Ultrasound, Pelvis

Ultrasound, Pelvis (Gynecologic, Nonobstetric)

Synonym/acronym: Lower abdominal ultrasound, pelvic gynecologic (GYN) sonogram, pelvic sonography.

Common use

To visualize and assess the pelvis for disorders such as uterine mass, tumor, cancer, cyst, and fibroids. This procedure can also be useful in evaluating ovulation and fallopian tube function related to fertility issues.

Area of application

Pelvis and appendix region.

Contrast

Done without contrast.

Description

Ultrasound (US) procedures are diagnostic, noninvasive, and relatively inexpensive. They take a short time to complete, do not use radiation, and cause no harm to the patient. High-frequency sound waves of various intensities are delivered by a transducer, a flashlight-shaped device, pressed against the skin. The waves are bounced back off internal anatomical structures and fluids, converted to electrical energy, amplified by the transducer, and displayed as images on a monitor. US is often used as a diagnostic and therapeutic tool for guiding minimally invasive procedures such as needle biopsies and fluid aspiration. The contraindications and complications for biopsy and fluid aspiration are discussed in detail in the individual monographs.

Gynecologic US is used to determine the presence, size, and structure of masses and cysts and determine the position of an intrauterine contraceptive device (IUD); evaluate postmenopausal bleeding; and examine other abnormalities of the uterus, ovaries, fallopian tubes, and vagina. This procedure is done by a transabdominal or transvaginal approach. The transabdominal approach provides a view of the pelvic organs posterior to the bladder. It requires a full bladder, thereby allowing a window for transmission of the US waves, pushing the uterus away from the pubic symphysis, pushing the bowel out of the pelvis, and acting as a reference for comparison in the evaluation of the internal structures of a mass or cyst being examined. The transvaginal approach focuses on the female reproductive organs and is often used to monitor ovulation over a period of days in patients undergoing fertility assessment. This approach is also used in obese patients or in patients with retroversion of the uterus because the sound waves are better able to reach the organ from the vaginal site. Transvaginal images are significantly more accurate compared to anterior transabdominal images in identifying paracervical, endometrial, and ovarian pathology, and the transvaginal approach does not require a full bladder.

This procedure is contraindicated for

    N/A

Indications

  • Detect and monitor the treatment of pelvic inflammatory disease (PID) when done in combination with other laboratory tests
  • Detect bleeding into the pelvis resulting from trauma to the area or ascites associated with tumor metastasis
  • Detect masses in the pelvis and differentiate them from cysts or solid tumors, as evidenced by differences in sound-wave patterns
  • Detect pelvic abscess or peritonitis caused by a ruptured appendix or diverticulitis
  • Detect the presence of ovarian cysts and malignancy and determine the type, if possible, as evidenced by size, outline, and change in position of other pelvic organs
  • Evaluate the effectiveness of tumor therapy, as evidenced by a reduction in mass size
  • Evaluate suspected fibroid tumor or bladder tumor
  • Evaluate the thickness of the uterine wall
  • Monitor placement and location of an IUD
  • Monitor follicular size associated with fertility studies or to remove follicles for in vitro transplantation

Potential diagnosis

Normal findings

  • Normal size, position, location, and structure of pelvic organs (e.g., uterus, ovaries, fallopian tubes, vagina); IUD properly positioned within the uterine cavity

Abnormal findings related to

  • Abscess
  • Adnexal torsion
  • Appendicitis
  • Endometrioma
  • Fibroids (leiomyoma)
  • Infection
  • Nonovarian cyst
  • Ovarian cysts
  • Ovarian tumor
  • Peritonitis
  • PID
  • Uterine tumor or adnexal tumor

Critical findings

  • Abscess
  • Adnexal torsion
  • Appendicitis
  • Infection
  • Tumor with significant mass effect
  • It is essential that a critical finding be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. Notification processes will vary among facilities. Upon receipt of the critical value the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, Hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical value, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • Patients with latex allergy; use of the vaginal probe requires the probe to be covered with a condom-like sac, usually made from latex. Latex-free covers are available.
  • Factors that may impair clear imaging

    • Incorrect placement of the transducer over the desired test site; quality of the US study is very dependent upon the skill of the ultrasonographer
    • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status
    • Retained gas or barium from a previous radiological procedure
    • Dehydration, which can cause failure to demonstrate the boundaries between organs and tissue structures.
    • Insufficiently full bladder, which fails to push the bowel from the pelvis and the uterus from the symphysis pubis, thereby prohibiting clear imaging of the pelvic organs in transabdominal imaging.
  • Other considerations

    • Failure to follow pretesting preparations may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient that this procedure can assist in assessing pelvic organ function.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex.
  • Obtain a history of the patient’s reproductive system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Note any recent procedures that can interfere with test results (i.e., barium procedures, surgery, or biopsy). There should be 24 hr between administration of barium and this test.
  • Endoscopic retrograde cholangiopancreatography, colonoscopy, and computed tomography of the abdomen, if ordered, should be scheduled after this procedure.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • Review the procedure with the patient. Address concerns about pain related to the procedure and explain that some pain may be experienced during the test, and there may be moments of discomfort. Inform the patient that the procedure is performed in a US department by an HCP who specializes in this procedure, with support staff, and takes approximately 30 to 60 min.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined.
  • Instruct the patient that a latex or sterile sheath-covered probe will be inserted into the vagina for the transvaginal approach.
  • Note that there are no food, fluid, or medication restrictions unless by medical direction.
  • Instruct the patient receiving transabdominal US to drink three to four glasses of fluid 90 min before the examination and not to void, because the procedure requires a full bladder. Patients receiving transvaginal US only do not need to have a full bladder.

Intratest

  • Potential complications: N/A
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure that the patient receiving transabdominal US drank three to four glasses of fluid and has not voided.
  • Ensure that the patient has removed all external metallic objects from the area to be examined prior to the procedure.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Instruct the patient to change into the gown, robe, and foot coverings provided. Remind her not to void before the procedure. Patients receiving transvaginal US do not need to have a full bladder.
  • Instruct the patient to cooperate fully and to follow directions. Ask the patient to remain still throughout the procedure because movement produces unreliable results.
  • Place the patient in the supine position on an examination table. The right- or left-side-up positions may be used to allow gravity to reposition the liver, gas, and fluid to facilitate better organ visualization.
  • Expose the abdominal and pelvic area and drape the patient.
  • Transabdominal approach: Observe that conductive gel is applied to the skin, and a transducer is moved over the skin while the bladder is distended to obtain images of the area of interest.
  • Transvaginal approach: Observe that a covered and lubricated probe is inserted into the vagina and moved to different levels. Images are obtained and recorded.
  • Ask the patient to breathe normally during the examination. If necessary for better organ visualization, ask the patient to inhale deeply and hold her breath.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Allow the patient to void, as needed.
  • When the study is completed, remove the gel from the skin.
  • Instruct the patient to resume usual diet and fluids, as directed by the HCP.
  • Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services. Provide contact information, if desired, for the American Cancer Society (www.cancer.org).
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include cancer antigens, colposcopy, CT abdomen, hysterosalpingography, KUB study, laparoscopy gynecologic, MRI abdomen, Pap smear, and PET pelvis.
  • Refer to the Reproductive System table at the end of the book for related tests by body system.
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