaginal imaging may depict endometriomas involving the rectal or small bowel wall that are indistinguishable from mesenchymal tumors (Fig 9).



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  		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.

 


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  		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.

 
Fecal Incontinence
Because the anus is in proximity to the posterior vaginal wall, damage to the anal sphincters is a well-documented sequela of complicated vaginal delivery (30,31). Fecal incontinence is the most common indication for US evaluation of the anus. Although the majority of affected patients are young women of childbearing age, older women may have similar problems due to muscular dysfunction (32,33). Occasionally, patients (both men and women) may have sphincter damage following surgery for fistula or even for hemorrhoid repair.

Transanal US has been the technique of choice for the assessment of the anorectum and anal sphincters in patients with fecal incontinence (34,35). However, this technique requires special adapters for transrectal probes and may compress the sphincters and distort the anatomic arrangement of the sphincter muscles. In addition, it scans the sphincters in the extreme near field of the transducer and consequently does not always provide optimal resolution of the muscle layers (32).

In contrast, imaging the anal canal with transvaginal probes positioned close to the introitus affords excellent evaluation of the anal sphincters and surrounding muscles in their resting state. Placing the probe in the vagina rather than within the anal canal itself allows positioning of the area of interest between 3 and 5 cm from the transducer crystal, which is the optimal zone for resolution, as compared with the extreme near field used with a transanal approach.

A comparison study of transvaginal and transanal US performed in women at our institution showed the two procedures to be in excellent agreement and to have similar reliability (36). In addition to preferring the transvaginal technique for assessment of the anal sphincters themselves, we also prefer the technique for its clearer assessment of the perineal body and puborectal sling. Transperineal imaging is also optimal in a patient shown to have perianal inflammatory disease if a transvaginal probe is used because these probes may be placed anywhere, always offering the advantages of high-frequency resolution.

Transducers used for anal sphincter evaluation may include side-fired transvaginal probes, which have limited availability on most conventional US imagers, or the more traditional end-fired probe, which is commonly used for transvaginal imaging. If the end-fired probe is selected, the examining hand must be markedly elevated toward the symphysis pubis so that the crystal is firing toward the anal canal. Imaging is performed with the patient in the dorsal lithotomy position with the probe inserted about 3 cm into the vagina. Gradual withdrawal of the probe will produce serial axial images of the anal canal. Long-axis images of the canal are produced by imaging in the perpendicular plane if a biplane transducer is used. More commonly, rotation of the end-fired transvaginal probe 90° from the plane in which the optimal axial image was obtained will show the anal canal and anorectal junction in long axis. Depression of the examining hand toward the table is often helpful for imaging the anal canal in a plane perpendicular to the transducer crystal. Imaging is also optimized with use of a water-filled balloon surrounding the transducer crystal.

The internal anal sphincter appears as a hypoechoic ring encircling the anal canal in continuity with the outer muscular layer of the rectum (Fig 10). The external sphincter appears as a less well-defined hyperechoic ring that blends imperceptibly with the perienteric fat (33). The anorectal junction is easily recognized by a change in shape: The more cephalic rectum appears flattened and oval, whereas the more caudal anal canal appears circular or round (Fig 10). The normal anal canal is approximately 3 cm in length. The puborectal muscle is a slinglike structure that diverges anteriorly and is related to the posterior and lateral margins of the anal canal (37).



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  		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).

 


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  		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).

 


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  		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).

 
Tears in the internal sphincter are seen as defects or discontinuity of the hypoechoic ring (Figs 11, 12). Defects in the external ring are harder to appreciate and usually appear hypoechoic or black compared with the more echogenic muscular fibers (Figs 12, 13). Defects secondary to birth trauma most commonly involve the anterior aspect of the anal canal, as one might expect given their mechanism of production. They may also be associated with loss or destruction of the perineal body, in which case the anal canal will be abnormally close to the transducer placed in the vagina (Fig 14). With nontraumatic dysfunction of the anal sphincters, there may be thinning or the sphincter may look entirely normal.



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  		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.

 


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  		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.

 


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  		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.

 


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  		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.

 

   URINARY TRACT APPLICATIONS
Top
 Abstract
 INTRODUCTION
 GASTROINTESTINAL APPLICATIONS
 URINARY TRACT APPLICATIONS
PERITONEAL APPLICATIONS
 VASCULAR APPLICATIONS
 MISCELLANEOUS APPLICATIONS
 CONCLUSIONS
 References
 
Ureteric Calculi
US has proved to be highly sensitive in the detection of renal calculi (38,39); however, opinions vary with regard to the optimal method for detection of ureterolithiasis (40). Some clinicians favor intravenous urography, whereas others advocate the use of US in conjunction with kidney-ureter-bladder radiography (41). None of these techniques is 100% sensitive. Because detection of ureteric stones can be difficult at US, indirect criteria are often used to support a clinical impression of passage of a urinary calculus. These include unilateral pelvicaliectasis corresponding to the side of pain, an abnormally elevated resistive index in the affected kidney, and unilateral absent ureteric jet on the affected side (42,43).

The ureterovesical junction is the most common site for a passing urinary calculus to lodge. At transabdominal US, experience and knowledge of the exact location and orientation of the intramural ureter allows detection of many stones at this site. However, overdistention of the bladder may cause caudal displacement of the trigone, making it difficult to visualize a calculus. In some patients, underdistention of the bladder may make it difficult to see anything. This is particularly true in large or pregnant patients and in patients in whom urinary frequency is related to the irritation associated with passage of a urinary stone. In such cases, transvaginal US may be optimal in the detection of distal ureteric calculi (44). The procedure is easy to perform and is well tolerated by most patients. Furthermore, it can be performed in patients for whom intravenous pyelography and radiography are contraindicated due to renal insufficiency, sensitivity to iodinated contrast material, or pregnancy.

Optimal transvaginal technique in searching for ureteric stones includes retention of a small amount of urine in the patient's bladder, although high-quality images can still be obtained if the bladder is empty. The intramural and distal ureter is generally located slightly anterior and lateral to the vaginal vault.

If the ureter is dilated, it can easily be seen as an elongated tubular structure entering the bladder obliquely. A distal ureteric calculus manifests as an echogenic focus, usually with sharp acoustic shadowing (Fig 15). There may be thickening or irregularity of the distal ureter and bladder at the ureterovesical junction due to edema caused by stone irritation (Fig 15).



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  		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.

 


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  		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.

 
The interpretation of images that show a stone but no dilated ureter or urine-filled bladder may be difficult because the only US finding may be the shadowing echogenic focus representing the calculus. Again, knowledge of the expected location of the ureterovesical junction is critical for correct interpretation.

Bladder Abnormalities
Cystoscopy is routinely performed in patients with unexplained hematuria. In young women, however, hematuria is most often benign and associated with urinary tract infection. We believe that US of the kidneys and bladder is an excellent screening modality in this patient population for detection of more significant disease. Stones, infections, and tumors of the bladder are the abnormalities most likely to be detected at both routine and transvaginal pelvic US. The transvaginal approach is particularly helpful in patients with poor bladder filling or with bladder diverticula, which are blind areas at cystoscopy (Fig 16).



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  		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.

 


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  		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.

 


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  		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.

 
Optimal transvaginal technique for bladder assessment includes retention of a small to moderate amount of urine in the patient's bladder. Anterior orientation of the probe and partial withdrawal of the probe from the vagina to evaluate the bladder base and urethra are recommended.

Inflammatory and neoplastic masses as well as miscellaneous masses may be seen (45). Transitional cell carcinoma is a solid mass that may demonstrate superficial calcification (Figs 16, 17). Bladder wall invasion and extension to the perivesical soft tissues (Fig 17) may be seen in transitional cell carcinoma and other adjacent tumors, especially cervical cancer (46). Pheochromocytoma is a tumor that is rarely seen in the bladder; when present, however, it manifests as a solid mass with normal and intact overlying mucosa (Fig 18). Inflammatory masses may be associated with generalized pelvic inflammatory disease or may reflect localized bladder inflammation. In contrast to neoplastic bladder processes, inflammation causes edema with thickening of the tissue planes and, often, localized intramural fluid pockets. Endometriomas may manifest as complex bladder wall masses (47,48) that are not as uniformly solid as transitional cell tumors and do not demonstrate superficial calcification (Fig 19). Affected patients are invariably young women with hematuria accompanying the menses.



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  		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.

 


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  		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.

 


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  		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.

 


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  		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.

 


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  		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.

 


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  		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.

 
Urethral Abnormalities
At US, the normal urethra appears as an elongated, hypoechoic tract that is more pronounced at transvaginal or transperineal imaging; therefore, its appearance may be misinterpreted. Calculi, tumors, and diverticula in this location can be evaluated with transvaginal US.


   PERITONEAL APPLICATIONS
Top
 Abstract
 INTRODUCTION
 GASTROINTESTINAL APPLICATIONS
 URINARY TRACT APPLICATIONS
 PERITONEAL APPLICATIONS
VASCULAR APPLICATIONS
 MISCELLANEOUS APPLICATIONS
 CONCLUSIONS
 References
 
The pouch of Douglas is the most dependent portion of the peritoneal cavity and as such often demonstrates abnormality in diffuse peritoneal disease. Although suprapubic US may demonstrate evidence of either masses or fluid in this area, transvaginal imaging is superior in the characterization of both entities. Furthermore, even minute quantities of peritoneal fluid may be identified in this location with transvaginal imaging.

Meticulous technique is of great importance in imaging the pouch of Douglas. To ensure evaluation of the entire pouch, the transducer should be angled from anterior to posterior by elevating and depressing the examining hand. The lateral margins of the pouch should be examined by angling the transducer toward both pelvic side walls. The latter are optimally assessed in the transverse plane.

Fluid Collections
Characterization of free fluid in the pouch of Douglas in conjunction with clinical findings often allows correct diagnosis of the underlying process. Small amounts of clear fluid are believed to be a normal finding at pelvic US in premenopausal women. Increasing amounts of fluid and the presence of particles, strands, and air are suggestive of complications. Blood, pus, inflammatory exudate, crystalline particles, and neoplastic cells may all produce particulate ascites. Inflammatory cells or neoplasia that are suspected at pelvic US may be confirmed with aspiration of fluid via either the transvaginal or suprapubic route.

Use of high-frequency transducer crystals and increased gain settings can help identify particles within ascitic fluid. Therefore, technical considerations for transvaginal study of the peritoneum should include selection of the highest-frequency transducer available and use of a gain setting higher than that which provides optimal gray-scale imaging.

Blood.—Gynecologic US practitioners are familiar with the appearance of blood in the peritoneal cavity (most commonly associated with rupture that occurs during an ectopic pregnancy) at transvaginal US. Particulate ascites in a patient with suspected ectopic pregnancy has a strong association with this condition (49). Similarly, blood in the peritoneal cavity, whether of gynecologic or nongynecologic origin, will often demonstrate particulate material in the dependent pelvic pouch. In addition to particulate ascites, blood clots also collect in the dependent pouch, where they appear as solid or complex masses, often with mixed echogenicity. Spontaneous organ rupture, recent surgery or trauma, and malignant ascites should all be considered as potential causes of hemoperitoneum.

Inflammatory Exudate.—Particulate ascites in association with pelvic inflammatory disease is usually easily recognized as part of the local inflammatory process. In contrast, diffuse peritoneal inflammation may be more difficult to recognize, especially if clinical findings are not considered. Frank purulent peritonitis is usually associated with known or suspected disease of the gastrointestinal tract (Fig 20). However, tuberculosis may manifest at US with particulate ascites as the only positive finding (50,51). Patients with renal failure who have undergone long-term peritoneal dialysis may develop a productive exudative peritonitis characterized by extensive stranding or thickening of the peritoneal surfaces (52).



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  		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.

 


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  		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.

 
Neoplastic Exudate.—Both malignant tumor cells and blood from neoplastic conditions will produce particulate ascites that is indistinguishable from particulate ascites from other causes. However, implants on the visceral or parietal peritoneal surfaces are suggestive of tumor or peritoneal carcinomatosis (Figs 21, 22). These implants may appear as nodules ranging from tiny studs to large deposits. Conversely, they may appear as continuous sheets of tumor cells, in which case a rind or soft-tissue plaque can be seen covering the involved organs or walls of the pelvic cavity (Fig 21). Implants from mucinous tumors may demonstrate focal or diffuse calcification, and psammomatous calcifications can be seen as tiny, punctate, bright echogenic foci within the tumor seeds (Fig 23). In our experience, the use of transvaginal US for evaluation of the pelvic pouch in all patients with either new or suspected recurrent malignant peritoneal disease has led to improved staging of ovarian cancer (53).



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  		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.

 


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  		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.

 


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  		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.

 


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  		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.

 
Peritoneal Inclusion Cysts (Benign Encysted Fluid).—Peritoneal inclusion cysts are benign fluid collections that lack a true epithelial wall. These cysts are most commonly encountered in the true pelvis in patients who have undergone multiple surgical procedures. They have an increased association with previous or current inflammatory bowel disease, endometriosis, and fibroids treated with myomectomy. These fluid collections are often large and detected incidentally at either US or CT, in which case they are often mistaken for ovarian cancer. Their appearance at transvaginal US is diagnostic in that large fluid collections are most often seen enveloping the normal ovaries (53). The margins of the fluid collections are the pelvic side walls laterally, the uterus medially, and the bowel superiorly (Fig 24). Clinical evaluation has common features in that these masses are not palpable to the referring physician despite their large size, and affected patients are most often asymptomatic.



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  		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.

 


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  		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.

 
Pseudomyxoma Peritonei
Pseudomyxoma peritonei is a diffuse peritoneal process that may be associated with dissemination of a mucin-producing neoplasm or with rupture of a mucocele of the appendix (54). Onset is often insidious, and routine or transvaginal US may be the first examination to raise suspicion for this diagnosis.

Both benign and malignant subtypes of pseudomyxoma peritonei have similar morphologic features at transvaginal imaging. The dependent pelvic pouch is typically filled with a complex mass that represents a collection of mucinous material. The ovaries may be seen within the collection if they are not involved. Scalloping of the solid visceral organs, which is virtually pathognomonic of the diagnosis, is rarely demonstrated in the pelvic region.


   VASCULAR APPLICATIONS
Top
 Abstract
 INTRODUCTION
 GASTROINTESTINAL APPLICATIONS
 URINARY TRACT APPLICATIONS
 PERITONEAL APPLICATIONS
 VASCULAR APPLICATIONS
MISCELLANEOUS APPLICATIONS
 CONCLUSIONS
 References
 
Abnormalities of the regional vascular structures, especially the internal iliac vessels and their branches, may be optimally assessed with transvaginal US. Aneurysms, varices, arteriovenous fistulas, arteriovenous malformations, and pseudoaneurysms may all be accurately identified and characterized with this technique.

As with routine US, we recommend the inclusion of color Doppler imaging in the evaluation of any unexplained cystic mass or cystic tubular structure that could possibly have a vascular origin. This is especially true in patients with a history of trauma, recent surgery, or infection in whom vascular injury may have occurred. Both aneurysms and pseudoaneurysms (Fig 25) are often unexpected findings, and tubular cystic areas that actually represent tortuous vascular structures—either arteries or (more commonly) veins—may be mistaken for dilated fallopian tubes. The spectral characteristics of the Doppler waveforms and the measurement indices are also contributory.



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  		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.

 


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  		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.

 


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  		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.

 

   MISCELLANEOUS APPLICATIONS
Top
 Abstract
 INTRODUCTION
 GASTROINTESTINAL APPLICATIONS
 URINARY TRACT APPLICATIONS
 PERITONEAL APPLICATIONS
 VASCULAR APPLICATIONS
 MISCELLANEOUS APPLICATIONS
CONCLUSIONS
 References
 
Geographic tumors in the presacral space and along the side walls of the true pelvis can be identified, measured, characterized, and localized relative to the other pelvic organs with transvaginal US (55). Teratomas of nonovarian origin and tailgut cysts have US features similar to those of ovarian dermoid cysts, often appearing as a complex mass with low-level internal echoes (Fig 26). Rectal duplication cysts manifest as a well-defined cystic mass, usually in the presacral space between the rectum anteriorly and the sacrum posteriorly. Lymphoma and other malignant processes in the true pelvis may have a variety of appearances similar to their appearances elsewhere.



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  		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.

 


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  		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.

 

   CONCLUSIONS
Top
 Abstract
 INTRODUCTION
 GASTROINTESTINAL APPLICATIONS
 URINARY TRACT APPLICATIONS
 PERITONEAL APPLICATIONS
 VASCULAR APPLICATIONS
 MISCELLANEOUS APPLICATIONS
 CONCLUSIONS
References
 
Transvaginal US is a noninvasive, readily available imaging technique that has greatly enhanced diagnostic sensitivity and accuracy in both gynecologic and nongynecologic disease. In many patients, its inclusion in a US study allows more complete and accurate interpretation of abnormalities as well as improved detection of pelvic disease. Therefore, we recommend that routine transvaginal US not be limited to evaluation of gynecologic organs. We also recommend the use of transvaginal US in all women in whom vague or uncertain abnormalities are detected at routine suprapubic US or who are at risk for pelvic sepsis and peritoneal disease, regardless of other imaging findings. We also recommend that transvaginal US in these patients include examination of the bowel, pelvic pouch, urinary tract, and pelvic side walls.


   Footnotes
 
2 Current address: Department of Medical Imaging, Watford General Hospital, Watford, Herts, England. Back

**. indicates multiple body systems. Back

CME FEATURE This article meets the criteria for 1.0 credit hour in category 1 of the AMA Physician's Recognition Award. To obtain credit, see the questionnaire on pp S259-S266.

LEARNING OBJECTIVES After reading this article and taking the test, the reader will be able to: • Understand the advantages of modified transvaginal US for assessment of portions of the gastrointestinal tract, urinary tract, and peritoneal cavity. • Discuss the proper orientation of transvaginal US images for optimal study of the gut and urinary tract. • List the typical appearances of common nongynecologic pelvic diseases at transvaginal US.


   References
Top
 Abstract
 INTRODUCTION
 GASTROINTESTINAL APPLICATIONS
 URINARY TRACT APPLICATIONS
 PERITONEAL APPLICATIONS
 VASCULAR APPLICATIONS
 MISCELLANEOUS APPLICATIONS
 CONCLUSIONS
 References
 

  1. Chang TS, Bohm-Velez M, Mendelson EB. Non-gynecological applications of transvaginal sonography. AJR 1993; 160:87-93.[Abstract/Free Full Text]
  2. Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology 1986; 158:355-360.[Abstract/Free Full Text]
  3. Wilson SR, Toi A. The value of sonography in the diagnosis of acute diverticulitis of the colon. AJR 1990; 154:1199-1202.[Abstract/Free Full Text]
  4. Sarrazin J, Wilson SR. Manifestations of Crohn's disease at US. RadioGraphics 1996; 16:499-520.[Abstract]
  5. Weber AM, Zeigler C, Belinson JL, Mitchinson AR, Widrich T, Fazio V. Gynecologic history of women with inflammatory bowel disease. Obstet Gynecol 1995; 86:843-847.[Medline]
  6. Caterino S, Meli C, Capotondi C, et al. Role of ultrasonography in emergency surgery. Ann Ital Chir 1995; 66:87-98[Italian].[Medline]
  7. Kimmey MB, Martin RW, Hagitt RC, Wang KY, Franklin DW, Silverstein FE. Histologic correlates of gastrointestinal ultrasound images. Gastroenterology 1989; 96:433-441.[Medline]
  8. Wilson SR. Gastrointestinal tract sonography. Abdom Imaging 1996; 21:1-8.[Medline]
  9. Jeffrey RB, Jr, Laing FC, Lewis FR. Acute appendicitis: high-resolution real-time US findings. Radiology 1987; 163:11-14.[Abstract/Free Full Text]
  10. Jeffrey RB, Jr, Laing FC, Townsend RR. Acute appendicitis: sonographic criteria based on 250 cases. Radiology 1988; 167:327-329.[Abstract/Free Full Text]
  11. Marshall EY, Jeffrey RB, Jr. Sonography of appendicitis and diverticulitis. Radiol Clin North Am 1994; 32:899-912.[Medline]
  12. Borushok KF, Jeffrey RB, Jr, Laing FC, et al. Sonographic diagnosis of perforation in patients with acute appendicitis. AJR 1990; 154:275-278.[Abstract/Free Full Text]
  13. Mann CV. The vermiform appendix In: Mann CV, Russell RCG, Williams NS. Bailey and Love's short practice of surgery. 22nd ed. New York, NY: Chapman & Hall, 1995; 1194-1214.
  14. Bondarenko NM, Sernevich PG, Moskalenko VT. Difficulties and errors in the diagnosis of acute gynecologic diseases and acute appendicitis. Vestn Khir Im I I Grek 1989; 142:122-123[Russian].
  15. Freeman SR, McNally PR. Diverticulitis (review). Med Clin North Am 1993; 77:1149-1167.[Medline]
  16. Hulnick DH, Megibow AJ, Balthazar EJ, et al. Computed tomography in evaluation of diverticulitis. Radiology 1984; 152:491-495.[Abstract/Free Full Text]
  17. Broekman BA, Puylaert JB, Van Dessel T. Sigmoid diverticulitis in the female: transvaginal sonographic findings. J Clin Ultrasound 1993; 21:393-395.[Medline]
  18. vanSonnenberg E, D'Agostino HB, Casola G, Goodacre BW, Sanchez RB, Taylor B. US-guided transvaginal drainage of pelvic abscesses and fluid collections. Radiology 1991; 181:53-56.[Abstract/Free Full Text]
  19. Dancygeir H, Frick B. Crohn's disease of upper gastrointestinal tract. Endoscopy 1992; 24:555-558.[Medline]
  20. Gore RM. Cross-sectional imaging of inflammatory bowel disease. Radiol Clin North Am 1987; 25:115-131.[Medline]
  21. Maconi G, Parente F, Bollani S, Cesana B, Bianchi Porro G. Abdominal ultrasound in the assessment of extent and activity of Crohn's disease: clinical significance and implication of bowel thickening. Am J Gastroenterol 1996; 91:1604-1609.[Medline]
  22. Wilson SR. The gastrointestinal tract In: Wilson SR, ed. Diagnostic ultrasound. 2nd ed. St Louis, Mo: Mosby–Year Book, 1997.
  23. Maconi G, Bollani S, Bianchi Porro G. Ultrasonographic detection of intestinal complications in Crohn's disease. Dig Dis Sci 1996; 41:1643-1648.[Medline]
  24. Dinkel E, Dittrich M, Peters H, Baumann W. Real time ultrasound in Crohn's disease: characteristic features and clinical implication. Pediatr Radiol 1986; 16:8-12.[Medline]
  25. Adams LS, Peltekian KM, Mitchell MJ. Detection of Crohn's ileitis by endovaginal ultrasonography. Abdom Imaging 1994; 19:400-402.[Medline]
  26. Seagore A, Milson JW, Talbott TM, Muldon JP, Mazier WP. Intrarectal ultrasound in the staging and management of rectal cancer. Am J Surg 1988; 54:352-355.
  27. Badea R, Badea G, Dejica D, Henegar E. The role transvaginal sonography as compared with endorectal sonography in the evaluation of rectal cancer: preliminary study. Surg Endosc 1991; 5:89-91.[Medline]
  28. Wang KY, Kimmey MB, Nyberg DA, et al. Colorectal neoplasms: accuracy of US in demonstrating the depth of invasion. Radiology 1987; 165:827-829.[Abstract/Free Full Text]
  29. Bin W, Jianguo L, Baowie D. The sonographic appearances of small bowel tumors. Clin Radiol 1992; 46:30-33.[Medline]
  30. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993; 329:1905-1911.[Abstract/Free Full Text]
  31. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994; 308:887-891.[Abstract/Free Full Text]
  32. Sultan AH, Loder PB, Bartram CI, Kamm MA, Hudson CN. Vaginal endosonography: new approach to image the undisturbed anal sphincter. Dis Colon Rectum 1994; 37:1296-1299.[Medline]
  33. Sandridge DA, Thorp JM. Vaginal endosonography in the assessment of anorectum. Obstet Gynecol 1995; 86:1007-1009.[Medline]
  34. Law PJ, Bartram CI. Anal endosonography: technique and normal anatomy. Gastrointest Radiol 1989; 14:349-353.[Medline]
  35. Cuesta MA, Meijer S, Dersen EJ, Boulkan H, Meuwissen SG. Anal sphincter imaging in fecal incontinence using endosonography. Dis Colon Rectum 1992; 35:59-63.[Medline]
  36. Stewart LK, Wilson SR. Transvaginal sonographic assessment of the anal sphincter: reliable or not?. AJR 1999; 173:179-185.[Abstract/Free Full Text]
  37. Sultan AH, Nicholls RJ, Kamm MA, Hudson CN, Beynon J, Bartram CI. Anal endosonography and correlation with in vitro and in vivo anatomy. Br J Surg 1993; 80:508-511.[Medline]
  38. Erwin BC, Carroll BA, Sommer FG. Renal colic: the role of ultrasound in initial evaluation. Radiology 1984; 152:147-150.[Abstract/Free Full Text]
  39. Middleton WD, Dodds WJ, Lawson TL, Foley WD. Renal calculi: sensitivity for detection with US. Radiology 1988; 167:239-244.[Abstract/Free Full Text]
  40. Hill MC, Rich JI, Mardial JG, Finder CA. Sonography vs excretory urography in acute flank pain. AJR 1985; 144:1235-1238.[Abstract/Free Full Text]
  41. Sinclair D, Wilson SR, Toi A, Greenspan L. The evaluation of suspected renal colic: ultrasound scan versus excretory urography. Ann Emerg Med 1989; 18:556-559.[Medline]
  42. Burge HJ, Middleton WD, McClennan BL, Hildebolt CF. Ureteral jets in healthy subjects and in patients with unilateral ureteral calculi: comparison with color Doppler US. Radiology 1991; 180:437-442.[Abstract/Free Full Text]
  43. Platt JF, Rubin JM, Ellis JH. Acute renal obstruction: evaluation with intrarenal duplex Doppler and conventional US. Radiology 1993; 186:685-688.[Abstract/Free Full Text]
  44. Laing FC, Benson CB, DiSalvo DN, Brown DL, Frates MC, Loughlin KR. Distal ureteral calculi: detection with vaginal US. Radiology 1994; 192:545-548.[Abstract/Free Full Text]
  45. Djavan B, Roehrborn CG. Bladder ultrasonography (review). Semin Urol 1994; 12:306-319.[Medline]
  46. Iwamoto K, Kigawa J, Minagawa Y, Miura H, Terakawa N. Transvaginal ultrasonographic diagnosis of bladder wall invasion in patients with cervical cancer. Obstet Gynecol 1994; 84:160-161.[Medline]
  47. Sampietro Crespo A, Fernandez Duran AM, Ruiz Mondejar R, et al. Bladder endometriosis: a new case and review of the literature. Arch Esp Urol 1995; 48:314-317[Spanish].[Medline]
  48. Vercellini P, Meschia M, De Giorgi O, Panazza S, Cortesi I, Crosignani PG. Bladder detrusor endometriosis: clinical and pathogenetic implications. J Urol 1996; 155:84-86.[Medline]
  49. Atri M, Leduc C, Gillett P, et al. Role of endovaginal sonography in the diagnosis and management of ectopic pregnancy. RadioGraphics 1996; 16:755-775.[Abstract]
  50. Jain R, Sawhney S, Bhargava DK, Berry M. Diagnosis of abdominal tuberculosis: sonographic findings in patients with early disease. AJR 1995; 165:1391-1395.[Abstract/Free Full Text]
  51. Kedar RP, Shah PP, Shivde RS, Malde HM. Sonographic findings in gastrointestinal and peritoneal tuberculosis. Clin Radiol 1994; 49:24-29.[Medline]
  52. Cochran ST, Do HM, Ronaghi A, Nissenson AR, Kadell BM. Complications of peritoneal dialysis: evaluation with CT peritoneography. RadioGraphics 1997; 17:869-878.[Abstract]
  53. Sohaey R, Gardner TL, Woodward PJ, Peterson CM. Sonographic diagnosis of peritoneal inclusion cysts. J Ultrasound Med 1995; 14:913-917.[Abstract]
  54. Ronnett BM, Kurman RJ, Zahn CM, et al. Pseudomyxoma peritonei in women: a clinicopathologic analysis of 30 cases with emphasis on site of origin, prognosis and relationship to ovarian mucinous tumors of low malignant potential. Hum Pathol 1995; 26:509-524.[Medline]
  55. Foshager MC, Hood LL, Walsh JW. Masses simulating gynecologic diseases at CT and MR imaging. RadioGraphics 1996; 16:1085-1099.[Abstract]




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