Anatomy and Physiology
Uterus: The uterus is a muscular pear-shaped organ occupying the pelvis with homogeneous isoechoic to hyperechoic texture. Uterine musculature has three layers. The middle myometrial layer forms the major uterine part and is homogeneous in echotexture. The innermost compact, thin and hypoechoic myometrium forms the sub-endometrial halo and is described as a junctional zone. The outermost myometrial layer is thinner and may have dot-like calcifications of arcuate arteries on sonography when the uterus is senile. The uterus helps to give orientation to understand pelvic anatomy with any sonography technique.
Endometrium: Endometrium has a dynamic echo pattern corresponding to the patient’s menstrual cycle and hormonal status. The postmenstrual endometrium is thin and linear. Pre ovulatory endometrium has a trilaminar pattern and is 4 to 8 mm thick. Postovulatory endometrium is homogeneous and more echogenic with a 7 to 14 mm thickness.
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Cervix: Cervix is a cylindrical structure in continuity with the uterus with a homogeneous echo pattern. Internal os serves as a landmark delineating cervix and the endocervical canal from the uterine body and endometrial cavity, respectively.
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Fallopian tube: Fallopian tube is a tubular structure usually not visualized normally in sonography except in case of any pathology enhancing its dimensions.
Ovary: Ovary is an oval structure with hyperechoic stroma and variable anechoic cystic follicles fluctuating in line with the menstrual cycle and varying in size between 5 to 25 mm in diameter. The ovaries are positioned laterally to the uterus and medial to internal iliac vessels.[3]
Vagina: Vagina is a muscular collapsed tubular structure visualized caudally to the cervix appreciated in transabdominal sonography.
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Ureters: Ureters are difficult to visualize and are seen in the transverse section near the uterine cervix laterally.
Urinary bladder: Urinary bladder is the anterior-most and an essential landmark in pelvic sonography. In transabdominal scanning, a distended bladder allows better visualization of pelvic structure, as discussed earlier. However, in transvaginal sonography, the empty bladder allows better visualization of the uterus.
Bowel: Bowels are visualized as tubular structures with variable echo patterns and visible peristalsis and are often confused with cystic structures.
Cul-de-sac: Cul-de-sac is a well-defined invaginated fold of the peritoneum posterior to the uterus, normally having minimal free fluid collection following ovulation. Fluid collection in abnormal quantities with internal moving echoes and solid or cystic lesions in cul-de-sacs are of diagnostic significance.
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