Normal pelvic ultrasound report template
A normal female pelvic ultrasound report for a transvaginal study, and a combined transabdominal and transvaginal version. Measurements are left as [ ] placeholders.
TRANSVAGINAL PELVIC ULTRASOUND
HISTORY: [ ]
TECHNIQUE: A transvaginal scan was performed in the usual fashion employing grayscale imaging and color flow Doppler imaging.
COMPARISON: None available.
FINDINGS:
The uterus is anteverted.
The uterus is normal in size and echogenicity, measuring approximately [ ] cm.
No gross myometrial mass is seen.
The endometrial stripe is normal in thickness and echogenicity, measuring approximately [ ] mm.
No gross endometrial mass is seen.
Both ovaries are normal in size and echogenicity, containing multiple small anechoic follicular cysts.
The right ovary measures approximately [ ] cm, and the left ovary measures approximately [ ] cm.
Both ovaries demonstrate normal color flow Doppler and duplex Doppler signal; there is no stigmata of ovarian torsion seen.
No adnexal mass or free fluid is seen in the pelvis.
IMPRESSION:
1. Unremarkable transvaginal pelvic ultrasound as described above.TRANSABDOMINAL AND TRANSVAGINAL PELVIC ULTRASOUND
HISTORY: [ ]
TECHNIQUE: A transabdominal scan was initially performed. Transvaginal scan was performed to optimally evaluate the adnexal regions which were poorly visualized on the transabdominal scan.
COMPARISON: None.
FINDINGS:
TRANSABDOMINAL SCAN:
The bladder shows smooth contour.
The uterus is anteverted.
The uterus is normal in size and echogenicity, measuring approximately [ ] cm.
No gross myometrial mass is seen.
The endometrial stripe is poorly visualized but grossly unremarkable.
No gross adnexal mass is seen.
No free fluid is seen in the pelvis.
TRANSVAGINAL SCAN:
The uterus is normal in size and echogenicity.
There is no gross myometrial mass lesion seen.
The endometrial stripe is normal in thickness and echogenicity, measuring approximately [ ] mm.
Both ovaries are normal in size and echogenicity. The right ovary measures approximately [ ] cm, and the left ovary measures approximately [ ] cm.
Both ovaries demonstrate normal color flow Doppler and duplex Doppler signal; there is no evidence of ovarian torsion seen.
No adnexal mass or free fluid is seen in the pelvis.
IMPRESSION:
1. Unremarkable transabdominal and transvaginal pelvic ultrasounds as described above.Plain text. Pastes cleanly into PACS, RIS, PowerScribe, Word, or a browser. Fields in [ ] need your input. Add it to your collection to keep your own edited copy and share it with colleagues.
What to check before you sign a normal Pelvic ultrasound
A normal template is only safe if you have looked at everything it mentions.
- LMP and clinical question. Endometrial thickness only means something against the day of the cycle, or menopausal status.
- Uterine measurements in three planes. Record length, AP, and transverse, and keep them in the same order every time so follow-up comparison is easy.
- Endometrium in the sagittal plane. Measure double-layer thickness at the thickest point, excluding any fluid in the cavity.
- Both ovaries, with measurements. If an ovary is not seen, say so. 'Not visualized' is different from 'normal'.
- Pouch of Douglas. A small amount of fluid can be physiological. More than a small volume, or echogenic fluid, needs a comment.
Common mistakes with this template
Endometrium reported without the cycle phase
A 12 mm endometrium is normal in the secretory phase and not in a postmenopausal patient. Put the LMP or menopausal status in the history line.
An ovary called normal when it was not seen
Bowel gas often hides one ovary on transabdominal scans. State 'not visualized' rather than leaving the normal line in.
Transvaginal wording on a study that was not transvaginal
Doppler and follicle detail usually come from the transvaginal scan. If only a transabdominal scan was done, edit the technique and ovary lines to match.
Questions
What does a normal pelvic ultrasound report look like?
It records the uterus orientation and size, a homogeneous myometrium, endometrial thickness appropriate for the cycle, a normal cervix, both ovaries with measurements and normal appearance, no adnexal mass, and no significant free fluid, ending with an impression such as 'Unremarkable transvaginal pelvic ultrasound'.
What is a normal endometrial thickness?
It varies with the menstrual cycle, from a thin line after menstruation to over 10 mm in the secretory phase. After menopause, thresholds of about 4 to 5 mm are commonly used in patients with bleeding. Follow your local guideline.
Is free fluid in the pelvis normal?
A small volume of fluid in the pouch of Douglas is common and usually physiological, especially around ovulation. Larger volumes or echogenic fluid need clinical correlation.
Who wrote this template
Written by Dr Gayathri Priyadharshinee, radiologist, from the normal templates she uses in her own reporting. You are free to copy it and adapt the wording to your department's style.
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