The ultrasound: uterus
The ultrasound: adnexa
Includes evaluation of the ovaries and Fallopian tubes. The entire ovarian size should be measured in three orthogonal planes. Any abnormalities should be quantified, measured and documented. The sonographic characteristics of any ovarian abnormality should be described according to terminology published by the International Ovarian Tumor Analysis (IOTA) group
‘Kissing’ ovaries, an ultrasound diagnosis of ovaries fixed to each other indirectly indicates intra‐abdominal adhesions and possibly underlying DE of the Fallopian tubes and/or bowel.
The ultrasound: site‐specific tenderness
SST-‘soft markers’- The key anatomic locations to assess in this component of the scan include the uterus, adnexa, USLs and POD. Currently, the IDEA group recommends a scoring system of 0 or 1; 0 for no pain and 1 for pain. However, this test is still limited in that no scoring system has been validated as yet.
The ultrasound: Sliding sign
The test is considered positive when the uterus and cervix move independently (i.e. slide) along the anterior rectum and sigmoid . Clinically and surgically, this is reassuring for a non‐obliterated POD. Conversely, if the uterus and cervix move in unison with the anterior rectum and sigmoid, the test is negative and the POD is thought to be obliterated.
Schematic Drawing Demonstrating How to Elicit the ‘Sliding Sign’ in an Anteverted Uterus (a) and Retroverted Uterus
The ultrasound: anterior and the posterior compartment
Lesions may appear as hypoechoic linear or spherical lesions, with or without regular contours . The uterovesical region should be examined for tethering to the uterus (i.e. obliteration of the space). The concept of the ‘sliding sign’ can be applied here as well. The operator should hold the TV probe in the anterior fornix with one hand and the other hand should be placed over the suprapubic region. By balloting the uterus between the probe and hand, the operator can judge whether the posterior bladder slides freely over the anterior uterine wall,
When the bladder and uterus move together, the operator should document a negative ‘sliding sign’, representing an obliterated space. An independently moving bladder from the uterus represents a positive ‘sliding sign’.
The posterior compartment sites include USLs, posterior vaginal fornix, rectovaginal septum (RVS), anterior rectum, anterior rectosigmoid junction and sigmoid colon. Done by gently placing the TV probe in the posterior vaginal fornix
Schematic and Ultrasound Images Demonstrating an Isolated RVS Nodule. Note the Hyperechoic Nature of the RVS (Red Star) and Adjacent Hypoechoic Layers of Vagina (Yellow Star) and Rectal Wall Muscularis (Green Circle).