76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete

Name of the Procedure:

Ultrasound, Pelvic (Nonobstetric), Real-Time with Image Documentation; Complete

Summary

A pelvic ultrasound is a non-invasive imaging procedure that uses high-frequency sound waves to create real-time images of the pelvic organs, including the uterus, ovaries, fallopian tubes, bladder, and surrounding structures. This type of ultrasound is typically conducted for non-pregnant (nonobstetric) patients and includes comprehensive image documentation.

Purpose

The pelvic ultrasound helps diagnose and evaluate conditions such as pelvic pain, abnormal menstrual bleeding, ovarian cysts, uterine fibroids, and other abnormalities of the pelvic organs. The goal is to obtain clear images for accurate diagnosis and treatment planning.

Indications

• Pelvic pain
• Abnormal menstrual cycles or unexplained bleeding
• Suspected ovarian cysts or uterine fibroids
• Infertility assessments
• Follow-up on previously diagnosed pelvic conditions
• Monitoring the progression of diagnosed pelvic diseases

Preparation

• The patient may be asked to drink plenty of water before the exam to ensure a full bladder, which provides better imaging of the pelvic organs.
• Patients should inform the physician of any medications they are taking and any allergies, especially to latex or ultrasound gel.
• No fasting is typically required.

Procedure Description

1. The patient lies on an examination table, and a warm, water-based gel is applied to the lower abdomen.
2. A transducer (a handheld device) is moved over the abdomen, emitting sound waves that create images on a monitor.
3. For a more detailed view, a transvaginal ultrasound might be performed, where a covered transducer is gently inserted into the vagina.
4. The radiologist or technician captures the necessary images in real-time and stores them for further analysis.
5. The procedure does not require sedation or anesthesia.

Duration

The procedure typically takes about 30 to 60 minutes, depending on the complexity of the case and whether a transvaginal ultrasound is also performed.

Setting

The procedure is usually performed in a hospital's radiology department, outpatient imaging center, or specialized clinic.

Personnel

• Radiologist or sonographer (performs and interprets the ultrasound)
• Radiology technician (assists with the procedure)
• Nurse (provides patient care if needed)

Risks and Complications

• Minimal risks are associated with this non-invasive procedure.
• Rarely, some patients may experience mild discomfort during the transvaginal ultrasound.
• No radiation exposure.

Benefits

• Provides detailed, real-time images for accurate diagnosis.
• Non-invasive and painless.
• No exposure to ionizing radiation.
• Quick recovery with immediate resumption of normal activities.

Recovery

• No specific post-procedure care is required.
• Patients can resume normal activities immediately after the procedure.
• Any further instructions or follow-up appointments will be provided by the healthcare team.

Alternatives

• MRI (Magnetic Resonance Imaging) of the pelvis: Offers more detailed images but is more expensive and time-consuming.
• CT (Computed Tomography) scan of the pelvis: Useful for certain diagnoses but exposes the patient to ionizing radiation.
• Physical pelvic examination: Less detailed and only useful for specific conditions.

Patient Experience

• During the procedure, the patient might feel mild pressure from the transducer on the abdomen or from the transvaginal probe.
• The gel might feel cold initially but quickly warms up to body temperature.
• Most patients experience no pain and can return to daily activities immediately.
• For any discomfort, the staff will ensure the patient's comfort throughout the procedure.