Uterine Abnormalities Continued

Uterine Abnormalities Leiomyoma (Fibroids) Lipomatous Uterine tumors Leiomyosarcoma Adenomyosis Arteriovenous Malformations

Leiomyoma or Fibroids Most common neoplasm of uterus Estrogen dependant Composed of smooth muscle and fibrous connective tissue

Fibroids- symptoms Frequently asymptomatic Symptoms Pain Uterine bleeding

Fibroid Classification Intramural most common Confined to the myometrium Submucosal Projecting into uterine cavity (distorting or displacing endo) Produce symptoms frequently (less common) Associated with infertility Subserosal Projecting from peritoneal surface

Fibroids Sonographic Features Figure 15-10 Variable appearance Hypoechoic or heterogeneous mass Distortion of external uterine contour Attenuation of sound beam or shadowing w/o discrete mass Calcification Degeneration or necrosis

Fibroids

Lipomatous Uterine Tumors or Lipoleimyomas Uncommon Benign Consist of Mature lipocytes Smooth muscle Or fibrous tissue

Sonographically Highly echogenic, attenuating mass within the myometrium Absence of Color Flow within Usually asymptomatic Make sure within uterus (confuse with ovarian dermoid)

Leiomyosarcoma Rare Malignant (1.3% of uterine cancers) may arise from a leiomyoma Asymptomatic or uterine bleeding Same symptoms and appearance “Fibroid”

Sonographically Fig 15-12 Rumack Similar to a rapidly growing or degenerating Fibroid Rarely diagnosed preoperatively Exception May see local invasion (bladder or rectum) Distant metastases Clue: Rapid growth & post menopausal growth

Adenomyosis Common condition Endometrial glands and stroma within myometrium Associated with adjacent smooth muscle hyperplasia Two Forms Diffuse Nodular Can have fibroids present as well Makes severity of adenomyosis difficult to diagnose

Adenomyosis More common Diffuse Nodular More common Widely scattered adenomyosis foci within the myometrium Composed of adenomyomas (circumscribed nodules)

Clinical presentation Nonspecific Uterine enlargement Pelvic pain Dysmenorrhea Menorrhagia Seen more in women who have had children

Adenomyosis Not well seen using transabdominal ultrasound Transvaginal much better

Sonographic Features of adenomyosis fig.15-13 Rumack Diffuse ut enlargement Diffusely heterogeneous myometrium Asymmetrical thickening of myometrium Inhomogeneous hypoechoic areas Myometrial cysts Poor delineation of endo-myometrial border Focal tenderness with transvaginal transducer Subendometrial echogenic linear striations Subendometrial echogenic nodules

LOCALIZED aDENOmyosis Can be confused with fibroid Inhomogeneous, circumscribed areas within myometrium

Localized Adenomyomas Lieomyomas Localized Adenomyomas Usually well defined borders Peripheral vascularity Ill defined borders Internal vascularity

MRI and ultrasound both good at diagnosing adenomyosis

Arteriovenous malformations AVM’S Vascular plexus of arteries and veins with no capillary network Rare lesions Most cases acquired Pelvic trauma Surgery Gestational trophoblastic neoplasia

AVM’s usually diagnosed Postabortion and postpartum periods Symptoms Severe vaginal bleeding D&C Could worsen bleeding leading to hemorrhage

Sonographic appearance of avm’s (Fig 15-14) Nonspecific 2D ultrasound Multiple tortuous anechoic structures Subtle myometrial heterogeneity Myometrial or endometrial mass Color Doppler Better +++color flow shown, colored mosaic pattern Spectral Doppler High velocity, low resistance arterial flow, high velocity venous flow (more like an artery)

Differential Diagnosis of avm’s RPOC GTN (gestational trophoblastic neoplasia) Subinvolution of placental bed ***negative hCG help to distinguishing

Treatment of avm’s Wait to see if resolve (maybe not AVM) If severe bleeding immediate treatment emboization

Abnormalities of Cervix Nabothian cysts Cervical polyps Leiomyomas Cervical carcinoma

Nabothian cysts Vary in size mm’s – 4cm Single or multiple Benign Simple or have internal echoes ?infection or hemorrhage Multiple cysts can result enlargement of cervix

Cervical polyps Leiomyoma's 8% cx Cause vaginal bleeding Can be seen U/S usually diagnosed clinically Leiomyoma's 8% cx Pedunculated May prolapse into vagina

Cervical carcinoma Adenoma Malignum Usually Diagnosed clinically U/S may show solid retrovesical mass (look like fibroid) MRI best for staging Adenoma Malignum Rare Associated Peutz-Jeghers syndrome (inherited) U/S appears as multiple cystic areas seen within a solid cx mass (nabothian cysts not associated with a mass)

Pitfall after hysterectomy Cervical remnant mistaken for Mass Can measure 4.4mm AP AND 4.3 mm Length

terminology Salpinges- fallopian tubes Cornua- “Horns” or lateral angle Collis- “neck” Cervix Colpos- Vagina Metra- Endometrial Cavity Hemata- Blood Hydro- Water Pyo- pus

Short answers Obstruction of the genital tract 1. Congenital causes? 2. Acquired causes? 3. Define Hydrometrocolpos, pyometracolpos,hematometracolpos Hydrocolpos, pyocolpos, hematocolpos Hematometra, pypmetra, hydrometra 4. What are the sonographic appearances of genital tract obstruction? Are there differences before the age of menstruation and after?

Abnormalities of vagina Imperforate hymen Most common congenital abn. Female genital tract Gartner’s duct cysts Remnants of caudal end of mesonephric duct Anterolateral or anterior wall of vagina Asymptomatic Usually small Associated with renal and ureteral abnormalities

Solid masses very rare Pitfalls Neurofibroma u/s not used for diagnosis (may be used for staging) Pitfalls Vaginal cuff and cervical cuff after hysterectomy Mistaken for mass Vaginal cuff upper limit Transvag- 2.2mm (AP) Transabd- 2.4mm (AP)

Rectouterine recess or pcds Fluid within is a normal finding in asymptomatic women Found throughout phases of cycle Possible Sources of fluid Blood or fluid from (follicular rupture, retrograde menses)

Pcds fluid collections Pathological Seen with general ascites, blood (ruptured ectopic or hemorrhagic cyst), pus (infection) U/S Used to differentiate type of fluid Anechoic Serous fluid Fluid containing echoes Blood, pus, mucin (clotted blood can look very echogenic)

PcDS Pelvic abscesses hematomas