Non-Gynecological Findings on Pelvic Scans - SD

Introduction

This is Dr. Oksana Bal Taric from Thomas Jefferson University.

This talk is about non gynecologic findings on pelvic scans.

I'd like to talk about causes of some of these non gynecologic findings, and I'll talk about gastrointestinal findings. Genitourinary findings that mainly refers to the urinary tract vascular etiologies, some unusual retroperitoneal tumors, and abdominal wall masses.

Ultrasound vs. CT for Pelvic Evaluation

We all know that ultrasound is an excellent modality for evaluating the female pelvis. But what we're actually doing is we're focusing on pelvic organs. So it's more of a focused examination.

When you look at CT, CT has a broader scope of the structures that we can look at. It is used for more generalized type of evaluations. It's much better for evaluation of bowel. We see the entire urinary tract, especially the ureters, which we can't see really with ultrasound. We can see pelvic sidewall structures, muscles, bones, vessels, nodes, et cetera.

And when we deal with complicated pelvic situations, often both examinations are complimentary.

Gastrointestinal Findings

There are gastrointestinal causes of pelvic pain. Acute appendicitis is probably the best known cause of right lower quadrant pain. We can also pick up colitis, diverticulitis, ileitis, and enteritis, sometimes colon cancer show up on ultrasound. We can see small bowel obstruction and some unusual processes.

Most of all, most of the time these are CT diagnoses, but we sometimes see them on ultrasound, acute appendicitis.

Acute Appendicitis

Let's start with that. This is the most common cause for right lower quadrant pain. It has pain fever, elevated white count, nausea, tenderness, when the presentations are not typical, when they're atypical. This could lead to a delay in diagnosis. And this is a fear of a lot of clinicians. They do not want to see a perforation or an abscess. They know that this prolongs the course, increases the complications, so they want an early diagnosis.

We also want to have a good diagnosis and not to do unnecessary surgeries. And cross-sectional imaging has improved our diagnostic accuracy. We're always trying to balance the perforation rate at surgery and the negative laparotomy rate in the past. Without these cross-sectional imaging techniques, the negative laparotomy rate was running at 20%. We would like to bring the negative laparotomy rate down below 5%, and we certainly are heading in that direction.

Now, when we think about which modality to use, we turn to the literature and the literature shows us that a number of different articles have been written with on this problem. And the sensitivities and specificities that are reported for both ultrasound and CT, they run somewhat similar. They're about 76 to 98% depending on what you read, both for ultrasound and for CT.

Ultrasound is limited by a number of factors we all know about, bone and gas, et cetera. But it's probably best decided by the body habitus of the patient. So if it's a thin young patient, it should do quite well. In an obese heavier patient, it does not do very well at all. Those should go to CT. Also, the choice between these two is heavily influenced by the institutional preference and the available expertise. So if your institution does not have people well experienced with ultrasound, they may feel uncomfortable. They'll send all these cases to CT. However, if you have a strong ultrasound section, they may offer to do the ultrasounds first. So that's often institutional preference.

Sonography is preferred in children because of the radiation, in thin women because it's easier to get at the appendix and pregnant women. This is where we should start. We should start with ultrasound. CT on the other hand, is preferred in heavy or obese patients. Typically it's preferred in males. Now, even thin males do better with CT because the abdominal wall musculature tends to attenuate the sound. And then we don't have as good penetration CTs better when the abdomen is rigid. Non-compressible. We can't do our graded compressions with the ultrasound. So CTs better there.

If we think the process has gone on to more advanced, complicated appendicitis where there's been a perforation or an abscess, we go onto CT, or if the appendix is suspected or known to be in an unusual location.

So here are some CTs showing us appendicitis. Now, here is a blind ending tubular structure that has some fat stranding around it. Look how close it is to the skin. This is easily done by ultrasound. Here's another patient with a very large appendicolith and dilated appendix. Again, this is something that could be visualized with ultrasound because it's right under the abdominal wall. Here's another appendicitis with edema surrounding the appendix and a little appendix with, if we compress this abdomen, possibly we could see this. And here's a younger patient with an acute appendicitis and a lot of surrounding fat stranding. Again, compression leads us right into the appendix. So all of these cases could be handled fairly easily with ultrasound first.

But if we have cases such as an appendix that wants to cross the midline, or at least land in the midline, look how deep it is to bowel loops. We would not be able to visualize this with ultrasound because of the interference with bowel gas. Here's another one. Shows up in the middle here, protected by all these bowel loops that would shadow out this area. Here's another one that drops down into the pelvis. We could approach this through a vaginal approach. If we scan carefully. And here's another one that shows up under the liver, way high up it goes superiorly and behind the hepatic flexure. That again would be probably very difficult to see with ultrasound.

Now, when we want to look for the appendix, one of the first things we have to remember is that this is located not that deep in the body. It's right under the abdominal wall. So we need to look under the abdominal wall, which means it's more superficial, which means we have to use high frequency transducers, usually seven to 13 megahertz. Five to nine is about what most people use. Five to 10. But we also need to do graded compression. So we want a flat surface to the probe. So we're actually looking at this type of anatomy. Here are our layers of the abdominal wall. Peritoneum is right under here and under it then resides this acutely inflamed appendix, so we don't have to see that far deep into the pelvis. We focus on this more superficial area.

We see here, blind ending tubular structure, multi-layered with some debris in the lumen and surrounding hyperechoic fat. So our ultrasound criteria for acute appendicitis are a blind ending tubular structure, which is non-compressible and has no peristalsis. We can see, especially in this cross section, a multi-layered appearance that's gut signature. What we see is we see bright dark, bright, dark, and then surrounding brightness. And those are our layers of the bowel wall. The mucosa surrounding that is a hypoechoic muscularis mucosa. Then comes the thick bright line, that's the submucosa. Then comes the muscularis propria, and around that, the serosa. So this is classical for bowel.

Here's another appendix in cross-section, multi-layered, non-compressible. And it should measure over six millimeters to be considered abnormal. Occasionally we will see an appendicolith. So here's our blind ending tubular structure. It has some fluid in the middle. And then we have a small, bright reflector, an appendicolith. Here's another one. You look carefully. And there's the appendicolith with the faint acoustical shadow.

We also wanna look around at the fat to look for brightness of the fat and hyperemia hyperemia within the wall, and also hyperemia of the fat surrounding the appendix. This is not always helpful to see hyperemia within the wall. It is much more likely to see hyperemia within the surrounding fat.

Now, when this appendix goes on to a more complicated state, when it perforates, we have additional findings. We will see interruptions within the wall disrupted wall continuity. We'll see marked thickening of the wall. The appendix gets a lot thicker, over 13 millimeters, they almost all perforate. They can accumulate much more fluid. There are layers of edema around them. There is increased dense echogenicity of surrounding fat.

Here's a transvaginal scan showing us one of these pelvic appendices. It's a blind ending. Tubular structure, multi-layered, turn transverse. Here we have the multi-layered approach. There's no peristalsis in here. You press on it. That's what hurts. The only thing we can't do is we can't compress it because as we push on it, we just keep pushing it up into the towards the false pelvis and up towards the abdomen. Here's another example. A thick walled appendix containing fluid. But notice it's blind ending. It would have no peristalsis.

The appendix can then go on to rupture. And an abscess may form that becomes more indistinct. It's harder to see. We were looking at this area, wondering what's going on? Do we have some kind of abscess happening here? Is it related to the ovary or not? We realized that it was separate. It's always very helpful when little arrows come up to show us things like the echogenic focus, the shadows, which is the appendicolith. And then this actually, as we scanned around, was the limits of this mass. This is already pus and an abscess that has formed at the tip of this perforated appendix.

Once we have a perforation and abscess formation, we lose tissue planes. Things become matted together, very indistinct, difficult to define. Here's the uterus. Here's an ovary. And then there was this complex sort of cystic area. The CT does better with that. The CT shows us this mixed densities, some enhancement. The bowel is pushed, so there's a mass effect. There's fluid in the pelvis. And actually, that was an appendix. This was the ruptured appendix, and the appendicolith fell out into the pelvic cavity. This can go on then to look like an abscess.

Now we're looking from below. We're looking from transvaginally from below. So we have a pretty good chance of seeing the pus and the fluid component. If we were looking transabdominally, this gas that layers here would interfere with seeing the entire abscess. And also, if there were bowel loops overlying this, we wouldn't be able to see. So here's this whole area of inflamed bowel, and there's an interloop abscess here. And the rest of the bowel being pushed over.

These type of patients need drainage surgeries, not always the answer. Interventional radiology in this day and age is extremely helpful because they can drain this with a catheter. Sometimes we drain these abscesses per vagina or per rectum, and these patients do well with antibiotics. It's a nightmare opening up this type of abdomen surgically because you clean out the pus, and inadvertently pus goes into other places. And a couple weeks after the surgery, they may end up with more abscesses. So interventional radiology, then we guide them with ultrasound. They put their catheters in and drain this nicely.

Other Gastrointestinal Issues

Other things that we see are abnormal bowel loops. Other types of bowel loops. Like here, we see small bowel loops that have thickened walls. We can see haustra or valvulae conniventes. These are these lacy circulars that tell us that that is small bowel. Sometimes the loops are dilated filled with fluid. Sometimes they're narrowed or strictured. They have decreased peristalsis. They don't compress well. As they're distended, they start losing their multilayered look because of the edema invading the wall. Surrounding fat may be hyperechoic due to the inflammation and infiltration. And occasionally we may pick up abnormally enlarged lymph nodes.

Here's a patient that had left sided pain and in the left side of the abdomen as we were looking at her kidney. After we examined her pelvis, we found something that looked like very thickened bowel markings, thickened wall non peristaltic bowel. Another case similar kind of appearance, a very thickened bowel wall. The CT shows us that this is indeed the colon with a very abnormally thickened edematous wall. And these patients have colitis. The differential includes infectious colitis, c diff especially, clostridium difficile in this pop in hospital patients, inflammatory ulcerative colitis, Crohn's disease can cause this ischemic colitis, as well. These are all in our differential.

This patient had very dilated, thick walled abnormal bowel. Look at the colon here. There's some fluid around. And here's the CT showing that this occurred in the left colon. It extended pretty high here towards the splenic flexure. This is the perfect location for ischemic colitis, where we have this watershed, areas where the circulation from the superior mesenteric artery in the inferior mesenteric artery crossover. And that's a very known spot for ischemic colitis.

When colitis goes on to a severe form, toxic megacolon occurs, the wall becomes markedly thickened. It has these thumbprints along the wall. It develops these so-called pseudo polyps. This is from the mucosa. This colon is very ill. It's friable. It's likely to perforate. And we can alert the clinicians then to go on and do a CT. This patient as I recall, had a right lower quadrant renal transplant and was having pain. We looked at the transplant and adjacent to it, found this extremely abnormal loop of colon. She ended up having CT, which showed this toxic megacolon showed the extent much better.

This case was interesting. We did her right upper quadrant, this patient's right upper quadrant, looking for a cause of jaundice and some pain that she had. And we found something that looked like a metastasis in the left lobe of her liver. But the right lobe of her liver was very heterogeneous. It seemed to have multiple masses in it, and it seemed to have a fairly clear demarcation of the process being very abnormal in the right lobe of the liver. And that kind of lit up a light bulb that if that's affecting the right lobe, maybe it's something that's draining into the liver from the right side of the body that's causing a problem. And so we went down, looking down along the right flank, and sure enough, at the bottom of the colon, we found an abnormal mass within her cecum. So this was biopsied, and this is a colon cancer. Here's a CT showing this large mass distorting this lumen, and biopsy, again, showed colon or squamous carcinoma, which you can sometimes diagnose by ultrasound.

This patient had some pain, and we were doing a pelvic scan, and somebody thought that this looked like the left ovary. This is a sagittal through her left pelvis pretty high up. We thought this was her left ovary. And sometimes we find them high in the false pelvis. But when we did our transvaginal, we found a beautiful, normal looking left ovary deep down in the pelvis. So this wasn't an ovary up here. And I would bet with you that if we really sat down and thought about how many times we call things ovaries that are not ovaries on a daily basis in ultrasound, I think that we could be honest and say that we make up a lot of ovaries, a lot of pseudo ovaries. So it's very good for us to pursue these and find features. Like here we found little follicles. Now we know for sure this is the ovary. Now we have to think, what is that going on? We pursue this with a CT scan. The bowel wall is thick, and there's a lot of surrounding fat edema and biopsy reveals colon cancer. So this is actually the tumor itself that we were looking at in the left side of the pelvis.

Other things that we can see are small bowel problems. Here is a patient with Crohn's disease. She has a lot of GI symptoms. There are thick walled bowel loops here in the right side. There's circumferentially, symmetrically, thickened in the distal ileum. Sometimes you'll appreciate mucosal ulcerations. There's surrounding fat stranding, and this can go on to terrible problems of fistula formations, collections and strictures, et cetera.

This patient with chronic right lower quadrant pain right under her abdominal wall was this long loop of bowel thick walled. It went on and on and on. It continued. This was not an appendix. It has bowel signature, but it's not the appendix because it was not blind ending. We turned on it, it looks like bowel. It correlates beautifully with the terminal ileum, which is very abnormal here, causing mass impression into the cecum. So this is Crohn's disease terminal ileitis.

Another patient here presented with pelvic pain and pressure. There were a lot of GI complaints. She had had a hysterectomy, so they wanted us to take a look and see what's going on in the pelvis. There were no female organs, but here we have a very abnormal structure that has a very hyperemic wall. And we realized eventually that this was the rectum. So this was a patient with Crohn's disease and rectal involvement.

Diverticulitis is a well known cause of left lower quadrant pain. And if we suspect that usually these patients go to CT, but it is a left lower quadrant problem. Sometimes if the patient's younger or can't have a CT, we could start with an ultrasound. They'll have this pain. They have white count fever, sort of like an appendix, but on the other side, they can complain of constipation, diarrhea. So the problem usually starts in the distal left colon and sigmoid, where we see these diverticula. And then surrounding inflammatory change, by far, most of these patients go to CT, but we could see a diverticulum once in a while. We could see surrounding mass change.

Here is one that has thickened wall. It was bulging from the bowel and had surrounding inflammatory change. And this was tender just as we poked at this diverticulum. We can see abscesses that form as a complication of the diverticulitis in this patient. Notice the very bright echogenic pericolonic edematous fat, which corresponds with this fat stranding. In this patient with acute diverticulitis, we certainly can see an abscess. An abscess looks like an abscess. This one contains pus, this one with the bowel gas, the gas within the abscess shadows out. And we can't see very much beyond that.

Now, sometimes you'll see lots of fluid filled dilated bowel loops. These can be small bowel obstructions, but sort of a late phase of bowel obstructions. Think about bowel obstruction as the bowel obstructs. The peristalsis is trying to fight the obstruction. There's hyper peristalsis. It's not getting through. The fluid is backing up. All these secretions that are coming down from the mouth and stomach et cetera, builds up. And then the gas gets burped out or absorbed or passed, and the bowel continues to fill and fill with fluid. That's the kind of bowel that we're talking about here. If it still had gas in it, we really wouldn't be able to see too much. But this is fluid, so we can see. And we know now that this very far gone dangerous kind of situation. And we already have ascites. This kind of bowel can perforate. These patients are very sick and usually don't have much peristalsis.

Here's a patient. This one was 33 weeks pregnant, and she had had some abdominal pain that was unexplained, and we had done a right upper quadrant ultrasound. She didn't have any gallstones. She came back again the next day, still complaining of this pain. We started searching further around, and we found abnormal small bowel loops, dilated loops, loops with thickened mucosa, valvulae conniventes, or also called circulars, and debris within this bowel. Very low peristaltic activity. Long loops of these dilated segments. And we called a small bowel obstruction.

Here's similar cases, dilated loops filled with bowel. These loops are filled with fluid. There's a lot of them. This patient went to surgery, and sure enough, she had a small bowel obstruction, which you can imagine ultrasound can do quite well with such an abdomen.

What we don't do very well with ultrasound is actually trying to find the point of obstruction. And CT does great with that. CT can track the bowel here. We have very dilated loop and loops coming to this point. And then beyond it, we don't have dilated loops. We look in the pelvis loops are small. These are small bowel loops. They're not dilated. So somewhere in here is the cause of the obstruction. We call that a transition point. We can do coronal reconstructions. We see the dilated stomach, proximal bowel dilated. And then somewhere in here is the obstruction in this case was an adhesion, an adhesive band that obstructed the bowel. And there's the non dilated bowel beyond. So CT will show us a much larger area and be able to diagnose this better.

Sometimes. Ultrasound triumphs in making a really good call. This patient had pelvic pain. It was chronic. She came, she had multiple different studies, and came one day for this ultrasound. Her pelvic organs were completely fine, but we noticed this unusual kind of hypoechoic structure. As we looked, we evaluated, we saw that there was peristalsis going through here. So the lumen of the bowel is here, where the green is. But the lesion here in orange, as we see, was actually in the wall of the bowel. It stayed with the bowel, but it was in the wall. We thought it might have been an endometrial implant or something. An intramural abscess, maybe even a colon cancer. And she eventually went to surgery. And this was a leiomyoma of the sigmoid wall. So this is a mass in the wall of this sigmoid.

As far as lymphoma goes, we might pick up some pelvic nodes. Sometimes we can pick up something in the floating around in the abdomen. Something that we call a pseudo kidney sign, which is a large mass of lymphoma tissue compressing the mesenteric vessels in the middle. That's what gives us that pseudo kidney appearance. Here it is on CT, this large lymphoma, these nodes blending together this mass like appearance and compression of the central mesenteric vessels. So, bowel lymphoma, mesenteric lymphoma can do this. Sometimes small bowel tumors can do this. Otherwise, lymphomas might be just nondescript masses in the abdomen and pelvic area.

Other things that we might see are masses with ascites here we have peritoneal carcinomatosis. This is a large omental cake of peritoneal disease carcinomatosis surrounded by fluid. Here's the corresponding CT where we see the ascites. And this is the tumor, the omental so-called cake. The large tumor mass of peritoneal carcinomatosis easy enough to just guide a needle straight into it under ultrasound to get a tissue and cells.

So that's the GI system.

Genitourinary Findings

The urinary tract system has things that occur down in the pelvis. Things related to the ureter, like calculi bladder, calculi bladder clots, bladder tumors. I'd like to show you some of these.

Now, one general principle of scanning kidneys is that if we find hydronephrosis, these branching fluid-filled tubular structures, we want to track the pelvis down towards the ureter. And we should keep tracking until we find the cause of obstruction. So we try to head down into the urinary bladder. We track along the flank. In this case, we come to the culprit. That's a calculus with shadowing, we turn 90 degrees. There's there it is causing an acoustical shadow. If we don't see it, we keep going down to the bladder. We might find the stones lodged at the ureteral vesical junction as here, or stones in the very distal part of the ureter, we can turn on color doppler in this case. There's no blood flow coming out through this obstructed ureter, not blood flow, urine flow out of this obstructed ureter. And here we have a nice jet coming from the left side.

This is another patient, similar problem where the stone is lodged at the ureteral vesical junction. There is no jet coming from this area. And there's a beautiful geyser here, seen in black and white coming out of the left ureteral orifice. So we know there's obstruction going on at the same time. And we have the obstructing calculus.

Now, if we suspect that the symptoms direct us towards a possible distal ureteral calculus, transvaginal sonography is a very nice, sophisticated, elegant way of finding that calculus. And here it is. Here's the distal ureter with the shadowing calculus heading straight towards this collapsed urinary bladder. On this vaginal scan, we turn on it. There it is the stone. There's a little bit of the mucosa around it. Here's another one. A little stone stuck at the ureteral vesical junction. This is the collapsed urinary bladder. Here's another example with the shadowing. So that's a very nice way of demonstrating this.

On the CT you see the obstructing stone. But do you really have to give this patient 750 to thousand x-ray equivalent dose of radiation? Just to find that dot. And just to figure out that that's the obstructing calculus, it seems to me that if it's a young woman and you can do this vaginally or with ultrasound, why not, other cause cases where the stone is just about ready to pop into the urinary bladder. Sometimes it even the color can show you that it sort of sprays the urine all the way around that stone. And sometimes it can actually push it. The urine pushes the stone and it flops into the bladder.

There are other things in the related to the urinary system that we can see. Here was a dilated tubular structure filled with fluid. This was thought to be a hydrosalpinx. There wasn't any peristalsis or anything, but it looked a little odd. So we tracked it. We kept following and trying to unravel it, and we tracked it down into the bladder where we saw this kind of configuration turned on the Doppler. And we saw urine actually being shooting through this little tiny orifice through this ureteral seal. And then this distal sort of mega ureter squirting urine in the bladder.

Here's another kind of a case where you have that dilated ureter. There's the little ureteral bulging into the bladder. As we see here on CT, there's the ureterocele extending into the urinary bladder.

Now another thing that we always teach our sonographers is to, when they complete the transvaginal exam, look around to see if there's anything else going on. Take a peek at the urinary bladder. Is everything okay? I'm not saying to evaluate the bladder, I'm just saying to keep your eyes open for something that could be going on. And so they did one day on this 30-year-old lady who was pregnant for the first time. It's her first trimester scan. Everything was fine, little embryo inside the uterus. But when we took a peek at the bladder, something looked very irregular. So we started looking at that. There's her uterus. And here there is indeed a lod irregular mass within the urinary bladder. So we filled her bladder and we did a transabdominal scan. And there it is, an irregular shaped mass stuck to the bladder wall cystoscopy did removal. This is a transitional cell cancer in a young woman and a woman who's actually pregnant. We have several such cases that we've seen over the years. Bladder cancers in first trimester pregnancies. Not that they're related, but just to warn you that this can happen in young women also.

Now, here's a woman at the opposite end of the spectrum in age. This is an 80-year-old lady who came in for postmenopausal bleeding and you think of right away of endometrial cancer. So we're looking at her endometrium. Her endometrium was nice and thin. Her ovaries were normal. She had a normal postmenopausal uterus, but we peaked at the bladder and we saw two very regular areas. We did some more investigation turned on the doppler. We are proving here that there is internal blood flow in the mass. That means this mass is solid because if it has blood flow, it's solid and it's not a blood clot. And our tracing has to include arterial flow. So she went on to have this proven to be bladder cancer.

So what happened? Well, upon closer discussion with the patient, she had pinkish when she wiped herself with toilet tissue, she had pinkish blood on the tissue. And she thought it was vaginal bleeding. It actually was hematuria. We know that 1%. There's a 1% incidence of bladder tumors in women with postmenopausal bleeding where they mistake vaginal bleeding for hematuria.

Now, here's another patient. This one has a mass in the bladder. And the question comes up, is this a bladder tumor or could it possibly be a blood clot? Well, if it moves, it's not gonna be tumor. If it moves and it has no blood flow, that's extra support that it's not a tumor. So we start out supine, we see the mass, we roll the patient towards her right, the mass falls towards the right. Then we turn her way over to the left mass, now falls towards the left. We have now proven that that is not a bladder cancer, that is a blood clot. And the colored doppler would confirm that.

So we have stones that could occur in the bladder of various types. Here's a smaller one. This is a very large stone. This certainly couldn't be passed. This was almost four centimeters. It rocked and rolled. We call it rock and roll. We rolled the patient and the rock falls side to side. Sometimes there's lots of stones for whatever reason in the bladder we can see cystitis that manifests with wall thickening, sometimes so thick that we have pseudo polyp formation. We might see gas in the wall of the bladder. This, we moved the patient. This did not shift. So it's not intraluminal air or gas. It was actually stuck in the wall. And we have these very strong reverberations coming out of this region. This patient had emphysematous cystitis, which is gas in the wall. Usually these are diabetics. It's unusual to have them get to this type of examination, but anything can happen where prepared for it.

Vascular Etiologies

There are vascular etiologies that we see in the pelvis. I'd like to talk about some of these.

In the pelvis, when we see fluid-filled tubular structures, we would usually think of hydrosalpinges. But I do strongly recommend that when you see a tortuous tubular structure filled with fluid in the pelvis, turn on the color doppler because it's very possible that this could be a vein. If it has peristalsis, it's bowel loops. But if it has blood flow, then it's a vascular structure. So we have to keep those three things in mind. They can look like mimics. That's the prominent veins, the hydrosalpinges, and the loop of bowel.

Here's another one. They this was thought to be a hydrosalpinx. It was followed for a while and this woman with pain, and they were ready to do a drainage of this hydrosalpinx per vagina. But somebody thought of doing a color and it turned out to be a huge pelvic varix. So definitely stay out of trouble by turning on the doppler.

Another patient here, very large tubular dilated structures turn on the power doppler or the color doppler. And we have lots and lots of blood flow. This turned out to be a large pelvic arteriovenous malformation. CT would show the extent of this arteriovenous malformation much more. It would show us the feeding vessels. It would show us the early draining vein. It can track this thing superiorly and show us the full extent which ultrasound would not be able to do.

Another thing that's important to remember in scanning anywhere in the body is if there is a cystic structure and it does not really meet criteria of cyst, or it looks a bit odd, always turn on the color doppler. So here, this post-menopausal lady, here's her bladder, and in the left adnexa, there was a cystic mass. Now if you're not careful, you may pass this off as some kind of ovarian cystic mass. Does she need surgery? But something's not right about it. It doesn't have a thin wall. It doesn't really have good sound transmission. Why does it have this thick, bright wall? It doesn't quite look like a cyst. So let's turn on the Doppler and see what's going on. And it is an iliac artery aneurysm. Certainly a gynecologist would not want to operate on an iliac artery aneurysm.

Unusual Retroperitoneal Tumors

Few other things at the end I wanna mention is some of these unusual retroperitoneal pelvic tumors. Now we know that we usually looking at ovaries and uterus, but there are other soft tissues all around the pelvis and masses could arise from there. There's fat, there's connective tissue, fascia, muscle, blood vessels, nerve tissue, lymph tissue, all kinds of embryologic tissue remnants. So we can have lipomas, fibromas, leiomyomas, angiosarcomas, spindle cell tumors, neurogenic tumors, teratomas, all kinds of tumors occurring from tissue other than uterus and ovaries. They can be benign or malignant like fibroma, fibrosarcoma, lipoma, liposarcoma. And there could be various combinations of these tissues like angio myx. So fibroma, hemangioma, cytoma, angiomyolipoma, et cetera.

So occasionally we'll see a pelvic mass. Now this, this is the uterus, transverse pelvic scan. Here's the uterus endometrium. And in the right adnexa pelvis, there's this very lobulated solid looking mass. We do transvaginal. And that confirms. It shows us things a lot nicer, the soft tissue differentiation here. But all in all, it's a solid mass. It's sitting right up next to the uterus. We found the ovaries separately, so it's an extra ovarian extrauterine solid mass. Didn't really know what it was related to. Did some more investigation. CT didn't help, it just showed a solid mass pushing the uterus. MRI was kind of unusual showing these kind of papillary projections. They weren't sure what it was. Surgery showed a spindle cell tumor of some kind of smooth muscle origin. So they called it a STUMP tumor. A smooth muscle tumor of unknown malignant potential. Where did this arise from? Did it arise from the pelvic sidewall from a to a, a smooth muscle in vessels, whatever? It's doubtful that this was a fibroid.

Here's another patient. This is a doctor's wife who had had pelvic pressure and pain and rectal discomfort, constipation. And ultrasound was not clear. It showed something, but it was just very difficult to scan. So we went on to CT and there's a mass deep in the pelvis here. There's the rectum being pushed over. She has a pessary in place, so discredit disqualify that. But the mass is solid and pushes into the soft tissues around her rectum. It's growing into the ischiorectal fossa, and it's actually growing so far down that she's sitting on it and is very uncomfortable here. Surgery revealed an angio myxoma. So fibroma, of course, the doctor's wife has to have a very unusual problem. And here you go, an extra peritoneal, unusual pelvic kind of tumor.

Abdominal Wall Masses

In conclusion, I would like to talk a little bit about some abdominal wall masses, because patients who come for pelvic ultrasound because of pelvic pain could actually be having pain related to the abdominal wall. As you talk to them, they seem to say, well, it isn't really down there that deep. It's really over here. And they point directly to the abdominal wall where we can find hernias, endometriosis, and even unusual tumors like desmoid.

So abdominal wall hernias, hernias in general are the most common abdominal wall mass. When the hernia is in an obese abdomen, it would be very hard sometimes to differentiate it as a hernia. It feels like a mass. These are related to fascial defects. It might just be an incisional defect through which herniates bowel loops. Omental fat and including fluid. Sometimes you can maneuver cause maneuvers, ask the patient to cough, do a Valsalva maneuver and the hernia becomes more prominent. You can push it, try to push contents back in, see if it's reducible. So those are the hernias.

But abdominal wall endometriosis, sometimes it's a little more complicated because it can look like a very ugly, irregular solid mass in the abdominal wall. And people who have no experience with this may think this is some kind of a malignancy like sarcoma. Maybe this needs biopsies, et cetera. You should know that endometriosis seeds abdominal scars in about 1% of patients with c-section scars and other scars in the abdomen, even in the track of a laparoscope that even goes through the umbilicus, it can track into that area of scarring. Ultrasound is the best technique for imaging. These things shows us a very nice resolution of this solid tissue. CT and MR are not that specific. These are usually solid masses with very regular borders. And on talking to the patient, you can elicit a cyclic type of pain. You can use color doppler and you can guide a needle into it and actually do a biopsy if you're not certain.

And the last case, I wanna show you something that sometimes we get too complacent. We see masses and fibroids and ovaries, and we just kind of routinely go through these cases, but we have to back off once in a while and try to work things out. This patient had a mass and it was pressing on her bladder. And the mass was, she also had a fibroid here, bulging from the anterior wall. And there's the rest of her uterus. And this mass was lurking out here and was thought to be just another myoma at surgery. It was proven to be a desmoid tumor. This was not related to the uterus at all. This is arising from the fascia or the aponeurosis of the muscle in the abdominal wall, often at the site of a previous scar. And was a completely separate tumor. Had nothing to do with her fibroids, just was similar. Maybe if we would have worked this out and tried to move this, we would've seen that it moves separate. We would've known that the ovaries are separate. And maybe we would've placed this as a abdominal wall mass, I'm not sure. But it was just mistaken for a large fibroid.

Conclusion

So anything can happen. We see GI, GU, vascular, all kinds of tumors. Ultrasound shows many non gynecologic findings. CT. MR helped to further define the extent in the origin. And often these examinations, ultrasound and CT are complimentary. And MR usually comes to the rescue and becomes the more most definitive test.

So that's the end. And thank you for your attention.