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Referring Provider Information Page

Milestones Diagnostics™ offers advanced pelvic ultrasound for endometriosis and assessment of all gynecologic abnormalities. Examinations use internationally standardized reporting, including the IDEA consensus for endometriosis, the MUSA criteria for adenomyosis, and the IOTA terminology for adnexal cysts and masses.

 

Below is information to allow you to select the most appropriate examination for your patient:

Diagnosing Endometriosis

Endometriosis is diagnosed with an advanced pelvic ultrasound, which is the recommended imaging for deep and ovarian endometriosis(1) and the only non-surgical method for diagnosing superficial endometriosis(2). This ultrasound is typically longer than most basic gynecology ultrasounds and typically takes 30–60 minutes. An advanced pelvic ultrasound evaluates all common sites of deep endometriosis.

 

Below is an explanation of the structures evaluated and the maneuvers performed in basic, augmented, and advanced pelvic ultrasound.

 

Figure: Canadian Association of Radiologists: Practice statement on advanced pelvic ultrasound for endometriosis(3)

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Indications for Advanced Pelvic Ultrasound for Endometriosis(4)

 

  • Dysmenorrhea

  • Pelvic pain

  • Unexplained infertility

  • Tubal factor infertility with unknown etiology

  • Pre-surgical planning with suspected endometriosis

  • Pre-surgical planning with known adenomyosis

SonoPODography

SonoPODography is a variant of a saline infusion sonohysterogram that combines advanced pelvic ultrasound for the evaluation of endometriosis. Saline is instilled into the uterus via a sonohysterogram catheter, which then spills through the fallopian tubes into the pelvis. This fluid provides an anechoic background to improve sensitivity in detecting superficial endometriosis.4 An advanced ultrasound is performed as usual.

 

Indications for SonoPODography(5)

 

  • Above indications for Advanced Pelvic Ultrasound for Endometriosis

  • Negative endometriosis ultrasound with insufficient pelvic free fluid

 

Note: SonoPODography is unnecessary if deep endometriosis or endometriomas have been diagnosed, since further diagnosis of superficial endometriosis will not change management.

Saline Infusion Sonohysterogram (SHG/SIS)

Saline is instilled into the uterus via a sonohysterogram catheter. Fluid distends the cavity, improving visualization of intracavitary pathology.(5)

 

Indications for Sonohysterogram (6, 7)

  • Suspected submucosal fibroid (FIGO 0-3)

  • Suspected endometrial polyp

  • Suspected intrauterine adhesions/synechiae

  • Symptomatic cesarean scar defect/isthmocele

  • Recurrent pregnancy loss

  • Uterine anomaly with infertility (note: 3D rendering of the uterine cavity is performed as part of the basic ultrasound. SHG may be suggested if a Mullerian anomaly is suspected on basic ultrasound.)

HyCoSy (Tubal Patency Assessment)

Following a sonohysterogram, small bubbles (echogenic) within agitated saline are used to determine tubal patency. Assessment of tubal patency is a standard part of the infertility workup. (7)

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Analgesia

Oral Medications

Non-steroidal anti-inflammatory drugs (NSAIDs) can be used by most patients and can be especially helpful during procedures such as a sonohysterogram or an endometrial biopsy. Patients may take this 1-2 hours before their appointment. Please do not prescribe benzodiazepines or opioids, since these increase the risk of syncopal episodes.

Penthrox

Methoxyflurane, or Penthrox, is a short-acting patient-administered inhaled anesthetic that provides analgesia and anxiolysis. Please provide a prescription for Pentrox for patients who have difficulty with vaginal ultrasounds, severe anxiety, or chronic pain. Penthrox comes in a “green whistle” that the patient brings to their appointment. Penthrox should not be combined with NSAIDs.

 

E.g., Rx: Penthrox inhaler, one.

Local Anesthetic

In select cases, we use a local anesthetic administered by paracervical block. This helps with pain derived from cervical manipulation and is used during difficult cannulation when the benefits outweigh the risk of discomfort of a paracervical block.

Muscular/Myofascial Pain

Myofascial pelvic pain is common among patients with endometriosis and is a contributing factor to 95% of chronic pelvic pain. Patients with myofascial pain often present with dyspareunia, sacroiliac (SI) joint pain, constipation, or voiding dysfunction. Discomfort is common when a muscle in spasm is touched by an ultrasound probe, similar to dyspareunia. We maintain awareness of the pelvic floor muscles' locations and do our best to avoid discomfort.

 

If your patient is waiting for an appointment and has myofascial pelvic pain, please refer them to pelvic floor physiotherapy as part of their overall treatment.

Mini Ultrasound
Probe

We selectively use an endovaginal mini probe for patients who cannot accommodate the width of a typical 3D endovaginal probe. This measures 4-6mm in diameter compared to 7-10mm. This can be used for virginal or adolescent patients, or postmenopausal patients who are not sexually active. The mini probe is used for transrectal sonography in patients unable to tolerate a transvaginal approach. The probe offers similar image quality but lacks 3D capabilities (relevant for Müllerian anomalies).

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Trauma-Informed and Compassionate Care

Milestones Diagnostics™ is dedicated to providing trauma-informed and compassionate care to all our patients. Many gynecology patients, especially those with chronic pain, may have had previous negative healthcare interactions. From clinic design, ongoing staff training and language use to ultrasound techniques, we strive to make the appointment as safe and as comfortable as possible.

Pelvic Ultrasound Examinations

Basic Ultrasound

Overview

Standard protocol for evaluation of the uterus, fallopian tubes, and ovaries. Please provide a clinical question for a more detailed report.

 

Indications for Basic Ultrasound: 

 

  • Abnormal uterine bleeding

  • Dysmenorrhea

  • Pelvic Pain

  • Ovarian cyst/mass

  • Pelvic Mass

  • Polyendocrine metabolic ovarian syndrome (PMOS), formerly PCOS

  • Pregnancy of unknown location

  • Ectopic pregnancy

  • Amenorrhea

  • Postmenopausal bleeding

  • Infertility

  • Localization of IUS/IUD

  • Follow-up of previously detected abnormality

  • Etc.

Dynamic Pelvic Floor Ultrasound

Overview

This examination is performed during pregnancy to evaluate the function and voluntary control of the pelvic floor (levator ani) using transperineal or transvaginal ultrasound. 

 

Clinical Considerations: The levator ani muscles are dynamically evaluated at rest, during a Kegel (strain), and when pushing down. During obstetrical labor, these muscles must stretch to three times their resting length.(7) Inability to fully relax the pelvic floor while pushing may increase the risk of levator ani avulsion from the bony pelvis.(8) This is the mechanism by which pelvic organ prolapse. Inability to effectively relax the levator ani is more common among patients with chronic pelvic pain, dyspareunia, and those with myofascial pain, but it is also common in the general population.(9)

 

The dynamic pelvic floor ultrasound helps identify patients who would benefit from antepartum pelvic floor physiotherapy. Muscle training with physiotherapy improves voluntary control, reduces the length of labor, and may reduce cesarean section and operative vaginal delivery rates.(10) Emerging research indicates that dynamic and static measurements of the levator ani may predict risk of cesarean section or operative vaginal delivery.(9,11) Scheduling this ultrasound in the first or second trimester will permit adequate time for physiotherapy to show benefit.

 

It is always appropriate to recommend antepartum physiotherapy, regardless of ultrasound results.

 

Indications for dynamic pelvic floor ultrasound: 

 

  • Pregnant patients desiring a reduced risk of birth trauma

  • Chronic pelvic pain

  • Myofascial pelvic pain

Detailed Pelvic Floor Ultrasound

Overview

This examination is performed post-partum using transvaginal or transperineal 3D/4D ultrasound and evaluates the levator ani muscles for obstetrical trauma. It may be scheduled as early as 1 week postpartum, within 6 months postpartum, or when symptoms of pelvic organ prolapse arise. Ultrasounds performed closer to the index delivery will show injuries more clearly. It may guide conservative or surgical management of pelvic organ prolapse and other urogynecologic conditions. This ultrasound can also be used to evaluate lower urogenital tract cysts or masses, mesh complications, or evaluation of urethral bulking placement. (12) 

 

Indications for a detailed pelvic floor ultrasound: 

 

  • Forceps-assisted vaginal delivery

  • Pelvic organ prolapse

  • Surgical planning

  • Sexual dysfunction

  • Urinary or fecal incontinence

  • Mesh complications

  • Vaginal cysts and masses

 

Approximate risk of complete levator ani avulsion(13,14)

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Potential clinical implications of complete levator ani avulsion: 

 

  • Pelvic organ prolapse

  • Sexual function

  • Prolapse surgery recurrence

  • Possible urinary or fecal incontinence

Jenn Kirstiuk, LPN

Cost

Unfortunately, not all exams offered at Milestones Diagnostics™ are fully covered by public healthcare. We believe that these examinations should be accessible to all patients, regardless of financial ability. We are advocating for coverage for all exams, however, until then some exams may incur out-of-pocket fees. Patients should contact Milestones Diagnostics for the current fee schedule.

Footnotes

  1. Singh SS, Allaire C, Al-Nourhji O, et al. Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline. J Obstet Gynaecol Can. 2024;46(5):102450. doi:10.1016/j.jogc.2024.102450
     

  2. Freger SM, Leonardi M. Advancements in Ultrasound Diagnosis of Superficial Endometriosis: Current Challenges and Emerging Techniques. Gynecol Obstet Invest. 2025;90(4):363-373. doi:10.1159/000543075
     

  3. Al-Arnawoot B, Chang S, Duigenan S, Kielar AZ, Leonardi M. CAR Practice Statement on Advanced Pelvic Ultrasound for Endometriosis. Canadian Association of Radiologists Journal. 2023;74(4):643-649. doi:10.1177/08465371231165986
     

  4. Bafort C, Condous G, Van Schoubroeck D, et al. Ultrasound as a noninvasive diagnostic tool to detect deep endometriosis using the International Deep Endometriosis Analysis terminology. Fertil Steril. 2026;125(5):860-869. doi:10.1016/j.fertnstert.2025.12.021
     

  5. Leonardi M, Robledo KP, Espada M, Vanza K, Condous G. SonoPODography: A new diagnostic technique for visualizing superficial endometriosis. Eur J Obstet Gynecol Reprod Biol. 2020;254:124-131. doi:10.1016/j.ejogrb.2020.08.051
     

  6. Practice Bulletin No. 136: Management of Abnormal Uterine Bleeding Associated With Ovulatory Dysfunction Obstetrics & Gynecology. 2013;122(1):176-185. doi:10.1097/01.AOG.0000431815.52679.bb
     

  7. Practice Committee of the American Society for Reproductive Medicine. Practice Committee of the American Society for Reproductive Medicine. Fertility evaluation of infertile women: a committee opinion. Fertil Steril. 2021;116(5):1255-1265. doi:10.1016/j.fertnstert.2021.08.038
     

  8. Lien KC, Mooney B, DeLancey JO, Ashton-Miller JA. Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol. 2004;103(1):31-40. doi:10.1097/01.AOG.0000109207.22354.65
     

  9. Bø K, Hilde G, Tennfjord MK, Stær-Jensen J, Siafarikas F, Engh ME. Pelvic floor muscle variables and levator hiatus dimensions: a 3/4D transperineal ultrasound cross-sectional study on 300 nulliparous pregnant women. Int Urogynecol J. 2014;25(10):1357-1361. doi:10.1007/s00192-014-2408-8
     

  10. Brunelli E, Del Prete B, Casadio P, Pilu G, Youssef A. The dynamic change of the anteroposterior diameter of the levator hiatus under Valsalva maneuver at term and labor outcome. Neurourol Urodyn. 2020;39(8):2353-2360. doi:10.1002/nau.24494
     

  11. DeLancey JOL, Masteling M, Pipitone F, LaCross J, Mastrovito S, Ashton-Miller JA. Pelvic floor injury during vaginal birth is life-altering and preventable: what can we do about it?. Am J Obstet Gynecol. 2024;230(3):279-294.e2. doi:10.1016/j.ajog.2023.11.1253
     

  12. Youssef A, Brunelli E, Fiorentini M, Pilu G, Spelzini F. Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment. Am J Obstet Gynecol. 2024;230(3S):S856-S864. doi:10.1016/j.ajog.2022.12.323
     

  13. Handa VL, Roem J, Blomquist JL, Dietz HP, Muñoz A. Pelvic organ prolapse as a function of levator ani avulsion, hiatus size, and strength. Am J Obstet Gynecol. 2019;221(1):41.e1-41.e7. doi:10.1016/j.ajog.2019.03.004
     

  14. Woon Wong K, Okeahialam N, Thakar R, Sultan AH. Obstetric risk factors for levator ani muscle avulsion: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2024;296:99-106. doi:10.1016/j.ejogrb.2024.02.044

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