SONOGRAPHIC PELVIC ANATOMY Ellen Miller, MD, Michael Cassara, DO, John Pellerito, MD, Steven Ostrow, MD, Paul Speer, MD, Brent Thompson, PhD, Daniel Ohngemach

Goals  Understand the normal anatomy of the female pelvic reproductive tract.  Understand the normal physiologic changes that occur during the menstrual cycle.  Employ appropriate technique and etiquette to perform a transabdominal pelvic sonogram.

Learning Objectives  Identify the transducer used for transabdominal and transvaginal pelvic ultrasound.  Describe proper patient preparation for pelvic sonography, including the use of a chaperone.  Demonstrate appropriate transducer orientation to anatomic points of interest.  Identify the following pelvic structures on a transabdominal and a transvaginal sonogram: urinary bladder, vagina, cervix, uterus, ovaries, external iliac vessels.  Describe the sonographic appearance of the following pelvic structures: urinary bladder, vagina, cervix, uterus, ovaries, external iliac vessels.

Learning Objectives  Perform transabdominal and transvaginal ultrasonography of the pelvis to locate the following structures: urinary bladder, vagina, cervix, uterus, ovaries, external iliac vessels.  Describe changes that occur to the uterus and ovaries over the course of the normal menstrual cycle.  Correlate the above changes with changes in hormones of the hypothalamic-pituitary-ovarian axis.  Demonstrate appropriate communication and interaction with a patient receiving a pelvic ultrasound study.

Logistics: Pre-work  Pre-reading: review of recommended selections covering: pelvic gross anatomy and microanatomy; physiology of hypothalamic-pituitary-ovarian axis  Video review of basic principles of ultrasound imaging  Video tutorial of basic pelvic sonogram acquisition, including appropriate communication, patient position, and use of the ultrasound transducer

Logistics - Basics  Suggested time: 2 hours per cohort  Suggested number of students/group: 5-8  Suggested materials: labeled ultrasound atlas  Suggested scanning faculty: 1 per scanning station—4 per 50 students  Suggested case faculty: 1 per case station—1 per 50 students  Target Learner: preclinical student with a prior introduction to basic ultrasound principles

Logistics – Case  premenopausal patient with amenorrhea  review of anatomy, histology and physiology of the hypothalamic-pituitary-ovarian axis and menstrual cycle  comparison of ultrasound images of the follicular and luteal phase ovaries and uterus

Logistics - Organization Hands-on: Transabdominal with Standardized Patient 12 students (~30 min.) Hands-on: Transvaginal with Phantom 13 students (~30 min.) Round-table Case Discussion Incorporating Menstrual Cycle Physiology 25 students (~60 min.)

Assessment  Faculty assessing students—formative assessment at end of week  Anatomic identification of pelvic structures on transabdominal and transvaginal ultrasound images  Correlation of structures seen on ultrasound with a gross specimen  Correlation of histological images with ultrasound images of the uterus and ovaries  Correlation of ultrasound images of the uterus and ovaries with hormone levels during the menstrual cycle  Planning of an appropriate protocol for pelvic ultrasound examination—transducer selection, communication with patient, patient preparation for exam

Evaluation  Assessment of effectiveness of program format in satisfying learning objectives by student  Anonymous assessment of faculty by student  Long-term assessment of medical student acquisition of skills outlined by learning objectives