Transvaginal (endovaginal) pelvic ultrasound report template
A structured transvaginal (endovaginal) pelvic ultrasound report template used for transvaginal / endovaginal ultrasound, targeted uterine / adnexal assessment, pelvic doppler, specialist fertility procedure. It covers 12 sections and 54 fields, and includes a one-click normal preset.
Technique
Transvaginal ultrasound was performed with verbal consent and a chaperone present.
Sample normal transvaginal (endovaginal) pelvic ultrasound report
This is the text SonoTez generates when the doctor applies the template's normal preset. Measurements are left for the doctor to enter.
Technique
Transvaginal ultrasound was performed with verbal consent and a chaperone present.
Findings
Uterus
The myometrium is homogeneous.
No fibroid is seen.
Cervix
The cervix appears normal.
Right ovary
Texture: normal.
No right ovarian lesion is seen.
Left ovary
Texture: normal.
No left ovarian lesion is seen.
Pouch of Douglas
No free fluid in the pouch of Douglas.
What to include: sections and measurements
Uterus
- Position: anteverted · retroverted · axial
- Length (cm)
- AP (cm)
- Width (cm)
- Volume (mL) calculated
- Myometrium: homogeneous · heterogeneous
- Fibroids: none seen · present
Fibroids repeatable
- Location: subserosal · intramural · submucosal · pedunculated · cervical
- Wall: anterior · posterior · fundal · right lateral · left lateral
- Size 1 (mm)
- Size 2 (mm)
- Description
Endometrium
- Thickness (double layer) (mm)
- Appearance: trilaminar · homogeneous echogenic · heterogeneous · fluid in cavity
- Focal abnormality: none seen · present
- Description
Cervix
- Length (mm)
- Appearance: normal · bulky · fluid in canal · nabothian cyst(s) · focal lesion
- Description
Uterine cavity contents
- Gestational sac: none seen · present - use an obstetric template
- Retained products: none seen · echogenic material - possible retained products
Right ovary
- Length (cm)
- Width (cm)
- Height (cm)
- Volume (mL) calculated
- Texture / appearance: normal · bulky · heterogeneous
- Follicles (as seen)
- Largest / dominant follicle (mm)
- Cyst / mass: none seen · present
Right ovarian lesions repeatable
- Appearance: unilocular cyst · multilocular cyst · solid · mixed cystic-solid · other
- Size 1 (mm)
- Size 2 (mm)
- Features: septations · solid component · internal echoes · internal vascularity on colour doppler · calcification
- Description
Left ovary
- Length (cm)
- Width (cm)
- Height (cm)
- Volume (mL) calculated
- Texture / appearance: normal · bulky · heterogeneous
- Follicles (as seen)
- Largest / dominant follicle (mm)
- Cyst / mass: none seen · present
Left ovarian lesions repeatable
- Appearance: unilocular cyst · multilocular cyst · solid · mixed cystic-solid · other
- Size 1 (mm)
- Size 2 (mm)
- Features: septations · solid component · internal echoes · internal vascularity on colour doppler · calcification
- Description
Pouch of Douglas
- Free fluid: none seen · present
- Description
Ovarian morphology assessment (indication-specific)
- Right ovary follicle count (as counted)
- Left ovary follicle count (as counted)
- Follicle distribution: peripheral · scattered
- Counting method / approach
Other findings
- Other findings
Writing the impression
Answer the clinical question first, list the remaining findings in order of importance, and keep anything new out of the impression. If a structure was not fully seen, say so and give the reason. See how to write an ultrasound report for wording and certainty terms.