Surface transperineal ultrasound and vaginal abnormalities: applications and strengths

Abstract

The role of ultrasound in the assessment of the female pelvis whether using transabdominal/transluminal approach is well established. Little was reported about the use of the superficial transperineal approach that could provide a full assessment of the lower cervix and vagina, which may be overlooked in the standard examinations. The proximity of the probe to the vagina helps not only the detection of organ abnormalities but also proper characterization and differentiation of vaginal masses. . We discuss the diagnostic role of this superficial ultrasound approach in improving the perception and interpretation of the anatomy and different diseases of the vagina.

Figure 1.

A superficial transperineal ultrasound sagittal orientation. (a) the original ultrasound image and (b) the same image with line tracing and delineation of the different pelvic structures: anterior there is the landmark which is the symphysis pubis (SP): semilunar line, then the urethra (U) , followed by the anterior vaginal wall (Va), the posterior vaginal wall (Vb), and the most posterior the rectal walls (R).

Figure 2.

Normal vagina with two opposing walls and collapsed lumen. Ultrasound images (a) the original image without and (b) the same image with line tracing and delineation of the different pelvic: anterior is the urethra (U), followed by the anterior vaginal wall (Va), the posterior vaginal wall (Vp), the hyperechoic line in-between is the vaginal lumen. Calibre in the image was placed to show how to measure the thickness of the vaginal wall in a double layer, single layer thickness.

Figure 3.

A coronal oblique plane of transperineal ultrasound, a. and b. showing posterior fornix of the normal vagina, during introducing the probe deeper in the vagina to see the whole vaginal length and the vaginal fornices. (a) The probe splaying both vaginal walls (V). UB, Urinary bladder. (b) The cervical lips, upper vagina and in between the vaginal fornices are seen.

Figure 4.

A multiplanar 3D transperineal ultrasound, (a) sagittal, (b) coronal and (c) axial views that demonstrated the vaginal walls (red arrows). (d) Axial reformatted volume rendering image showing butterfly shaped vagina (white arrow).

Figure 5.

Bicornate bicollis uterus with obstructed hemivagina. Case (1): (a and b) transabdominal pelvic ultrasound, (a) axial plane showing two uterine cavities, (b) sagittal plane showing double vagina with obstructed hemivagina and proximal dilatation that is seen filled with turbid slightly echogenic content (i.e. haematcolpus) and there is another collapsed normal vagina (arrow). (c) Transperineal ultrasound showing the obstructed hemivagina.

Figure 6.

Bicornate bicollis uterus with obstructed hemivagina. Case (2): (a) axial Pelvic ultrasound showing bicornuate uterus with distended right horn, (b) sagittal pelvic ultrasound showing haemato-colpus with obstruction in lower vagina, (c) transperineal showing transverse vaginal septum with non-canalized lower vaginal pouch.

Figure 7.

Vaginal atresia in a 5-year-old child (a) Transabdominal pelvic ultrasound, sagittal plane where the uterine cavity is distended and fluid-filled (hydrometra). (b)Transperineal ultrasound, sagittal plane showed cord like hypoechoic vagina suggestive of vaginal atresia (arrows) and anterior to it, note the urethra (arrow head).

Figure 8.

Pregnant female 31 weeks complaining of vaginal fullness. (a) Transperineal ultrasound showed a large cyst filling the vaginal canal. (b) The four-dimensional transperineal ultrasound showed the exact location of the cyst in the anterolateral portion of the vagina walls consistent with Gartner's cyst.

Figure 9.

70-year-old female presenting sanguious vaginal discharge. (a) Sagittal transperineal ultrasound revealed an oval hypoechoic mass seen arising from the anterior vaginal wall as presented in “b”. The mass is highly vascular on colour Doppler “c”. (d) Transvaginal pelvic ultrasound showed left larger similar adnexal mass. A biopsy was taken from the vaginal mass that revealed primary vaginal tumour (amelanotic melanoma).

Figure 10.

Patient complaining of rectovaginal fistula that could not be traced on previous MRI. (a) Transperineal ultrasound supported by injection of saline in the anal canal using a Foleys catheter (curved arrow); note the injected saline is seen within the lumen of the vagina with suspected wall defect. (b) MRI sagittal T2-weighted image; thin cuts guided by the ultrasound findings—the defect could be seen (arrows).