radiology

1. BENIGN PELVIC DISEASES IN
FEMALES
MODERATOR DR JYOTI ARORA
PRESENTED BY DR SANGEETA JHA

2. Uterine ovarian Fallopian tubes
Cangenital anomalies
(Mullerain duct anomalies)
Ovarian cystic masses
Follicular cyst
Hemmorrhagic cyst
Theca lutein cyst
Polycystic ovarian disease
Cystadenomas
Hydrosapinx
Pyosalpinx
hematosapinx
Uterine masses/lesions
Leiomyoma
Adenomyosis
Endometrial polyp
Endometrial hyperplasia
Uterine synechiae
Uterine A-V malformation
Ovarian solid-cystic masses
Tubo ovarian abscess
Endometrioma
Dermoid cyst or mature cystic
teratoma
Ovarian torsion
Ectopic pregnancy
Ovarian solid masses
Fibroma
Thecoma
Non –ovarian cystic masses
Peritoneal inclusion cyst
Paraovarian cyst
Mucocoele of appendix

3. MULLERAIAN DUCT ANOMALIES
• The müllerian ducts are paired embryologic structures that
undergo fusion and resorption in utero to give rise to the
uterus, fallopian tubes, cervix, and upper two-thirds of the
vagina.
Normal process of
• ductal development (6wks),
• ductal fusion (6-9wks),and
• septal reabsorption (9-12wks).
Interruption at stage of
• ductal development - hypoplasia or aplasia of uterus.
• ductal fusion -bicornuate uterus and uterine didelphis.
• septal reabsoption -arcuate and septate uterus.
• It is often associated with primary amenorrhea, infertility,
obstetric complications, and endometriosis.
• MDAs are commonly associated with renal and other
anomalies

4. ASSOCIATED ANOMALIES
MDAs are also commonly associated with
Renal anomalies-30%–50%
including renal agenesis (most commonly unilateral
agenesis), ectopia, hypoplasia, fusion, malrotation,
and duplication .
• Other
vertebral bodies -(29%)
wedged or fused vertebral bodies and spina
bifida(22%–23%),
cardiac anomalies (14.5%), and
syndromes such as Klippel-Feil syndrome (7%) .

5. IMAGING MODALITIES
• HSG-limitation to see fundal contour
• USG
• MRI-standard procedure of imaging.

6. • The Müllerian duct anomaly classification is a seven point system that can
be used to describe a number of embryonic Müllerian duct anomalies:
• class I: uterine agenesis/uterine hypoplasia
– a: vaginal (uterus: normal/ variety of abnormal forms)
– b: cervical
– c: fundal
– d: tubal
– e: combined
• class II: unicornuate uterus/unicornis unicollis, ~6-25%
– a: communicating contralateral rudimentary horn contains endometrium
– b: non-communicating contralateral rudimentary horn contains endometrium
– c: contralateral horn has no endometrial cavity
– d: no horn
• class III: uterus didelphys, ~5-11%
• class IV: bicornuate uterus: next commonest type, ~10-39%
– a: complete division, all the way down to internal the os
– b: partial division, not extending to the os
• class V: septate uterus: commonest anomaly, ~34-55%
– a: complete division, all the way down to internal the os
– b: incomplete division
• class VI: arcuate uterus, ~7%
• class VII: in utero Diethylstilbestrol (DES) exposure: T shaped uterus

7. Classification of MDAs on the basis of the American Society for Reproductive Medicine system. DES = diethylstilbestrol. (Courtesy of Joanna Culley,

8. Mayer-Rokitansky-Küster-Hauser syndrome. (a) Sagittal T2-weighted MR image shows complete
absence of the cervix and uterus with an abnormally truncated vagina ending in a blind pouch
(arrowhead) between the rectum (r) and urinary bladder
(b) Axial T2-weighted image shows the presence of normal ovaries (*).

9. UNICORNUATE UTERUS
Results from normal development of one mullerian duct and near
complete to complete arrested development of the contralateral
duct.
This anomaly has four subtypes:
(a) no rudimentary horn
(b) rudimentary horn with no uterine cavity
(c) rudimentary horn with a communicating cavity to the normal
side, and
(d) rudimentary horn with a noncommunicating cavity.
40% cases are associated with renal anomalies
ipsilateral to the rudimentary horn, with renal agenesis
being the most common (67% of cases)

10. Unicornuate uterus with no rudimentary horn.
HSG image shows a small, oblong uterine cavity (*) deviated to the right
of midline with a single fallopian tube (arrowhead).

11. Unicornuate uterus with no rudimentary horn. .
axial T2-weighted MR image shows a single uterine horn (*) and cervix (arrowhead).
Coronal T2-weighted MR image shows absence of soft tissue adjacent to the right
unicornuate cervix (arrowhead), a finding indicating absence of a rudimentary horn.

12. Unicornuate uterus with an obstructed noncommunicating rudimentary
horn. Axial T2- weighted MR images show a normal-appearing left
unicornuate uterus (arrow in a) and an obstructed noncommunicating
right rudimentary horn with layering debris (* in b).

13. UTERINE DIDELPHIS
 complete failure of müllerian duct fusion.
 Duplication of the uterine horns, cervix, and proximal
vagina .
 Usually asymptomatic
 Hematometrocolpos may occur if there is transverse
hemivaginal septum resulting in ipsilateral
obstruction
 Patients with hemivaginal obstruction present with
dysmenorrhea secondary to endometriosis,
infections, and pelvic adhesions attributed to
retrograde menstrual flow from the obstructed side .
 It is commonly associated with ipsilateral renal
agenesis

14. HSG demonstrates two separate, oblong endometrial
cavities with contrast opacification of fallopian tubes
• USG-widely divergent uterine horns with separate,
non communicating endometrial cavities.
There is two cervices and duplicated upper vaginas
• MR-Endometrial-to-myometrial ratio and zonal
anatomy are normal.
Duplication of the proximal vagina may be visualized at
MR imaging, and this may be further improved by
instillation of viscous liquid, such as ultrasound gel, into
the vagina before imaging.

15. Transverse transabdominal US image shows a uterus didelphys, with two uterine
horns (u) separated by echogenic fat (*). There is a viable embryo (arrow) in the left
uterine horn.

16. Uterus didelphys with an obstructed hemivagina.
(a) Coronal T2W MR image shows widely separated horns of a uterus (white arrows).
Two hemivaginas (arrowheads).
absent left kidney (black arrow) with bowel in the renal fossa, which is ipsilateral to the
obstructed hemivagina.
(b) Axial T2-weighted image shows the two hemivaginas (arrowheads); the obstructed,
dilated left hemivagina contains heterogeneous debris (*).

17. • BICORNUATE UTERUS-
 incomplete or partial fusion of the müllerian ducts .
 presence of a cleft (>1 cm in depth at MR imaging)
in the external contour of the uterine fundus.
 The duplicated endometrial cavity may be associated
with cervix duplication (bicornuate bicollis) or be
without cervix duplication (bicornuate unicollis).

18. • HSG- Opacification of two symmetric fusiform uterine
cavities (horns) and fallopian tubes. Historically, an
intercornual angle of greater than 105° was used for
diagnosis.
• US-divergent uterine horns and separation of uterine
cavities may be optimally seen in the secretory phase
of the menstrual cycle due to echogenicity of the
endometrium .
• MR-both uterine horns have normal zonal anatomy.
The appearance of a duplicated cervix (“owl eyes”) is
seen in patients with a bicornuate bicollis uterus, which
can be confidently diagnosed in the absence of vaginal
duplication

20. SEPTATE UTERUS-
Most common form of MDA (55%),
The septum originates from the midline of the
uterine fundus and extend caudally.
Result of complete or partial failure of reabsorption
of the uterovaginal septum.
The septum –partial
- complete(extends upto external cervical os
in some cases upto upper vagina.)
Fibrous tissue and myometrium

21. • HSG-HSG cannot be used to evaluate the
external uterine contour and therefore does
not allow reliable differentiation of septate
from bicornuate uterus .
• USG-interruption of the myometrium by a
septum at the fundus . The fibrous component
of the septum is less echogenic relative to
myometrium .
• MR-the uterus is normal in size.The key to
differentiating a septate uterus from a
bicornuate uterus is the external fundal
contour.

22. HSG image of a partial septate uterus shows a thin
linear filling defect (arrow) extending from the uterine
fundus, separating the uterine cavity into two
symmetric cavities

23. USG image of partial septate uterus shows the isoechoic muscular septum and
hypoechoic fibrous septum (*), extends just proximal to the internal cervical os
(arrowhead).The apex of the fundal contour (arrow) is more than 5 mm above a line
drawn between the tubal ostia (white line).

24. Axial T2-weighted MR image of a complete septate uterus shows a normal
external uterine contour (black arrow). The hypointense fibrous septum (white
arrows) originates from the isointense muscular septum and extends into the
cervical os (arrowhead). A hypointense uterine fundal fibroid (f) is also present.

25. • A line drawn between the uterine ostia may
be used to differentiate between a septate
and bicornuate uterus. In a septate uterus, the
apex of the external fundal contour is more
than 5 mm above the interostial line. By
comparison, in a bicornuate or didelphys
uterus, the apex of the external fundal
contour is below or less than 5 mm above the
interostial line .

26. Difference between septate and bicornuate
uterus
• Features septate uterus bicornuate uterus
1.Depth of fundal cleft ≤ 1cm > 1cm
2.Fundal contour convex or flat deep fundal
concavity
3.Intercornual angle < 75° >105°
4.Intercornual distance < 4 cm > 4 cm
5.Intercornual Fibrous or myometrial myometrial
tissue

28. • ARCUATE UTERUS-
Near reabsorption of the uterovaginal septum.
Only mild indentation of the external fundal
contour .
This is mild form of MDA and is typically
associated with normal-term gestation.

29. • HSG-A single uterine cavity with a broad
saddle-shaped indentation at the uterine
fundus .
• USG –shows a broad, smooth inward contour
deformity of the uterine fundus .
There is a normal external contour.
MR -Normal-sized uterus and the normal
convex external uterine fundal contour. There is
a broad-based, smooth prominence of soft
tissue at the fundus with indentation of the
endometrial cavity .

30. HSG image shows a broad-based uterine fundal
filling defect (black arrowhead). White
arrowheads = patent fallopian tubes

31. Coronal 3D US image shows the broad-based fundal myometrial
prominence (*) and a convex external uterine contour
(arrowheads).

32. Axial gadolium-enhanced T1-weighted fat-saturated MR
image shows the convex external uterine contour (arrow) and
the broad-based prominent fundal myometrium (*).

33. • DES Uterus –
classic T-shaped configuration of uterus in
31% of exposed women .
 T-shaped appearance is secondary to the
shortened upper uterine segment .
 The fallopian tubes are often truncated and
have an irregular appearance .
constriction bands at the midfundal segment
may be present, which leads to narrowing of
the proximal fallopian tube

34. HSG image shows the classic T-shaped
uterine cavity due to DES exposure

35. UTERINE LEIOMYOMA
• Found in 20-30% of women in reproductive years.
Well circumscribed and surrounded by pseudocapsule.
INTRAMURAL
 most common
 mostly asymptomatic
SUMUCOSAL
 mostly symptomatic
 may protude into cervical canal k/a cervical fibroid.
SUBSEROSAL
 mostly projects into endometrial canal.
 may undergo torsion and thereafter infarction.
 Lateral growth of subserosal leiomyoma may extend between two
layers of broad ligament k/a intra-ligamentous leiomyoma.
 Large tumours may develop hyaline,cystic and myxomatous
degeneration.
 In postmenopausal women may undergo calcification.

36. Common symptoms
bleeding,
pain, pressure over adjacent organs
infertility.
USG
• hypo to hyper,
• homogenous to heterogenous,
• with or without acoustic shadowing depending on contents,
• but most common appearance is well marginated round or oval
mass and shows peripheral supply.
MR
• most sensitive imaging for leiomyoma , can identify lesions even
smaller than 3mm.
• most common appearance is –hypo on T2WI,iso to myometrium on
T1WI,presence of calcification shows signal void on both T1 and
T2WI.
• MR facilitates differentiation of pedunculated leiomyoma from an
adnexal mass on basis of typical signal intensity and morphology.

37. .
POST CONTRAST MR
 less enhancing than both endometrium and myometrium
 Fibroids with myxomamatous degeneration shows
heterogenous contrast enhancement.
 helpful in localising uterine artery supplying the fibroids
and further in management as uterine artery embolisation.
Exophytic leiomyoma shows bridging vessel sign which
refers to presence of flow voids on both T1 and T2 from
branches of uterine artery that are localised between mass
and uterus.
Malignant degeneration is rare(0.1-0.6%) and should be
suspected if a leiomyoma enlarges suddenly , or if indistinct
border ,irregullar contour along with contrast
enhancement noted on MR imaging.

38. A- shows well defined intramural fibroid .B- shows submucosal
fibroid with displacement of endometrium posteriorly.

39. • Axial T2-
weighted MR
image shows
submucosal
(large *),
intramural
(small *),
intracavitary
(straight arrow),
and subserosal
(curved arrow)
leiomyomas

40. Prolapsed pedunculated leiomyoma manifesting as a vaginal mass
Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within
a distended vaginal canal , which is continuous superiorly with the endometrial canal .

41. sagital T2WI shows
hemmorrhagic degeneration in
subserosal leiomyoma
Axial T1-weighted SE MR image
obtained 4 months later shows
maturation of the hemorrhage
with high signal intensity confined
to the rim

42. Broad ligament fibroid -Right adnexal mass with whorled
internal appearance

43. BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA.

44. ADENOMYOSIS
 It is uterine endometriosis in which there is ectopic
endometrial glands and stroma with surrouding smooth
muscle hyperplasia within the myometrium.
 TYPES-Focal(also k/a adenomyomas)
diffuse
 May occur along with fibroids.

45. USG
TVS is most sensitive.
diffuse form-bulky uterus with
1)poorly defined hypoechoic myometrium.
2)heterogenous myometrium.
3)asymmetrically thickened myometrial wall
4)shaggy endometrium with poor definition
between endometrium and myometrium.
5)scattered small (<5mm)myometrial cysts.
Focal form-shows indistinct margin and presence of
hypoechoic lacunae in hyperechoic myometrium
with several cysts.

46. PELVIC MRI:
 modality of choice to diagnose and characterize
adenomyosis,
 T2W images (sagittal and axial) are most useful.
 sensitivity of 78-88% and a specificity of 67-93% .
 thickening of the junctional zone of the uterus >12 mm,
either diffusely or focally (normal junctional zone measures
no more than 5 mm)
• small high T2 signal regions representing small regions of
cystic change the region may also have a striated
appearance.
• T1: Foci of high T1 signal are often seen, indicating
menstrual hemorrhage into the ectopic endometrial tissues.
• T1 C+ (Gd): contrast enhanced MR evaluation is usually not
indicated in adenomyosis, however if performed, it shows
enhancement of the ectopic endometrial glands.

47. NORMAL MR ANATOMY OF UTERUS
T1WI
The entire uterus is isointense to muscle and different
anatomic zones cannot be identified
T2WI
• The central high-signal intensity endometrium and
secretions
• The middle low-signal intensity junctional
zone(innermost layer of myometrium ) measures 2 to 8
mm.
• The appearance of the junctional zone changes with
sustained myometrial contractions or uterine
peristalsis are important to distinguish from
leiomyomas or adenomyosis.
• The outer intermediate-signal intensity of the
myometrium.

48. Uterus is evaluated between isthmus and end of uterine cavity (white lines).
Junctional zone (short arrows) should be measured from several sites on
anterior and posterior walls. Junctional zone measure can be compared with
entire thickness of myometrium (long arrows) evaluated at same site.

51. MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of
junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents
abnormal stromal glands inside the myometrium. B: MRI (coronal T2WI) shows
the same finding as well as bilateral ovarian simple cysts.

52. Axial and sagittal T1, T2 and postcontrast
images reveal bulky uterus with thickening and
heterogeneity of junctional zone (JZ), poorly
defined endomyometrial
junction, multiple small T2 hyperintense foci in
JZ showing heterogeneous contrast
enhancement – Diffuse
adenomyosis

53. features adenomyosis Leiomyoma
Margins Poorly defined Well circumscribed
Centre Junctional zone Any layer of uterus,
originates in
myometrium
Appearance Focal or diffuse focal
T2 signal intensity Small hyperintense
foci
Hypointense unless
degeneration present
Thickened junctional
zone
Yes >12mm No
Mass effect on
endometrium
Minimal or none + if intracavitary or
submucosal

54. ENDOMETRIAL POLYP
• are localized hyperplastic overgrowth of endometrial
glands and stroma which are covered by endometrium.
• may be sessile or pedunculated and usually attached to
the uterine fundus.
USG-thickened endometrium, a focal echogenic area in the
endometrium or occasionally an endocavitary mass
surrounded by fluid. With Color Doppler, a feeding artery
may be seen in the pedicle of the polyp.
SONOHYSTEROGRAPHY- is an ideal technique for diagnosis .
This is because a polyp seen as a round echogenic mass
within the endometrial cavity is much more easily
identified when there is fluid in the endometrial cavity
outlining the mass

55. MR
T1WI- isointense to endometrium.
T2WI-intermediate signal intensity.
Contrast enhanced MRI- improve the sensitivity
of detection
polyps generally enhance less than the
edometrium but more than myometrium .

57. SUBMUCOSAL FIBROID ENDOMETRIAL POLYP
Broader base
More irregular contour on
sonohysterography.
Sessile or pedunculated, almost well
defined echogenic mass on
sonohysterography
Normal layer of endometrium is seen
overlying submucosal fibroid.
Outlined by endometrium.
MR-generally of lower intensity than
polyp on T2WI.
Isointense to myometrium on T1WI
Intermediate –T2
Iso to endometrium on T1.
CEMR-non enhancing ,lower signal
intensity than both endometrium or
myometrium.
Polyps enhances less than the surrounding
endometrium but more than myometrium.

59. • ENDOMETRIAL HYPERPLASIA-
• On ultrasonography, a bilayer endometrial width
>5 mm is regarded as abnormal in symptomatic post
menopausal women.
>8mm In asymptomatic postmenopausal women on
HRT, cut off values range from < 5 to > 8 mm while in
>8mm in premenopausal women in the proliferative
phase and
> 16 mm in the secretory phase.

60. TVS reveals diffuse thickened echogenic
endometrium with small cysts within–
Endometrial hyperplasia

65. POLYCYSTIC OVARIAN SYNDROME
According to Rotterdam crieteria
 1) one or both ovaries demonstrate 12 or more follicles
measuring 2–9 mm in diameter ,or
 2) The ovarian volume exceeds 10 cc.
Only one ovary meeting either of these criteria is sufficient
to establish the presence of polycystic ovaries
 Stromal echogenicity on USG.
• Any follicle >10 mm or corpus luteum
should prompt repeat US during the next menstrual cycle)
• Ovarian volume, calculated with the simplified formula
for an ellipsoid (0.5 × length × width × thickness)

67. characteristic T2-weighted MR imaging appearance of a
polycystic ovary is abundant hypointense central stroma with
small peripheral T2-hyperintense cysts

68. CYSTADENOMAS
SEROUS CYSTADENOMA-
 Counts for 25% of benign
epithelial neoplasm
 Thin walled ,unilocular of
size upto 10cm.
 Contain clear fluid ,little or
no septations.
 Papillary projections are
generally absent.
 Bilateral upto 23% of cases.
MUCINOUS CYSTADENOMA-
 45%
 Thick walled,multilocular of
size 15- 30 cm.
 Contain thick mucinous
content,
 septas and papillary
projections are present but
les than 3mm thick in
benign form
 Less commonly
bilateral(upto 5%)
 Chances of malignancy is
more.

69. Serous cystadenoma

70. Mucinous cystadenoma

71. DERMOID CYST OR MATURE CYSTIC TERATOMA-
USG-
 Focal or diffuse hyperechoic component with distal
acoustic shadowing represent fat.-k/a dermoid plug
 Fluid fluid level or layering of fat k/a floating fat sign.
 Hyperechoic lines or dots k/a dermoid mesh represent
different component within like hair or calcification.
 No internal flow on colour Doppler.
 When a dermoid produces ill-defined acoustic shadowing
that obscures the posterior wall of the lesion, it is termed
as“Tip-of-the-iceberg-sign”. This is produced by a mixture
of matted hair and sebumwhich is highly echogenic
because of multiple tissue interfaces.

72. CT
 Detection of fat (–130 to -90 HU),hair ,teeth and fat-
fluid level.
MRI
 Fat is identified when the signal intensity of the mass
(or part of it) is isointense to subcutaneous fat on both
T1 and T2 weighted sequences and
 internal or external chemical shift artefact indicating
fat water interface is present.
 On fat saturation sequence, suppression of signal that
was of high signal intensity on T1 weighted sequence;
confirms the presence of fat within the mass
Intramural solid enhancing component on cross sectional
images suggest malignancy.

73. Cystic ovarian mass with an echogenic mural
nodule in the periphery representing “dermoid
plug”-cystic teratoma

74. Ovarian mature cystic teratoma-
shows cystic ovarian mass of fat attenuation,
with fat fluid level, central hair ball and areas of calcification

75. A) B/L complex masses with bright signal of fat anteriorly
on T1W image. (B) T1W fat-suppressed image showing
suppression of fat signal with chemical shift artifact at fat fluid
interface

76. Endometriosis
is defined as the presence of endometrial
epithelium and stroma in an ectopic site outside
the uterine cavity . Endometriosis occurs in 10%
of the female population and almost, exclusively,
in women of reproductive age . The most
common symptoms are dysmenorrhea,
dyspareunia, pelvic pain, and infertility although
endometriosis may be asymptomatic .

77. Superficial endometriosis ( Sampson's syndrome )
 superficial plaques are scattered across the
peritoneum, ovaries and uterine ligaments.
 minor symptoms and usually also less structural
changes in the pelvis.
 At laparoscopy, implants are be seen as superficial
powder-burn or gunshot lesions.
Deep pelvic endometriosis- (Cullen's syndrome)
 There is subperitoneal infiltration of endometrial
deposits.Severe symtoms and more invasive.
MRI is of use for the diagnosis of deep infiltrating
endometriotic lesions and for the assessment of disease
extension. Preoperative mapping of disease extension is
important to decide whether surgical intervention is
indicated, and if so, for planning complete surgical
excision

78. SITES.
• Pelvic:
• -Uterine=
adenomyosis(50%).
• Extra-uterine:
- Ovary 30%.
• - Pelvic peritoneum 10%.
- Fallopian tube.
- Vagina.
- Bladder &rectum.
- Pelvic colon.
• - Ligaments.
• Extra-pelvic
• Umbilicus.
• Scars(Laparotomy).
• Lung &pleura.
• Others.

79. Endometriomas - also known as chocolate cysts
 Develop when superficial endometriotic lesions on the surface
of the ovary invaginate.
 Blood produced by such an implant during each menstrual
cycle cannot escape and will accumulate within the ovary,
forming a cyst known as an endometrioma.
 present as complex cystic masses, often thick-walled with a
homogeneous content.
 On transvaginal ultrasound, endometriomas may be seen as
thick-walled cysts with low level echoes.
SYMPTOMS -
• Pelvic pain(65%).
• . Dysmenorrhea, especially suggestive of endometriosis the pain if it occurs
after years of pain free menstruation.
• . Deep dyspareunia.
• . Chronic pelvic pain.
• . Ovulation pain with menstrual irregularity.
• . Other types of pain- Sciatica.
- Infertility(35%).

80. TVS showing a unilocular ovarian cyst with low level internal echoes –
characteristic of
Endometrioma.

81. B/L ENDOMETRIOMA

82. • HYDROSALPINX –Hydrosalpinx occurs when an inflammatory
process produces adhesions of the fimbriated end of the
fallopian tube, trapping the intraluminal secretions and
dilatation of the ampullary and infundibular portions of the
tube.
• It may occur either in isolation or as a component of a
complex pathologic process (eg, pelvic inflammatory disease,
endometriosis, fallopian tube tumor,peritubal obstruction,
due to previous surgery or tubal pregnancy)
Diagram shows the anatomy
of a normal fallopian tube. There
are four segments, from the medial
aspect
to the lateral aspect: the intramural
portion, the isthmus, the ampulla, and
the infundibulum at the fimbriated end.

83. USG
Tubular, elongated extra-ovarian structure with folded
configuration (incomplete septation )
Three appearances of tubal wall structure
“COGWHEEL “ SIGN- which is anechoic cogwheel shaped
structure visible in the cross section of the tube with thick walls,
“BEADS ON A STRING” SIGN, which are hyperechoic mural
nodules of 2 to 3 mm in size and seen on the cross-section of the
fluid filled distended tube.
INCOMPLETE SEPTA -which are hyperechoic septa that originate
as a triangular protrusion from one of the walls, but do not reach
the opposite wall

84. (A) TVS reveals tubular elongated extraovarian structure. (B) Incomplete septation and
absence of vascularity on CDS - Hydrosalpinx

85. A and B: T2W axial and sagittal images showing a hyperintense tubular structure
with folded configuration in the right adnexa – Hydrosalpinx

86. • In case of complex masses causing hydrosalpinx MR is
more sensitive modalities.
• MR demonstrates incomplete septations and a separate
normal ovary.
• MR can also help in finding the etiology of hydrosalpinx. If
hydrosalpinx is due to endometriosis, signal intensity
characteristics of the tubal fluid are similar to those in
endometriomas (high T1 and low T2 signal intensities). In a
patient with adhesions, signal intensity of the dilated tube
follows that of simple fluid (low T1 and high T2 signal
intensities).
The hydrosalpinx appears as a fluid-filled tubular structure
that arises from the upper lateral margin of the uterine
fundus and is separate from the ipsilateral ovary. A dilated
fallopian tube folds upon itself to form a sausage like C- or S-
shaped cystic mass.

87. Hydrosalpinx in a 38-year-
old woman who
underwent surgical
resection of a
left ovarian cyst 3 years
earlier.
T2-weighted MR images
show a tubular cystic
lesion (solid arrows) in the
left adnexa.
The lesion is separate
from the normal left
ovary (open arrow). The
presence of a
hydrosalpinx with a
peritubal
adhesion was confirmed
at surgery

88. • MR imaging features of tubal pregnancy
include hematosalpinx, enhancement of
the dilated tube wall, presence of a
gestational sac, bloody ascites, and a
heterogeneous adnexal mass.

89. Left tubal pregnancy (at 9 weeks of gestation) in a 44-
year-old woman.
(a, b) Sagittal contrast-enhanced
fat-suppressed T1-weighted MR images show a C-
shaped cystic structure (arrows in b) that contains a
focally enhancing gestational sac (arrow in a) in the left
adnexa. U = uterus.
(c) Coronal contrast-enhanced fat-suppressed T1-
weighted MR image shows a mildly dilated left fallopian
tube (white arrow) with a focally thickened and
enhancing wall(black arrows). At surgery, the presence
of an unruptured tubal pregnancy was confirmed.
B = urinary bladder, U = uterus.

90. TUBO-OVARIAN ABSCESS
Late complication of PID
• Tuberculosis,actinomycosis and
xanthogranulomatous infections are major
causes.
• Bilateral adnexal involvement is the rule.
USG
 unilocular or multilocular complex mass
 irregular borders and thickened wall.
 Multiple internal septations
 Fluid in cul de sac

91. CT
 Thick wall and shaggy margins
 complex adnexal mass with centers of low attenuation.
 presence of air confirms the diagnosis.
MR
 unilocular or multilocular cystic mass with a thicker wall than
that seen in functional ovarian cyst.
 The abscess fluid has variable signal but usually is of very high
signal intensity on T2-weighted image and low signal intensity
on T1-weighted image
 The abscess wall and adjacent inflammatory changes as well
as septations enhance intensely with gadolinium.
 Infiltration of pelvic fat surrounding the mass may be seen.

92. TVS reveals bilateral multilocular complex adnexal masses with septations and associated free
fluid–
Tubo-ovarian abscesses

94. Pyosalpinx associated with tubo-ovarian abscess

95. b/l tubo-ovarian abcess dilated
tube and enhancing wall on
post contrast study

96. Actinomycosis
 occurs in presence of IUCD.
 it is more solid as compared to other bacterial
abscess.
 Diffuse infiltration of the uterus, adnexa and pelvic
musculature with obliteration of fascial planes is
the hall mark of the disease.
 A linear, solid, well-enhancing lesion extending
directly from the mass into adjacent fascial planes is
a characteristic CT and MR imaging finding.
 Small rim-enhancing lesions in the solid part of the
mass are also suggestive of actinomycosis.
 Differentiated from malignancy can be done only by
identification of sulphur granules within the
aspirate.

97. actinomycosis

98. When a complex cystic tubo-ovarian abscess
occurs in association with ascites and
lymphadenopathy, it may be difficult to
differentiate the abscess from an ovarian
malignancy. However, ovarian cancer is not
usually associated with tubal dilatation.
Therefore, the detection of a hydrosalpinx
within a complex adnexal mass may aid in the
differential diagnosis

99. OVARIAN TORSION
• acute condition requiring prompt surgical intervention
• caused by partial or complete rotation of the ovarian pedicle
on its long axis.
• It is most commonly associated with an adnexal mass,usually
a dermoid cyst,
• but may also occur spontaneously.

100. ON GRAY-SCALE ULTRASOUND
• Unilateral enlarged ovary (>4cm in maximum
dimension ,vol>20 cc in premenopausal and >10 cc in
postmenopausal women)
• central afollicular stroma and multiple uniform 8–12-
mm peripheral follicles
• free fluid,
• a twisted pedicle
ON COLOUR DOPPLER
• Worlpool sign- is swirling target of vessel in twisted
pedicle.
Torsion first affect venous then arterial flow.
Absence of venous flow
Absent diastolic flow forming a spike waveform pattern

102. 23-year-old woman with enlarged right torsed ovary.
Sagittal fast spin-echo T2-weighted MRI shows 10-cm
ovary (arrow) with mildly T2 hyperintense afollicular
central stroma and peripheral follicles.

103. 18-year-old female with ovarian torsion. T2-weighted, sagittal MR image
showing "whirlpool appearance" of the right adnexa (thick arrow)
suggestive of ovarian torsion. Right ovarian cystic mass is also seen (thin
arrow).

104. ECTOPIC PREGNANCY-
Most common symptoms are-acute abdominal pain
bleeding par vagina
abdominal mass
Positive pregnancy test(b-HCG>2000mIU/mL).
• Risk Factors of Ectopic Pregnancy
Prior ectopic pregnancy
History of pelvic inflammatory disease, gynecologic surgery
Infertility
intrauterine device
History of placenta previa
Use of in vitro fertilization
Congenital uterine anomalies
History of smoking
Endometriosis

105. Ovarian ectopic
3%of cases
Should be differentiated from normal corpus
luteum cyst of pregnancy.
Tubal ectopic
most common location(>95%)
75%–80% - ampulla
10% -isthmus
5% - fimbrial end
2%–4% interstitial and corneal
Others-cervical, abdominal and scar ectopic

107. On USG
Endometrial findings-
Absent G-sac in endometrial cavity or Pseudosac with
absent or poor decidual reaction
Tubal ectopic-we can find a tubal ring with a yolk sac and
embryo or yolk sac only or without any central identifying
features.
a complex adnexal mass separate from the ovary
ovarian ectopic-The presence of a gestational sac,
chorionic villi, or an atypical cyst with a hyperechoic ring
within the ovary, along with the normal fallopian
tubes, is suggestive of an ovarian pregnancy
Colour Doppler
Ring of fire appearance
Low impedance ,high diastolic flow(low RI,high velocity)

108. Tubal interstitial pregnancy with embryo within the G-sac

109. Tubal ring sign-yolk sac surrounded
by thick echogenic ring.
Same patent
Pseudosac in in endometrial cavity

110. Ampullary ectopic showing ring of fire appearance on doppler

111. Scar ectopic pregnancy.
A G-sac in the anterior lower uterine segment in the region of
the cesarean section scar.

112. BENIGN SOLID OVARIAN MASSES
Arise from ovarian stroma also k/a sex cord stromal
tumours.
Fibroma
Thecoma
Fibroadenoma
 80% of these tumours produce hormones except
fibroma.
 Fibroma is common in postmenopausal women and
are generally asymptomatic.
 Ascites seen 50% of patient with fibroma larger than
5cm.
 MEIG’S SYNDROME –triad of ovarian fibroma ,ascites
and pleural effusion.

113. USG- hypoechoic mass with marked posterior
attenuation of the sound beam seen separate from
the uterus and a non-visualized ovary.

114. • MR-
Hypointense on both T1 and T2 images and
shows mild enhancement.

115. MEDANTA CASES