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Probe Position/Version/Flexion

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But before then, let's start with

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some uterine axis technology and

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that's going to be version inflection.

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Version is easy to remember

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because it has the V in the cervix.

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So version is cervix positioning.

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So if the cervix is antiverted, that means

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the internal aspect of the cervix is pointing

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anteriorly towards the bladder, or the external

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aspect is pointing posteriorly towards the rectum.

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Usually the uterus flexes in the

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same direction as the cervix.

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But not always.

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So, for example, if you have an anti-flexed

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uterus, the uterine body is going to be

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positioned anteriorly towards the bladder.

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Your most common positioning is going

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to be antiverted and anti-flexed,

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and then followed by retroverted.

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Retroflexed is the next most common.

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However, you can have any kind of

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mixture of positioning, and it can even

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change during any single examination.

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So if you're with me so far, it seems pretty

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straightforward, but we're going to add a little

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bit more complexity because the positioning of

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the cervix that will help decide where the probe

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is positioned within the vagina, whether you're

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in the anterior or the posterior fornix, and

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that's going to alter the imaging appearance.

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And to explain that a little bit

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better, here's another little schema.

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So if you have an anteverted anti-flexed uterus

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right here, and this is your transvaginal

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probe, it's going to go in the anterior

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fornix right here, and that's going to create

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your standard image of the female pelvis.

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However, if it is a retroverted retroflexed

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uterus, you're not going to go into the

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posterior fornix here, and you can see that

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the probe itself is actually flipped here.

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And so that's going to make the cervix appear

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to come from the other side of the screen.

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And so as long as you keep that

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in mind, that is what's happening.

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You'll be able to interpret these images easily.

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So with that in mind, let's see some examples.

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So here we go back to our transabdominal view,

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the same uterus that we saw earlier, right?

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Vagina down here, cervix down here, anterior

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uterus up here, and a nice full bladder.

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Same patient on their transvaginal imaging.

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This is an anteverted, anti-flexed.

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So your cervix is somewhere down here.

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The internal os, we're going to estimate

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it somewhere around here, is pointing

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this way, which is towards the bladder.

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We don't see the bladder in this

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field of view because it's empty,

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but it'd be somewhere up here.

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The external os of the cervix is somewhere

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down here, and it's vaguely pointing

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towards the rectum, which is back here.

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The uterus itself, too, is also generally

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pointing anteriorly towards the bladder.

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So this is antiverted, anti-flexed, and

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this is the most common one you'll see.

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This is its positioning on CT.

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It's the same patient again.

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Antiverted, anti-flexed, and that

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goes to prove to you here.

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Here's your bladder right

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here in your sagittal view.

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Everything is pointing anteriorly towards

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the bladder or the front of the patient.

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Again, antiverted, anti-flexed.

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This, however, is a retroverted retroflexed,

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and you can see it looks like the cervix

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is coming from the opposite side of the

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screen, and on the imaging that is what's

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happening, but that is again because the

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probe goes into the posterior fornix of the

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vagina, and it is flipped or inverted, so

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the cervix will look like it's coming from

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over here on the right side of the screen.

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I find in these, it is often very hard

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to measure the uterus accurately because

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of the bend that often occurs with this.

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So it's often going to seem under

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measured because you're just very rarely

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going to get that cervix in the same

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field of view as the rest of the uterus.

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So just something to keep in mind if you're

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comparing a size of the uterus and it changes

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positioning on different imaging dates.

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One other thing to keep in mind when you

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are reading a retroverted retroflexed uterus

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is that this is still going to be the

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anterior part of the uterus right here.

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This is the posterior. This is anterior.

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So the bladder is still going to be somewhere

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located over here, but this is the anterior.

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This is the posterior.

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If you're locating where fibroids are

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or polyps or something like that,

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this is anterior. This is posterior.

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So on CT, here's that same uterus.

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This is the positioning it would render.

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So bladder right here, rectum back here, and

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this is the uterus and the cervix right here.

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So that's the equivalent.

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Okay, so now let's get to some trickier ones.

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So this one, the image field of view

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is honestly a little bit too big.

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They probably could narrow this up a

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little bit, but as you're looking here,

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this one almost looks curved in some ways.

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It's, here's the kind of cervical area,

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and then the body of the uterus is

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up here, the fundus is back here, and

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then it sort of curves around here.

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So here's the line that I drew to

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help find the endometrium itself,

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which is what I use as my marker.

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And in this case, we have a retroverted uterus.

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It's coming just barely, but from

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the right side of the screen.

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But it is anti-flexed.

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The body is flexed anteriorly.

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So retroverted anti-flexed.

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And there's this one.

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This one the field of view is honestly

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probably a little bit too small.

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I could have widened this

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one up a little bit more.

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But this is an example of

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an anteverted retroflexed.

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So the cervix is right here coming

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from this side of the screen.

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And then the body of the uterus is

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going posteriorly towards the rectum.

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So anteverted retroflexed.

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And so it's interesting, again, these

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can change during an examination,

5:00

potentially, as long as that uterus

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isn't scarred in place due to adhesions.

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In this particular patient, this was

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them 10 months earlier. It was in a

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completely different position here.

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Right here, it was retroverted anti-flexed.

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And so, of course, then too, it

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can also change during an exam.

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That's why sometimes the technologist will

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start taking additional pictures that they

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already took of the endometrium or different

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measurements at the end of the exam, because

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that uterus flipped to a better imaging

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position where they could see it better.

Report

Faculty

Kathryn McGillen, MD

Assistant Professor of Radiology, Medical Director of Ultrasound

Penn State University Milton S Hershey Medical Center

Tags

Uterus

Ultrasound

Non-infectious Inflammatory

Neoplastic

Gynecologic (GYN)

Cervix

Body

Acquired/Developmental

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