The abdomen, when looking from in front, is divided into nine regions by imaginary planes (two vertical and two horizontal) forming abdominal surface anatomy. The nine regions are of clinical importance when examining and describing pathologies related to the abdomen. The horizontal planes are o...
Ectopic pregnancy refers to the implantation of a fertilised ovum outside of the uterine cavity.
The overall incidence has increased over the last few decades and is currently thought to affect 1-2% of pregnancies. The risk is as high as 18% for first trimester pregnancies with bl...
Macroglossia means an enlarged tongue. It may be absolute (greater than the 95th centile) or relative (enlarged compared with oral cavity).
Recognised associations include:
tends to be a relative macroglossia
may also have intermi...
Ovarian torsion, also sometimes termed adnexal torsion or tubo-ovarian torsion, refers to rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle.
It can be intermittent or sustained and results in venous, arterial and lymphatic stasis. It is a gynaecological ...
Robinow syndrome is a rare heterogenous genetic disorder with at least two distinct forms.
The syndrome can affects several systems which include:
mesomelic limb shortening: mesomelia
characteristic facies anomalies
The International Ovarian Tumour Analysis (IOTA) group ultrasound rules for ovarian masses are a simple set of ultrasound findings that classify ovarian masses into benign, malignant or inconclusive masses. These rules apply to masses that are not a classical ovarian mass (e.g. corpus luteum, en...
Ovarian dermoid cyst and mature cystic ovarian teratoma are terms often used interchangeably to refer to the most common ovarian neoplasm. These slow-growing tumours contain elements from multiple germ cell layers and are best assessed with ultrasound.
Although they have very simi...
Haematocolpos is a term given to a blood-filled dilated vagina due to menstrual blood in the setting of an anatomical obstruction, usually an imperforate hymen. In this condition, there is no distention of the uterine cavity, c.f. haematometrocolpos.
Patients may present...
The superficial perineal pouch is an anatomic space below the perineal membrane in the urogenital triangle of the perineum.
The superficial perineal pouch is below the perineal membrane in the urogenital triangle, anterior to the transverse line between the ischial tuberosities.
Post-ablation tubal sterilisation syndrome (PATSS) is a recognised delayed complication seen in patients who have undergone both endometrial ablation and tubal sterilisation. It has been reported in 6-8% of these patients and occurs when bleeding from residual endometrium is obstructed due to su...
Endometrial ablation is a minimally invasive surgical procedure that involves the destruction of the uterine endometrium commonly performed for menorrhagia in premenopausal or perimenopausal women.
It has evolved has an alternative to hysterectomy and is associated with good outcomes and patien...
Frontal bossing is a calvarial radiographic feature where the front of the skull appears protruding anteriorly. It is best appreciated on a sagittal or lateral image.
This feature can be seen in many conditions (in alphabetical order):
Immature ovarian teratomas are uncommon ovarian germ cell tumours. They differ from mature ovarian teratomas (dermoid cysts) both histologically by the presence of immature tissue, and clinically by their more malignant behaviour.
They are considerably less common than mature ovar...
Primary peritoneal neoplasms comprise of an uncommon group of heterogenous entities.
The list includes:
primary (malignant) peritoneal mesothelioma
primary perioneal multicystic mesothelioma
primary peritoneal well differentiated papillary mesothelioma
Syndactyly refers to a congenital fusion of two or more digits. It may be confined to soft tissue (soft tissue syndactyly / simple syndactyly) or may involve bone (bony syndactyly / complex syndactyly).
The overall estimated incidence is at ~1 per 2500 to 5000 live births 6,8. The...
Obstetric and gynaecological ultrasound is rampant with numerous cut off values. Some of these get revised over the years. The following list is a useful aid to refer to and revise.
rate of increase of a mean sac diameter per day in early pregnancy
generally accepted value for a th...
Ovarian cystic neoplasms can be either benign or malignant and can arise from epithelial, stromal, or germ cell components. In general, the risk of malignancy in unilocular cystic tumours <10 cm in women over the age of 50 years is thought to be low 3-4.
ovarian mature cystic teratoma
Myometrium cysts are cysts seen in the myometrium and these can be differentiated appropriately based on location and sonological or Doppler features.
adenomyosis: the cysts are most often seen in the endomyometrial junction region. They ideally are small <5 mm, however ma...
A large for date uterus is a clinical observation based on uterine fundal height, which may result in referral for ultrasound assessment, usually in mid to late pregnancy.
constitutionally large fetus
IUCD related uterine perforations are one of the causes of uterine perforation. It is rare, but a serious complication of an IUCD insertion, and is often clinically silent.
The incidence rate is reported at ~2 in 1000 2.
Perforation at the time of insertio...
Intra-uterine contraceptive devices (IUCD) are one of the most frequently used methods of contraception throughout the world. It prevents pregnancy by:
thinnning the endometrial lining
preventing sperm motility
There are two main types of IUCDs:
Body packing refers to the internal concealment of drugs within the gastrointestinal tract or other orifices. People who do this may be called body packers, (drug) mules, stuffers, couriers or swallowers. Drugs may be concealed within condoms, foil, latex or cellophane.
There is ...
Hydrocolpos is characterised by an expanded fluid filled vaginal cavity. When it is associated with distention of the uterine cavity, the term hydrometrocolpos should then be used. It may present in infancy with a lower abdominal mass, or be delayed till menarche.
A unicornuate uterus or unicornis unicollis is a type of Mullerian duct anomaly (class II) that is the second most commonly associated with miscarriages.
This type can account for ~10% (range 6-13%) of uterine anomalies and infertility is seen in ~12.5% (range 5-20%) of cases.
Endometrial thickness is a commonly measured parameter on routine gynaecological ultrasound and MR imaging. The appearance, as well as the thickness of the endometrium, will depend on whether the patient is of reproductive age or post-menopausal and, if of reproductive age, at what point in the ...
Borderline ovarian serous cystadenomas lie in the intermediate range in the spectrum of ovarian serous tumours and represent approximately 15% of all serous tumours.
They present at a younger age group 1-2 than the more malignant serous cystadenocarcinomas with a peak age of prese...
Ovarian serous neoplasms are the commonest subtypes of the epithelial ovarian tumours, being more prevalent than the mucinous ovarian tumours. They are subdivided according to their malignant potential and clinical behaviour into:
benign serous cystadenoma / serous cystadenofibroma
Ovarian borderline mucinous cystadenomas are a subtype of ovarian mucinous tumours and, as the name stands, are intermediate between mucinous cystadenomas and mucinous cystadenocarcinomas.
They account for ~ 10-15% of all ovarian mucinous tumours.
They are microscopica...
Ovarian mucinous tumours are a subgroup of ovarian epithelial tumours. They represent ~20% of all ovarian tumours and ~10% of all malignant ovarian tumours. They are subdivided according to their malignant potential and clinical behaviour into:
ovarian mucinous cystadenoma
ovarian borderline m...
Pelvic lipomatosis (also known as pelvic fibrolipomatosis) represents excessive deposition of fat in pelvis due to overgrowth of adipose cells leading to compression of pelvic organs.
The condition usually presents in patients 20-50 years of age. The condition is predominantly (2/...
Bartholin gland cysts are located in the postero-lateral inferior third of the vagina and are associated with the labia majora.
Most patients are asymptomatic 4.
infection: may turn into Bartholin gland abscesses
rare instances of development of adenocar...
MR defecography is a dynamic study for evaluation of the pelvic floor and pelvic organ prolapse.
There are four phases of evaluation:
Method of evaluation
Many variations in the techniques described below exist.
Uterine dehiscence is, usually, used to refer to the process of gradual myometrial rupture without a rupture of membranes. However, the term is used synonymously with uterine rupture by some authors. It is often described in the context of C-section scar where it is also termed an incisional deh...
Retained products of conception (RPOC) refer to the persistence of placental and/or fetal tissue in the uterus following delivery, termination of pregnancy or a miscarriage.
Retained products of conception complicate ~1-5% of all pregnancies (routine vaginal deliveries 12).
The cogwheel sign refers to an imaging appearance in pelvic imaging of thickening loops of the Fallopian tube seen on cross-section. There are infolding projections (sometimes looking like nodules) into the Fallopian tube lumen which is likened to that of a cogwheel. The sign is typically descri...
The claw sign is useful in determining whether a mass arises from a solid structure or is located adjacent to it and distorts the outline.
It refers to the sharp angles on either side of the mass, which the surrounding normal parenchyma forms when the mass has arisen from the parenchyma. As suc...
Tubal ring sign, also referred to as bagel sign or blob sign, one of the ultrasound signs of a tubal ectopic. It comprises of an echogenic ring which surrounds an unruptured ectopic pregnancy. It is said to have a 95% positive predictive value (PPV) for ectopic pregnancy.
Endometriosis is a common and clinically important problem in women of childbearing age. It is classically defined as the presence of functional endometrial glands and stroma outside the uterine cavity and its musculature 1. This is distinct from adenomyosis, in which endometrial tissue is confi...
Cumulus oophorus refers to an appearance in the ovary in which multiple granulosa cells enlarge around a developing oocyte. These support cells ("cumulus cells") serve multiple functions in the maturation of the oocyte. They may occasionally be seen during a pelvic ultrasound, and should not be ...
The uterine tube, also known as the fallopian tube, is a paired structure that bridges between each ovary and the uterus and functions to convey the mature ovum from the former to the latter. If conception occurs, it normally does so within the tube. It can be affected by a wide range of patholo...
Adenosquamous cell carcinoma (ASC) of the cervix is a rare histological subtype of cervical carcinoma.
It has components of both cervical adenocarcinoma and cervical squamous cell carcinoma.
An adenosquamous histology appears to be an independent predictor of poor outcome...
The bridging vessel sign refers to an appearance of vessels coursing from the uterus into an adjoining pelvic mass (a vascular bridge). This sign helps to differentiate a pedunculated subserosal uterine leiomyoma from other juxtauterine masses of ovarian, adnexal or bowel origin.
Colour and pow...
Hemimegalencephaly is a rare congenital disorder of cortical formation with hamartomatous overgrowth all or a part of a cerebral hemisphere. This results from either increased proliferation or decreased apoptosis (or both) of developing neurons 2.
Hemimegalencephaly is a cryptogen...
Struma ovarii tumour is a subtype of an ovarian teratoma and is composed entirely or predominantly of thyroid tissue and containing variable-sized follicles with colloid material.
It accounts for 0.3-1% of all ovarian tumours and ~3% of all mature cystic teratomas 1.
Androgen insensitivity syndrome (AIS), also known as the testicular feminisation syndrome, results from end-organ resistance to androgens, particularly testosterone. AIS may be complete or incomplete with variable imaging findings.
The incidence may vary depending on whether it i...
Perivascular epithelioid cells tumours (PEComas) are a group of related mesenchymal tumours and tumour-like conditions found in many locations. This group includes:
clear cell 'sugar' tumour of the lung
clear cell myomelanocytic tumour (CCM...
Interstitial ectopic pregnancy (also known as an intramural) is an important type of ectopic pregnancy with higher risks of rupture and haemorrhage compared to usual tubal ectopic pregnancies.
The term interstitial pregnancy is sometimes interchangeably used with cornual pregnancy...
Shorted fetal femur is a morphological descriptor and is usually defined when the femoral length falls below the 5th centile for gestational age (some define it when its under the 2.5th centile 5) or less than 0.91 predicted by the bi-pareital diameter. It can occur in isolated or in association...
A simple mnemonic to recall a list of commonly calcifying metastases is:
B: breast cancer
T: papillary thyroid cancer
O: ovarian cancer (especially mucinous)
M: mucinous adenocarcinoma (especially colorectal carcinoma)
In utero bowel perforation results in a chemical peritonitis (meconium peritonitis) from peritoneal leakage of sterile meconium.
It can result from many causes which include:
in utero intestinal ischaemia
Uterine perforation represents a serious complication that can occur as a result of any type of intrauterine procedure or implantation. Some authors use the term uterine rupture synonymously with the term uterine perforation.
IUCD insertion: IUCD related uterine perforation
Semilobar holoprosencephaly is a subtype of holoprosencephaly (HPE) characterised by an incomplete forebrain division. It is intermediate in severity, being worse than lobar holoprosencephaly and better than alobar holoprosencephaly.
Please refer on the general article of holopros...
Abscesses are focal confined collections of suppurative inflammatory material and can be thought of as having three components 1:
a central core consisting of necrotic inflammatory cells and local tissue
peripheral halo of viable neutrophils
surrounded by a 'capsule' with dilated blood vessel...
Ovarian cysts are commonly encountered in gynaecological imaging, and vary widely in aetiology, from physiologic, to complex benign, to neoplastic.
Small cystic ovarian structures should be considered normal ovarian follicles unless the patient is pre-pubertal, post-menopausal, pregnant, or the...
The corpus luteum is a temporary endocrine structure involved in ovulation and early pregnancy.
During ovulation, the primary follicle forms the secondary follicle and subsequently the mature vesicular follicle.
At ovulation the follicle ruptures expelling the ovum into the fallopian tube. The...
An ovarian follicle (also known as a Graafian follicle in its mature state) is the basic unit of female reproductive biology and is composed of roughly spherical aggregations of cells. It contains a single oocyte.
An ovarian follicle can be initiated to grow and develop, culminating in ovulati...
A collision tumour of the ovary is an uncommon ovarian neoplasm where there is co-existence of two adjacent but histologically distinct tumours with no histologic admixture at the interface.
The exact pathogenesis is not well known. They are most commonly composed of ovarian teratoma...
Mucinous cystadenocarcinoma of the ovary is a rare malignant ovarian mucinous tumour. This type can account for 5-10% of all ovarian mucinous tumours. It is a type of ovarian epithelial tumour.
Retrospective studies have suggested that many mucinous carcinomas initially diagnosed as...
Paraovarian cysts (POCs) are remnants of Wolffian duct in the mesosalpinx that do not arise from the ovary. They account for ~10-20% of adnexal masses 3-4.
They typically occur in women at the ages of 20-40 years old.
Most are asymptomatic, although patient...
Surgical haemostatic material is used to control bleeding intraoperatively and is hence frequently voluntarily left in the operative bed, not to be confused with a gossypiboma which is foreign material left by mistake. It can mimic an abscess on imaging studies. Various types are available, the ...
Squamous cell carcinoma (SCC) of the cervix is the most common histological subtype of cervical cancer and accounts for 80-90% of cases.
Most cervical squamous cell carcinomas grow at the squamocolumnar junction (SCJ). In younger women, the SCJ is located outside the external uterine...
Ovarian hyperstimulation syndrome (OHSS) is a complication of ovarian stimulation treatment (ovarian induction therapy) for in vitro fertilisation. Rarely, it may also occur as a spontaneous event in pregnancy (see spontaneous ovarian hyperstimulation later in the article).
The clinical syndrom...
Physiological pelvic intraperitoneal fluid refers to the presence of a small volume of free fluid in the pelvis, particularly the pouch of Douglas. It occurs in young females of reproductive age and can be a mimic of traumatic free fluid in abdominal trauma.
Unfortunately, pelvic free fluid may...
Ruptured ovarian cysts are one of the most common causes of acute pelvic pain in premenopausal women. The sonographic appearance depends on whether a simple or hemorrhagic ovarian cyst ruptures, and whether the cyst has completely collapsed. The most important differential consideration is a rup...
The cul-de-sac, also known as the pouch of Douglas or rectouterine pouch, is an extension of the postero-inferior reflection of the peritoneal fold between the uterus (anteriorly) and rectum (posteriorly). It is the most inferior aspect of the peritoneal cavity and therefore the first location w...
The gonadal arteries are the paired primary vascular supply to the ovaries in the female and the testes in the male. As the anatomy of the gonadal arteries differs substantially between the sexes, they are covered separately:
Ovarian tumours are relatively common and account for ~6% of female malignancies. This article focuses on the general classification of ovarian tumours. For specific features, refer to the sub-articles.
Primary ovarian tumours
Surface epithelial stromal ovarian tumours (60...
Serum CA-125 is well recognised as an ovarian cancer-associated marker and is an antigen determinant on a high-molecular-weight glycoprotein. The normal range of CA-125 is 0-35 U/mL.
Serum CA-125 levels can also be used to monitor the response to treatment as well as a prognostic indicator sinc...
Human epididymis protein 4 (HE4) is an emerging serum biomarker in the assessment of epithelial ovarian tumours. HE4 is a member of the whey associated protein (WAP) gene cluster and has uncertain biological function 1.
Early results indicate that HE4 has higher sensitivity and sensitivity than...
Endometrioid carcinomas of the ovary are a sub-type of epithelial ovarian tumours. The vast majority are malignant and invasive. On imaging, they are usually characterised as complex nonspecific solid-cystic masses and found associated with endometriosis.
Endometrioid carcinomas ...
Evaluation of known endometriosis with MRI requires a slightly different protocol to a routine pelvic MRI (see Pelvic MRI protocol: routine), and should probably be reserved for known cases of endometriosis rather than for the assessment of pelvic pain.
IV (or IM) Buscopan® is administered to r...
Uterine artery embolisation (UAE) is used as an alternative to hysterectomy in selected patients and MRI assessment is key in allowing not only pre-procedure assessment but also assessing post-procedural outcome.
For a general discussion of the underlying condition refer to the article on ute...
Ovarian vein thrombosis (actually most often a thrombophlebitis) occurs most commonly in postpartum patients and can result in pulmonary emboli. A presentation is usually with acute pelvic pain in the postpartum period, then termed puerperal ovarian vein thrombosis or postpartum ovarian vein th...
A persistent right umbilical vein (PRUV) is an uncommon vascular anomaly which is often detected in utero.
The estimated prevalence is at ~2 per 1000 births 1-2.
In the normal situation, the right umbilical vein begins to obliterate in the ~4th week of gestation and di...
Uterine choriocarcinomas are one of the commonest choriocarcinomas and are often associated with gestational trophoblastic disease (GTD).
These tumours typically occur in women of childbearing age as a gestational choriocarcinoma. Most such cases present within one year of an ant...
Noonan syndrome (NS) is a genetically and phenotypically heterogenous non aneuploidic congenital RASopathy. Affected individuals can bear some clinical features similar to that of Turner syndrome.
The estimated incidence is at ~1 in 1000-2500 11. As individuals have normal number...
Noonan syndrome with multiple lentigines, previously known as LEOPARD syndrome (LS), is a rare autosomal dominant RASopathy that has many similarities to Noonan syndrome.
Despite a change in formal name, the 'LEOPARD' acronym is still useful to summarise the clinical feat...
Adenomyosis of the uterus is a common, benign uterine pathology. It is thought by many to be on the spectrum of endometriosis, with ectopic endometrial tissue in the myometrium. Adenomyosis may present with menorrhagia and dysmenorrhea. Ultrasound and MRI are imaging modalities that may show cha...
It is important to have a systematic way of approaching a case with subfertility in the exam.
Ultrasound is the initial examination of choice. Always say that you would further assess the uterus with 3D ultrasound. You may also say that in my department we would perform a sonohysterogram or HS...
Fitz-Hugh-Curtis syndrome (FHCS) refers to the development of a perihepatitis in association with pelvic inflammatory disease (PID).
The prevalence in adults with mild to moderate PID (gonorrhoic) may approximate 4% 10. The prevalence may be higher in genital tuberculosis 12. It ...
Pelvic inflammatory disease (PID) is a broad term that encompasses a spectrum of infection and inflammation of the upper female genital tract, resulting in a range of abnormalities.
The highest incidence is seen among sexually active women in their teens, with 75% cases being und...
Asherman syndrome, also known as uterine synechiae, is a condition characterised by the formation of intrauterine adhesions, which are usually sequela from injury to the endometrium, and is often associated with infertility.
There is a tendency for the condition to develop soon af...
Uterine agenesis is the extreme of Mullerian duct anomalies (Class I) where there is a complete absence of uterine tissue above the vagina.
The uterine agenesis-hypoplasia spectrum accounts for ~10-15% of all Müllerian duct anomalies.
Tubo-ovarian abscesses (TOA) are one of the late complications of pelvic inflammatory disease (PID).
Patients typically present with fever, elevated white blood cell count, lower abdominal-pelvic pain, and/or vaginal discharge. Fever and leukocytosis may sometimes be abse...
Ruptured corpus luteal cysts are one of the commonest causes of spontaneous haemoperitoneum in a woman of reproductive age.
Presentation is variable, ranging from completely asymptomatic to severe abdominal pain due to peritoneal irritation.
The corpus luteum ...
Hyaline degeneration is the most common form of degeneration that can occur in a uterine leiomyoma.
It is thought to occur in up to 60% of uterine leiomyomas 3.
As with many other types of degeneration, it happens when fibroids outgrow their blood supply 4. Hyaline de...
Subserosal uterine leiomyoma is a subtype of uterine leiomyoma that often exophytically projects outwards from a subserosal location. While its exact definition may vary, a leiomyoma is often called subserosal if >50% of the fibroid protrudes out of the serosal surface of the uterus 2. They can ...
Intramural uterine leiomyoma is the most common type of uterine leiomyoma in terms of location. They are centred primarily within the myometrium. A large intramural uterine leiomyoma can, however, have a submucosal or subserosal component.
They are usually asymptomatic; h...
Polycystic ovarian syndrome (PCOS), recently referred also as hyperandrogenic anovulation, is a chronic anovulation syndrome associated with androgen excess.
The diagnosis is made on the combined clinical, biochemical and sonographic grounds. The revised 2003 ASRM/ESHRE Rotterdam consensus cri...
Red or carneous degeneration is one of four main types of degeneration that can involve a uterine leiomyoma. While it is an uncommon type of degeneration, it is thought to be the most common form of degeneration of a leiomyoma during pregnancy 3.
Patients with a leiomyoma...
Submucosal leiomyomas of the uterus refer to a subtype of uterine leiomyoma that primarily projects into the endometrial cavity. They are least common albeit the most symptomatic type of leiomyoma.
Submucosal leiomyomas can be a common source of abnormal uterine bleeding ...
Myxoid uterine leiomyoma is a relatively rare pathological subtype of uterine leiomyomas. It is not to be confused with myxoid degeneration of a uterine leiomyoma which has a related but no identical meaning.
Myxoid leiomyomas contain abundant myxoid material between smooth muscle ce...
Uterine leiomyomas, also referred as uterine fibroids, are benign tumours of myometrial origin and are the most common solid benign uterine neoplasms. Commonly an incidental finding on imaging, they rarely cause a diagnostic dilemma. There are various medical, surgical and interventional treatme...