Practice of Ultrasound: Part 7 -- An ultrasound conundrum
Article Thumbnail ImageSeptember 17, 2012 -- presents the seventh in a series of columns on the practice of ultrasound from Dr. Jason Birnholz, one of the pioneers of this modality.
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Fellow UltraSounder,

The practice of ultrasound mirrors one of the major trends of our healthcare system: delivery of best services to as much of the entire population as possible. This is a very tall order, but how we reconcile the traditional and new approaches to this problem will significantly affect the way ultrasound and medicine are practiced hereafter.

All images courtesy of Dr. Jason Birnholz.

This ultrasound practice conundrum is embodied in two cases in which ultrasound provided some unexpected information. Both married women in their 40s happened to have been scheduled on the same day from different gynecological services with a referral indication of a possible pelvic mass.

In both cases there is a column of mucus, extending distally from the focal zone of endocervical inflammation. There were no other abnormal findings. On starting the exam, patient 1 said she had midcycle mucorrhea, occasionally bloody, and that this had been going on for more than five years, beginning about a year after her last Caesarian section. The second patient complained of pelvic "heaviness," and after the exam she said there was mucorrhea for at least a year, which she had assumed was related to a tubal ligation.

The patients were informed of the findings at the time of the exam, and the technical report to the referring physicians noted that chronic focal endocervicitis is a feature of chlamydia. We thought this important because neither of these patients fits the typical profile for this infection. The affected area of the cervix is thicker and more polypoid in patient 1, as the indolent infection had persisted for a much longer period of time.

Small points about cervical mucus and scanning

Modern endovaginal probe design tends toward a wide field-of-view with a near "end-fire" configuration, which is suboptimal for imaging the ovaries and often the entire uterus. When the probe is inserted, it points at the sacrum. Most of the time, all of the action is up or down. The further an ovary is from the vaginal apex, the likelier it is to be at the periphery of the field-of- view of the tightly curved array, where image quality is reduced.

The first true endovaginal probe I used had a linear array set at a slant of about 60°, which provided great coverage of the sites where the pelvic viscera are usually located and put the things I was looking at or near the "sweet spot" for image quality. Many colleagues I've spoken with say they like the improved image quality of the new systems, but there are more times when they cannot find either or both ovaries than there ever were with the original design. Ditto for gestational sacs high in the fundus, especially in an obese patient.

I mentioned my first true endovaginal probe so that I could include a little history. I do not know who may have first come up with the plan for an endovaginal probe, but in the mid 1980s the great German ultrasound pioneer Dr. Manfred Hansmann told me that he had been inserting a small-footprint 5-MHz probe endovaginally. He had patients in stirrups so that he could angulate the probe more easily.

I did some copycatting as soon as I got home with a 10-MHz probe that had been intended for intraoperative work. The pictures were great, when things could be seen, but it was essentially impossible to aim. I should add that I have never used stirrups, preferring a simple supine, knees-flexed position and patient self-insertion.

In any case, all of the newer high-frequency endovaginal probes are great for the cervix because it is always close to the probe. Cervical mucus is essential for sperm transport, and mucus production is triggered by nitric oxide at midcycle. It is now well-established that mucus properties are a better indicator of fertility than a temperature chart and, conversely, inadequate mucus production is another factor to be considered as a cause of infertility.

Even excluding detection of cervical cancer as an indication, the cervix would appear to be one of the great applications of ultrasound waiting to be "discovered" because the columnar junction is directly visible.

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