Dynamic ultrasonography: An idea whose time has come
An ultrasound expert makes the case for using ultrasound-enhanced bimanual examination as a routine part of gynecologic care to assist in diagnosis and enhance patient care
Endometriosis
Dynamic ultrasonography can be a significant part of a nonlaparoscopic, presumptive diagnosis of endometriosis when there is no obvious ovarian endometrioma.5 The evidence for this comes from a classic paper by Okaro and colleagues, “The use of ultrasound‐based ‘soft markers’ for the prediction of pelvic pathology in women with chronic pelvic pain–can we reduce the need for laparoscopy?”6 In that study, 120 consecutive women with chronic pelvic pain scheduled for laparoscopy underwent vaginal ultrasonography. Hard markers were defined as structural abnormalities, such as classic endometriomas or hydrosalpinges.
These markers demonstrated a 100% correlation (24 of 24 women) with laparoscopic findings, as one might have suspected. In addition, soft markers (VIDEOS 6A–6C) were defined as reduced ovarian mobility, site-specific pelvic tenderness, and the presence of loculated peritoneal fluid in the pelvis. These were predictive of pelvic pathology in 73% of these women (37 of 51).6
Thus, women who have soft markers on dynamic scanning but no obvious anatomic abnormalities can be treated with a high degree of sensitivity without the need for laparoscopic intervention.
Pelvic organ prolapse and incontinence
With the vaginal probe in place, and even a small amount of urine in the bladder, the patient can be asked to bear down (Valsalva maneuver), and cystocele (VIDEO 7) and/or hypermobility of the urethra (VIDEO 8) is easily discerned with dynamic ultrasonography. This information is not available on static anatomic imaging.
A tool that enhances patient care
Dynamic ultrasonography is an important and emerging topic in gynecologic imaging. Static images and even cine clips will yield only anatomic information. Increasingly, whoever holds the transducer—whether it be the gynecologist, radiologist, or sonographer—needs to examine the patient with the probe and include liberal use of the abdominal hand as well. Incorporating this concept will enhance the overall diagnostic input of ultrasound scanning, not just imaging, into better and more accurate patient care. ●
VIDEO 1A Liberal use of your nonscanning hand on dynamic scanning shows “wiggling” of debris classic of a hemorrhagic corpus luteum
VIDEO 1B Liberal use of your nonscanning hand helps identify a small postmenopausal ovary
VIDEO 2A Dynamic scanning can give the correct diagnosis even though clips were used! This clip appears to show a relatively normal uterus
VIDEO 2B Dynamic scanning can give the correct diagnosis even though clips were used! Same patient as in VIDEO 2A showing what appears to be a solid adnexal mass
VIDEO 2C Dynamic scan clearly shows the “mass” to be a pedunculated fibroid
VIDEO 3A Video clip of a classic endometrioma
VIDEO 3B Classic endometrioma showing no Doppler flow internally
VIDEO 4A Video of dynamic assessment in a patient with pain symptoms with a hydrosalpinx
VIDEO 4B Another example of video of dynamic assessment in a patient with pain symptoms with a hydrosalpinx
VIDEO 4C Another example of video of dynamic assessment in a patient with pain symptoms with a hydrosalpinx
VIDEO 5A Sliding organ sign with normal mobility (Courtesy of Dr. Ilan Timor-Tritsch)
VIDEO 5B Sliding sign showing adherent ovary (Courtesy of Dr. Ilan Timor-Tritsch)
VIDEO 5C Normal mobility (Courtesy of Dr. Ilan Timor-Tritsch)
VIDEO 5D Left ovary: Normal mobility (Courtesy of Dr. Ilan Timor-Tritsch)
VIDEO 5E Right ovary: Normal mobility (Courtesy of Dr. Ilan Timor-Tritsch)
VIDEO 5F Normal mobility even with a classic endometrioma (Courtesy of Dr. Ilan Timor-Tritsch)
VIDEO 5G Adherent ovary (Courtesy of Dr. Ilan Timor-Tritsch)
VIDEO 6A Dynamic scanning shows the ovary to be “stuck” in the cul-de-sac in a patient with endometriosis
VIDEO 6B Dynamic scanning in another patient with endometriosis showing markedly retroverted uterus with adherent bowel posteriorly
VIDEO 6C Dynamic scanning in another patient with endometriosis showing markedly retroverted uterus with adherent bowel posteriorly
VIDEO 7 Cystocele or urethral lengthening are key elements for the diagnosis of incontinence with or without pelvic relaxation
VIDEO 8 Urethral lengthening is a key element for the diagnosis of incontinence with or without pelvic relaxation
