Transvaginal Ultrasonography in the Diagnosis of Extrauterine Pelvic Diseases

Stefano Guerriero; Silvia Ajossa; Marta Gerada; Bruna Virgilio; Monica Pilloni; Rosendo Galvan; M Carmen Laparte; Juan Luis Alcázar; Gian Benedetto Melis

Disclosures

Expert Rev of Obstet Gynecol. 2008;3(6):731-752. 

In This Article

Abstract and Introduction

Abstract

Extrauterine pelvic diseases include several kinds of adnexal masses. In addition, pelvic adhesions and deep endometriosis can be considered extrauterine pelvic diseases. In this article we will review a practical approach to adnexal pathologies using simple transvaginal ultrasonographic findings of several benign masses. Moreover, we will investigate the additional role of color Doppler and explain a simplified presurgical triage of adnexal masses that uses color Doppler as a secondary test for the detection of ovarian cancer, already confirmed by several studies. We will also evaluate the new insight of transvaginal ultrasonography in the detection of pelvic adhesions and deep endometriosis. A possible improvement in the field of the preoperative diagnosis of ovarian cancer in the next years comes from the constitution of the International Ovarian Tumor Analysis Group and from the introduction into clinical practice of 3D color Doppler sonography.

Introduction

Extrauterine pelvic diseases include several kinds of adnexal masses, such as hydrosalpinx, peritoneal cysts, endometrioma, cystic teratoma, serous cyst, hemorrhagic cyst, serous and mucinous cystadenoma, tubo-ovarian complex secondary to pelvic inflammation and ovarian cancer, as well as other less frequent pathologies. In addition, there are other extrauterine pelvic diseases including adhesions and deep endometriosis, which is a recently investigated pathology causing a decrease in quality of life in women.

The transabdominal probe has not been found to be useful in the evaluation of the female pelvis because of the relatively poor resolution associated with the use of lower frequency ultrasound (US);[1] whereas the transvaginal probe increases the accuracy of ultrasonography,[2,3,4,5] and this technique is frequently used as a first-imaging modality when an extrauterine pelvic disease is suspected.[6] Many adnexal masses have a typical transvaginal B-mode US appearance related to macroscopic pathology. Some authors call this approach 'pattern recognition', i.e., subjective evaluation of the gray-scale US image;[7,8] others call it 'sonohistology' ( Table 1 ).[9] In some cases, however, uncertain ultrasonographic findings related to benignity are also present, such as in cases of mucinous cystoadenomas, fibroadenomas or tubo-ovarian complex. All masses with uncertain or dubious appearances should be graded as malignant.[10] In this case, solid excrescences or solid portions of the tumor should be evaluated using vascular flow with color Doppler sonography (conventional or power) and the mass should be graded as malignant if flow is shown within the excrescences or solid areas, and as benign if there is no flow.[10]

With recently growing interest, transvaginal ultrasonography (TVUS) has been used in cases of suspicion of pelvic adhesions[11] and of deep endometriosis,[12] providing a more detailed ultrasonographic scan.

In this review we will summarize a practical approach to adnexal pathologies using simple ultrasonografic findings of benign pathology ( Table 1 ). Moreover, we will investigate the additional role of color Doppler and we will explain a simplified presurgical triage of adnexal masses that uses color Doppler as a secondary test,[10] already confirmed by several studies. We will also evaluate the new insight of TVUS in the detection of adhesions and deep endometriosis.

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