International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
Pelvic Anatomy on Ultrasound and Methodology of Ultrasonographic Exam - Anna Stepniewska, MD
The regional val, which is difficult for pronouns, is famous for wine and I hope once you can try it. So I am happy to be here. Thank you. It's a very great pleasure and honor. So I'd like to thank Professor Martin, professor Kin for this possibility. Now we'll speak about the ultrasound and methodology of ultrasound, pelvic ultrasound and about anatomy anomic aspects of that. Why? Because ultrasound is an easy exam. You could take it in your ambulatory, you don't need any expensive equipment, additional expensive equipment. You can do it immediately with your patient and you can be the same patient who speaks, follows patient, but also performs diagnosis, perhaps surgery. So for the patient is the only person who may do every step of the treatment of a diagnosis and also because so that you don't set patient for the exam and then you have to see her back and then you perform the consult with her.
But you do everything together. However you need a methodology, you need some reference point because if not, you perform it well only for a simple case. While in a complex case you may have some difficulties. So I will explain you some tips and tricks. Of course, everybody then has to improve his qualities and as you can see, we don't only perform ultrasound of uterus and ovaries, but we go around of these organs. So methodology of the ultra sonography is important to perform always before the rectal vaginal examination because so that you can feel also the structures and also to remember in all cases of deep endometriosis or suspected endometriosis to put also the probe and perform also the abdominal scan to exclude hydronephrosis. When we think about anatomy in ultrasound, we have completely to change our vision because we studied on books, then we perform perhaps surgery, but what we see in ultrasound is completely different.
So we have to remember that here is our probe. So what is close to it is codal. What is in the opposite direction is cranial. Anterior is where you have your bladder and posterior is the opposite. It may be very simple when you think about the uterus, but when you think about parametria for example, is not so easy. And also you should remember that ultrasound has the advantage of having this dynamic exam possibility of moving your probe and for example, you can introduce it in the anterior phonics, then move it into the posterior phonics according to that, visualize the structures you want.
So we start the exam from the inus and we observe the anterior and posterior compartment with all these organs. Then we observe well the uterus and we identify also the internal cervical loss in order to then observe the uterosacral ligaments which start on the tous posteriorly to this point. Then we move the transversal scan of the uterus and we observe the proximal to belt tract, which helps us to identify well the ovaries not only for uterine pathology but also to have this point and to look for our ovaries because sometimes it might not be so easy and we look for the sliding sign, also the lateral and the medial one because if absent it may be the sign of additions or of endometriosis like in this case, but it doesn't work. So how it works, for example, this is a patient sent to our attention because of suspected endometrioma, but when we follow our ultrasound, we notice that both ovaries are present and it was simply the cervical cyst which has this appearance or this case sent for suspected atypical endometrioma.
While again, we observe both ovaries and in fact it was clear cell cancer arising from recto vaginal endometriosis. So anatomy, anatomy helps in the diagnosis. We can also study well the vaginal wall from the inus and also the vaginal phonic. If you see the endometriosis nole, you can observe it on ultrasound, but also you feel that the tissue resistance is completely different. We follow of course this consensus opinion of different steps of studying pelvis for endometriosis and for example, for the bladder ultrasonography, you perform ultrasound retracting because here you don't see nothing, but if you retract your probe, you can observe this endometriosis nole in the bladder. Bladder endometriosis may be present on the dome or on the base of the bladder and it's important to also measure the distance from the ureters in order to program well your surgery and to understand whether you should put the double J before and you can see how the wall of bladder changes during infiltration of endometriosis.
We've spoken a lot about fibrosis. You can see it like this hypoechoic tissue close to the hypoechoic nole A and which is the differential diagnosis is that with cancer, with the cystics interstitial, and we should remember that the nodule of endometriosis has usually this oval shape and that it infiltrates ome infiltrates from up, from outside into outside. So usually first it attaches to the osa, then affects the muscularis and only at the end it attaches the inside of the bladder or of other organs, like for example, also the bowel. You can by moving your pro laterally and rotating it a little bit, you can observe also the ureters in the pelvic tract. You can see this jet of urine and you can also see the paralysis of ureters. And then you can see also the cross with the uterine artery, which can be seen in this position and has this typical doppler sign.
Then you can follow your ureters also in the upper part, respect to the cross with uterine artery. And we should remember that this course first is in this direction, but then you can see that it's quite parallel to the internal iliac vessels. With a complete changes this direction. It's important to see always this upper side because usually endometriosis attaches just the cross with the uterine artery, so perhaps the lower part of the ureter is normal, why the upper one is delayed. We can observe also the sliding sign in the posterior and anterior compartment. And then by moving our probe to the posterior phonics, you can see all the bowel. So usually when you study the bowel, we don't see the uterus, but because we are in the posterior phonics and we can see how changes the bowel wall from the normal one into infiltrated by endometriosis with these different signs of infiltration described.
There are some tips and tricks when you cannot find anymore the bowel because it's not always so easy to follow all the tracts. So for example, when you don't understand anything, perhaps because of adhesions or complete distortion of anatomy, we should remember that we have down the anus and we can start from this then in the sagittal plane, go ahead or we can go medially to the left ovary and usually here you see the sigmoid colon, which appears on ultrasound like that. And then by moving your probe, rotating your probe, you can see here the sigmoid colon and follow the bowel. You can observe these different shapes and dimension of nodules on the bowel in order to plan well your surgery and predict what kind of resection or what kind of surgery you should plan on your bowel.
Then we observe also the rectal vaginal septum. You should remember that from anatomic point of view is the part between vagina and lower rectum. And we move also to the uterine taros, which is the part where the uterosacral ligaments are attached. And below the uterosacral ligament we can observe also the recal vaginal ligament while the technique to observe uterosacral may be in longitudinal or transverse view. Here I've put the two movies with a liquid in the pouch of Douglas. I'll see whether it works. No, sorry, just to see these two kind of observing the uterosacral, which we cannot see, like this hyper coic bounce. Oh, perfect, it works Okay, here. Now it'll appear. Okay, so this is uterosacral in longitudinal view while here in the traverse view, when we have endometriosis, we can see it on ultrasound like this, hypoechoic nodules usually without any vascularization.
And then we go to parametria, which are these connective tissue surrounding the cervix and the uterus containing vessels, lymphatic and arterial and vessel and veins. And also the nerves structures. As we know it may be divided according to different classifications. We use the one which divides it into the anterior lateral and posterior parum. According to articles described by Dr. Chacar, our chief who describes in the anterior parum, the vesco uterine and vesco vaginal ligament and then lateral to the ureter, the lateral ligament of the bladder. Then in the lateral parameter, the upper side cranial side, we have macal ligament and the lower is the para cervix. And then in the posterior parametal we have the uterosacral rectovaginal ligaments and the lateral rectal ligaments.
So when we want to identify them on ultrasound, how can we do we already learned in the anterior parum? Immediately we can see, we know recognize ureter. So this is our point to identify the anterior parum. For the lateral one, we have a cross of uterine artery and ureter, so that's important. And in the posterior parum we now recognize in ultrasound the uterosacral ligament. So that's our point. And here you can see the images. So the anterior parum is this part surrounding ureter medially and laterally up to the cross with the uterine artery. The lateral parametrium is obtained on ultrasound. This by rotating our probe from this image into this and we can see ureter like that and uterine artery like that. And then we know that the cranial part is mac andro and the al part is par cervix. While in the posterior parum we follow the steps of obtaining uterosacral ligament and then we know that the lower part is rectal vaginal ligament.
I found this very interesting case of clear cell carcinoma when I've seen it on ultrasound. I immediately told that there is something strange, it's not a normal endometriosis, even if she was sent for this diagnosis because it was not only the huge dimension, but also you can see that there was some vascularization and also the color was a little bit different. It was more white, more hyper coic than the normal endometriosis. We can also move to the presacral space. So we are in this part, so we are below the posterior part of the rectum and we can see the scrum. And here if you have a lesion, of course it's not an endometriosis nole, but something else. For example, in this case we have tarlo cyst and there are now some new aspects which are really amazing because recently it was described also to see the neural structures in the pelvis.
So we try to obtain these images so we can see for example here the sacral plexus, which at the beginning perhaps it's not so easy to identify, but after some time you know how to find it. You observe this typical bundle of stroke EcoStruxure here, it's in this direction. So here you have the allof scrum, here's the ecal spine. Here you can see the ator internal muscle and here the branches of internal iliac artery. And here is the muscle, again is piriformis muscle. So here is thecal foramen and all these structures going out from the pelvis. This point well describe by these authors, they just put step by step how to obtain the images of the sacral plexus. And here the orientation of your probe cranial and codal is very important to obtain this image. And he described this bend of straw sign in the longitudinal view of sacral plexus.
When you rotate your probe, you can observe this honeycomb EcoStruxure. He also described the sacral lus roots of ultrasound. So you can see from the sacral foramina this typical shape of sacral lus roots. So it's really amazing because that means that ultrasound may really take place of MRI in different steps of study of pelvis. So as a conclusion, I could say that perhaps the future or just the presence is to unite the interest for laparoscopy and for ultrasound, not to give your patient to the others to study. But if you start step by step to follow these steps, one, you may be able to follow her to diagnose, to operate, and to see the recurrence without asking anybody, you can do immediately your diagnosis. You can verify your diagnosis with every patient. So your corneal nerve is very, very good. Okay? And you also perform your surgery with this conscious of what you have seen and you plan really well your surgery.
So you can do ultrasound counseling and decision in the same point. And also perform with her immediately counseling because you know which other risk according to the staging on ultrasound you've performed. Then you do all surgery if necessary and you can see whether it works and how can you improve also your diagnosis. And I think that this the future, but perhaps also the present. And I would like to invite you to Italy to our courses here. We have courses about anatomy, about surgery, about ultrasound, and we are very happy to see you. Thank you so much.
