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8.Evaluationofdelayedmenses9.Follow-upofapreviouslydetectedabnormality10.Evaluation,monitoring,and/ortreatmentofpatientswithinfertility11.Evaluationwhenthereisalimitedclinicalexami-nationofthepelvis12.Evaluationforsignsorsymptomsofpelvicinfection13.Furthercharacterizationofapelvicabnormalitynotedonanotherimagingstudy14.Evaluationofcongenitaluterine,gonadal,andlowergenitaltractanomalies15.Evaluationofexcessivebleeding,pain,orsignsofinfectionafterpelvicsurgery,delivery,orabortion16.Localizationofanintrauterinedevice(IUD)17.Screeningformalignancyinhigh-riskpatients18.Evaluationofincontinenceorpelvicorgan19.Guidanceforinterventionalorsurgicalprocedures20.Preoperativeandpostoperativeevaluationofpel-vicstructurescationsandResponsibilitiesofPhysiciansinterpretingorperformingthistypeofultrasoundexaminationshouldmeetthespeciAIUMTrainingGuidelinesinaccordancewithaccreditationpoliciesSonographersperformingtheultrasoundexamina-tionshouldbeappropriatelycredentialedinthespecialtyareainaccordancewithAIUMaccreditationpoliciesPhysiciansnotpersonallyperformingtheexami-nationmustprovidesupervision,asdenedbytheCentersforMedicareandMedicaidServicesCodeofFederalRegulations42CFRRequestfortheExaminationThewrittenorelectronicrequestforanultrasoundexaminationmustoriginatefromaphysicianorotherappropriatelylicensedhealthcareproviderorundertheprovidersdirection.Theclinicalinformationpro-videdshouldallowfortheperformanceandinterpre-tationoftheappropriateultrasoundexaminationandshouldbeconsistentwithrelevantlegalandlocalhealthcarefacilityrequirements.cationsoftheExaminationThefollowingsectiondetailstheexaminationtobeperformedforeachorganandanatomicregioninthefemalepelvis.Allrelevantstructuresshouldbeidenti-edbythetransabdominaland/ortransvaginalapproach.Atransrectalortransperinealapproachmaybeusefulinpatientswhoarenotcandidatesforintroductionofavaginaltransducerandinassessingthepatientwithpelvicorganprolapse.Morethan1approachmaybenecessary.GeneralPelvicPreparationForatransabdominalpelvicsonogram,thepatientbladdercanbedistendedifnecessarytodisplacethebowelfromtheeldofviewandtoprovideanoptimalacousticwindowtobettervisualizethepelvicstruc-tures,particularlyifatransvaginalexaminationcannotbeperformed.Occasionally,overdistentionoftheblad-dermaycompromisetheevaluation.Whenthisoccurs,imagingmayberepeatedafterpartialbladderempty-ing.Ifanabnormalityoftheurinarybladderisdetected,itshouldbedocumentedandreported.Foratransvaginalsonogram,theurinarybladderispreferablyempty.Thepatient,thesonographer,orthephysicianmayintroducethevaginaltransducer,preferablyunderreal-timemonitoring.Considerationofhavingachaperonepresentshouldbeinaccor-dancewithlocalpolicy.Thevaginaanduterusprovideanatomiclandmarksthatcanbeusedasreferencepointsfortheotherpel-vicstructures,whethernormalorabnormal.Inexam-iningtheuterus,thefollowingshouldbeevaluated:(a)theuterinesize,shape,andorientation;(b)theendometrium;(c)themyometrium;and(d)thecer-vix.Thevaginamaybeimagedwhileintroducingthetransducerandcanbealandmarkforthecervix.evaluationsofthevaginalmucosaandrectovaginalseptumaredesired,instillationof20mLofsterilegelintothevaginawithdistensionofthevaginalfornicesmaybehelpful.Theoveralluterinelengthisevaluatedinthesag-ittalviewfromthefundustothecervix(totheexter-nalos,ifitcanbeidentied).Thelengthcanbemeasuredasastraightlinefromthefundustotheexternalosbyusingtheouter-to-outertechniqueorAIUMPracticeParameterforthePerformanceofanUltrasoundExaminationoftheFemalePelvisJUltrasoundMed2020;9999:1 bymeasuringfromthefundalregionalongtheendo-metrialliningandendocervicalcanalusingtheouter-to-outertechnique.Thedepthoftheuterus(anteroposteriordimension)ismeasuredinthesamesagittalviewfromitsanteriortoposteriorwalls,per-pendiculartothelength.Themaximumwidthismea-suredinthetransverseorcoronalview.Ifvolumemeasurementsoftheuterinecorpusareperformed,thecervicalcomponentshouldbeexcludedfromtheuterinelengthmeasurement.AbnormalitiesoftheuterusshouldbeThemyometriumandcervixshouldbeevaluatedforcontourchanges,echogenicity,masses,andcystsaswellassymmetrybetweentheanteriorandposteriorsegmentsofthemyometrium.Fixedretroex-ionoftheuterus,particularlyinthepresenceofposte-rioradenomyosis,shouldberecognizedasapossibleindicatorofdeeplyinltratingendometriosisinthepos-teriorcul-de-sac.Thesizeandlocationofclinicallyrel-evantlesionsshouldbedocumented.Massesthatmayrequirefollow-uporinterventionshouldbemeasuredinatleast2dimensions,acknowledgingthatitisnotusu-allynecessarytomeasurealluterinebroids.Theendometriumshouldbeanalyzedforitsthick-ness,focalabnormalities,echogenicity,andthepres-enceandcharacteristicsofuidormassesinthecavity.Thethickestpartoftheendometriumshouldbemea-suredperpendiculartoitslongitudinalplaneintheanteroposteriordiameterfromechogenictoechogenicborders,usingtheouter-to-outertechnique(seeFigure1).Theadjacenthypoechoicmyometriumanduidinthecavityshouldbeexcluded(seeFigure2).Inreproductive-agedpostmenarchalpatients,assess-mentoftheendometriumshouldallowforvariationsexpectedwithphasesofthemenstrualcycleandwithhormonalsupplementation.11,13,14Itshouldbereportediftheendometriumisnotadequatelyseeninitsentiretyorispoorlydened;inthiscircumstance,themeasurementshouldnotbeincludedinthereport.Sonohysterographymaybeausefuladjuncttoevaluatethepatientwithabnormaluterinebleedingortofur-therclarifyanabnormallythickenedendometriumandtofurtherevaluateanincompletelyvisualizedendome-trium.(SeetheAIUMPracticeParameterforthePerformanceofSonohysterography.)IfthepatienthasanIUD,itslocationshouldbedocumented.Theadditionof3-dimensionalto2-dimensionalultrasound(transabdominal,transvaginal,transperineal,and/ortransrectal)canbehelpfulinmanycircum-stances,includingbutnotlimitedtoevaluatingtherelationshipofmasseswiththeendometrialcavity,identifyinguterinecongenitalanomaliesandathick-enedand/orheterogenousendometrium,andevaluat-ingthelocationandorientationofanIUDandtheintegrityofthepelvicoor.12,15Figure1.Measurementofendometrialthickness.Theendometrialthicknessismeasuredinitsthickestportionfromechogenictoechogenicborders(calipers)perpendiculartothemidlinelongitu-dinalplaneoftheuterus. Figure2.Measurementofendometriumwithuidincavity.Inthepresenceofendometrialuid,themeasurementsofthe2separatelayersoftheendometrium(calipers),excludingtheuid,areaddedtodeterminetheendometrialthickness. AIUMPracticeParameterforthePerformanceofanUltrasoundExaminationoftheFemalePelvisJUltrasoundMed2020 AdnexaIncludingOvariesandFallopianTubesWhenevaluatingtheadnexa,anattemptshouldbemadetoidentifytheovariesrstbecausetheycanserveasamajorpointofreferenceforassessingthepresenceofadnexalpathology.Ovariansizemaybedeterminedbymeasuringtheovaryin3dimensions(longitudinal,transverse,andanteroposteriordiame-ters)onviewsobtainedin2orthogonalplanes23,24withcalculationoftheovarianvolumeasnecessary.Anyovarianabnormalitiesshouldbedocumented.Theovariesmaynotbeidentiableinsomepatients.Thisoccursmostfrequentlybeforepubertyandaftermenopausewhentheovariesaresmallerand/orfolliclesarenotconsistentlypresenttoserveasalandmark.Theadnexalregionshouldbesurveyedforabnormalities,particularlymassesanddilatedtubularstructures.Ifanadnexalabnormalityisnoted,itsrelationshipwiththeovariesanduterusshouldbeassessed.Thesizeandsonographiccharacteristicsofadnexalmassesshouldbedocumented.Theadditionof3-dimensionalto2-dimensionalultrasoundcanbehelpfultodifferen-tiateovarianmultiseptatedcystsfromhydrosalpinges.Additionally,theuseoftheslide-bytechniquecandemonstratethepresenceorabsenceofmobilityoftheadnexalstructures.Anabnormalovarianlocation,suchasintheposteriorcul-de-sacwithadhesion,par-ticularlytotheuterus,pelvicsidewall,orcontralateralovary,shouldbedocumented,asthismayindicateendometriosis,othersourcesofadhesions,ordisplace-mentoftheovaryinthesettingofovariantorsion.Documentationshouldincludewhetherthemassiscysticorsolidand,ifcystic,simpleorcomplex.Adetaileddescriptionofcomplexcystsshouldbepro-vided,includingthepresenceorabsenceofseptations(thickorthin),solidcomponents,muralnodules,excrescencesorpapillations,andvascularcharacteris-ticsifappropriate.Ifthesonographiccharacteristicsaresuggestiveofaspecicdiagnosis,suchasahemor-rhagiccyst,anendometrioma,amatureteratoma,hydrosalpinx,orapedunculatedbroid,thisinforma-tionshouldalsobeprovided.Spectral,color,and/orpowerDopplerultrasoundmaybeusefultoevaluatethevascularcharacteristicsofpelviclesions.Thecul-de-sacandbowelposteriortotheuterusmaybeevaluatedforthepresenceoffreeuid,loculateduid,oramass.Ifamassisdetected,itssize,position,shape,sonographiccharacteristics,andrelationshipwiththeovariesanduterusshouldbedocumented.Differen-tiationofnormalloopsofbowelfromamassmaybecultifonlyatransabdominalexaminationisper-formed.Therectosigmoidcolonwallmaybeimagedfromtheposteriorvaginalfornix.Specialattentiontotheposteriorcul-de-sacshouldbemadeinwomenwithpelvicpain,xedretroexionoftheuterus,orsono-graphicevidenceofposterioradenomyosisandinthosewithknownorclinicallysuspectedendometriosis.12,37Hypoechoicmasseswithtaperingendsintherecto-sigmoidwallmaybeseenindeeplyinltratingendome-36,37Thepresenceofadhesionsinthecul-de-sacmaybeinferredintheabsenceofanormaluterineslid-ingsign36,38duringdynamicimaging.Accurateandcompletedocumentationisessentialforhigh-qualitypatientcare.Writtenreportsandultrasoundimages/videoclipsthatcontaindiagnosticinformationshouldbeobtainedandarchived,withrecommenda-tionsforfollow-upstudiesifclinicallyapplicable,inaccordancewiththeAIUMPracticeParameterforDocumentationofanUltrasoundExaminationEquipmentSpecicationsTheultrasoundexaminationofthefemalepelvisshouldbeconductedwithareal-timescanner,prefer-ablyusingsector,curvedlinear,and/orendocavitarytransducers.Thetransducershouldbeadjustedtooperateatthehighestfrequencyappropriatefortheclinicalcircumstance,realizingthatthereisatrade-offbetweenresolutionandbeampenetration.QualityandSafetyPoliciesandproceduresrelatedtoqualityassuranceandimprovement,safety,infectioncontrol,andequipmentperformancemonitoringshouldbedevel-opedandimplementedinaccordancewiththeAIUMStandardsandGuidelinesfortheAccreditationofUltrasoundPractices.AIUMPracticeParameterforthePerformanceofanUltrasoundExaminationoftheFemalePelvisJUltrasoundMed2020;9999:1 ALARA(AsLowasReasonablyAchievable)PrincipleThepotentialbenetsandrisksofeachexaminationshouldbeconsidered.TheALARAprinciplebeobservedforfactorsthataffecttheacousticalout-putandbyconsideringthetransducerdwelltimeandtotalscanningtime.FurtherdetailsonALARAmaybefoundinthecurrentAIUMpublicationUltrasoundSafetyInfectionControlTransducerpreparation,cleaning,anddisinfectionshouldfollowmanufacturerrecommendationsandbeconsistentwiththeAIUMGuidelinesforCleaningandPreparingExternal-andInternal-UseUltrasoundTransducersBetweenPatients,SafeHandling,andUseofUltrasoundCouplingGel.EquipmentPerformanceMonitoringMonitoringprotocolsforequipmentperformanceshouldbedevelopedandimplementedinaccordancewiththeAIUMStandardsandGuidelinesfortheAccreditationofUltrasoundPracticesThisparameterwasdevelopedbytheAIUMincol-laborationwiththeAmericanCollegeofRadiology(ACR),theAmericanCollegeofObstetriciansandGynecologists(ACOG),theSocietyforPediatricRadiology(SPR),andtheSocietyofRadiologistsinUltrasound(SRU).Weareindebtedtothemanyvol-unteerswhocontributedtheirtime,knowledge,andenergytodevelopingthisdocument.CollaborativeSubcommitteesReemAbu-Rustum,MD,FAIUMBerylBenacerraf,MD,FAIUMBryannBromley,MD,FAIUMStevenGoldstein,MD,FAIUMMarcelaBohm-Velez,MD,FAIUMchairSafwanSafarHalabi,MDJamieHui,MDPallaviSagar,MDScottYoung,MDWendyR.Brewster,MD,PhDBethanySkinner,MDHarrisL.Cohen,MD,FAIUMCiceroT.Silva,MDKirsteenBurton,MD,PhDLoriMankowskiGettle,MD,MBAAIUMExpertAdvisoryGroupAdrianClaudiuBalica,MDLaurenCastleberry,MDLauraDetti,MD,FAIUMGenevieveBennett,MDYvetteGroszman,MD,MPH,FAIUMAIUMClinicalStandardsCommitteeBryannBromley,MD,FAIUMchairJamesM.Shwayder,MD,JD,vicechair,FAIUMNirvikarDahiya,MD,FAIUMRobGoodman,MBBCh,MBA,BMScRachelBo-mingLiu,MD,FAIUMJeanSpitz,MPH,CAE,RDMS,FAIUMJohnStephenPellerito,MD,FAIUMOriginalcopyright1995;Revised2019,2014,2009,2006,2004;Renamed20151.LangerJE,OliverER,Lev-ToaffAS,ColemanBG.Imagingofthefemalepelvisthroughthelifecycle.2012;32:2.Timor-TritschIE,MonteagudoA,RebarberA,GoldsteinSR,TsymbalT.Transrectalscanning:analternativewhentransvaginalscanningisnotfeasible.UltrasoundObstetGynecol2003;21:473479.3.StagnoSJ,ForsterH,BelinsonJ.Medicalandosteopathicboardspositionsonchaperonesduringgynecologicexaminations.1999;94:3524.DavenportMS,BrimmD,RubinJM,KazerooniEA.Patientpref-erencesforchaperoneuseduringtransvaginalsonography.Radiol(NY)2016;41:3245.WalkerDK,SalibianRA,SalibianAD,BelenKM,PalmerSL.Overlookeddiseasesofthevagina:adirectedanatomic-pathologicapproachforimagingassessment.2011;31:AIUMPracticeParameterforthePerformanceofanUltrasoundExaminationoftheFemalePelvisJUltrasoundMed2020 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PRACTICEPARAMETERAIUMPracticeParameterforthePerformanceofanUltrasoundExaminationoftheFemalePelvisheAmericanInstituteofUltrasoundinMedicine(AIUM)isamultidisciplinaryassociationdedicatedtoadvancingthesafeandeffectiveuseofultrasoundinmedicinethroughprofessionalandpubliceducation,research,developmentofclinicalpracticeparameters,andaccreditationofpracticesperformingultrasoundexaminations.AIUMPracticeParameterforthePerformanceofanUltra-soundExaminationoftheFemalePelviswasdeveloped(orrevised)bytheAIUMincollaborationwithotherorganizationswhosemembersuseultrasoundforperformingthisexamination(s)(see).Recommendationsforpersonnelrequire-ments,therequestfortheexamination,documentation,qualityassurance,andsafetymayvaryamongtheorganizationsandmaybeaddressedbyeachseparately.ThisPracticeParameterisintendedtoprovidethemedicalultrasoundcommunitywithrecommendationsfortheperfor-manceandrecordingofhigh-qualityultrasoundexaminations.TheparameterreectswhattheAIUMconsiderstheappropriatecriteriaforthistypeofultrasoundexaminationbutisnotintendedtoestablishalegalstandardofcare.Examinationsperformedinthisspecialtyareaareexpectedtofollowtheparameterwithrecog-nitionthatdeviationsmayoccurdependingontheclinicalIndicationsIndicationsforpelvicultrasoundincludebutarenotlimitedtothe1.Evaluationofpelvicpain2.Evaluationofpelvicmasses3.Evaluationofendocrineabnormalities,includingpolycystic4.Evaluationofdysmenorrhea(painfulmenses)5.Evaluationofamenorrhea6.Evaluationofabnormaluterinebleeding7.Evaluationofpostmenopausalbleedingdoi:10.1002/jum.15205 ©2020bytheAmericanInstituteofUltrasoundinMedicine JUltrasoundMed2020;9999:10278-4297www.aium.org