Transvaginal sonographic evaluation of the retrodisplaced uterus

To determine the clinical value of transvaginal sonography in the assessment of retrodisplaced uteri, the authors reviewed, retrospectively, 500 consecutive transvaginal (TV) and transabdominal (TA) sonograms. Of the 494 patients examined, 27 had a retrodisplaced uterus. Transvaginal sonography was superior to TA sonography in 25 patients, providing improved visualization of the endometrial canal, myometrium, adnexa and cul-de-sac. In 7 of these 25 patients, the findings that suggested the diagnosis were only seen on TV scanning. These findings included intrauterine pregnancy (three patients), fluid collection in the cul-de-sac (two patients), fluid collection in the endometrial canal (one patient) and an embedded intrauterine contraceptive device (one patient). The two techniques yielded the same information in two other patients. In no patient was TA sonography more informative than TV sonography. The authors, therefore, conclude that TV sonography is the procedure of choice in assessing a retrodisplaced uterus and that additional examination with TV sonography is advisable whenever a retrodisplaced uterus is suspected.     

Transvaginal and transabdominal sonography: prospective comparison

Transvaginal (TV) and transabdominal (TA) sonography were compared in a prospective study. A total of 230 examinations (126 pelvic, 104 pregnancy) were performed on 215 patients, ranging in age from 14 to 80 years. The improved anatomic detail on TV scans yielded new information in 138 (60%) examinations and better visualization of pelvic structures in 51 (22%) examinations. There was no important difference in diagnostic information provided by the two imaging modalities in 36 (16%) cases, and TV images were worse in five (2%). The clinical diagnosis was altered on the basis of TV sonographic findings in 54 (24%) cases and confirmed with certainty in 166 (72%). Diagnostic problems posed by TA scanning were not resolved by TV scanning in ten (4%) instances. Statistical analysis indicated that TV scanning was significantly better than TA scanning in the visualization of gestational sac contents (P less than .005), detection of fetal heart motion (P less than .001), and evaluation of the endometrial canal in the retroverted or retroflexed uterus (P less than .001). TV scanning was significantly better than TA scanning in visualization of the ovaries in patients with uterine leiomyomas (P less than .005) but not significantly better in peri- and postmenopausal patients (P greater than .05).     

Transvaginal sonography: comparison with transabdominal sonography in the diagnosis of pelvic masses

In a retrospective study, we compared transvaginal sonograms with transabdominal sonograms in 67 women referred for evaluation of palpable pelvic masses. The diagnoses included ovarian cyst (27), endometrioma (12), complex cyst (four), dermoid (three), infection (three), ovarian malignancy (two), and uterine fibroid (three). The final diagnosis was made surgically in 41 patients (61%) and by a combination of sonographic and clinical correlation in the remaining patients. More information about the internal architecture or anatomy of the mass was provided by the transvaginal images than by the transabdominal scans in 51 (76%) of the patients. Transabdominal sonography did not provide more diagnostic information in any of the patients examined. Transvaginal sonography was helpful in obese patients, in those with a large amount of bowel gas, and in those unable to achieve adequate bladder filling. Six simple cysts and four complex pelvic masses were identified solely on transvaginal sonograms. The results suggest that transvaginal sonography has considerable advantages over conventional transabdominal sonography in the evaluation of pelvic masses in women.     

Ectopic pregnancy: features at transvaginal sonography.

A retrospective review of the transvaginal sonograms of 50 women with laparoscopically confirmed ectopic pregnancy was performed to determine whether certain sonographic findings can be detected to confirm the diagnosis. Forty-seven of the 50 pregnancies were tubal. A tubal ring (a 1-3-cm mass consisting of a 2-4-mm concentric, echogenic rim of tissue surrounding a hypoechoic center) was seen in 23 of 34 (68%) ectopic pregnancies in which the fallopian tube had not ruptured, and the tubal ring could be distinguished from a corpus luteum cyst in most cases. Transvaginal sonography also depicted simple (n = 22) or particulate (bloody) (n = 13) peritoneal fluid associated with ectopic pregnancy. In each case in the series, at least one abnormal uterine, adnexal, or peritoneal finding was detected at transvaginal sonography. Because of its improved resolution of uterine and adnexal structures, transvaginal sonography is recommended as a means for detailed evaluation of patients suspected of having an ectopic pregnancy.     

Value of transperineal sonography in the assessment of vaginal atresia

We studied the value of transperineal sonography in the preoperative assessment of seven patients with clinically suspected vaginal atresia. Although transabdominal scanning is useful to determine if hydrocolpos or hydrometrocolpos is present, this method does not allow measurement of the thickness of a caudally placed obstructive septum. This information is useful in planning reconstructive surgery. All seven patients had transabdominal sonography, with five showing a low-lying obstruction. In those five patients, the distance between the perineal surface and the caudal aspect of the distended vagina, measured with electronic calipers on the transperineal sonograms, ranged from 1.0 to 4.0 cm. We conclude that when vaginal atresia is clinically suspected, transabdominal sonography should be performed to confirm the diagnosis. When a low-lying obstruction is identified, transperineal sonography should be performed to determine the length of the obstructive segment.     

Endovaginal sonographic evaluation of ectopic pregnancy: a prospective study

To determine the value of endovaginal sonography for evaluating women with a suspected ectopic gestation, we prospectively studied a group of 84 pregnant women in whom conventional transabdominal sonograms failed to show a living embryo. Of 84 patients studied, 25 had an ectopic gestation, 32 had a normal intrauterine pregnancy, and 27 had an abnormal (nonviable) intrauterine pregnancy. Endovaginal sonography, compared with transabdominal sonography, provided additional information in 50 cases (60%) and less information in only three cases (4%). Of 25 ectopic gestations, endovaginal sonography provided new information in 15 cases (60%) including detection of an extrauterine gestational sac (10 cases), extrauterine embryo (two cases), or adnexal mass (three cases) not observed on transabdominal sonography. Of 32 normal intrauterine pregnancies, endovaginal sonography provided additional information in 26 cases (81%) including detection of a yolk sac (14 cases), living embryo (11 cases), or small gestational sac (one case) not seen on transabdominal sonography. Of 27 abnormal intrauterine pregnancies, endovaginal sonography showed additional information in nine cases (33%) including detection of embryonic demise (three cases), retained intrauterine products (four cases), or a yolk sac (two cases) not seen on transabdominal sonography. Patient acceptance of endovaginal sonography was excellent; 82% of the patients preferred this method to transabdominal sonography, 13% expressed no preference, and 5% preferred transabdominal sonography. We conclude that endovaginal sonography can provide significant additional information in the majority of women who are referred for sonography with a suspected ectopic gestation. We believe that this method should become a integral part of sonographic evaluation in women who are suspected of having an ectopic gestation when conventional transabdominal sonography fails to show a living embryo.     

Occult and clinically suspected testicular tumor. Assessment using real-time sonography

The diagnostic value of real-time-sonography was evaluated in 62 patients with suspected and occult testicular tumors. In 28 patients intratesticular tumors were identified on real-time-sonograms. In addition 7 clinically occult tumors were diagnosed by real-time-sonography. It was not possible to differentiate between orchitis and tumors on sonograms (3 cases). There was correlation only between the morphologic appearance of tumors on sonograms and the corresponding histology. Using high frequency transducers sonography proved to be an useful diagnostic modality to identify or to rule out occult intratesticular tumors.     

Sonography of the salivary glands

In a blinded retrospective study of the efficacy of sonography of the salivary glands, we obtained sonograms on 849 patients. The patients were referred over the last 5 years from the ear, nose, and throat department of our university hospital. Eight-eight percent of the patients had symptoms related to the salivary glands. One hundred fifty-six of the patients (18%) were subsequently proved to be normal. The remaining 693 patients had diseases confirmed by histologic examination (332 patients), sialography (274 patients), or clinical follow-up (87 patients). Of these, 289 had salivary gland tumors (231 benign, 58 malignant), 185 had calculi, 154 had inflammation, 48 had autoimmune disease, 14 had cysts, and three had trauma. Two hundred eighty-seven (95%) of the 302 space-occupying lesions could be completely delineated by sonography, and the benign or malignant nature of the lesions was correctly assessed in 272 (90%). Of the 185 patients with calculi, the calculi were visualized and localized (intraductal vs intraglandular) on the sonograms in 174 (94%) patients. Abscesses were shown on the sonograms in 13 patients, and acute inflammation was shown on the sonograms in 84 patients. These results indicate that sonography is a useful procedure for diagnosis of diseases of the salivary glands.     

Diagnosis of ectopic pregnancy: endovaginal vs transabdominal sonography

During a 25-month period, 193 women with the clinical diagnosis of suspected ectopic pregnancy had transabdominal and endovaginal sonograms. Most had quantitative determinations of serum human chorionic gonadotropin (HCG). Endovaginal sonography was diagnostic of ectopic pregnancy in 23 (38%) of the 60 patients with surgically proved ectopic pregnancies: transabdominal sonography was diagnostic in 13 patients (22%). All 83 intrauterine pregnancies were identified with endovaginal sonography, compared with 34 identified with transabdominal sonography. Endovaginal sonography was somewhat more helpful in the diagnosis of missed abortion and blighted ovum. Eighty endovaginal sonograms were classified as indeterminate as compared with 141 transabdominal studies. This indeterminate group included patients with complete abortions, ectopic pregnancies without sonographic evidence of an extrauterine gestation, incomplete abortions, and patients with subsequent negative serum levels. As in prior reports, endovaginal sonography was superior to transabdominal sonography in the evaluation of suspected ectopic pregnancies. Overall, endovaginal sonography was diagnostic in 113 patients, whereas transabdominal sonography was diagnostic in 52 patients. The finding of an extrauterine fetal pole or embryo was diagnostic for an ectopic pregnancy. Pelvic fluid, the appearance of the endometrium, and a single positive serum HCG determination were not helpful in making the diagnosis of ectopic pregnancy.     

Sonographic diagnosis of neutropenic typhlitis

Five immunosuppressed patients with neutropenic typhlitis were studied with sonography. In four, sonography was the imaging technique that first suggested the diagnosis. In each case, sonography showed thickening of the right colon wall (1-2.5 cm) with low- or high-level echoes. Serial sonograms were used to monitor the daily progress of the disease in two patients. Sonography appears to be a useful tool not only to detect typhlitis in patients with symptoms suggestive of the disease, but also to follow their clinical course.     

Transvaginal echography: initial experiences in oncologic gynecology

The authors report their initial experience in a selected group of 30 patients with suspected gynecological neoplasms (10 ovarian tumors, 8 recurrences of ovarian tumors, 6 cervical carcinomas, 3 ovarian cysts, 3 fibromyomas) who underwent both transabdominal (US) and transvaginal (TV) sonography. All the scans were retrospectively reviewed. In 18 cases US and TV provided equivalent information as to the organ of origin of the mass, while TV was more useful in 9 cases, and US in 3 cases. The anatomical relationship of the mass to the adjacent organs was better demonstrated by TV in 15 cases, while in 15 cases the information provided by US and TV was equivalent. The two techniques yielded the same results as to the internal architectural details of the mass in 9 cases, while TV was superior in 18 cases and US in 3 cases. TV allowed the early identification of: small amounts of free fluid in the cul-de-sac in 3 cases, compression of the ureter in 1 case, and compression of the uterine vessels in 1 case. These findings had not been demonstrated by US. Our preliminary results indicate that adjuvant TV sonography provides important diagnostic information in gynecological neoplasms in about 39% of patients.     

Ectopic pregnancy: evaluation with endovaginal color flow imaging.

Endovaginal sonography and endovaginal color flow imaging were compared in 155 patients with clinical suspicion of ectopic pregnancy. Sixty-five patients (42%) had surgically confirmed ectopic pregnancies. Thirty-six of the pregnancies were diagnosed with endovaginal sonography alone, the criteria being an extrauterine sac or ectopic fetus (sensitivity, 54%). Sixty-two ectopic pregnancies were diagnosed with endovaginal color flow imaging (sensitivity, 95%) when an ectopic fetus or sac was seen or placental flow was identified in an adnexal mass separate from the ovary and uterus. The diagnosis of ectopic pregnancy was excluded with endovaginal sonography (specificity, 98%) and endovaginal color flow imaging (specificity, 98%) by finding an intrauterine gestation, nonvisualization of an adnexal mass, and absence of placental flow. Three false-positive and three false-negative diagnoses were made with endovaginal color flow imaging (positive predictive value, 97%). The addition of color Doppler flow imaging to endovaginal sonography allows increased sensitivity in the detection of ectopic pregnancy.     

Invasion of the seminal vesicles by prostatic cancer: detection with transrectal sonography

Endorectal sonography provides a potential means of detecting seminal vesicle invasion by prostatic cancer that is too subtle for diagnosis by digital rectal examination. To assess this application of sonography, we examined 300 patients with transrectal sonography of the prostate and seminal vesicles followed by histologic examination of the seminal vesicles from core biopsies and/or prostatectomy specimens. Of the 38 patients with histologically proved seminal vesicle invasion by prostatic cancer, 35 (92%) had an abnormal appearance of the seminal vesicles on sonography. Of 167 patients with prostatic cancer without histologic evidence of seminal vesicle involvement, sonograms showed abnormal seminal vesicles in 42 (25%). In 95 patients with histologically normal prostates and seminal vesicles, sonograms showed abnormal seminal vesicles in 11 (12%). The sonographic findings correlating best with tumor invasion of the seminal vesicles were hyperechogenicity and a combination of two or more of the following abnormalities: cystic dilatation, asymmetry, enlargement, and anterior displacement. Our experience in these patients suggests that endorectal sonography can be useful in the detection of seminal vesicle involvement by prostatic cancer.     

Endometrial abnormalities: evaluation with transvaginal sonography

The value of transvaginal sonography in detecting gynecologic disease currently is being defined. To evaluate transvaginal depiction of the endometrium, transvaginal sonograms were compared with conventional transabdominal scans in 29 patients whose sonograms revealed endometrial abnormalities. The two techniques were compared for image quality and ability to provide unique diagnostic information. Sonographic findings included fluid collections (16), thickened and/or echogenic endometria (10), endometrial irregularities (two), and echogenic foci (two). Clinical diagnoses included early intrauterine pregnancies (five), pseudogestational sacs of ectopic pregnancy (one), intrauterine contraceptive devices (two), endometrial carcinoma (one), and intrauterine synechiae with amenorrhea (Asherman syndrome) (two). In most cases (77%), diagnostic information was obtainable by either transabdominal or transvaginal sonograms, although in 23% transvaginal scanning provided unique diagnostic information not available with the transabdominal technique. In no case did transabdominal sonography contribute diagnostic information not provided transvaginally. The quality of the transvaginal image was judged to be better than that of the transabdominal image in 63% of cases; image quality was the same in 33% of cases and worse in 3% of cases. The results show that transvaginal sonography is often superior to transabdominal scanning in the evaluation of endometrial abnormalities. Transvaginal sonography may be the preferred technique in these cases.     

Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries

OBJECTIVE: We compared sonography and MRI for assessing hamstring injuries in professional football players (Australian football) 3 days, 2 weeks, and 6 weeks after an injury and identified imaging characteristics at baseline that may be useful in predicting the time needed for return to competition. MATERIALS AND METHODS: Sixty men who are professional football players presented with suspected acute hamstring strain underwent sonography and MRI within 3 days of injury; those who were injured returned 2 and 6 weeks later for follow-up MRI and sonography. Two radiologists interpreted either the MR images or the sonograms and were blinded to the results of the other technique. The following six parameters were measured at each assessment: the muscle injured, the site of injury within the muscle, the longitudinal injury length (expressed in millimeters), the cross-sectional injured area (expressed as a percentage), and the presence of interand intramuscular hematoma. RESULTS: At baseline, MRI identified abnormalities in 42 (70.0%) of 60 patients, whereas sonography found abnormalities in 45 (75%) of 60. At 2 weeks, 29 (59.2%) of 49 scans showed abnormalities on MRI and 25 (51.0%) of 49 showed abnormalities on sonograms. Of those players who were injured at baseline, 15 (35.7%) of 42 and 10 (22.2%) of 45 still showed abnormal results on scans at 6 weeks on MRI and sonography, respectively. However, all but one player had returned to competition. The biceps femoris was the most commonly injured muscle and the musculotendinous junction was the most common site of injury. Injuries appeared significantly larger on MRI than on sonography at all time points. Our analysis showed that at baseline, the longitudinal length of hamstring tear on MRI had the highest statistical correlation with recovery (r = 0.58, p < 0.0001) and was the best radiologic predictor for return to competition. CONCLUSION: Sonography is as useful as MRI in depicting acute hamstring injuries and because of lower costs may be the preferred imaging technique. However, MRI is more sensitive for follow-up imaging of healing injuries. The longitudinal length of the strain as measured on MRI is a strong predictor for the amount of time needed until an athlete can return to competition.     

Arteriovenous malformations of the kidneys: diagnosis and follow-up with color Doppler sonography in six patients

We performed color Doppler sonography in six patients with arteriovenous malformations of the kidneys. The diagnosis was established by angiography in all patients. Color Doppler sonograms were obtained at a large Doppler frequency-shift range (55 cm/sec of maximal average flow velocity at zero Doppler angle) to depict high-velocity blood flow in the malformation. In all patients, the malformations were seen as focal areas of flow, portrayed as a mixing of lighter colors. These were reflected by a rapid flow rate and marked tortuosity of the vessels. The sonograms showed a small peripheral malformation that was indistinct on selective renal angiography. However, flow in normal vessels grouped in the hilum obscured lighter-color flow of a small central malformation. In three patients who had total or partial ablation of the malformations with alcohol, follow-up color Doppler sonograms showed that the focal areas of flow, represented as mixing of lighter colors, disappeared or became smaller. This study shows that color Doppler sonography is a useful noninvasive procedure for diagnosing arteriovenous malformations of the kidney.     

Gray-scale ultrasound in tubal pregnancy

Sonographic signs were correlated with clinical data, surgical findings, and pathology in 15 patients withtubal pregnancy. Sonograms showed absence of intrauterine gestation in 12 patients. In 3, structures resembling gestational sacs were produced by decidual reaction and blood in the uterine cavity separating the endometrial echoes. The uterus was normal in size in 6 cases. Almost all sonograms showed a pelvic mass (usually adnexal) displacing the uterus. Seven patients had predominantly sonolucent masses, 3 had complex masses, and 4 had both types. Only one woman exhibited a definite gestational sac in an extrauterine location. Four patients had a negative pregnancy test at the time of sonography. Meticulous sonographic technique and a high index of suspicion will facilitate the diagnosis of tubal pregnancy in most cases.     

In vitro fertilization: sonographic perspective

The applications of sonography were evaluated in 220 patients undergoing 354 in vitro fertilization cycles. A baseline sonogram demonstrated adnexal abnormalities in 10.7% of cycles. Serial sonograms were beneficial in monitoring follicular development. Oocyte harvest was canceled in 18.4% of cycles owing to inadequate follicle growth progression, as demonstrated by ultrasound. An additional 9% of cycles were canceled owing to the development of a single lead follicle. Six percent of cycles were accompanied by a spontaneous rise in serum luteinizing hormone values, necessitating sonographic correlation to exclude ovulation.     

Hilar biliary obstruction: preliminary results with Levovist-enhanced sonography

OBJECTIVE: The aim of this study was to investigate the value of using Levovist in the postvascular phase of sonography performed to assess hepatic hilar biliary obstruction. SUBJECTS AND METHODS: In our prospective study, 50 patients underwent routine sonography followed by postvascular Levovist-enhanced pulse inversion imaging of the liver. Thirty-six patients had malignant disease (28 invasive parenchymal tumors and eight intraductal tumors), and 14 had benign disease. The 36 malignancies included 29 cholangiocarcinomas, six invasive gallbladder carcinomas, and one colon metastasis. Fourteen patients had benign disease: benign strictures (n = 5), primary sclerosing cholangitis (n = 5), chronic Mirizzi's syndrome (n = 1), varicosities of the parabiliary venous plexus (n = 1), and inflammatory liver lesions (n = 2). Sonographic findings in all 50 patients were correlated with findings from other imaging modalities (n = 50) as well as surgical specimens (n = 20), core biopsies (n = 3), and both clinical and imaging follow-ups (n = 24). RESULTS: Seventeen (61%) of the 28 invasive intraparenchymal malignancies were visualized on routine sonograms, whereas all 28 (100%) were visualized on enhanced sonograms (p < 0.01). In 15 (88%) of 17 patients in whom tumor was seen on routine sonograms, contrast-enhanced sonography showed further mass extent, increased conspicuity, or satellite nodules not visualized on the baseline image. All eight noninvasive intraductal malignancies were correctly identified and staged on the routine sonography. In one of these patients, hepatic invasion was prospectively overcalled on the enhanced image. Of the 14 benign lesions, three had inflammatory periductal abnormalities seen exclusively or to advantage on the enhanced study. Correct prediction of resectability in the 16 patients with malignant disease who underwent surgery improved from 11 (69%) of 16 on unenhanced sonography to 15 (94%) of 16 on enhanced sonography (p = 0.13). CONCLUSION: Detection and staging of malignant hilar obstructions are improved by the use of Levovist in the postvascular phase of sonography compared with routine sonography.     

Sonographic and computed tomographic evaluation of intrahepatic calculi

Intrahepatic calculi in non-Asian patients were studied by sonography and computed tomography (CT). Three patients were studied by CT cholangiography also. In two cases, the calculi were consecutive to Caroli disease, and in two others, the biliary stones were formed proximal to a stenosis of a previous surgical anastomosis. Five patients spontaneously developed intrahepatic calculi. All sonograms were abnormal. Image specificity was good, even when bile ducts were not dilated, if appropriate technique allowed identification of a double-arc-shadow pattern. Sonography strongly suggested the diagnosis in eight patients and was nonspecific in only one. On CT, calculi had various densities, and they were not visible in two patients. CT cholangiography was not particularly helpful. Finally, CT added little more information when performed after sonography. Both examinations strongly underestimate the number of stones, and direct cholangiography remains indicated if surgery is planned.