Salvatore LaRusso, M.Ed.

, RDMS, RT(R)

▪ Understanding the anatomy and physiology

is crucial to understanding pathology

▪ Two approaches to evaluation

– Transabdominal
Anatomy and Physiology – Endovaginal

▪ TA ▪ Approach varies based on

– Full bladder – Age
– Good overview – Sexually active
– 3.5 to 6.0 mHz

▪ TA
▪ EV – Bladder helps visualization
– Empty
– 7.5 to 12 mHz
▪ EV
– Focused view – Iliac vessels
– Uterus
– Primary landmarks

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

Pelvic LandMarks Bony Pelvis

▪ External Landmarks ▪ Four Bones

– Vulva – 2 innominate
▪ Mons pubis – Sacrum
▪ Labia majora – Coccyx
▪ Labia minora
▪ Clitorus ▪ Innominate
▪ Ureteral opening – Anterior
▪ Vestibule of vagina – Lateral margins
– Vagina separate
▪ Sacum and Coccyx
▪ Forms the canal from vestibule to cervix
– posterior

▪ Anatomically ▪ True pelvis

– 2 parts – Posterior wall
– True pelvis and False pelvis ▪ Sacrum and coccyx
– Posterolateral wall
▪ Piriformis
– Divided by imaginary line ▪ Coccygeus
▪ Superior sarcum – Anterolateral wall
▪ Anterior symphysis ▪ Hip bones
▪ Obturator internus
▪ Ishium
▪ Pubis

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

Muscles

▪ True pelvis ▪ Landmarks

– Inferior – Differentiate from adnexal structures
▪ Levator ani
▪ Coccygeus
– Pelvic diaphram ▪ Vary in shape
▪ Hypoechoic with hyperechoic striations

False Pelvis muscles True pelvis muscles

▪ Psoa Major ▪ Piriformis

– Lumbar vertebra ▪ Obturator internus
– Join iliacus
▪ Pelvic sidewall ▪ Muscles of the pelvic floor
▪ Form iliopsoas
– Anterior to hip ▪ Piriformis
– Attach lesser trochanter – Flat
– Triangular
– Anterior sacrum
– Pass through sciatic notch
– Insert superior greater trochanter

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

▪ Obturater Internus ▪ Levator Ani

– Three muscles
▪ Pubo coccygeus
– Triangle ▪ Iliococcygeus
▪ Puborectalis
– Antero lateral
▪ Surround obturator foramen – Pubococcygeus
▪ Insert greater trochanter ▪ Anterior
▪ medial

Bladder and Ureters

▪ Iliococcygeus ▪ Bladder
– Anterolateral pelvic wall – Anterior
– To coccyx – Post to pubis

▪ Puborectalis – Function
– Lower symphysis ▪ Collect and store urine
– Surround rectum
– Forms a sling – Empty
▪ Entirely in the true pelvis

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

Ureters Vagina

▪ Descend inferiorly ▪ Muscular tube

– Run anterior to psoas
– Behind peritoneum
▪ Collapsed
– Along lateral cervix ▪ External genitalia to cervix
– Upper portion of vagina
– Enter the trigone of the bladder ▪ Posterior to bladder, urethra
▪ Anterior to rectum and anus
– Forms a 90 degree angle with cervix
– Approx. 9 cm long
▪ Longest along posterior wall

Vagina Uterus

▪ Extends upward
▪ Lower half within perineum ▪ Hollow pear shaped
▪ Upper half above pelvic floor
▪ Divided into
– Fundus
▪ Four fornicies – Body
▪ Arterial supply – Cervix
– Vaginal and uterine arteries
– Drains into iliac vein

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

Uterus

▪ Covered with perineum ▪ Normal Anatomy

– Except anterior below os – Derived from Mullerian ducts
– Elongate and fuse about 12th week
▪ Supported by – Pear shaped
– Levator ani – Largest pelvic organ
– Cardinal ligaments ▪ 6 to 8 cm long
– Sacral ligaments ▪ 3 to 5 AP and lat
– Round and anteverted
▪ Varies with age and parity

Cervix

▪ Fundus ▪ Lower portion

– Widest
– Superior
▪ Divided into
– Exocervix
▪ Lateral borders – Endocervix
– Cornua
▪ Exocervix
▪ Body – Squamous epithelium
– Between fundus and cervix – Continuous with vagina
– Largest portion
▪ Endocervix
– Columnar cells
– Excrete mucous

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

Cervix Uterus

▪ Internal Os ▪ Wall
– Opening to the uterine cavity – Consists of
▪ Perimetrium
▪ Serosal layer
▪ External Os ▪ Muscular
– Opening to the vagina ▪ Middle layer
▪ Thickest
▪ Smooth muscle

▪ Mucous
▪ Glandular
▪ endometrium

Endometrium

▪ Two layers ▪ Functional

– Zona Functionalis – Superficial layer of glands
▪ Superficial – Sheds during menses

– Zona Basalis
▪ Deep basal layer ▪ Basal
– Blind ends of endometrial glands
– Regenerates new endometrium

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

Ligaments Broad

▪ Supported by ▪ Lateral aspect to pelvic sidewall

– Broad
– Round
▪ Mesovarium
– Uterosacral – Posterior fold
– Cardinal – Encloses ovary

▪ Mesosalpinx
– Upper fold
– Encloses ovary

Positions

▪ Round ▪ Variable
– Fundus to anterior pelvic side walls

▪ Average position
▪ Cardinal – Anteverted
– Extend across pelvic floor laterally ▪ “verted” Flex at cervix
– Support cervix ▪ Cervical canal forms 90 degree or smaller angle with cervix
– Anteflexed
▪ “flex” at fundus
▪ Canal and fundus curved upon cervix

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

▪ Retroverted
– Tipped backward
– Cervical canal less than 90 degrees from vagina

▪ Retroflexed
– Curve backwards upon cervix

▪ Dextroversion
– Deviates to right

▪ Levoversion
– Deviates to left

Fallopian tubes Tubes

▪ Coiled ▪ Four anatomic portions

▪ Muscular – Infundibulum
▪ Lateral
▪ Open into peritoneal cavity ▪ Widest
▪ Umbrella
▪ 10 -12 cm long ▪ fimbria
– Ampulla
▪ 1 – 4 mm diameter ▪ Middle
▪
▪ Lie superior to ▪
Longest
most coiled
▪ utero –ovarian ligaments ▪ Fertilization occurs

▪ Tubo – ovarian blood vessels

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

Ovaries

▪ Almond shaped
– Isthmus
▪ Medial ▪ 3 cm menarcheal
– Interstitial
▪ Passes through uterine wall ▪ Attached at posterior aspect of broad
ligament by mesovarium
▪ Lie in ovarian fossa
▪ Medial to Iliac vessels
▪ Dual blood supply
– Ovarian artery
▪ Off aorta
– Uterine artery

Ovarian anatomy

▪ Venous drainage ▪ Outer layer

– Ovarian vein – Cortex
▪ Left into renal vein – Surrounds medulla
▪ Right into Inferior Vena Cava – Consists of follicles
▪ Positions
– Anterior to iliac vessels ▪ Produce
– Medial to iliac vessels – Ovum
– Highly variable – Estrogen
▪ Especially after pregnancy
▪ Secreted by follicles
– Progesterone
▪ Secreted by Corpus luteum

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

Ovary Vasculature

▪ Supported by ▪ Common Iliacs

– Ovarian ligaments from cornua – Anterior and medial to psoas
– Suspensory ligaments
▪ laterally ▪ Internal Iliacs
– Extend into pelvis
– Posterior wall
– Multiple branches
– Perfuse pelvic organs
▪ Uterus
▪ Vagina
▪ Rectum
▪ bladder

▪ Uterine artery
– Arises from internal iliac
– Tortuous
– Spirals along side of uterus
– Within the broad ligament
– Courses laterally at cornua and anastomoses with ovarian
– Many branches to feed serosa and myometrium
– Form arcuate
▪ Can be seen as vessels within myometriun sonographically

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

Physiology

▪ Radial arteries ▪ Reproductive

– supply blood to endometrium – 11 – 13 years
– Extend through myometrium to base – end around 50
– Branch into spiral arteries
– Supplies zona basalis
▪ Cycle
– 28 days
– Begins at 1st day of menses

▪ Defined
– Premenarch
– Menarche
– Menopause

Follicular Development

▪ Ovum released once per month

▪ Regulated ▪ Occurs mid cycle
– Hypothalmus
– About day 14
– Production of
▪ Estrogen ▪ Immature = oocyte
▪ Progesterone
– From ovaries ▪ Each ovary about 200,000

▪ Ovulation regulated by the hypothalamus

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

▪ Puberty ▪ FSH
– Cyclical release of – Causes follicles to develop
▪ Gonado tropin releasing hormones – Follicular phase
▪ First day of bleeding to day 14
▪ Stimulate the pituitary gland ▪ Grow and increase estrogen
▪ One reaches maturity
– Secretes varying levels of:
– Graffian follicle (about 2cm)
– Gonadotropins
▪ FSH (follicle stimulating hormone) ▪ LH
▪ LH (luteinizing hormone) – Increases rapidly 24 to 36 hours before ovulation
– Peaks 10 to 12 hours FSH surges trigger ovulation

▪ Luteal Phase
– After ovulation
– 14 days

–Corpus luteum
▪ Starts secreting progesterone
▪ 9 to 11 days after
▪ degeneration

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

Endometrial

Endometrial

▪ Three stages ▪ Estrogen stimulates growth

– Menstrual Phase
▪ 3-5 days
– Begins with declining progesterone ▪ Proliferative phase
– Decreased blood flow – lasts until luteinization of graffian follicle
▪ Progesterone
– Sloughs off zona fucntionalis – Spiral arteries enlarge
– Follicular phase of cycle – Endometrial cells enlarge
– Ovulate
– No conception
– Follicles produce estrogen

▪ Secretory phase
– Luteal phase

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

▪ Proliferative
– 4 – 8mm
– Hypoechoic three line sign
▪ Just before ovulation
– 6 – 10mm
– Isoechoic
▪ Secretory
– 7 – 14mm
– Echogenic

▪ HRT
– <5mm

Abnormal Cycles

▪ Menorrhagia ▪ Amenorrhea
– Abnormally heavy or long – Primary
▪ Oligomenorrhea ▪ Delayed beyond 18 y

– Abnormally short or light – Secondary

▪ Cessation after menses
▪ Polymenorrhagia
– Less than 21 days
▪ Dysmenorrhagia
– Painful
▪ Amenorrhea
– Absence

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

Pelvic Recesses

▪ Vesico-uterine pouch ▪ Recto-uterine

– Anterior cul de sac – Posterior cul de sac
▪ Anterior to fundus between uterus and bladder – Posterior to uterus and cervix and anterior to rectum

Congenital Anomalies

▪ Retro pubic ▪ Mullerian Ducts

– Space of Retzius – Uterus derived from fusion of the caudal part of the duct
– Between bladder and symphysis
▪ Uterus Didelphys
– Complete failure of fusion
– Complete duplication
– rare

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.

 Salvatore LaRusso, M.Ed., RDMS, RT(R)

▪ Bicornuate ▪ Unicornuate
– Cervix fuses – Development of only one mullerian duct
– Fundus does not – And or varying degrees of contralateral side

▪ Septus
– Fusion occurs ▪ Aplasia
– Median septum fails to reabsorb – Very rare
▪ Total or partial

▪ Frequently associated with GU anomalies

▪ Approx 1/3 will have renal agenesis or
ectopia

©2018. Gulfcoast Ultrasound Institute. All Rights Reserved.