Transvaginal Ultrasound

Transvaginal Ultrasound:A transvaginal scan is 
inappropriate like a child or if there is no consent or if the patient has known fibroids so you can do a detailed survey with a comfortably full bladder but everyone else with the consent you would start transfer generally so most gynie scans are transferred channel only and you start the examination with the patient having emptied her bladder and no bowel prep you count if necessary do the transabdominal scan.

  • History
  • Equipment
  • Bladder: full or not
  • Probe orientation
  • Patient Position
  • Inserting Probe
  • Image optimization

History equipment whether the patient should have a full bladder or not probe orientation positioning of the patient and where you should sit inserting the probe image optimization and then I'll show you a systematic scan with stills show you how to look at the torus and the posterior compartment and then a quick report.

 Imagine a patient lying down

Under your screen with her head at the marker end and her feet there that's theorientation in the longitudinal plane so just to show you that again this is an odd trans abdominal scan because it's you can easily see the gray stripe that's at the top of the probe, you have your marker on the patient's right you have the marker on the machine on the patient's right and then the fan of sound that comes out of the probe is displayed everything from the marker side to this side everything from the other side to this side so the patient's right will be here and the patient's left will be here you then go to thelongitudinal plane by rotating your probe at 90 degrees and so that the marker is uppermost at the head end and then the fan of song that comes out at the marker end of the probe comes to this side and at the other side here so it's just like the patient is lying down underneath your screen transvaginal it's just the same but you can't see the gray strip on the tip of the probe so clearly but  if you really look you you might see it but otherwise look for where the marker on the probe is so you look at the screen

Probe in the transverse plane

The marker on the probe would be on your left side of the patient's right if you prefer and then you set up the machine so that the marker is on the same side so it's on the patient's right and then you insert the probe into the vagina and the fan of sound is displayed on the screen in the transverse plane so this would be the patient's right this would be her left if you're now with the transfer journal probe rotate it 90 degrees clockwise and now the marker is on the top of the probe the upper side toward the head then the fan of sound is displayed on this way on the screen so everything from the marker side goes to the marker side everything from the other side goes there so again it's like the patient is lying down underneath your image with her head here and her feet here normally thought you would start the transfer journal scan with the marker on the top you wouldn't go for the transfer journal for you first you'd have the marker

 Insert your probe

 Immediately you'd have the head end here and the feet end there so just to show that again in the transverse playing with a transfer journal probe the file of sound comes out this way and it is displayed marker to mark a side another side so, in a transverse plane, this is the patient's right this is her left and in the transvaginal, this sound is coming out like this and it will be displayed marker side to mark a side another sid so she's lying down so the image that appears when you're looking at a patient like this and you'd have the bladder at the front you'd have the uterus behind the vagina there and bowel there so in the longitudinal plane this is what it looks like you see the marker is on the top left-hand side though this is the anterior wall of the uterus this is the fondest and this is the posterior wall and you can imagine that she's lying down just underneath there so this is the cervix and this is the uterus but in the transverse again my marker is there this is the patient's right and that's her left .


The transverse view 

Through the uterus

so how to have the patient lying down she should be lying down flat and preferably not on a wedge because patients on a wedge bottom under the wedge tips the pelvic organs toward the patient's head and makes the ovaries much harder to find better to half the bottom at the edge of the bed overhanging the end slightly and then with the patient's legs on stirrups if she has stirrups then you sit between the legs facing the patient that's the la SOTA me position on a low stool on wheels if you don't have lithotomy poles have her feet on a chair and you now need to sit to the patient's right and this is harder on your right shoulder but if you don't have little Tumi poles you don't have them and I like to have the bed relatively quite high with sides up so they can't fall off so the patient is level with your upper abdomen and then you hold the probe with your right hand and use your left hand to control.

The machine I like the room quite dark so I can see the screen better but I have at least one light and the other patient cover her for privacy and use plenty of gel on the outside of a covered transvaginal probe you don't need to put extra on the inside or on the outside just plenty of gel and then gently is the main thing.





patient  consent 

patients in advance that if you're quiet it just means you're concentrating and what I always say is I'm so sorry but I can't talk while I scan because I literally can little one thing at a time

the next instruction I gave is please put your arms by your sides let your bottom sink into the bed and let your knees go floppy and this is it works every time and then you can gently and slowly insert the transfer channel probe you angle it at about 45 degrees backward toward the sacrum following the line of the vagina now you'll be in the longitudinal plane so you have your marker on the top side of the probe and you orientate your image accordingly if it's difficult to insert the probe reassure the patient

make sure she's still consenting to what you're doing and put extra lubricants on the outside of the probe doesn't say relax because it means absolutely nothing but say again put your arms by your sides let your bottom sink into the bed and let your knees go floppy they encourage the patient to take some nice slow deep breaths and then gently press with the probe after each second or third deep breath.

The transverse plane 

You need to aim for your try and fundus and then this time draw a horizontal line with the fundus and follow the ovarian ligament in this video I'm going to start longitudinal then I'm going to go to transverse and move up to the ovarian ligament so that's my longitudinal going to go transverse up to the fundus and there is the ovarian ligament and you can follow that out by dipping your hand up and down a little bit if you lose it and there is the ovary so we'll just do that again in a minute longitudinal view if the uterus aim for fundus go transverse interstitial portion of fallopian tube a very indignant there it is again a very in ligament and there is the ovary on the end of it harder to do in some people you don't have the same landmarks to prove that you looked in the right place and it's the very ligament it's not the fallopian tube and you can follow it by dipping down your whole hand slightly as you go laterally so that's the view you'd get you might get to see the internal iliac vein or you might not

it's just a harder view to get and if you don't see the ovary in here you can't prove that you looked in the right place where it's at least.

The longitudinal view

 With the vessels, you can say I looked in the right place but essentially it's really valuable to learn both ways and just practice it on patients in whom there's not a lot wrong and before you know it you'll be able to do it when you find the ovary you rotate on the ovary to get the longest length so I found it and I'm gonna rotate my hand till I find the longest length that'll be the length that'll be the depth and then I need to rotate my hand 90 degrees and that's the width you then need to comment on where the ovary is is it in the ovarian fossa way you'd expect it or is it in fact glued to the back of the uterus is normal in size is it active or is their atrophy are their follicles particularly if you're doing a fertility scan or are thinking about polycystic ovaries is there a cyst or a mass and how mobile is the ovary in this

case those little follicles who you need to take at least one measurement of it,


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