0:01

But before then, let's start with

0:03

some uterine axis technology and

0:05

that's going to be version inflection.

0:08

Version is easy to remember

0:09

because it has the V in the cervix.

0:11

So version is cervix positioning.

0:14

So if the cervix is antiverted, that means

0:17

the internal aspect of the cervix is pointing

0:20

anteriorly towards the bladder, or the external

0:23

aspect is pointing posteriorly towards the rectum.

0:27

Usually the uterus flexes in the

0:29

same direction as the cervix.

0:31

But not always.

0:32

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

0:34

uterus, the uterine body is going to be

0:36

positioned anteriorly towards the bladder.

0:39

Your most common positioning is going

0:41

to be antiverted and anti-flexed,

0:43

and then followed by retroverted.

0:45

Retroflexed is the next most common.

0:47

However, you can have any kind of

0:48

mixture of positioning, and it can even

0:51

change during any single examination.

0:53

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

0:55

straightforward, but we're going to add a little

0:57

bit more complexity because the positioning of

1:00

the cervix that will help decide where the probe

1:03

is positioned within the vagina, whether you're

1:05

in the anterior or the posterior fornix, and

1:09

that's going to alter the imaging appearance.

1:11

And to explain that a little bit

1:12

better, here's another little schema.

1:14

So if you have an anteverted anti-flexed uterus

1:17

right here, and this is your transvaginal

1:19

probe, it's going to go in the anterior

1:20

fornix right here, and that's going to create

1:22

your standard image of the female pelvis.

1:25

However, if it is a retroverted retroflexed

1:28

uterus, you're not going to go into the

1:30

posterior fornix here, and you can see that

1:32

the probe itself is actually flipped here.

1:34

And so that's going to make the cervix appear

1:36

to come from the other side of the screen.

1:38

And so as long as you keep that

1:39

in mind, that is what's happening.

1:42

You'll be able to interpret these images easily.

1:45

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

1:48

So here we go back to our transabdominal view,

1:50

the same uterus that we saw earlier, right?

1:53

Vagina down here, cervix down here, anterior

1:55

uterus up here, and a nice full bladder.

1:58

Same patient on their transvaginal imaging.

2:00

This is an anteverted, anti-flexed.

2:03

So your cervix is somewhere down here.

2:06

The internal os, we're going to estimate

2:08

it somewhere around here, is pointing

2:09

this way, which is towards the bladder.

2:11

We don't see the bladder in this

2:12

field of view because it's empty,

2:13

but it'd be somewhere up here.

2:15

The external os of the cervix is somewhere

2:17

down here, and it's vaguely pointing

2:18

towards the rectum, which is back here.

2:21

The uterus itself, too, is also generally

2:23

pointing anteriorly towards the bladder.

2:25

So this is antiverted, anti-flexed, and

2:27

this is the most common one you'll see.

2:30

This is its positioning on CT.

2:32

It's the same patient again.

2:34

Antiverted, anti-flexed, and that

2:35

goes to prove to you here.

2:36

Here's your bladder right

2:37

here in your sagittal view.

2:38

Everything is pointing anteriorly towards

2:40

the bladder or the front of the patient.

2:42

Again, antiverted, anti-flexed.

2:47

This, however, is a retroverted retroflexed,

2:49

and you can see it looks like the cervix

2:50

is coming from the opposite side of the

2:52

screen, and on the imaging that is what's

2:54

happening, but that is again because the

2:56

probe goes into the posterior fornix of the

2:58

vagina, and it is flipped or inverted, so

3:01

the cervix will look like it's coming from

3:03

over here on the right side of the screen.

3:05

I find in these, it is often very hard

3:08

to measure the uterus accurately because

3:10

of the bend that often occurs with this.

3:12

So it's often going to seem under

3:14

measured because you're just very rarely

3:16

going to get that cervix in the same

3:17

field of view as the rest of the uterus.

3:19

So just something to keep in mind if you're

3:20

comparing a size of the uterus and it changes

3:23

positioning on different imaging dates.

3:26

One other thing to keep in mind when you

3:28

are reading a retroverted retroflexed uterus

3:31

is that this is still going to be the

3:33

anterior part of the uterus right here.

3:35

This is the posterior. This is anterior.

3:37

So the bladder is still going to be somewhere

3:39

located over here, but this is the anterior.

3:41

This is the posterior.

3:42

If you're locating where fibroids are

3:44

or polyps or something like that,

3:46

this is anterior. This is posterior.

3:47

So on CT, here's that same uterus.

3:51

This is the positioning it would render.

3:53

So bladder right here, rectum back here, and

3:56

this is the uterus and the cervix right here.

3:58

So that's the equivalent.

4:03

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

4:04

So this one, the image field of view

4:06

is honestly a little bit too big.

4:07

They probably could narrow this up a

4:08

little bit, but as you're looking here,

4:10

this one almost looks curved in some ways.

4:12

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

4:15

and then the body of the uterus is

4:16

up here, the fundus is back here, and

4:18

then it sort of curves around here.

4:20

So here's the line that I drew to

4:21

help find the endometrium itself,

4:23

which is what I use as my marker.

4:25

And in this case, we have a retroverted uterus.

4:27

It's coming just barely, but from

4:29

the right side of the screen.

4:31

But it is anti-flexed.

4:32

The body is flexed anteriorly.

4:34

So retroverted anti-flexed.

4:37

And there's this one.

4:38

This one the field of view is honestly

4:39

probably a little bit too small.

4:40

I could have widened this

4:41

one up a little bit more.

4:43

But this is an example of

4:44

an anteverted retroflexed.

4:46

So the cervix is right here coming

4:50

from this side of the screen.

4:52

And then the body of the uterus is

4:53

going posteriorly towards the rectum.

4:55

So anteverted retroflexed.

4:57

And so it's interesting, again, these

4:59

can change during an examination,

5:00

potentially, as long as that uterus

5:02

isn't scarred in place due to adhesions.

5:04

In this particular patient, this was

5:05

them 10 months earlier. It was in a

5:07

completely different position here.

5:11

Right here, it was retroverted anti-flexed.

5:14

And so, of course, then too, it

5:15

can also change during an exam.

5:17

That's why sometimes the technologist will

5:18

start taking additional pictures that they

5:21

already took of the endometrium or different

5:22

measurements at the end of the exam, because

5:24

that uterus flipped to a better imaging

5:26

position where they could see it better.