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 THIRD EDITION

Shaaban
Rogers | Olpin
Rezvani | El Sayed | Menias
 THIRD EDITION

ii
Akram M. Shaaban, MBBCh
Professor
Department of Radiology and Imaging Sciences
University of Utah
Salt Lake City, Utah

Douglas Rogers, MD
Assistant Professor
Department of Radiology and Imaging Sciences
University of Utah
Salt Lake City, Utah

Jeffrey Dee Olpin, MD

Professor of Radiology, Abdominal Imaging Division
Department of Radiology and Imaging Sciences
University of Utah
Salt Lake City, Utah

Maryam Rezvani, MD
Associate Professor of Radiology
Department of Radiology
University of Utah School of Medicine
Salt Lake City, Utah

Rania Farouk El Sayed, MD, PhD

Assistant Professor of Radiology
Head of Cairo University MRI Pelvic Floor Center of
Excellency and Research
Lab Unit
Department of Radiology
Cairo University Hospitals
Cairo, Egypt

Christine O. Menias, MD
Professor of Radiology
Mayo Clinic School of Medicine
Scottsdale, Arizona
Adjunct Professor of Radiology
Washington University School of Medicine
St. Louis, Missouri

iii
 Elsevier
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Ste 1800
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DIAGNOSTIC IMAGING: GYNECOLOGY, THIRD EDITION ISBN: 978-0-323-79692-7

Inkling: 978-0-323-79693-4
Copyright © 2022 by Elsevier. All rights reserved.

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Notices

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Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv
 Dedications
To my parents, who taught me the value of perseverance and hard work.
To my wife, Inji, my son, Karim, and my daughters, May and Jena, the jewels
of my life, thanks for your understanding and tremendous support.
To all my residents and fellows, whose challenging questions made
me a better radiologist.

AMS

To the people who make academic radiology worthwhile, including

my mentors, who believe in the merit of my work and continue to teach me,
and the residents with passion, who make teaching fulfilling.

DR

v
vi
Contributing Author
Refky Nicola, MS, DO
Associate Professor of Radiology
SUNY Upstate Medical University Hospital
Syracuse, New York

Additional Contributing Authors

Oguz Akin, MD
Nyree Griffin, MD, FRCR
Winnie Hahn, MD
Olga Hatsiopoulou, MD, FRCR
Marcia C. Javitt, MD, FACR
Shephard S. Kosut, MD
Deborah Levine, MD, FACR
Patricia Noël, MD, FRCPC
Caroline Reinhold, MD, MSc
Evis Sala, MD, PhD
Marc S. Tubay, MD
Paula J. Woodward, MD

vii
viii
 Preface
We are delighted to present Diagnostic Imaging: Gynecology, third edition, the most
comprehensive point-of-care imaging resource for gynecologic disorders. The goal of this
book is to take the wide range of wonderfully complex topics related to gynecologic imaging
and simplify them into a useful and easy-to-understand reference for caretakers at any level
of experience, including trainees, general radiologists, gynecology imaging specialists, and
gynecologists. This has been achieved using concise, bulleted text and thoughtful grouping
of pertinent disease entities by organ, including uterus, cervix, vagina/vulva, ovary, fallopian
tubes, multiorgan disorders, and pelvic floor.

Our passionate team of radiologists has thoroughly updated the text and references from
the successful second edition, reflecting recent advances in technology and understanding of
pathologic conditions as well as changes to TNM/WHO classifications, FIGO staging, and AJCC
prognostic groups. Extensive efforts have been made to revamp the already fabulous image
galleries with new, high-quality, instructive cases for every entity. More than 2,300 annotated
images (and an additional 840 supplemental digital images) exhibit multimodality correlation
between ultrasound, sonohysterography, hysterosalpingography, MR, PET/CT, and gross
pathology.

The superb radiologic images we present were only possible because of the fine work of our
remarkable sonographers and CT/MR technologists. We are also fortunate to collaborate with
Laura Wissler, Lane Bennion, and Richard Coombs, who are the most talented and experienced
medical illustrators. They possess a rare combination of profound anatomic knowledge and an
ability to generate elegant representations of complex structures. Their contributions allow
those who contemplate their illustrations to quickly attain a deeper level of comprehension.

This production was especially efficient because of the cohesive efforts of our team, including
the image editors (Lisa Steadman and Jeffrey Marmorstone), text editors (Arthur Gelsinger,
Rebecca Bluth, Nina Themann, Terry Ferrell, and Megg Morin), graphic designer (Tom Olson),
production editors (Emily Fassett and John Pecorelli), lead editor (Kathryn Watkins), and senior
manager (Karen Concannon).

Our team is very proud of this work, and we are sure that this new volume will be a rich and often-
used addition to your practice’s collection of resources.

Akram M. Shaaban, MBBCh

Professor
Department of Radiology and Imaging Sciences
University of Utah
Salt Lake City, Utah

Douglas Rogers, MD
Assistant Professor
Department of Radiology and Imaging Sciences
University of Utah
Salt Lake City, Utah

ix
x
Acknowledgments
LEAD EDITOR
Kathryn Watkins, BA

LEAD ILLUSTRATOR
Laura C. Wissler, MA

TEXT EDITORS
Arthur G. Gelsinger, MA
Rebecca L. Bluth, BA
Nina Themann, BA
Terry W. Ferrell, MS
Megg Morin, BA

IMAGE EDITORS
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

ILLUSTRATIONS
Richard Coombs, MS
Lane R. Bennion, MS

ART DIRECTION AND DESIGN

Tom M. Olson, BA

PRODUCTION EDITORS
Emily C. Fassett, BA
John Pecorelli, BS

xi
xii
Sections
SECTION 1:
Techniques

SECTION 2:
Uterus

SECTION 3:
Cervix

SECTION 4:
Vagina and Vulva

SECTION 5:
Ovary

SECTION 6:
Fallopian Tubes

SECTION 7:
Multiorgan Disorders

SECTION 8:
Pelvic Floor

xiii
 TABLE OF CONTENTS

98 Endometritis
SECTION 1: TECHNIQUES Douglas Rogers, MD and Christine O. Menias, MD
PELVIS 102 Pyomyoma
Douglas Rogers, MD
4 Ultrasound Technique and Anatomy
Douglas Rogers, MD and Marc S. Tubay, MD BENIGN NEOPLASMS
10 Sonohysterography
Akram M. Shaaban, MBBCh and Douglas Rogers, MD MYOMETRIUM
14 Hysterosalpingography
Douglas Rogers, MD and Marc S. Tubay, MD 106 Uterine Leiomyoma
20 CT Technique and Anatomy Jeffrey Dee Olpin, MD and Maryam Rezvani, MD
Marc S. Tubay, MD and Refky Nicola, MS, DO 112 Leiomyomas: Degeneration, Variants, and
24 MR Technique and Anatomy Complications
Marc S. Tubay, MD and Refky Nicola, MS, DO Jeffrey Dee Olpin, MD and Marc S. Tubay, MD
28 PET/CT Technique and Imaging Issues 120 Benign Metastasizing Leiomyoma
Marc S. Tubay, MD and Refky Nicola, MS, DO Akram M. Shaaban, MBBCh and Winnie Hahn, MD
122 Diffuse Leiomyomatosis
SECTION 2: UTERUS Douglas Rogers, MD and Christine O. Menias, MD
124 Intravenous Leiomyomatosis
INTRODUCTION AND OVERVIEW Douglas Rogers, MD
128 Disseminated Peritoneal Leiomyomatosis
36 Anatomy of the Uterus
Douglas Rogers, MD and Christine O. Menias, MD
Paula J. Woodward, MD and Akram M. Shaaban, MBBCh
132 Lipomatous Uterine Tumors
AGE-RELATED CHANGES Douglas Rogers, MD and Christine O. Menias, MD
56 Endometrial Atrophy ENDOMETRIUM
Jeffrey Dee Olpin, MD and Maryam Rezvani, MD 136 Endometrial Polyps
CONGENITAL Maryam Rezvani, MD and Jeffrey Dee Olpin, MD
142 Endometrial Hyperplasia
58 Introduction to Müllerian Duct Anomalies Maryam Rezvani, MD and Jeffrey Dee Olpin, MD
Akram M. Shaaban, MBBCh
62 Müllerian Agenesis MALIGNANT NEOPLASMS
Akram M. Shaaban, MBBCh
68 Unicornuate Uterus ENDOMETRIUM
Akram M. Shaaban, MBBCh
146 Endometrial Carcinoma
74 Uterus Didelphys
Maryam Rezvani, MD
Akram M. Shaaban, MBBCh, Nyree Griffin, MD, FRCR, and
162 Uterine Adenosarcoma
Caroline Reinhold, MD, MSc Douglas Rogers, MD
80 Bicornuate Uterus 166 Endometrial Stromal Sarcoma
Akram M. Shaaban, MBBCh Douglas Rogers, MD
84 Septate Uterus 170 Uterine Carcinosarcoma
Akram M. Shaaban, MBBCh Douglas Rogers, MD
90 Arcuate Uterus 174 Gestational Trophoblastic Neoplasms
Akram M. Shaaban, MBBCh Akram M. Shaaban, MBBCh
92 DES Exposure
Akram M. Shaaban, MBBCh MYOMETRIUM
INFLAMMATION/INFECTION 184 Uterine Leiomyosarcoma
Douglas Rogers, MD
94 Asherman Syndrome, Endometrial Synechiae
Douglas Rogers, MD and Christine O. Menias, MD

xiv
 TABLE OF CONTENTS
VASCULAR
188 Uterine Arteriovenous Malformation
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD
194 Uterine Artery Embolization Imaging
Jeffrey Dee Olpin, MD and Maryam Rezvani, MD
SECTION 4: VAGINA AND VULVA
INTRODUCTION AND OVERVIEW
288 Vaginal and Vulvar Anatomy
Marc S. Tubay, MD

TREATMENT-RELATED CONDITIONS CONGENITAL

200 Tamoxifen-Induced Changes 296 Lower Vaginal Atresia
Jeffrey Dee Olpin, MD and Maryam Rezvani, MD Douglas Rogers, MD
206 Contraceptive Device Evaluation 298 Imperforate Hymen
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Douglas Rogers, MD
214 Post Cesarean Section Appearance 300 Vaginal Septa
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Douglas Rogers, MD

ADENOMYOSIS BENIGN NEOPLASMS

218 Adenomyosis 302 Vaginal Leiomyoma
Jeffrey Dee Olpin, MD and Maryam Rezvani, MD Akram M. Shaaban, MBBCh, Olga Hatsiopoulou, MD,
224 Adenomyoma FRCR, and Evis Sala, MD, PhD
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD 308 Vulvar Slow-Flow Vascular Malformation
228 Cystic Adenomyosis Douglas Rogers, MD
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD 312 Vaginal Paraganglioma
Douglas Rogers, MD
SECTION 3: CERVIX
MALIGNANT NEOPLASMS
INTRODUCTION AND OVERVIEW 316 Vaginal Carcinoma
234 Anatomy of the Cervix Akram M. Shaaban, MBBCh
Marc S. Tubay, MD 328 Vaginal Leiomyosarcoma
Akram M. Shaaban, MBBCh, Olga Hatsiopoulou, MD,
BENIGN NEOPLASMS FRCR, and Evis Sala, MD, PhD
240 Endocervical Polyp 330 Embryonal Rhabdomyosarcoma
Douglas Rogers, MD Douglas Rogers, MD
244 Cervical Leiomyoma 334 Vaginal Yolk Sac Tumor
Douglas Rogers, MD Akram M. Shaaban, MBBCh, Olga Hatsiopoulou, MD,
FRCR, and Evis Sala, MD, PhD
MALIGNANT NEOPLASMS 338 Bartholin Gland Carcinoma
248 Corpus Uteri Sarcoma Douglas Rogers, MD
342 Vulvar Carcinoma
Maryam Rezvani, MD
Maryam Rezvani, MD
260 Adenoma Malignum
354 Vulvar Leiomyosarcoma
Douglas Rogers, MD
264 Cervical Sarcoma Douglas Rogers, MD
Douglas Rogers, MD 356 Vulvar and Vaginal Melanoma
268 Cervical Melanoma Akram M. Shaaban, MBBCh
Akram M. Shaaban, MBBCh 362 Aggressive Angiomyxoma
Douglas Rogers, MD
TREATMENT-RELATED CONDITIONS 366 Merkel Cell Tumor
Douglas Rogers, MD
272 Posttrachelectomy Appearances
Jeffrey Dee Olpin, MD and Maryam Rezvani, MD LOWER GENITAL CYSTS
MISCELLANEOUS 368 Gartner Duct Cysts
Marc S. Tubay, MD and Akram M. Shaaban, MBBCh
274 Cervical Glandular Hyperplasia 372 Bartholin Cysts
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Marc S. Tubay, MD and Akram M. Shaaban, MBBCh
278 Nabothian Cysts 378 Urethral Diverticulum
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Marc S. Tubay, MD and Akram M. Shaaban, MBBCh
282 Cervical Stenosis 382 Skene Gland Cyst
Douglas Rogers, MD Marc S. Tubay, MD and Akram M. Shaaban, MBBCh

xv
 TABLE OF CONTENTS
532 Yolk Sac Tumor
MISCELLANEOUS Akram M. Shaaban, MBBCh, Evis Sala, MD, PhD, and
386 Vaginal Foreign Bodies Christine O. Menias, MD
Douglas Rogers, MD 536 Choriocarcinoma
394 Vaginal Fistula Akram M. Shaaban, MBBCh and Evis Sala, MD, PhD
Marc S. Tubay, MD and Akram M. Shaaban, MBBCh 540 Carcinoid
Akram M. Shaaban, MBBCh, Evis Sala, MD, PhD, and
SECTION 5: OVARY Christine O. Menias, MD
546 Ovarian Mixed Germ Cell Tumor and Embryonal
INTRODUCTION AND OVERVIEW
Carcinoma
402 Anatomy of the Ovaries Akram M. Shaaban, MBBCh
Paula J. Woodward, MD and Akram M. Shaaban, MBBCh 550 Struma Ovarii
Akram M. Shaaban, MBBCh
PHYSIOLOGIC AND AGE-RELATED CHANGES
410 Follicular Cyst
SEX CORD-STROMAL
Akram M. Shaaban, MBBCh 556 Granulosa Cell Tumor
414 Corpus Luteum Akram M. Shaaban, MBBCh
Marc S. Tubay, MD and Akram M. Shaaban, MBBCh 562 Fibroma, Thecoma, and Fibrothecoma
420 Hemorrhagic Ovarian Cyst Akram M. Shaaban, MBBCh
Paula J. Woodward, MD 568 Sertoli and Sertoli-Leydig Cell Tumors
426 Ovarian Inclusion Cyst Akram M. Shaaban, MBBCh and Christine O. Menias, MD
Marc S. Tubay, MD 574 Sclerosing Stromal Tumor
Akram M. Shaaban, MBBCh and Evis Sala, MD, PhD
NEOPLASMS
METASTASES AND HEMATOLOGIC
432 Overview of Ovary, Fallopian Tube, and Primary
Peritoneal Carcinoma 578 Ovarian Metastases
Akram M. Shaaban, MBBCh Akram M. Shaaban, MBBCh
584 Ovarian Lymphoma
EPITHELIAL Akram M. Shaaban, MBBCh
452 Serous Cystadenoma
Akram M. Shaaban, MBBCh, Marcia C. Javitt, MD, FACR,
NONNEOPLASTIC OVARIAN LESIONS
and Shephard S. Kosut, MD 590 Endometrioma
458 Mucinous Cystadenoma Maryam Rezvani, MD and Jeffrey Dee Olpin, MD
Akram M. Shaaban, MBBCh, Winnie Hahn, MD, and 600 Endometriosis
Deborah Levine, MD, FACR Maryam Rezvani, MD and Jeffrey Dee Olpin, MD
464 Adenofibroma and Cystadenofibroma 610 Ovarian Hyperstimulation Syndrome
Akram M. Shaaban, MBBCh Marc S. Tubay, MD and Refky Nicola, MS, DO
470 Serous Carcinoma 614 Theca Lutein Cysts
Akram M. Shaaban, MBBCh and Oguz Akin, MD Akram M. Shaaban, MBBCh, Patricia Noël, MD, FRCPC,
476 Mucinous Carcinoma and Caroline Reinhold, MD, MSc
Akram M. Shaaban, MBBCh 618 Polycystic Ovary Syndrome
482 Seromucinous Tumors Maryam Rezvani, MD and Refky Nicola, MS, DO
Akram M. Shaaban, MBBCh and Christine O. Menias, MD 624 Peritoneal Inclusion Cysts
488 Endometrioid Carcinoma Marc S. Tubay, MD and Refky Nicola, MS, DO
Akram M. Shaaban, MBBCh
494 Clear Cell Carcinoma VASCULAR
Akram M. Shaaban, MBBCh and Oguz Akin, MD 632 Ovarian Vein Thrombosis
500 Carcinosarcoma (Mixed Müllerian Tumor) Marc S. Tubay, MD and Akram M. Shaaban, MBBCh
Akram M. Shaaban, MBBCh 638 Pelvic Congestion Syndrome
504 Brenner Tumors Douglas Rogers, MD
Akram M. Shaaban, MBBCh 642 Acute Adnexal Torsion
Akram M. Shaaban, MBBCh
GERM CELL 648 Massive Ovarian Edema and Fibromatosis
510 Mature Cystic Teratoma (Dermoid Cyst) Akram M. Shaaban, MBBCh
Akram M. Shaaban, MBBCh
520 Immature Teratoma
Akram M. Shaaban, MBBCh
526 Dysgerminoma
Akram M. Shaaban, MBBCh and Oguz Akin, MD

xvi
 TABLE OF CONTENTS
756 MR of Stress Urinary Incontinence
SECTION 6: FALLOPIAN TUBES Rania Farouk El Sayed, MD, PhD
CONGENITAL MIDDLE COMPARTMENT
656 Paratubal Cyst 762 Anatomy of Uterocervical and Vaginal Support
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Rania Farouk El Sayed, MD, PhD
774 MR of Pelvic Organ Prolapse
INFLAMMATION/INFECTION
Rania Farouk El Sayed, MD, PhD
660 Hydrosalpinx
Maryam Rezvani, MD POSTERIOR COMPARTMENT
664 Salpingitis Isthmica Nodosa 782 Anatomy of Anal Canal and Anal Sphincter Complex
Paula J. Woodward, MD Rania Farouk El Sayed, MD, PhD
796 MR of Fecal Incontinence
BENIGN NEOPLASMS Rania Farouk El Sayed, MD, PhD
668 Tubal Leiomyoma 804 MR of Obstructed Defecation
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Rania Farouk El Sayed, MD, PhD

MISCELLANEOUS MULTICOMPARTMENTAL
672 Hematosalpinx 816 Multicompartmental Imaging
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Rania Farouk El Sayed, MD, PhD

SECTION 7: MULTIORGAN DISORDERS

PELVIC INFLAMMATION
676 Pelvic Inflammatory Disease
Akram M. Shaaban, MBBCh and Maryam Rezvani, MD
686 Genital Tuberculosis
Maryam Rezvani, MD
690 Actinomycosis
Maryam Rezvani, MD

MALIGNANT NEOPLASMS
694 Genital Lymphoma
Douglas Rogers, MD and Christine O. Menias, MD
700 Genital Metastases
Douglas Rogers, MD

ABNORMAL SEXUAL DEVELOPMENT

704 Complete Androgen Insensitivity Syndrome
Douglas Rogers, MD and Christine O. Menias, MD
706 Disorders of Sexual Development
Douglas Rogers, MD
710 Gonadal Dysgenesis
Douglas Rogers, MD and Christine O. Menias, MD

SECTION 8: PELVIC FLOOR

OVERVIEW
716 Anatomy of the Pelvic Floor
Rania Farouk El Sayed, MD, PhD
734 MR of the Pelvic Floor
Rania Farouk El Sayed, MD, PhD

PELVIC FLOOR DYSFUNCTION

ANTERIOR COMPARTMENT
738 Anatomy of Bladder and Urethral Support
Rania Farouk El Sayed, MD, PhD

xvii
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 THIRD EDITION

Shaaban
Rogers | Olpin
Rezvani | El Sayed | Menias
 SECTION 1

Techniques

Pelvis
Ultrasound Technique and Anatomy 4
Sonohysterography 10
Hysterosalpingography 14
CT Technique and Anatomy 20
MR Technique and Anatomy 24
PET/CT Technique and Imaging Issues 28
 Ultrasound Technique and Anatomy

KEY FACTS
Techniques

TERMINOLOGY ○ TVUS provides high-resolution images of uterus, cervix,

• Ultrasound is imaging modality that transmits high-
frequency sound waves into tissues and generates images
from reflected waves
• Pelvic sonography can be performed using number of
techniques (B-mode, M-mode, Doppler, 3D, 4D)
PREPROCEDURE
• Transabdominal ultrasound (TAUS) is usually performed
with full bladder
• Transvaginal pelvic ultrasound (TVUS) is performed with
empty bladder
PROCEDURE
• Most pelvic sonographic examinations utilize both
transabdominal and transvaginal techniques
○ TAUS allows for larger field of view with lower resolution
compared to TVUS
and adnexa with constrained field of view compared to
TAUS
• Pelvic ultrasound requires dedicated evaluation and
reporting of
○ Uterus: Size, contour, positioning, myometrial
echotexture/masses
○ Endometrium: Thickness, appearance,
presence/positioning of IUD
○ Adnexa: Ovarian size, presence of cystic/solid mass,
ovarian vascular flow, tubal abnormalities
○ Cul-de-sac: Presence of fluid or mass, uterine sliding
• Probes must be thoroughly cleansed according to
manufacturer and local institution guidelines

Longitudinal Transvaginal Ultrasound Transverse Transvaginal Ultrasound

(Left) Longitudinal
transvaginal ultrasound
demonstrates normal
appearance of the uterus,
including endometrium ſt,
myometrium st, cervix ﬇,
and cul-de-sac ﬈. The
endovaginal probe is
positioned within the anterior
vaginal fornix ﬉. By
convention, the left side of the
image is anterior, and the
right is posterior. (Right)
Transverse transvaginal
ultrasound demonstrates
normal appearance of the
uterus, including endometrium
ſt and myometrium st.

Longitudinal Transabdominal Ultrasound Ovary Transvaginal Ultrasound

(Left) Longitudinal
transabdominal ultrasound
shows the uterus ſt, vagina
st, and urinary bladder ﬇.
Transabdominal ultrasound
offers a larger field of view
but less resolution compared
to transvaginal ultrasound.
(Right) Transvaginal
ultrasound shows a normal
ovary ſt with few small
follicles st and adjacent
bowel ﬇.

4
 Ultrasound Technique and Anatomy

Techniques
○ Allows generation of 3D sonographic movies
TERMINOLOGY
Abbreviations PREPROCEDURE
• Transabdominal ultrasound (TAUS) Indications
• Transvaginal ultrasound (TVUS)
• Common indications for pelvic sonography include
• Saline-infused sonohysterogram (SIS) abnormal uterine bleeding, pelvic pain, contraception
Definitions evaluation, pelvic mass, and pregnancy
• Ultrasound is imaging modality that transmits high- Contraindications
frequency sound waves into tissues and generates images • TVUS should be avoided in patients with intact hymen or
from reflected waves prior to having had intercourse
○ TAUS provides large field of view ○ Transperineal/translabial sonography can be performed
– Lower frequencies are used to allow for greater depth when needed
of view ○ Patients may decline study due to being uncomfortable
□ Results in lower resolution images with procedure
– Useful for large masses
– Characterizes lesions that are out of range of vaginal Getting Started
probe • Things to check
– Mid- to late gestations are generally better evaluated ○ Full bladder for TAUS
with TAUS – Full bladder acts as acoustic window for
○ TVUS provides higher resolution images of uterus, cervix, uterus/adnexa
and adnexa – Displaces small bowel from field of view
– Higher frequencies allow for higher resolution images ○ Empty bladder for TVUS
but with constrained field of view – Describe use of transvaginal probe to patient
– Key modality for uterine, cervical, and adnexal – Some sonographers prefer to have patient insert
pathology endovaginal (EV) probe
– Useful to evaluate early pregnancy – Exam should be relatively painless
• B-mode (grayscale, 2D mode) ultrasound – If bladder is too distended, it may push uterus and
○ Reflected sound wave data is reconstructed to produce ovaries out of field of view
2D grayscale image of plane of tissue ○ In women of childbearing age, serum β-hCG levels may
○ Most commonly used mode be necessary
• M-mode ultrasound ○ Have chaperone
○ Column of tissue perpendicular to probe is interrogated • Equipment list
to evaluate for motion/velocity ○ Ultrasound machine
○ Demonstrates embryonic/fetal cardiac activity and heart ○ Appropriate transducers
rate – 3.5-7 MHz for transabdominal scans (curved or sector)
• Doppler ultrasound uses frequency shifts of reflected – 5-12 MHz for EV scans (dedicated EV probe)
sound waves to detect flowing blood – 7-15 MHz for superficial translabial/transperineal
○ Color Doppler: Flow is assigned color based on direction scans (linear probe)
of flow and overlaid on B-mode images ○ Safety issues
○ Power Doppler: Measures intensity of Doppler shift – Thermal and mechanical indices are used as proxies
overlaid on grayscale image; more sensitive than color for bioeffects of ultrasound
Doppler for detection of slow flow □ These should be minimized, particularly when
○ Pulsed-wave (spectral) Doppler: Velocity tracing is imaging embryos
generated, allowing for waveform analysis ○ Commercial probe cover or condom to cover EV probe
– Duplex Doppler: Pulsed-wave Doppler displayed with for TVUS
grayscale anatomic images – If latex allergy, do not use latex probe covers
– Triplex Doppler: Pulsed-wave Doppler displayed with ○ Dedicated EV probe cleaning system and solution
grayscale images overlaid with color Doppler
○ Superb microvascular imaging: New technique with high PROCEDURE
sensitivity for blood flow within small diameter and slow-
flow vessels Patient Position/Location
• 3D ultrasound • Best procedure approach
○ Acquires volume of ultrasound data that can be ○ TAUS: Supine position
manipulated at ultrasound machine or at dedicated ○ TVUS: Lithotomy position
workstation to produce multiplanar images or 3D – Feet in stirrups if bed is equipped
reconstructions – Pillow under buttocks can be utilized if needed,
○ Can produce images of similar orientation and quality to especially if bed does not have stirrups
MR – Similar positioning for translabial or transperineal
• 4D ultrasound: 3D ultrasound data is acquired continuously examinations
over time

5
 Ultrasound Technique and Anatomy
Techniques
• In many centers, routine pelvic ultrasound examinations
include both TAUS and TVUS
○ Patient undergoes TAUS with full bladder
○ After voiding, patient undergoes TVUS
• Transperineal/translabial evaluations
○ Use sector or linear transducer covered with condom or
commercially available probe cover
○ Useful for visualization of labial/vulvar, distal urethral,
and vaginal abnormalities
○ Evaluation of primary amenorrhea in patients with intact
hymen
○ Evaluation of cervix and lower uterus in late-term
pregnant patients when TVUS is contraindicated
• Transrectal ultrasound is rarely used to evaluate anal
sphincter in setting of pelvic floor dysfunction
Equipment Preparation
• Probes must be meticulously cleansed according to
manufacturer's and local institutional guidelines
• Must have gel both inside and outside of EV probe cover to
prevent artifact from interposed air
• Postmenopausal women with atrophic vaginitis may not
tolerate TVUS
○ Use small probe and extra lubricating gel
○ Allow patient to insert EV probe
• Warmed ultrasound gel is better tolerated by patients
Procedure Steps
• TAUS and TVUS examinations should include
○ Uterine imaging
– Uterine flexion/version
– Uterine measurements
□ Measure uterus length on longitudinal/sagittal
midline image from fundus to external cervical os
□ AP measurement is perpendicular to length
measurement
□ Uterine width is measured on
transverse/orthogonal image of uterus
– Myometrium evaluation
□ Longitudinal and transverse images/cines through
entire uterus
□ Myometrial masses should be
documented/measured
□ Evaluate for adenomyosis
□ In cases of suspected müllerian duct anomalies, 3D
ultrasound can depict external uterine contour to
help characterize anomaly
– Endometrium evaluation
□ Measure endometrial thickness perpendicular to
long axis of uterus on midline sagittal image
□ If there is fluid within endometrial cavity, it should
be excluded by measuring each endometrial layer
separately
□ Evaluate focal endometrial thickening or masses
(color Doppler may be helpful to evaluate for
vascular stalk)
□ If IUD is present, dedicated imaging in longitudinal
and transverse planes should be obtained
□ Acquisition of 3D volume with coronal reformatted
image is useful to evaluate IUD position
– Cervical images
6
□ Transverse and longitudinal images through cervix
– In setting of prior hysterectomy, vaginal cuff should
be evaluated
○ Adnexal imaging
– Ovaries should be measured in 3 orthogonal planes
– Obtain color and pulsed wave Doppler images of
ovaries, documenting arterial and venous waveforms
– Measure any abnormal adnexal lesion in 3 planes and
evaluate for Doppler flow within lesion
– Determine if lesion arises from ovary or is separate
from ovary
□ Gently press with EV probe; adnexal lesion arising
from ovary will move with ovary, whereas
paraovarian lesion will move independent from
ovary with pressure
– Bladder filling &/or emptying can help determine
etiology and location of pelvic cyst in cases where
large cyst is mistaken for urinary bladder
– If ovaries are difficult to find, obtain coronal view of
uterine fundus and angle laterally to region of broad
ligament
□ Alternatively, locate iliac vasculature in longitudinal
plane and slowly image toward midline
– Scan between uterus and ovaries to assess for other
adnexal masses
□ May identify paraovarian cysts/masses, ectopic
pregnancy, or dilated fallopian tube
□ 3D ultrasound can help confirm tubular nature of
suspected hydrosalpinx
○ Posterior compartment/cul-de-sac imaging
– Evaluate for free fluid
– Torus uterinus is common location for adhesions from
deep pelvic endometriosis; may perform "sliding sign"
between posterior uterus and anterior rectum
○ In patients with focal tenderness/pain, this region should
be thoroughly evaluated
• In cases of pelvic masses, TAUS may also include evaluation
of kidneys for hydronephrosis/hydroureter
• For TVUS evaluation, EV probe should be slowly and gently
inserted
○ As probe is being inserted, assess for vaginal wall masses
○ Scan generally performed through anterior vaginal wall
with probe positioned in anterior fornix
○ If uterus is retroverted or retroflexed, scan may be
performed through posterior vaginal wall
○ Some patients have pain when cervix is manipulated, so
avoid excess probe pressure
○ In patients with bowel gas obscuring visualization of
ovary, gentle abdominal pressure can displace bowel
loops and allow for better visualization
• Transperineal evaluation
○ Sagittal midline views of vagina, cervix, and lower uterus
are obtained
○ Parasagittal views as indicated
○ If performed during pregnancy
– Relationship between internal cervical os and
placental margin should be evaluated
– Measure cervix and assess for funneling
Findings and Reporting
• Uterine size
 Ultrasound Technique and Anatomy

Techniques
• Uterine contour 15. Lev-Toaff AS: Sonohysterography: evaluation of endometrial and
myometrial abnormalities. Semin Roentgenol. 31(4):288-98, 1996
• Uterine positioning
16. Freimanis MG et al: Transvaginal ultrasonography. Radiol Clin North Am.
○ Version: Positioning of uterus with relation to vagina 30(5):955-76, 1992
○ Flexion: Positioning of uterine fundus in relation to cervix 17. Lyons EA et al: Transvaginal sonography of normal pelvic anatomy. Radiol
Clin North Am. 30(4):663-75, 1992
• Description of myometrial echotexture
18. Forrest TS et al: Cyclic endometrial changes: US assessment with histologic
• Description of myometrial masses, including location, size, correlation. Radiology. 167(1):233-7, 1988
and position within uterine wall 19. Fleischer AC et al: Sonographic depiction of normal and abnormal
• Appearance of cervix endometrium with histopathologic correlation. J Ultrasound Med. 5(8):445-
52, 1986
• Description of endometrium
○ Endometrial thickness
○ Presence of endometrial masses, fluid, cystic change,
IUD, focal thickening, or areas that are ill defined or not
well imaged
• Ovarian size
• Ovarian arterial and venous waveforms detected on duplex
Doppler evaluation
• Description of adnexal masses
○ Ovarian cysts
○ Complex or solid adnexal masses
○ Tubal abnormalities
• Free fluid
• Evaluation for deep pelvic endometriosis

POST PROCEDURE
Expected Outcome
• No harmful effects from pelvic sonography
• TAUS and TVUS are generally well tolerated
Things to Do
• Cleanse probes according to manufacturer and institution
guidelines

SELECTED REFERENCES
1. Shwayder JM: Normal pelvic anatomy. Obstet Gynecol Clin North Am.
46(4):563-80, 2019
2. Cunningham RK et al: Adenomyosis: a sonographic diagnosis. Radiographics.
38(5):1576-89, 2018
3. Van den Bosch T et al: Ultrasound diagnosis of endometriosis and
adenomyosis: state of the art. Best Pract Res Clin Obstet Gynaecol. 51:16-24,
2018
4. Armstrong L et al: Three-dimensional volumetric sonography in gynecology:
an overview of clinical applications. Radiol Clin North Am. 51(6):1035-47,
2013
5. Sakhel K et al: Begin with the basics: role of 3-dimensional sonography as a
first-line imaging technique in the cost-effective evaluation of gynecologic
pelvic disease. J Ultrasound Med. 32(3):381-8, 2013
6. Andreotti RF et al: Sonographic evaluation of acute pelvic pain. J Ultrasound
Med. 31(11):1713-8, 2012
7. Langer JE et al: Imaging of the female pelvis through the life cycle.
Radiographics. 32(6):1575-97, 2012
8. American Institute of Ultrasound in Medicine: AIUM practice guideline for
the performance of pelvic ultrasound examinations. J Ultrasound Med.
29(1):166-72, 2010
9. Dietz HP: Pelvic floor ultrasound: a review. Am J Obstet Gynecol. 202(4):321-
34, 2010
10. Forsberg F et al: Comparing image processing techniques for improved 3-
dimensional ultrasound imaging. J Ultrasound Med. 29(4):615-9, 2010
11. Valsky DV et al: Three-dimensional transperineal ultrasonography of the
pelvic floor: improving visualization for new clinical applications and better
functional assessment. J Ultrasound Med. 26(10):1373-87, 2007
12. Timor-Tritsch IE et al: Three-dimensional inversion rendering: a new
sonographic technique and its use in gynecology. J Ultrasound Med.
24(5):681-8, 2005
13. Bega G et al: Three-dimensional ultrasonography in gynecology: technical
aspects and clinical applications. J Ultrasound Med. 22(11):1249-69, 2003
14. Langer RD et al: Transvaginal ultrasonography compared with endometrial
biopsy for the detection of endometrial disease. Postmenopausal
Estrogen/Progestin Interventions Trial. N Engl J Med. 337(25):1792-8, 1997

7
 Ultrasound Technique and Anatomy
Techniques

Ultrasound Probes M-Mode

(Left) This image
demonstrates the different
types of probes used in
gynecologic ultrasound: 2D
endovaginal probe ﬉, 3D
endovaginal probe ſt, 3D
curved transabdominal probe
﬈, 2D curved transabdominal
probe st, 2D sector probe ﬊,
2D linear probe ﬇. (Right) M-
mode ultrasound in a 1st-
trimester pregnancy shows
embryonic cardiac activity ﬉,
confirming viability of the
gestation ſt. M-mode is
typically used in obstetric
ultrasound imaging.

Color Doppler: Arterial Flow Color Doppler: Venous Flow

(Left) Transverse transvaginal
color Doppler evaluation
shows color flow within the
right ovary st with
corresponding low-resistance
spectral arterial waveform ſt.
Note the normal dominant
follicle ﬇. (Right) Transverse
transvaginal color Doppler
evaluation shows color flow
within the left ovarian stroma
st with nonpulsatile spectral
venous waveform ſt.

Power Doppler 3D Ultrasound

(Left) Longitudinal
transabdominal ultrasound
shows a complex, cystic
adnexal mass st. Power
Doppler evaluation
demonstrates blood flow
within a heterogeneous mural
nodule ſt. (Right)
Reconstructed coronal 3D
image of the uterus
demonstrates a thick,
muscular septum ſt and a
maintained outer uterine
contour st, consistent with a
septate uterus.

8
 Ultrasound Technique and Anatomy

Techniques
IUD Position Endometrial Polyp
(Left) Reconstructed 3D
coronal view of the uterus
shows an IUD ſt positioned
within the endometrial cavity.
Uterine embedment is better
evaluated on 3D
reconstructions than 2D
studies. (Right) Reconstructed
3D coronal view of the uterus
shows a polyp protruding into
the endometrial cavity
outlined by fluid ſt.

Endometrial Cancer Hydrosalpinx

(Left) Longitudinal
transabdominal pelvic
ultrasound in a patient with
postmenopausal bleeding
shows the uterus st with a
thickened endometrium ſt.
This was biopsy-proven
endometrial cancer. (Right)
Longitudinal transvaginal
ultrasound demonstrates a
cystic adnexal lesion with
tubular configuration ſt,
representing hydrosalpinx.

Transperineal Ultrasound C-Section Scar Endometriosis

(Left) Longitudinal
transperineal ultrasound
demonstrates the normal
urethra st.
Transperineal/translabial
ultrasound can be used to
evaluate the vagina or
urethra, or when transvaginal
ultrasound is contraindicated.
(Right) Transverse ultrasound
of the superficial pelvic wall in
a patient with a palpable
lesion and cyclical pain shows
an irregular hypoechoic mass
st proven to be C-section scar
endometriosis on biopsy.
Superficial lesions are best
evaluated with high-frequency
linear probes.

9
 Sonohysterography

KEY FACTS
Techniques

TERMINOLOGY ○ Premenopausal women

• Saline-infused sonohysterogram (SIS) – Early proliferative phase (days 4-10) of menstrual
○ Catheter is inserted into uterine cavity, and sterile saline cycle, when endometrium is at its thinnest
is injected into endometrial canal to better characterize ○ Postmenopausal women
endometrial abnormalities – Generally any time if not on hormone replacement
therapy
PREPROCEDURE
PROCEDURE
• Indications
○ Determine cause of abnormal vaginal bleeding • Catheter must be flushed with sterile saline before
○ Infertility and repeated pregnancy loss insertion to remove air bubbles
○ Congenital abnormality of uterine cavity • Normal uterine cavity should expand symmetrically upon
saline instillation
• Contraindications
• Endometrium should normally be uniform in thickness,
○ Pregnancy
homogeneous in echotexture
○ Active pelvic infection
○ Excessive vaginal bleeding
○ Patients with intrauterine device in place
• Negative pregnancy test must be obtained prior to
procedure
• Timing

Typical Equipment Saline-Infused Sonohysterogram

(Left) Included in a typical tray
are a tenaculum ſt (to
sterilize the cervix), speculum
st, cleanser ﬈, lubricating
gel ﬇, a 5- to 7-French
catheter ﬊ with a 3-mL
syringe for the balloon, and a
20-mL syringe containing
sterile saline. (Right) Sagittal
transvaginal ultrasound during
saline-infused
sonohysterogram shows
distention of the uterine cavity
with saline. The endometrium
is of uniform thickness and
homogeneous echotexture ſt.

Transvaginal Ultrasound: Abnormal

Uterine Bleeding Sonohysterogram: Endometrial Polyp
(Left) Longitudinal
transvaginal ultrasound in a
patient with abnormal uterine
bleeding shows focal
endometrial thickening near
the fundus ſt. (Right)
Subsequent saline-infused
sonohysterogram more clearly
demonstrates an endometrial
polyp ſt. The remainder of
the endometrium is uniformly
thin st.

10
 Sonohysterography

Techniques
• Postmenopausal women
TERMINOLOGY
○ Not undergoing hormone replacement therapy
Abbreviations – Any time
• Saline-infused sonohysterogram (SIS) ○ Undergoing sequential hormone therapy (estrogen
followed by progesterone)
Synonyms
– At end of progesterone phase
• Sonohysterography
Definitions PROCEDURE
• Catheter is inserted into uterine cavity, and sterile saline is Patient Position/Location
injected into endometrial canal to better characterize • Lithotomy position with appropriate draping and
endometrial abnormalities chaperone

PREPROCEDURE Equipment Preparation

Indications
• Determine cause of abnormal vaginal bleeding
○ In premenopausal women
– Distinguish anovulatory bleeding from
anatomic lesion
○ In postmenopausal women
– Distinguish between atrophy and anatomic lesion that
may require biopsy
• Infertility and repeated pregnancy loss
• Congenital abnormality of uterine cavity
• Preoperative or postoperative evaluation of uterine
leiomyomas, polyps, or cysts
• Suspected uterine synechiae
• Further evaluation of suspected endometrial abnormalities
detected by transvaginal ultrasound
○ Increased diagnostic accuracy, compared to ultrasound,
for diagnosis of endometrial abnormalities, such as
endometrial polyps, in women with postmenopausal
bleeding
Contraindications
• Pregnancy
• Active pelvic infection
• Excessive vaginal bleeding
• Patients with intrauterine device in place
Getting Started
• Things to check
○ Negative pregnancy test must be documented
• Medications
○ Anesthesia or analgesia is not usually required
○ NSAID may be offered 30-60 minutes prior to
examination to help reduce pain of cramping
○ Prophylactic antibiotics are not routinely advised
– May be administered to patients who are at increased
risk for infection
Timing
• Premenopausal women
○ Early proliferative phase (days 4-10) of menstrual cycle,
when endometrium is at its thinnest
– Saline can more easily distend uterine cavity and
better accentuate endometrial pathology
– Physiologic changes during secretory phase may
simulate pathologic conditions
□ Irregularities in contour of endometrium may be
misinterpreted as small polyps or focal areas of
endometrial hyperplasia
• Equipment needed
○ Sterile speculum with open side
○ Cervical sounds in event that catheter does not pass
easily through cervix
○ 20-mL syringe
○ Tenaculum
– Used to clean cervix
○ Clamps
○ 5- to 7-French hysterosonography catheter with 3-mL
syringe for balloon
– Several different catheters available for SIS
Procedure Steps
• Speculum is inserted into vagina, and cervical os is located
and cleaned with povidone iodine solution
• Catheter must be flushed with sterile saline before
insertion to remove air bubbles
○ Air introduced into endometrial canal may obscure
abnormalities during scanning
• Catheter is inserted into cervical canal
• Catheter balloon tip is then inflated using 1-2 mL of saline
• Speculum is removed
• Standard transvaginal ultrasound probe is then inserted
alongside catheter
• Warm sterile saline is instilled into endometrial cavity via 20-
mL syringe attached to catheter while transducer is moved
from side to side (cornua to cornua) in long-axis position
○ Amount of fluid instilled will vary depending on
distention of uterus and patient tolerance
○ Saline should be slowly injected to avoid vasovagal
reaction
• Saline is then instilled while balloon is deflated and slowly
retracted in order to image portions of lower uterine
segment previously obscured by balloon
• Ideally, all portions of endometrium should be imaged to
exclude any abnormalities
○ Addition of 3D images may improve differentiation of
myometrial and endometrial lesions and better
demonstrate congenital abnormalities
Findings and Reporting
• Normal uterine cavity should expand symmetrically upon
saline instillation
○ Nondistensible uterine cavity is indicative of
adhesions/Asherman syndrome
• Endometrial thickness
○ Premenopausal
11
 Sonohysterography
Techniques

– Endometrium should be uniform in thickness, 2. Tahmasebi F et al: Transvaginal saline contrast sonohystography to
investigate postmenopausal bleeding: a systematic review. Cureus.
homogeneous in echotexture 12(8):e10094, 2020
○ Postmenopausal 3. Christianson MS et al: Comparison of sonohysterography to
– Normal atrophic endometrium should measure < 2.5 hysterosalpingogram for tubal patency assessment in a multicenter fertility
treatment trial among women with polycystic ovary syndrome. J Assist
mm in single-layer thickness Reprod Genet. 35(12):2173-80, 2018
– Atrophic endometrium should be smooth and 4. Fadl SA et al: Diagnosing polyps on transvaginal sonography: is
uniform in echotexture sonohysterography always necessary? Ultrasound Q. 34(4):272-7, 2018
• SIS can determine whether endometrium is diffusely or 5. Sabry ASA et al: Diagnostic value of three-dimensional saline infusion
sonohysterography in the evaluation of the uterus and uterine cavity lesions.
focally thickened Pol J Radiol. 83:e482-90, 2018
○ Diffuse thickening → blind endometrial biopsy 6. Maheux-Lacroix S et al: Imaging for polyps and leiomyomas in women with
abnormal uterine bleeding: a systematic review. Obstet Gynecol.
○ Focal areas of thickening → hysteroscopic biopsy 128(6):1425-36, 2016
• SIS is acceptable imaging modality for assessment of tubal 7. Yang T et al: Sonohysterography: principles, technique and role in diagnosis
patency of endometrial pathology. World J Radiol. 5(3):81-7, 2013
8. Allison SJ et al: saline-infused sonohysterography: tips for achieving greater
success. Radiographics. 31(7):1991-2004, 2011
OUTCOMES
Problems
• Failure to complete procedure
○ Patient discomfort
○ Cervical stenosis and scarring, leading to difficult
catheterization and backflow of saline
• Variable uterine position can complicate catheter insertion
• Cervical stenosis
○ Cervical dilator may be used
○ Guidewire can be passed through cervical os with
subsequent passage of non-balloon-tipped catheter over
guidewire into cervical os
• Difficult distention of endocervical canal
• Air introduced into endometrial canal, leading to echogenic
artifact that can obscure abnormalities
○ Flushing catheter with saline before procedure is
essential
• Backflow of saline around balloon and through cervix →
underdistention of uterine cavity
○ Gently retract inflated catheter balloon to occlude
internal cervical os
• Balloon hyperinflation may obscure underlying pathology
○ Move or partially deflate balloon
Complications
• Pelvic pain
○ 3.8% of patients
• Vagal symptoms
○ 3.5% of patients
• Nausea
○ 1% of patients
• Postprocedure fever
○ 0.8% of patients
• Rarely, endometritis
Diagnostic Performance
• Sensitivity and specificity of SIS in diagnosis of endometrial
polyps is 87% and 86%, respectively
○ Compared to 62% and 73% for transvaginal
ultrasonography
○ Compared to 92% and 85% for hysteroscopy

SELECTED REFERENCES
1. Kaveh M et al: Comparison of diagnostic accuracy of saline infusion
sonohysterography, transvaginal sonography, and hysteroscopy in
evaluating the endometrial polyps in women with abnormal uterine
bleeding: a systematic review and meta-analysis. Wideochir Inne Tech
Maloinwazyjne. 15(3):403-15, 2020
12
 Sonohysterography

Techniques
Transvaginal Ultrasound: Inflated Catheter Transvaginal Ultrasound: Catheter
Balloon Balloon, Deflated and Retracted
(Left) Longitudinal
transvaginal ultrasound
obtained during saline-infused
sonohysterogram shows the
inflated catheter balloon ſt
and normal, uniformly thin
endometrium st. (Right)
Longitudinal transvaginal
ultrasound taken later in the
procedure shows the catheter
balloon deflated and retracted
slightly ſt in order to image
the lower uterine segment
endometrium st.

Transvaginal Ultrasound: Leiomyoma Leiomyoma: Endometrial and Myometrial

Involving Endometrium Components
(Left) Transverse transvaginal
ultrasound demonstrates a
heterogeneous leiomyoma
involving the endometrium ſt.
(Right) 3D image obtained
during saline-infused
sonohysterogram in the same
patient delineates the
endometrial and myometrial
components of the leiomyoma
ſt.

Transvaginal Ultrasound: Uterine Transvaginal Ultrasound: Uterine

Synechiae Synechiae
(Left) Longitudinal
transvaginal ultrasound
obtained during saline-infused
sonohysterogram
demonstrates uterine
synechiae ſt. (Right)
Transverse transvaginal
ultrasound during saline-
infused sonohysterogram in
the same patient shows the
uterine synechiae ſt.

13
 Hysterosalpingography

KEY FACTS
Techniques

TERMINOLOGY ○ Endometrial and fallopian tube morphology is evaluated,

• Fluoroscopic evaluation of uterine cavity and fallopian and tubal patency is confirmed with free spillage of
tubes contrast into peritoneal cavity
• Look for
PRE-PROCEDURE ○ Tubal abnormalities
• Infertility is primary indication – Occlusion
○ Other indications include recurrent pregnancy loss, – Hydrosalpinx
müllerian duct anomalies, uterine/endometrial masses, – Salpingitis isthmica nodosa
tubal abnormalities ○ Müllerian duct abnormalities
• Absolute contraindications include pregnancy, active pelvic ○ Endometrial filling defects
inflammatory disease (PID), severe iodine allergy – Polyp
○ Active menstrual bleeding may affect interpretation – Leiomyoma
• Confirmation of nonpregnant status prior to procedure – Synechia
PROCEDURE ○ Adenomyosis
• Procedure involves cannulation of cervix with balloon- POST-PROCEDURE
tipped catheter and injection of contrast into endometrial • Significant complications are rare; minor complications
cavity under fluoroscopy include cramping and minimal bleeding
• Infection/PID is very uncommon

Normal Hysterosalpingogram Normal Hysterosalpingogram

(Left) Frontal fluoroscopic
image from a
hysterosalpingogram (HSG)
shows the normal appearance
of the uterus st and fallopian
tubes ſt with free spillage of
contrast into the peritoneal
cavity ﬉. (Right) Frontal
image shows a normal HSG
with a smooth endometrial
contour. The fallopian tube
segments are well visualized
(interstitial ſt, isthmic st,
ampullary ﬇), and there is
free spillage of contrast into
the peritoneal cavity ﬈.

Hysterosalpingogram Equipment Hysterosalpingogram Catheter

(Left) Included in a typical HSG
tray are ring
forceps/tenaculum ſt used to
sterilize the cervix, speculum
st, iodine-based cleanser ﬈,
and lubricating gel ﬇. A
uterine sound ﬊ is often
included but rarely used.
(Right) Image demonstrates a
typical balloon-tip HSG
catheter. The inflatable
balloon ſt is shown along
with the plastic catheter
stiffener ﬈, the contrast-
filled syringe ﬇, the syringe
﬊ to inflate the balloon, and
the balloon stopcock st.

14
 Hysterosalpingography

Techniques
○ Minimize by ensuring no bleeding/spotting on day of
TERMINOLOGY study
Abbreviations ○ Increased risk of contrast intravasation
• Hysterosalpingogram (HSG) – Venous or lymphatic intravasation is clinically
insignificant
Definitions
• Fluoroscopic evaluation of uterine cavity and fallopian Getting Started
tubes • Things to check
○ β-hCG
Advantages
○ Date of last menstrual cycle
• Best method to assess fallopian tube patency – Examination scheduled during days 7-12 of menstrual
• Relatively easy to perform cycle when endometrium is thin and smooth
• Medications are typically not required – Patient should call to schedule on 1st day of
Disadvantages menstrual bleeding if cycle is irregular
○ Abstinence from sexual intercourse from time menstrual
• Relatively invasive
bleeding ends until day of study to reduce potential for
• Ionizing radiation
early pregnancy
• May be uncomfortable
○ If there is suspected PID
– Erythrocyte sedimentation rate (ESR) to evaluate for
PREPROCEDURE active PID
Indications – Negative gonorrhea and chlamydia cultures are
• Infertility acceptable in patients with coexistent inflammatory
○ Evaluate tubal patency conditions (e.g., arthritis, sarcoidosis, collagen vascular
○ Integral part of routine work-up in most centers; typically disease)
performed in conjunction with US – Antibiotic prophylaxis should be considered in
• Other indications include patients with history of PID
○ Recurrent pregnancy loss ○ History of severe iodine allergy or latex allergy
– Evaluate structural causes of secondary infertility • Medications
○ Uterine abnormalities ○ Patient may take NSAID pain reliever 1 hour prior to
procedure (acetaminophen, ibuprofen)
– Müllerian duct anomalies
○ Glucagon or butylscopolamine can be used to prevent
– Polyps
tubal spasm
– Leiomyomas
– Not routinely required
– Adhesions/synechiae (Asherman syndrome)
– Contraindications to glucagon include
– Adenomyosis
pheochromocytoma and insulinoma
○ Tubal abnormalities
○ Anxiolytics may be helpful in some patients
– Tubal occlusion
○ Antibiotics are not routine but may be considered in
□ Identify level of tubal occlusion
select patients (history of PID, hydrosalpinx diagnosed
□ Most common cause is pelvic inflammatory disease on HSG) in consultation with referring OB/GYN
(PID)
• Equipment list
– Tubal disease
○ Private fluoroscopic suite with adequate lighting
□ Hydrosalpinx
○ Stirrups for fluoroscopy table
□ Peritubal adhesions
○ Sterile equipment
□ Salpingitis isthmica nodosa
– Vaginal speculum
□ Cornual/tubal polyps
– 5-French balloon-tipped HSG catheter
○ Tubal evaluation following intervention
□ Other catheter types are infrequently used
– Confirm occlusion by tubal occlusive devices
– Cervical dilator (if needed)
– Evaluate for patency following reversal of tubal
○ Water-soluble, nonionic contrast medium
ligation
– Dedicated HSG contrast agents are available
Contraindications – Conventional iodinated IV contrast agents may be
• Pregnancy used
○ Risk of pregnancy loss – Prepare at least 10 mL of contrast media; more is
○ Ionizing radiation rarely necessary
• Active PID ○ Oil-based agents are associated with higher rate of
○ Risk of worsening infection, sepsis complications (oil emboli, granuloma formation)
• Severe iodine allergy – Recent metaanalyses have shown that HSG with oil-
based contrast increases pregnancy rates in subfertile
○ Extremely rare with use of currently available low-
women
osmolar, nonionic contrast agents
• Active menstrual bleeding may cause difficulty in
interpretation

15
 Hysterosalpingography
Techniques
PROCEDURE
Patient Position/Location
• Best procedure approach
○ Cervical cannulation: Lithotomy position with feet in
stirrups
– Patient's buttocks positioned slightly over edge of
table
– If stirrups are not available, feet placed on fluoroscopy
table in frog-leg position with pelvis elevated off table
with towels/cushion
○ Contrast administration and imaging: Supine position
– Patient carefully moved to center of fluoroscopy table
after catheter placement and speculum removal
Equipment Preparation
• Procedure performed under sterile conditions with sterile
gloves
• Test-inflate catheter balloon and flush catheter with
contrast to eliminate air from system
Procedure Steps
• Careful and detailed procedural explanation and patient
reassurance and informed consent
• Insert sterile, lubricated speculum into vagina and obtain
clear view of cervical os
• Sterilize cervix using iodine solution
○ Can use noniodinated agent for patients with iodine
allergy
• Cannulate cervical os with 5-French HSG catheter
○ Use catheter stiffener to help guide catheter through
external os and into endometrial lumen
• Slowly inflate balloon to extent that patient can tolerate
○ Do not overinflate balloon with more air than in syringe
• Gently provide traction on catheter to ensure positioning
within endometrial lumen and seat against internal os
○ Cervix may slightly bulge with gentle traction
• Carefully withdraw speculum from vagina, making sure to
not dislodge catheter
• Obtain scout radiograph of pelvis with catheter in place
before contrast medium is instilled
• Under fluoroscopic imaging, slowly instill iodinated contrast
medium
○ Avoid air bubbles, as they can hinder interpretation
○ Typically < 10 mL of contrast is necessary
• Obtain spot radiographs after contrast instillation
○ Early frontal filling view of uterus: Evaluate for any filling
defects or contour abnormalities
○ Frontal view of fully distended uterus: Evaluate uterine
morphology
○ Bilateral shallow oblique frontal views: Evaluate fallopian
tubes
○ Delayed frontal view of uterus: Document free
intraperitoneal spillage of contrast material
• Additional spot radiographs are necessary to document any
abnormality
• Oblique views of fallopian tubes help to "elongate" tube
and displace superimposed structures
• If no free intraperitoneal spill of contrast is visualized,
continue gentle contrast medium injection
16
○ If occlusion is due to tubal spasm, continued injection will
opacify tube after spontaneous relaxation
○ Glucagon or butylscopolamine may be administered in
cases of suspected tubal spasm, though not regularly
performed
○ Stop injection if contrast intravasation is observed or if
patient is too uncomfortable
• "Pull-back" view may be obtained to evaluate lower uterine
segment obscured by inflated balloon
○ Balloon is deflated and catheter is partially withdrawn
into endocervical canal
○ Gently inject more contrast and reimage lower uterine
segment
Findings and Reporting
• Normal findings
○ Smooth uterine cavity contour, patent fallopian tubes,
and bilateral free peritoneal spillage of contrast medium
○ Other normal findings include myometrial folds, C-
section scar/defect, endocervical gland opacification
• Abnormal findings
○ Uterine abnormalities
– Congenital abnormalities/müllerian duct anomalies
– Luminal filling defects (endometrial polyps, synechiae,
fibroids)
– Adenomyosis
○ Tubal occlusion (postinflammatory or after occlusive
procedure)
○ Other tubal abnormalities: Hydrosalpinx, tubal
adhesions, loculated spillage (indicative of local
adhesions/peritoneal inclusion cyst)
• Venous/lymphatic intravasation can be seen with
increased/excessive contrast injection pressure
○ Progressive opacification of uterine arcuate, parametrial,
and pelvic venous vasculature
○ Seen in up to 6% of patients, though more common in
setting of tubal occlusion
○ No clinical significance in isolation
Alternative Procedures/Therapies
• Radiologic
○ Sonohysterography
– No ionizing radiation
– Real-time imaging
– Superior for evaluation of endometrium (abnormal
uterine bleeding, polyps) and ovaries
– Less accurate for tubal patency
□ Can infer tubal patency by pooling of saline in cul-
de-sac
– 3D US is useful to evaluate uterine morphology in
cases of suspected müllerian duct anomalies or
endometrial lesions
○ MR
– No ionizing radiation
– Assessment of entire pelvis
– Multiplanar imaging capability and superb tissue
contrast
– Best used for evaluation of uterine congenital
anomalies, myometrium, and ovaries
• Surgical
○ Hysteroscopy
 Hysterosalpingography
– Direct visualization of uterine cavity
– Limited evaluation of fallopian tubes
○ Laparoscopic evaluation with dye test
– Requires general anesthesia
– Uterine cannulation is performed under direct
visualization
– Methylene blue contrast is injected into uterine cavity,
and spillage into peritoneal cavity is visualized via
laparoscope
– Ovaries can be evaluated
– Traditional gold standard in evaluation of infertility,
though invasive and typically not necessary
• Other
○ Hormone profile
○ Chlamydia serology for PID
○ Evaluation for male partner infertility
POST PROCEDURE
Expected Outcome
• Minor pain and cramping
○ During positioning of catheter and inflation of balloon
○ Secondary to uterotubal distention or peritoneal spill
– Reduced by slow injection of contrast medium
○ Self-limited, usually resolves quickly
○ Treated with NSAIDs
• Minor bleeding, usually lasting < 24 hours
• Higher rates of fertility after HSG are reported, though this
relationship is controversial
Things to Do
• Instruct patients to expect passage of small amount of
contrast from vagina
○ May be tinged with blood
○ Patients should use pad and avoid tampon use
• Instruct patients to watch for signs of infection
○ Development of fever or foul-smelling vaginal discharge
2-4 days following HSG
OUTCOMES
Problems
• Difficulty identifying cervix
○ Remove speculum and perform limited bimanual
examination to locate cervix
• Failure to cannulate cervical os
○ Can be difficult in cases of cervical stenosis
○ May use cervical dilators
○ Can use tenaculum to provide cervical traction
• Inadequate uterine filling either due to pain or inadequate
seal of balloon against cervix
○ Inject contrast medium more slowly if pain occurs
○ Provide gentle traction on catheter during injection to
help seat balloon against internal os and reduce contrast
reflux
○ Consider different cannula if problems with seal persist
• Tubal spasm may lead to false-positive result
○ Repeat injection or administrate antispasmodic agent
• Presence of blood clots in endometrial cavity may mimic
polyps
○ Ensure no bleeding/spotting on day of examination
Techniques
• Balloon may obscure lower uterine segment abnormality
○ Slowly inject additional contrast and obtain "pull-back"
view of lower uterine segment with balloon deflated
Complications
• Most feared complication(s)
○ Early pregnancy loss or radiation
– Appropriate timing of procedure and negative
pregnancy test minimizes risk
○ Infection/PID is uncommon (1.4-3.4%)
– Higher rates of postprocedure infection in setting of
hydrosalpinx (11%)
• Other complications
○ Cramping pain
○ Vasovagal reaction
– Secondary to cervical manipulation or inflation of
balloon
○ Allergic reaction to iodinated contrast (more common
with contrast intravasation)
○ Uterine or tubal perforation is extremely rare with
conventional flexible HSG catheters
○ Complications with oil-based contrast
– Intravasation of contrast (2.7% compared with 2.0%
with use of water-based contrast)
– Oil embolism (in 18 of 19,339 studies)
□ 4 cases with serious consequences in subfertile
women were reported in literature
SELECTED REFERENCES
1. Roest I et al: Safety of oil-based contrast medium for hysterosalpingography:
a systematic review. Reprod Biomed Online. 42(6):1119-1129, 2021
2. Zafarani F et al: Hysterosalpingography in the assessment of proximal tubal
pathology: a review of congenital and acquired abnormalities. Br J Radiol.
94(1122):20201386, 2021
3. Merritt BA et al: Imaging of infertility, part 1: hysterosalpingograms to
magnetic resonance imaging. Radiol Clin North Am. 58(2):215-25, 2020
4. Merritt BA et al: Imaging of infertility, part 2: hysterosalpingograms to
magnetic resonance imaging. Radiol Clin North Am. 58(2):227-38, 2020
5. Maheux-Lacroix S et al: Hysterosalpingosonography for diagnosing tubal
occlusion in subfertile women: a systematic review protocol. Syst Rev. 2:50,
2013
6. Trad M et al: Müllerian duct anomalies and a case study of unicornuate
uterus. Radiol Technol. 84(6):571-6, 2013
7. Carrascosa PM et al: Virtual hysterosalpingography: a new multidetector CT
technique for evaluating the female reproductive system. Radiographics.
30(3):643-61, 2010
8. ACOG Committee on Practice Bulletins--Gynecology: ACOG practice bulletin
No. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol.
113(5):1180-9, 2009
9. Chalazonitis A et al: Hysterosalpingography: technique and applications. Curr
Probl Diagn Radiol. 38(5):199-205, 2009
10. Lindheim SR et al: Hysterosalpingography and sonohysterography: lessons in
technique. AJR Am J Roentgenol. 186(1):24-9, 2006
11. Perquin DA et al: Routine use of hysterosalpingography prior to laparoscopy
in the fertility workup: a multicentre randomized controlled trial. Hum
Reprod. 21(5):1227-31, 2006
12. Simpson WL Jr et al: Hysterosalpingography: a reemerging study.
Radiographics. 26(2):419-31, 2006
13. Spring DB et al: Enhanced fertility after diagnostic hysterosalpingography
may be a myth. AJR Am J Roentgenol. 183(6):1728, 2004
14. Unterweger M et al: Three-dimensional dynamic MR-hysterosalpingography;
a new, low invasive, radiation-free and less painful radiological approach to
female infertility. Hum Reprod. 17(12):3138-41, 2002
15. Ubeda B et al: Hysterosalpingography: spectrum of normal variants and
nonpathologic findings. AJR Am J Roentgenol. 177(1):131-5, 2001
17
 Hysterosalpingography
Techniques

Hydrosalpinx Salpingitis Isthmica Nodosa

(Left) Frontal image
demonstrates a dilated and
tortuous left fallopian tube
ſt, consistent with
hydrosalpinx. There was no
free spillage of contrast from
the left tube. The right
fallopian tube st is normal.
(Right) Frontal image shows
the classic appearance of
salpingitis isthmica nodosa
(SIN) with small diverticular
outpouchings ſt arising from
the isthmic segment of the
fallopian tube. SIN can be
associated with infertility.

Tubal Occlusion With Filling Defect Tubal Occlusion With Filling Defect
(Left) Oblique frontal image
from an HSG shows a normal
left tube ﬈ without
opacification of the right tube.
A subtle, rounded filling defect
st is noted at the right tubal
orifice, found to be a small,
occluding polyp. (Right)
Oblique frontal image shows a
large, rounded, fixed filling
defect ﬈ within the left
uterine cornua, representing
an endometrial polyp. There is
resulting occlusion of the left
tubal orifice. The right tube st
is normal.

Contrast Intravasation Uterine Synechia

(Left) Frontal image from an
HSG shows contrast
intravasation into the uterine
arcuate venous vasculature ſt
with subsequent opacification
of the parametrial and pelvic
veins st. (Right) Frontal image
shows irregularity of the
endometrial contour with a
linear filling defect ﬈,
consistent with a uterine
synechia.

18
 Hysterosalpingography
Tubal Occlusive Contraceptive Devices
Müllerian Duct Anomaly
Diethylstilbestrol Exposure
Techniques
Failed Tubal Occlusion
(Left) Frontal image shows
bilateral Essure tubal occlusive
devices st. This procedure
was performed to confirm
tubal occlusion after device
placement. Note the small
amount of contrast
intravasation ſt due to
forceful injection. (Right)
Frontal image demonstrates
bilateral contraceptive tubal
occlusive devices ſt. On the
right, contrast opacifies the
tube distal to the device ﬇
with free spillage into the
pelvis, consistent with failure
of occlusion. The left tube was
occluded.
Müllerian Duct Anomaly
(Left) Frontal image shows 2
uterine cavities st separated
by a thick, intervening septum
ſt. There was a single cervix.
This may represent a septate
or bicornuate uterus; MR or 3D
US is necessary to evaluate the
external uterine contour.
(Right) Frontal fluoroscopic
image shows a single, tubular
uterine horn st with an
associated normal fallopian
tube ſt, consistent with a
unicornuate uterus. MR may
be necessary to evaluate for a
contralateral,
noncommunicating,
rudimentary horn.
Endometrial Polyps
(Left) Frontal fluoroscopic
spot radiograph shows a T-
shaped appearance of the
endometrial cavity contour
ſt, related to maternal
diethylstilbestrol (DES)
exposure. (Right) Frontal
image shows 2 ovoid, fixed
filling defects ſt within the
endometrial lumen,
representing polyps. Note the
calcified intramural
leiomyoma st.
19
 CT Technique and Anatomy

KEY FACTS
Techniques

PREPROCEDURE ○ Limited application in early cancer and local staging

• Indications for CT imaging include PROCEDURE
○ Staging of known ovarian cancer • Imaging is typically performed with oral and IV contrast
○ Follow-up of treated gynecologic malignancy • While CT is not study of choice in evaluation of gynecologic
○ Assessing postoperative complications pathology, pelvic organs are routinely imaged and
○ Assessment of pelvic infectious processes described in imaging report
○ Procedural guidance ○ Uterus: May have variable enhancement patterns
• CT is not contraindicated in pregnancy but should be used ○ Cervix: Typically has targetoid appearance
judiciously ○ Fallopian tubes: Usually not well visualized when normal
• Advantages of CT imaging include ○ Ovaries: Easily seen in premenopausal patients but
○ Rapid acquisition atrophic and often difficult to visualize after menopause
○ Isotropic voxels allow for improved multiplanar
reconstruction
○ Intraluminal contrast allows for easy distinction of bowel
from pelvic organs/pathology
• Disadvantages of CT include
○ Use of ionizing radiation
○ Contrast agents have associated morbidity/mortality

Uterus Uterus
(Left) Axial CECT shows the
normal appearance of the
uterus ﬈. The central
endometrium appears
hypodense, and the outer
myometrium can have a
variable pattern of
enhancement. (Right) Sagittal
CECT shows the normal
appearance of the uterus ſt.
Most uteri are anteverted and
anteflexed, as in this case. The
central hypodense
endometrium is best measured
on sagittal images.

Uterus Uterus
(Left) Axial CECT in a patient
with ascites due to hepatic
cirrhosis shows the normal
appearance of the uterus ﬈.
The presence of ascites allows
visualization of soft tissue
structures that would be
otherwise obscured, such as
the broad ligament ﬈ and the
suspensory ligament of the
ovary ſt. (Right) Sagittal
CECT in the same patient
shows the normal appearance
of the uterus ſt. The uterus is
anteverted and anteflexed.
The uterine body ﬈ usually
appears more enhanced than
the uterine cervix ﬊.

20
 CT Technique and Anatomy
TERMINOLOGY
Abbreviations
• Computed tomography (CT)
• CT angiography (CTA)
PREPROCEDURE
Indications
• Surveillance of ovarian cancer
○ Staging of disease (peritoneal spread of disease, nodal
involvement, malignant ascites)
○ Preoperative planning or neoadjuvant chemotherapy
• Local staging of advanced pelvic malignancies (such as
uterine and cervical carcinoma)
○ MR is usually modality of choice
○ CT is helpful when MR is contraindicated
• Follow-up of treated gynecologic malignancy
○ Assess for tumor recurrence
• Assess for postoperative complications
○ Abscess, fistula, lymphocele
• Assessment of pelvic infectious processes
○ Tuboovarian abscess/pyosalpinx/hydrosalpinx
○ Pyometra/myometrial abscess in clinical setting of
endometritis
• Localization of IUD when not visualized on US
• CT-guided biopsy
○ Provides histologic diagnosis
○ Helps to differentiate tumor recurrence from
postsurgical/radiation fibrosis
• CT-guided drainage of pelvic collection
• CT is not typically used as 1st-line examination to
characterize gynecologic pathology
○ US and MR are typically utilized
Contraindications
• CT is not contraindicated in pregnancy but should be used
judiciously
○ US and MR should be considered first
○ Avoid IV contrast
• Allergy to iodinated contrast is relative contraindication
○ Requires premedication, typically with oral steroids and
diphenhydramine
○ Consider noncontrast examination or alternate modality
Getting Started
• Things to check
○ Check renal function in patients receiving iodinated
contrast if
– Patient is > 60 years of age
– History of renal impairment
– History of hypertension requiring medication
– History of diabetes
– Patient is taking metformin
PROCEDURE
Patient Position/Location
• Patient is typically in supine position
• Prone or oblique imaging may be necessary for CT-guided
procedures
Techniques
Advantages
• Oral and rectal contrast opacification of GI tract
○ Allows differentiation of bowel from pelvic viscera and
tumor
• IV contrast enhancement of blood vessels and viscera
○ Helps improve soft tissue differentiation
– Pelvic blood vessels vs. lymph nodes vs. parametrial
tumor extension
○ Angiographic imaging can assess pelvic vascular
involvement
○ Differential enhancement patterns distinguish uterine
tumor from normal myometrium
○ Allows opacification of bladder and ureters
• Multidetector CT scan provides for rapid data acquisition
○ Rapid coverage of entire body
○ High spatial resolution
– Acquisition of isotropic voxels allows for improved
multiplanar reconstruction
○ Imaging in different circulatory phases can be acquired
Disadvantages
• Utilizes ionizing radiation
• Image quality may be degraded by
○ Body habitus, metallic hardware (hip prosthesis)
• Use of iodinated contrast agents associated with morbidity
and mortality
• Limited application in early-stage cancer and local staging
CT Technique
• Preprocedural administration of oral contrast medium
○ 750-1,000 mL of diluted positive oral contrast 2 hours
prior to examination
– Barium or iodine based
○ Delayed oral contrast medium regimen (48 hours) may
be useful if slow transit through gut
• IV contrast medium administration
○ 100-150 mL iodinated contrast medium
– Injection rate: 2-3 mL/s for routine studies
– Rate of 4-5 mL/s for angiographic applications
○ Images acquired 70-120 s after contrast for routine
studies
– Bolus-tracking technique vs. 20- to 40-s delay after
contrast injection
– Delayed imaging may be useful
□ 3-5 min for pelvic vein imaging (for
patency/thrombosis)
□ 5-10 min for bladder and ureteral opacification
• Submillimeter collimation images are acquired and
reconstructed into
○ 2- to 5-mm thick axial images
○ Sagittal and coronal images
○ 3D reconstructed images as needed
• CT cystography is performed to evaluate bladder
involvement by tumor or urogenital fistula
○ Imaging performed after bladder catheterization and
instillation of contrast
○ IV contrast is administered as well
• CT hysterosalpingography techniques have been described
○ Involves catheterization of endometrial cavity and
injection of diluted iodinated contrast material
21
 CT Technique and Anatomy
Techniques
○ CT of pelvis is performed with multiplanar and 3D
reformatted images
○ Allows for evaluation of tubal patency and uterine
morphology
CT Anatomy
• Uterus
○ Appearance varies, depending on age, uterine
positioning, parity, and presence of leiomyoma or
adenomyosis
○ Typically appears as triangular soft tissue structure,
contiguous with vagina
– Uterus is anteverted/anteflexed in most cases
– May appear enlarged on axial images if
retroflexed/retroverted
○ Posterior to urinary bladder, anterior to rectum
○ NECT: Uterus appears homogeneous; measures soft
tissue attenuation
– Central endometrium may be faintly visible as slightly
hypodense stripe
○ CECT: Differential enhancement of myometrium and
endometrium
– Varied enhancement of myometrium based on timing
of study, phase of menstrual cycle, patient age
□ Homogeneous (diffuse or minimal)
□ Subendometrial (thick or thin)
□ Outer myometrial
□ Patchy/heterogeneous
– Myometrium enhances to lesser degree in
postmenopausal patients
– Endometrium enhances to lesser degree on early-
phase acquisitions and becomes more isodense to
myometrium on delayed imaging
□ Endometrial thickness may be overestimated on
axial and coronal images; sagittal reformatted
images provide for more accurate measurement
• Cervix
○ Inferior segment of uterus, contiguous with vagina
○ Rounded appearance in axial plane
○ NECT: Homogeneous soft tissue density, isodense to
myometrium
○ CECT: Targetoid/layered appearance
– Central secretions/fluid: Hypodense
– Inner cervical mucosa: Hyperdense
– Inner stroma: Hypodense
– Outer stroma: Hyperdense
– On early postcontrast phases, cervix may appear
diffusely low density and simulate pathology
• Fallopian tubes
○ Normally not well visualized; may appear as tortuous
tubular structure in setting of hydrosalpinx/pyosalpinx
• Vagina
○ Thin-walled tubular structure extending from cervix to
introitus
○ Typically collapsed; may contain small amount of air,
fluid, or tampon
○ Characteristic H configuration
○ Mucosa will demonstrate smooth enhancement
• Ovaries
○ Routinely seen in premenopausal women
22
○ Small and atrophic in postmenopausal patients; not
always identified
– Often located adjacent to external iliac vasculature
○ Can be identified by following ovarian veins into pelvis
○ Uniform soft tissue density, lower than that of enhancing
myometrium
– Small, low-density cystic regions represent follicles
– Irregular, thick-walled, enhancing structure represents
corpus luteum
○ Position variable
– Usually posterolateral to uterine corpus
– Anterior and medial to ureter
– Posterior to round ligament
– Medial or posteromedial to external iliac vessels
– Ovarian mass displaces ureter laterally and posteriorly
vs. nodal mass lying lateral to ureter
• Pelvic ligaments
○ Broad ligament
– Not usually seen unless ascites is present
○ Round ligament
– Thin soft tissue attenuation band
– Extends laterally from lateral fundus to internal
inguinal ring
– Frequently seen
○ Uterosacral ligament
– Extends posteriorly from lateral cervix and vagina
– Tapers toward anterior body of S2 or S3
– Arcing band from cervix to sacrum
○ Cardinal ligament
– Extends laterally from cervix and upper vagina
– Merges with pelvic sidewall
– May be seen as triangular soft tissue structure
– Contains uterine vasculature
○ Ovarian ligaments
– Not usually identified on CT
– Proper ovarian ligament: Extends medially from ovary
to uterus; arises inferior to fallopian tube ostium
– Suspensory ligament of ovary: Extends from ovary to
pelvic sidewall; contains ovarian vasculature
OUTCOMES
Complications
• Most feared complication(s)
○ Anaphylactoid reaction to IV contrast administration
• Other complications
○ Contrast-induced nephropathy for patients receiving IV
iodinated contrast
SELECTED REFERENCES
1. Bhatt S et al: Value of "three dimensional multidetector CT
hysterosalpingography" in infertile patients with non-contributory
hysterosalpingography: a prospective study. J Reprod Infertil. 18(3):323-32,
2017
2. Katz DS et al: Computed tomography imaging of the acute pelvis in females.
Can Assoc Radiol J. 64(2):108-18, 2013
3. Sierra A et al: Utility of multidetector CT in severe postpartum hemorrhage.
Radiographics. 32(5):1463-81, 2012
4. Yitta S et al: Normal or abnormal? Demystifying uterine and cervical contrast
enhancement at multidetector CT. Radiographics. 31(3):647-61, 2011
 CT Technique and Anatomy

Techniques
Cervix Ovaries
(Left) Axial CECT shows the
normal targetoid appearance
of the cervix ﬈. The central
secretions are hypodense, the
mucosa is hyperdense, the
inner stroma is hypodense, and
the outer cervical stroma is
hyperdense. (Right) Axial CECT
shows normal-appearing
ovaries ſt, which may be
more difficult to identify in
postmenopausal patients due
to atrophy. The ovaries appear
hypodense to the myometrium
with numerous small
physiologic follicles.

Broad Ligaments Round Ligaments

(Left) Axial CECT
demonstrates the broad
ligaments ﬈ as they arise
from the lateral margins of
the uterus ﬊ and extend
laterally. The broad ligaments
are normally difficult to
identify unless they are
outlined by ascites or, as in
this case, intraperitoneal oral
contrast. (Right) Coronal CECT
shows the round ligaments ſt
as they arise from the uterine
fundus ﬇ and extend into the
inguinal canals. The round
ligaments are typically well
visualized on CT.

Uterosacral Ligaments Vagina

(Left) Axial CECT shows
normal bilateral uterosacral
ligaments ſt, which can be
seen as thin soft tissue bands
extending from the lateral
cervical margins posteriorly to
the sacrum. The uterosacral
ligaments can be a route of
disease spread, as in the
setting of cervical carcinoma
or endometriosis. (Right) Axial
CECT shows a normal
appearance to the
decompressed vagina ſt,
which classically has an H
configuration. The vaginal
mucosa is typically smoothly
enhancing.

23
 MR Technique and Anatomy

KEY FACTS
Techniques

PROCEDURE • Sequences utilized depend on clinical problem but typically

• Indications for MR include include T2WI, T1WI, and pre- and postcontrast T1WI FS
○ Characterization of adnexal masses • Gynecologic anatomy is well appreciated on MR
○ Staging of pelvic malignancies ○ Uterine and cervical zonal anatomy is well depicted on
sagittal T2WI
○ Evaluation of congenital anomalies
○ Ovaries are visualized in ovarian fossae, usually
○ Treatment follow-up
containing scattered physiologic follicles &/or corpus
○ Pelvic floor assessment
luteum
○ Imaging of pelvic pain during pregnancy
○ Appearance of pelvic organs varies with age, menstrual
• Contraindications for MR include implanted medical status, and parity
devices, ferromagnetic foreign bodies
○ Any implanted device must be confirmed safe for MR
prior to imaging
○ IV gadolinium contrast should not be administered in
patients at risk for nephrogenic systemic sclerosis
• Image is typically performed
○ In supine position using surface-array multichannel coil
○ In axial, sagittal, coronal, and oblique planes

Uterus Uterus
(Left) Sagittal T2WI MR shows
normal MR appearance of
uterus, which is anteverted
and anteflexed; uterine zonal
anatomy is well visualized
with thin junctional zone ﬈.
The endometrium is uniformly
thin ﬊. The cervix is darker
than the uterine body
myometrium ﬉. (Right) Axial
T2WI MR demonstrates a
normal appearance of the
right ovary st and uterus ﬇.
The uterine fundal outer
contour is slightly convex ﬈.

Uterus Uterus
(Left) Sagittal T2WI MR shows
an anteverted and retroflexed
uterus. The angle of version
describes the relation between
the cervix ﬈ and vagina ﬊,
while the angle of flexion
describes the relation between
the uterine cervix and body
﬉. (Right) Sagittal T2WI MR
shows an retroverted and
anteflexed uterus. The angle
of version describes the
relation between the cervix ﬈
and vagina ﬊, while the angle
of flexion describes the
relation between the uterine
cervix and body ﬉.

24
 MR Technique and Anatomy

Techniques
• Patient preparation
TERMINOLOGY
○ Empty bladder
Definitions ○ Reduce motion artifact from small bowel peristalsis
• Imaging modality that measures tissue response to – Fasting for 4-6 hours before MR examination
radiofrequency pulses in magnetic field to generate images – Antiperistaltic agent use is not routine
○ Vaginal administration of 40-60 mL of bacteriostatic
PREPROCEDURE surgical lubricant may be considered
Indications – Acts as intraluminal contrast agent
– Allows for improved evaluation of cervix and vagina
• Characterization of pelvic masses
• Staging of pelvic malignancies Advantages
• Evaluation of congenital (müllerian) anomalies • No ionizing radiation
• Treatment follow-up • Multiplanar capability
• Pelvic floor assessment (dynamic) • Excellent spatial and tissue contrast resolution, which is
• Evaluation of pelvic lymphadenopathy improved with higher-field magnets (3T)
• Pelvimetry • Can perform dynamic imaging, allowing for functional
• Evaluation of pelvic pain in pregnancy evaluation
• Allows definitive noninvasive diagnosis of certain malignant
Contraindications
tumors and benign conditions
• Cardiac pacemakers/implantable cardioverter-defibrillators
○ Alternative modalities should be pursued Disadvantages
○ Patients who are not pacemaker dependent may • Longer acquisition times
undergo MR evaluation in experienced centers under • May not be as widely available as CT or ultrasound
supervision of cardiologist if there are no suitable • Increased cost
alternatives
• Cochlear implants PROCEDURE
○ Certain devices may be safe for MR
Patient Position/Location
• Ferromagnetic intracranial aneurysm clips
• Patient is usually imaged in supine position
• Implanted neurostimulators
○ Certain devices may be safe for MR Equipment Preparation
• Ferromagnetic foreign bodies (intraocular) • Coil selection
• Pulmonary artery-monitoring catheters, temporary ○ Image commonly performed using surface-array
transvenous pacing leads, intraaortic balloon pumps, left multichannel coil
ventricular assist devices (LVADs) ○ Abdominal/pelvic coil provides for larger FOV but
• IV gadolinium contrast should not be administered in decreased resolution/signal
patients at risk for nephrogenic systemic sclerosis ○ Phase-array coil increases resolution and decreases
○ Chronic renal insufficiency with estimated glomerular imaging time
filtration rates < 30 mL/min ○ Endoluminal coils (endorectal and endovaginal coils) may
○ Dialysis patients be used in select cases
○ Acute kidney injury – Advantage: Provide for high-resolution images,
• Relative contraindications to MR include especially small cervical tumors or those with limited
○ Tattoos, including permanent eye liner parametrial invasion
○ Patients who suffer with claustrophobia – Disadvantage: Limited FOV that proves inadequate in
○ Compromised thermoregulatory systems assessing large tumors and extrauterine tumor extent
• Any implanted device must be confirmed safe for MR Alternative Procedures/Therapies
prior to imaging
• Radiologic
Getting Started ○ Ultrasound
• Things to check – Useful in initial evaluation of gynecologic complaints
○ Evaluation of renal function for patients receiving – Can help characterize uterine/adnexal lesions
contrast who meet following criteria ○ CT
– > 60 years of age – Most useful in staging of malignancy (extrapelvic
– History of renal disease involvement, lymphadenopathy)
– History of hypertension requiring medication – Used in follow-up of treated malignancy
– History of diabetes mellitus – Useful in evaluation of suspected tubo-ovarian
• Medications abscess
○ Anxiolytics may be helpful in patients with MR Technique
claustrophobia
○ Antiperistaltic agents (hyoscine butyl bromide or • Imaging planes
glucagon) may be used to limit small bowel motion ○ Axial plane
artifact – Pelvic anatomy is typically best recognized in axial
plane
25
 MR Technique and Anatomy
Techniques
– Good for evaluation of parametrium (i.e., parametrial
tumor extension)
○ Sagittal plane
– Best appreciation of uterine zonal anatomy
– Useful in evaluation of tumor extension to bladder,
cervix, rectum, and vagina
○ Coronal plane
– Provides complementary information in assessment
of uterus, cervix, parametrium, vagina, and ovaries
– Evaluation of lymphadenopathy and adnexal masses
○ Oblique planes (axial &/or coronal)
– Very helpful in evaluation of parametria in patients
with cervical cancer
– Allows for characterization of müllerian duct
anomalies
• Sequences most commonly utilized include
○ T2WI: Superb tissue contrast resolution and
demonstration of uterine and cervical zonal anatomy
and ovarian anatomy
– Imaging performed without fat suppression; pelvic fat
serves as intrinsic contrast
○ T1WI: Evaluation of pelvic soft tissues, lymph nodes, and
bone marrow
○ T1WI FS
– Helps to differentiate between fat and blood
– Improves detection and conspicuity of hyperintense
lesions surrounded by fat
– Provides baseline precontrast signal intensity to
compare to postgadolinium imaging
○ T1WI C+ FS
– Helps in characterization of adnexal lesions
– Essential in cervical cancer staging
□ Evaluation of extent of tumor (vaginal, parametrial,
pelvic sidewall)
□ Helps identify bladder, ureteral, or rectal
involvement
□ Pelvic lymphadenopathy
– Useful in staging ovarian cancer (when CT is not
performed)
– Evaluation of vascularity of uterine leiomyomata prior
to therapy
– Can be performed dynamically to evaluate lesion
enhancement characteristics
○ Diffusion-weighted imaging (DWI)/apparent diffusion
coefficient (ADC)
– Must be evaluated in conjunction with other imaging
sequences
– Provides information about water mobility, tissue
cellularity, and integrity of cellular membranes
– Aids in diagnosis and grading of tumors, as well as
predicting/assessing response to treatment
□ Low ADC values are associated with malignancy
(such as endometrial, ovarian, and cervical cancers),
although there is overlap between malignant and
benign tissues
□ Tumors with low cellularity or mucinous tumors
may have high ADC values
□ Pretreatment ADC values may help predict tumor
response to therapy
– Peritoneal implants from disseminated ovarian
cancers often have restricted diffusion
26
□ Small implants are more conspicuous than on other
sequences
– ADC values of malignant lymph nodes are typically
lower than that of normal nodes
□ Inflammatory/reactive nodes may also have low
ADC values
– Can help distinguish recurrent/residual tumor from
postoperative change
□ Viable tumors have low ADC values, whereas
postoperative inflammation has higher ADC values
– DWI/ADC can be used to monitor treatment of
leiomyomas
□ Treated lesions have increased DWI/decreased ADC
signal due to infarct-related diffusion restriction
□ ADC values may subsequently increase secondary
to necrosis
• Other imaging sequences/techniques include
○ Steady-state free precession (SSFP)
– Bright blood imaging technique
– Fast imaging sequence, relatively motion insensitive
– Can be acquired dynamically in evaluation of pelvic
floor dysfunction
– Useful in imaging of pregnant patients
○ Pelvic MRA
– Evaluation of pelvic vasculature prior to procedure
(uterine artery embolization)
– Evaluation for vascular involvement by pelvic
malignancy
○ MR perfusion
– Displays information about tissue perfusion,
microcirculation, and angiogenesis
– Aids in lesion detection and characterization and can
improve accuracy of tumor staging
– Changes in tumor perfusion, as marker of early
response to treatment may precede decrease in
tumor size
○ MR hysterosalpingography
– MR is performed after cannulation of cervix and
injection of dilute gadolinium contrast into
endometrial cavity
– Can evaluate for tubal patency, as well as structural
abnormalities
○ Blood oxygenation level dependent (BOLD) MR
– Measures differences in paramagnetic
deoxyhemoglobin in blood as marker of tumor
hypoxia
– Tumors with higher levels of hypoxia may be more
aggressive and resistant to therapy
– Identifies higher grade portions of tumor to help
guide therapy
○ MR lymphography
– Can detect metastases in normal-sized lymph nodes
with very high sensitivity and specificity
– Requires IV injection of ultra-small-particle iron oxide
(USPIO)
– USPIO is taken up by normal lymph nodes, whereas
metastatic lymph nodes show no uptake
○ Diffusion tensor imaging (DTI)
– Can help detect and quantify defects/asymmetries in
pelvic floor musculature
Another random document with
no related content on Scribd:
 In the same year the Cunard Line followed with the Carmania,
their first turbine liner, fitted with three turbines and three screws.
She was preceded a little by the Caronia, a sister ship in every way
except that the latter is propelled by two sets of quadruple-expansion
reciprocating engines, driving twin-screws. These ships have a
displacement of 30,000 tons, and a length over all of 675 feet. They
were built of a strength that was in excess of Board of Trade and
other requirements, and when we state that no fewer than 1,800,000
rivets were used in the construction of each, one begins to realise
something of the amount of work that was put into them. Their steel
plating varies in thickness from three-quarters of an inch to an inch
and an eighth in thickness, the length of each plate being 32 feet.
Fitted with a cellular bottom which is carried well up the sides of the
ship above the bilges, they can thus carry three and a half thousand
tons of water-ballast. The principles underlying the design and
construction of these ships were steadiness and strength, and in the
attainment of this they have been eminently successful. There are
eight decks, which may be detailed by reference to the photograph
of the Carmania facing page 188. Immediately below the bridge is
the boat deck. Then follow successively the upper promenade deck,
the promenade, the saloon, upper, and main decks. Below the water-
line come two other decks for stores and cargo, the depth from the
boat deck being eighty feet. Both of these ships are fitted with the
now well-known Stone-Lloyd system of safety water-tight doors,
which renders the vessel practically unsinkable. This enables the
doors to be closed by the captain from his bridge, after sufficient
notice has been given by the sounding of gongs, so that everyone
may move away from the neighbourhood of these doors. But should
it chance that, after they have been shut, any of the crew or
passengers have had their retreat cut off, it is only necessary to turn
a handle, when the door will at once open and afterwards
automatically shut again. The system is worked by hydraulics, and is
a vast improvement on the early methods employed to retain a ship’s
buoyancy after collision with an iceberg, vessel or other object. A
glance at the illustration will show that a very great amount of
consideration was paid to the subject of giving the Carmania a
comprehensive system of ventilation, a principle which has been
carried still further in the Mauretania and Lusitania.
In the event of war the Carmania and Caronia would be fitted
with twelve large quick-firing guns, for the hulls were built in
accordance with the Admiralty’s requirements for armed cruisers.
For this reason, also, the rudder is placed entirely under water, and
besides the ordinary set of steering gear, there is another placed
below the water-line.

A STUDY IN COMPARISONS: THE “MAGNETIC” AND “BALTIC.”

From a Photograph. By Permission of the London & North Western Railway.

On her trials the Carmania attained a speed of over 20 knots,

and the saving in weight by adopting turbine engines as compared
with the Caronia’s reciprocating engines was found to amount to 5
per cent. In actual size these fine ships are inferior to the Great
Eastern, but they were built with meticulous regard for strength, and
needed 2,000 tons more material than was used in the old Brunel
ship. The arrangements of the Carmania’s turbines are worthy of
note. There are three propellers and shafts. That in the centre is the
high-pressure turbine, whilst the “wing” (or two side) turbines placed
respectively to starboard and port are the low-pressure and astern
turbines. Steam is supplied by eight double-ended and five single-
ended boilers, which are fitted with Howden’s system of forced
draught. This latter enables the air to be heated before it enters the
furnace, and was patented in 1883. It is also in use on the
Mauretania.
The beautiful picture facing page 192 was taken in Holyhead
Harbour in June, 1909, and is a study in comparisons. At the left,
first come the two small steam craft, then the White Star passenger
tender, the Magnetic, a twin-screw steamer of 619 tons, and, finally,
the other White Star twin-screw mammoth Baltic, of 23,876 tons. The
Magnetic happens to be less than 100 tons smaller than the little
Sirius, which was the first steamer to cross the Atlantic entirely under
steam power in 1838. Therefore, if we but imagine in place of the
twin-screw tender the paddle Sirius, we can form some fairly
accurate idea of the extent to which the Atlantic steamship has
developed in less than seventy years, a development that neither
Fulton nor anyone else could have foretold in their wildest flights of
imagination. This Baltic, with her 24,000 tons, is one of the largest
vessels in the world—about 9,000 tons larger than Noah’s Ark, if we
take the Biblical cubit as equal to a foot and a half, which makes that
historic craft about 15,000 tons register. The Baltic has a length of
725¾ feet; the Ark measured 450 feet in length. The Baltic can carry
with the utmost ease and luxury 3,000 passengers, as well as 350
crew. Just how many animals she could put away in her holds as
well, if called upon, I do not know; but in any case it would be able to
put up a keen competition with the capacities of Noah’s craft.
Here, again, we find a White Star ship excelling not in speed, but
in size, for she was designed to do only 16½ knots at the outside.
She is propelled by quadruple-expansion engines. She made her
appearance in 1905, and is additionally interesting, as she exhibits a
slight divergence from the ten beams to the length principle, which
governed for so long a time the White Star ships; to come up to this
rule this vessel would have to be another 30 feet in length.
We have already explained the reason which underlies the
comparatively moderate speed of these ships, and mentioned that
the question of economical steaming was at the root of the matter.
As an example we might quote the case of the Majestic, belonging to
the same line, as an instance. This vessel consumes 316 tons of
coal per day to get a speed of 19 knots; the Baltic, a vessel nearly
twice and a half the size, requires only 260 tons of fuel a day for her
16½ knots.
And so we come to those two leviathans which form, without
exception, the most extraordinary, the most massive, the fastest, and
the most luxurious ships that ever crossed an ocean. Caligula’s
galleys, which were wondrously furnished with trees, marbles and
other luxuries which ought never to desecrate the sweet, dignified
character of the ship, were less sea-craft than floating villas exuding
decadence at every feature. There are some characteristics of the
Mauretania and Lusitania, with their lifts, their marbles, curtains,
ceilings, trees, and other expressions of twentieth century luxury,
which, while appreciated by the landsman and his wife, are
nauseating to the man who loves the sea and its ships for their own
sakes, and not for the chance of enjoying self-indulgence in some
new form. But all the same these two Cunarders are ships first, and
floating mansions only in a secondary sense. They are even more
than that: they are ocean-greyhounds of a new breed with a pace
that surpasses any other of the mercantile sea dogs.
These two historic craft are regarded in different ways by
different people. You may think of them as hotels, you may look at
them as representing the outcome of the greatest minds in naval
architecture, ship-construction and marine engineering. Or, again,
you may reckon up how much capital is tied up within their walls,
how much material they have eaten up, how many hundreds of men
they have given, and are giving, employment to. But whichever way
you regard them, from whatever standpoint you choose, there is
nothing comparable to them, there are no standards whatsoever by
which to judge them. We can only doff our hats to the organising and
originating geniuses who in one way or another brought these
marvels from out of the realm of impossibility to the actuality of the
broad Atlantic. Cover them with tier upon tier of decks, scatter over
them a forest of ventilators, roofs and chimneys, till they look like the
tops of a small town; fill them inside with handsome furniture, line
their walls with costly decorations; throw in a few electric cranes, a
coal mine, several restaurants, the population of a large-sized village
and a good many other things besides; give them each a length
equal to that of the Houses of Parliament, a height greater than the
buildings in Northumberland Avenue, disguise them in any way you
please, and for all that these are ships, which have to obey the laws
of Nature, of the Great Sea, just as the first sailing ship and the first
Atlantic steamship had to show their submission. I submit that to look
upon these two ships as mere speed-manufacturers engaged in the
record industry, as palatial abodes, or even as dividend-earners is an
insult to the brains that conceived them, to the honourable name of
“ship” which they bear.
The Mauretania and Lusitania are the outcome of an agreement
made between the British Government and the Cunard Steamship
Company, in which it was contracted to produce two steamships
“capable of maintaining a minimum average ocean speed of from 24
to 25 knots an hour in moderate weather.” In every way these ships
have exceeded the dimensions of the Great Eastern. There was no
precedent for them in dimensions, engine power, displacement or
aught else. It was not to be expected that such gigantic productions
as these could be the outcome of one mind; such a thing would be
impossible. It was only as a result of an exhaustive inquiry made on
behalf of the Cunard Company by some of the most experienced
ship-builders and marine engineers of this country, aided by the
constructive and engineering staff of the Admiralty, as well as by the
preliminary knowledge derived from models, that the best form for
obtaining this unprecedented speed was evolved. Whatever was
best in existing knowledge or materials was investigated. A special
committee, representing the Cunard Company, the Admiralty and
private industries went deeply into the question of engines; and with
right judgment, and, it must be said, with no little courage and
enterprising foresight, decided, after conferring with Mr. Parsons, to
choose turbines, applied to four shafts, each carrying a single screw.

THE “MAURETANIA,” WHEN COMPLETING AT WALLSEND-ON-TYNE.

From a Photograph. By Permission of the Cunard Steamship Co.

These two absolutely unique steamships differ entirely from the

previous fast liners that we have enumerated, as well as from those
large “intermediates” with moderate speed. The size of these
mammoths was decided upon, not with reference to their cargo-
carrying capacity—for they have practically no space for this—but in
order to be able to steam at an average speed of 25 knots in
moderate weather for 3,000 miles, to carry enough coal to last them
the voyage when consuming about a 1,000 tons per day, and to
carry an adequate number of passengers to allow the ships to pay
their way. It was impossible, therefore, to have given them any
smaller dimensions. I make this statement on the authority of no less
an expert than Sir William H. White, K.C.B., the illustrious naval
architect who was connected so closely with the birth of the
Mauretania. It was a happy coincidence that the turbine had already
shown itself capable of so much that to employ it in these ships
seemed a justifiable experiment. For otherwise, in order to obtain the
requisite speed the vessel could not have contained the large
amount of propelling apparatus. The working speeds of these two
ships exceeds by 1½ knots the highest speeds ever attained in the
Atlantic service. Had the reciprocating engine been employed
instead of the turbine there would have been serious risk of
troublesome vibration, the shafts would have had to have been of
very large dimensions; large-sized propellers would have been
necessary, and these latter, of course, would have been
unfavourable to high efficiency of propulsion, whilst with the more
rapidly revolving turbine the screws are still of moderate diameter.
But apart altogether from the questions of economy of space, liability
to accident and so on, there was a national consideration to be
reckoned. This country has now for many hundreds of years prided
itself on being the mistress of the seas, a title that was only won after
serious, hard struggles. Although that title has reference rather to
matters immediately connected with the Royal Navy, yet national
industry and a series of private enterprises had, as we have seen,
given us also an analogous position in regard to our mercantile
marine. This was until the German Kaiser Wilhelm der Grosse,
followed by the Kaiser Wilhelm II. and the Deutschland, took away—
in speed, at least—this title. It was, therefore, a matter affecting our
honour and our pride that we should put on to the water some ship
or ships that should be capable of winning back the “blue ribbon” of
the Atlantic, and restoring to us the supremacy of speed at sea.
There is, however, a more practical consideration. Without the
assistance of the Government it would have been financially
impracticable even for so wealthy a corporation as the Cunard
Company to cause such a couple of ships as these to be built. And
yet it was worth while that the nation should help the Company, for in
the event of war breaking out between us and another first-class
nation, it would not be long before we should be starved into
submission if by any chance our over-seas food supply were cut off.
It has been suggested with every appearance of probability, that in
such a condition the Mauretania and Lusitania might render the
highest service by making rapid passages across the Atlantic and,
being there loaded up with grain, might hurry back home again. Their
speed alone would save them from the enemy, except perhaps from
the latest and fastest types of fighting-ships. But if convoyed by the
Indomitable and Invincible battleship-cruisers, with their enormous
speed and equally enormous “smashing power,” the chances would
be in favour of the grain-ships reaching port. Thus when the British
Government advanced the sum of £2,000,000 sterling (which
amount represents about one-half of the total cost of the two
vessels) it was acting with a wisdom and a power for looking well
ahead that is not always possessed by political bodies. With their
very considerable capacities for passenger accommodation, these
two ships would also be invaluable if called upon to act as
transports.
The singularly impressive picture facing page 198 shows the
Mauretania whilst she was still lying on the Tyne at Wallsend before
being quite ready for service. It is by a happy coincidence that the
same picture shows a delightful contrast between this last word of
modern invention and the old-fashioned type of steam tug-boat in the
river, to the right. There is, in fact, so mighty a divergence in
character that it is not easy to catalogue both under the very elastic
and comprehensive title of steamship. Only by comparison with
existing ships can one gain any idea of the Mauretania’s colossal
qualities. The present writer was one of those who watched the
Mauretania docked for the first time at Liverpool immediately after
she had come round to the Mersey from the Tyne. By her was lying
another steamship, by no means out of date, whose appearance at
one time called forth some of the expressions of amazement and
wonder that these two Cunarders have brought about. For size and
speed this older “greyhound” was properly and legitimately famous,
but yet within the comparatively small dimensions of the dock-space
one was able to obtain a more accurate idea as to the exact
proportions of the Mauretania than when lying outside in the river,
where space brings with it deception; and it was amazing to remark
how utterly and unconditionally the new steamship overshadowed
the old. Even in such close proximity as one stood, everything else
looked small by comparison. The captain on the Mauretania’s bridge
resembled a small, black dot, the funnels looked like four great, red
caverns. A brand new thick rope warp was brought to the shore to
stop the Mauretania’s way. It was so heavy that a score of men were
needed to move it about. And yet although she seemed scarcely to
be moving the liner broke it in two just as a toy model breaks a piece
of cotton. Or, again, one may look at this same ship lying at her
mooring buoy on the Cheshire side of the Mersey and be lost in
wonder at her graceful curves. With such sweet lines you could not
doubt that she was also speedy. But it is not until one sees a good-
sized steam-tug go shooting by the buoy that one obtains any idea
as to measurements. The buoy is as big and bigger than the tug,
and, therefore, how many more times must the liner herself be
bigger than the tug? You see another steamer alongside this
mountain of steel and the steamer is nothing remarkable. But
presently as she comes down by the landing-stage, past a smaller
liner brought up to her anchor in the middle of the river, you find that
that little steamer is several sizes bigger than a moderate coaster. It
would have been so easy to make this finest ship in the world look
also the largest; it is a much finer achievement to have made her
look, what she is, the handsomest.
 STERN OF THE “MAURETANIA.”
From a Photograph. By permission of the Cunard Steamship Co.

Passing then to some of the details of these leviathans, we find

that they measure 790 feet long, 88 feet broad, whilst the depth from
the topmost deck to the bottom is 80 feet. Choose out some high
building or cliff 150 feet high, and it will still be 5 feet less than the
height of these ships from the bottom to the top of their funnels.
Their displacement at load draught is 40,000 tons; they each
develop 68,000 horse-power, and draw, when fully loaded, 37½ feet
of water. When crew and passengers are on board each ship
represents a community of 3,200 persons. They are fitted with bilge
keels, double bottoms, water-tight doors, and there are eight decks
in all. To hold such massive weights as these ships exceptionally
powerful ground tackle is necessitated. The main cable alone weighs
about 100 tons, and there are about 2,000 feet of this, or 333
fathoms. The double bottom of the Mauretania averages in depth 5
to 6 feet, and she has five stokeholds containing twenty-three
double-ended and two single-ended boilers; the coal bunkers are
arranged along the ship’s sides in such a manner as to be handy
and as a protection to the hull in case of collision. Three hundred
and twenty-four firemen and trimmers are engaged in three watches
of four hours in the stokehold.
The striking illustration facing page 200 shows the stern of the
Mauretania out of water, the photograph having been taken whilst
the vessel was being built at Wallsend-on-Tyne by Messrs. Swan,
Hunter and Wigham Richardson. It will be noticed that there are two
propellers on either side of the rudder. The two outermost are driven
by the high-pressure and the inside two by the low-pressure
turbines. The two inner propellers are also used for going astern,
and since the turbine can only turn in one direction these two are
each fitted with a high-pressure turbine, and when the ship is
steaming ahead these astern-turbines are simply revolving idly.
When we examined the interior of a turbine on page 186, we noted
that the steam is allowed to expand in stages therein. The turbines of
the Mauretania are arranged with eight stages of steam expansion,
while the blades vary in length from 2½ to 12 inches.
 THE “LUSITANIA.”
From a Photograph. By permission of the Cunard Steamship Co.

We would call attention once more to the modern custom

introduced by Harland and Wolff of cutting a hole, or “port,” in the
deadwood of the ship. On referring to the illustration facing page
200, it will be seen that the Mauretania possesses this feature in a
remarkable degree, so that the flow of water to the screws is very
free indeed. It will be noticed also that the rudder is of the balanced
type, so that part of it projects forward of its axis, whilst the whole of
it is some distance below the water-line. It will also be remarked that
the two “wing,” or outermost, propellers are placed a good deal
forward of the two inner screws, the object aimed at being to give
these forward screws plenty of clear water to work in without either
pair of propellers having to revolve in water disturbed by the other
pair. In examining this picture the reader will readily be able to obtain
the scale by remembering that the draught up to the water-line
shown is 37½ feet. The illustration facing this page shows the
appearance these sister ships possess at the bows. The present
photograph shows the Lusitania under way. The navigating bridge,
which will be discerned at a great height, has been necessarily
placed comparatively much nearer to the bows of the ship than is
customary in many liners. Here the binnacle, the engine-room
telegraph instruments, and other apparatus employed in the
controlling of the ship, are stationed, whilst immediately abaft of this
bridge, but in a connecting room, is the wheel-house. Into this small
space is concentrated the exceptionally serious responsibility of
ruling the ship, a responsibility which, though it now lasts but a short
time, thanks to the shorter passages of the steamship, is far heavier
than it was when steamships were less complicated and less huge. It
is a responsibility which covers not merely the ship herself, the crew,
the mails, and the passengers’ lives, but sometimes a very precious
cargo. Only whilst these pages are being written the Mauretania
steamed into Liverpool a veritable treasure ship, far surpassing in
this respect a whole fleet of some of those old Spanish treasure-
frigates. Stored in the strong-rooms of the Cunarder were precious
metals of the aggregate value of over a million pounds sterling,
consisting of 6½ tons of gold coin and 36 tons of bullion in the shape
of 1,100 bars of silver. Add all this to the value of the ship, her
furniture and her passengers’ belongings, and we get something
between three and four millions of money. The mere thought of it is
enough to make Sir Henry Morgan and other buccaneers and pirates
turn restlessly in their prison-graves.
Ever since they first came out the Mauretania and Lusitania have
been improving on their speeds. Their most recent remarkable
performances have been caused by important alterations to their
propellers. These were preceded by experiments made by the
Mauretania’s builders with their specially constructed electrically-
driven model launch. Since these two liners commenced running,
over twenty-four different sets of three-bladed, and seventeen sets of
four-bladed propellers have been tested, in addition to further
frequent experiments with models of the three-bladed propellers
originally supplied to the Mauretania. By modifying the bosses and
the blades, and adopting four blades instead of three, a very
extensive saving in horse-power was effected in experiments.
Finally, the Mauretania was fitted with four-bladed propellers on the
wing shafts, while three-bladed propellers were retained on the
inside shafts. The result has been a substantial raising of her
average speed, while the coal consumption has been about the
same or rather less, but this latter is thought to be due probably to
the improvements in stokehold organisation. Sir William H. White
has expressed himself as of the opinion that the recently much
increased speed of these two monsters is due much more to the
greater knowledge of the turbines, as well as the better stokehold
management, than to the propeller alterations. Up to May of the year
1908 the best average speed of the Mauretania on her westward trip
was 24·86 knots, but during the year 1909 it was raised to 26·6
knots. It was officially stated, on March 24th, 1910, that the Lusitania
made a new record on her westward trip by steaming at 26·69 knots
for a whole day, that is at the rate of 30·7 land miles. Leaving
Queenstown on the Sunday, she had up till noon of the following
Wednesday covered 2,022 knots, at an average of 25·97 sea miles.
A fortnight previous to this the Mauretania, for the last part of her
eastward voyage to Fishguard, steamed at an average speed of
27·47 knots per hour, or 31·59 land miles. The Lusitania is now fitted
with the Mauretania’s first propellers, and the chairman of the
Cunard Company has remarked that he has been informed that the
Mauretania would be glad to have them back again. The following
tables will give some idea of the comparative passages which these
ships have made. They are interesting as being reckoned not from
Queenstown, but from Liverpool landing-stage and the Cunard pier,
New York:—

Outward Voyages Days. h. m.

Lusitania Quickest passage 5 7 0
Mauretania Quickest passage 5 1 30
Lusitania Longest passage 6 18 0
Mauretania Longest passage 5 21 0
Lusitania Average passage 5 21 35
Mauretania Average passage 5 16 48

Homeward Voyages.
 Lusitania Quickest passage 5 15 30
Mauretania Quickest passage 5 5 0
Lusitania Longest passage 5 22 0
Mauretania Longest passage 5 17 0
Lusitania Average passage 5 19 22
Mauretania Average passage 5 12 14

But in spite of their bold dimensions and their efforts to prove

their superior prowess in contending with the mighty ocean, both the
Mauretania and the Lusitania have shown that after all they are still
yet ships, and are subject to those same laws which govern the rusty
old tramp, the square-yarded sailing ship, and the massive modern
liner. We may take but two recent instances, one as happening to
each of these two great vessels during the winter of 1910. In the
month of January, the Lusitania made the slowest passage in her
history, having encountered adverse winds and mountainous waves
ever since leaving Daunt’s Rock. On Monday, the 10th of January,
she ran into what was thought to be a tidal wave. Immediately an
avalanche of water broke on the promenade deck. The officers on
duty at the time calculated the liquid weight that came aboard at
2,000 tons, and 100 feet high. At the time of the occurrence the
captain and the passengers were below at dinner, and it was
fortunate that no one was on deck. The wave wrecked the pilot
house, which is 84 feet above the water-line; four lifeboats were
smashed, as well as eleven windows in the wheel-house.
Companion ladders were carried away, while the captain’s, officers’
and their stewards’ quarters below the bridge were so badly
damaged that they could not be used. The chief officer was on the
bridge at the time, and he found himself in water up to his armpits.
The quartermaster was swept off his feet, and struck against the
chart-room bulkhead, with the fragments of the steering wheel in his
hands, and the chart-room was flooded everywhere with water. As if
that were not bad enough, the masthead lights and sidelights were
extinguished by the wave. Happily, the chief officer kept his head
above all this excitement, and finding that the engine-room telegraph
gear was undamaged, signalled down to the engineer to reverse the
turbines. The captain, who had only left the bridge a few minutes
earlier, rushed back, and in less than half an hour the big ship was
on her course again, heading for New York, where she arrived
twenty-six hours late.
It was during the following month that the Mauretania also
suffered her worst passage on record. The weather was so bad from
the first that she was unable to land her pilot at Queenstown, who
had to go all the way to New York. During the first day or two the sea
became worse and worse. On the night of Sunday, February 20th,
the Mauretania was in the thick of a heavy gale and meeting seas of
rare magnitude. Some idea may be gathered of the conditions, when
it is mentioned that the speed of this colossal liner had to be reduced
to seven knots, and kept at that for the next five hours. It may be
remembered that the Astronomer Royal reported that the wind-
pressure at Greenwich that night showed a velocity of 100 miles an
hour. When full steam was again resumed, the Mauretania received
some punishing blows, and the upper works were subjected to a
series of continuous batterings from heavy head seas. The glass of
the bridge-house was shattered, several of the lifeboats were shifted,
the water got below and flooded the forecastle, and finally an anchor,
weighing 10,000 lbs., and 50 fathoms of cable were swept into the
sea. Reading all this whilst having in mind the magnitude of these
two steamships, truly we can say that the sea is no respecter of
persons, nor even of the most marvellous products of naval
architecture.
 THE “ADRIATIC.”
From a Photograph. By permission of Messrs. Ismay, Imrie & Co.

The four-masted steamship here illustrated is the White Star

Adriatic, which was built in 1906. This mighty vessel is of 25,000
tons, and though smaller than the two Cunarders with which we have
just dealt, is superior in size and speed to the White Star Baltic, and
until the advent of the Olympic and Titanic, was the biggest
production which the White Star Line has conceived. Like the Baltic,
the second Oceanic, and the Cedric, this Adriatic follows out the
modern White Star practice of giving mammoth size, moderate
speed, and considerable luxury. She steams at 17½ knots with an
indicated horse-power of 16,000. Unlike the more modern ships, the
Adriatic is propelled not by triple or even quadruple screws, but by
twin-screws, and is employed on the Southampton-Cherbourg-
Queenstown-New York route. Although not provided with turbines,
the Adriatic exhibits a minimum of vibration owing to the careful
regard which is now paid to ensure the balancing of the moving parts
of the reciprocating engine. She has two three-bladed screws, which
are made of manganese bronze, driven by twin engines, and her
dimensions are: length, 725·9 feet; beam, 77·6; depth, 54 feet. It will
be seen, therefore, that the old ten-beams to length rule is yet again
broken in the modern White Star leviathans.
In 1905, the German Hamburg-American Line became
possessed of the Amerika, which with the length of 670½ feet, beam
74·6, and a tonnage of 22,225, and a moderate speed, makes her
rather a rival of the White Star Baltic and Adriatic, than of the Cunard
ships or the Norddeutscher Lloyd Kaiser Wilhelm der Grosse and
Kaiser Wilhelm II., and the Hamburg Company’s own fast steamship,
the Deutschland. Although sailing under a foreign flag, she is to all
intents and purposes a British ship, for she was built at Harland and
Wolff’s famous Belfast yard, where the White Star ships have come
into being. Her speed is 18 knots, so that she is rather faster than
the latest White Star ships, although inferior to the fastest
contemporary liners. Carrying a total of 4,000 passengers and crew,
the Amerika is one of the finest vessels, not merely in the German
fleet, but in the whole world.

THE “GEORGE WASHINGTON.”

From a Photograph. By permission of the Norddeutscher Lloyd Co., Bremen.
 THE “BERLIN.”
From a Photograph. By permission of the Norddeutscher Lloyd Co., Bremen.

The George Washington, which is seen steaming ahead in the

illustration herewith, was the first of the Norddeutscher Lloyd
steamers to make a considerable advance on the 20,000 tons
(registered) limit. In length, breadth and tonnage she was launched
as the biggest of all German ships, and some of her details are not
without interest. Her speed of 18½ knots is obtained by two engines
with an indicated horse-power of 20,000, and her gross register is
26,000 tons. She is propelled by twin-screws, and was built of steel
according to the highest German standards, with five steel decks
extending from end to end, a double bottom, which is divided up into
twenty-six water-tight compartments, while the ship herself is divided
by thirteen transverse bulkheads which reach up to the upper deck,
and sometimes to the upper saloon deck, and separate the vessel
into fourteen water-tight compartments. A special feature was made
in the bulkheads to render them of such a strength as to be able to
resist the pressure of the water in the event of collision. The three
upper decks seen in the photograph show the awning, the upper
promenade, and the promenade-decks; while, as in the Mauretania
and her sister, and in the Adriatic, electric lifts are installed for the
convenience of the passengers wishing to pass from one deck to the
other. The four pole-masts are of steel, and have between them no
fewer than twenty-nine derricks. The George Washington’s engines
are of the quadruple-expansion type, with two sets of four cylinders,
the propellers being two three-bladed, made of bronze. The difficulty
with large reciprocating engines has always been to cause them to
work without giving forth considerable vibration. But the careful
arrangement of the cranks of the engine so as to balance each other
tends to neutralise the vibration. It is easier to balance four cranks
than three, and in this German ship the four-crank principle is
followed. Steam is supplied by four single-ended and eight double-
ended boilers, the Howden draught system being employed.
The Berlin, the other latest modern liner of the Norddeutscher
Lloyd Line, will be seen in the next illustration. Unlike her sister, she
has been given only two masts, and in another illustration, in a later
chapter, we show this ship under construction. She was recently built
at Bremen for the Mediterranean to New York service, and carries
3,630 persons, inclusive of crew. Like other modern German liners,
this vessel is handsomely furnished, and the public rooms are all
united in a deckhouse lighted by a large number of cupola-shaped
sky-lights. She has a registered tonnage of 19,200 gross, and in the
Norddeutscher fleet ranks next after the Kaiser Wilhelm II. She
passed into the hands of her owners at the end of 1909.